Anxiety Relief: A Sample 15 Week Masterclass with 20 Cognitive Behavioral Therapy Strategies

https://www.youtube.com/watch?v=AEBJsS7OhZQ
CEUs are available at AllCEUs.com/Anxiety-Master hey there everybody and welcome to this video  on 20 anxiety relief strategies i’m your host   dr donnelly snipes in this video i’m going to  walk you through the basic strategies that i  
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use to address generalized anxiety in someone  who comes into my office now it’s important   to remember that every person is different and  every person may display their anxiety slightly   differently so this just gives you a general  idea of tools and techniques that i might use  
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we’re going to start out by looking at what i go  over in the assessment or intake interview and   how that relates to the symptoms of  anxiety then we’ll explore other things   that i rule out or rule in that might  be contributing to the person’s symptoms  
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then we summarize the typical interventions that  i use when treating generalized anxiety disorder   and i finish up by listing 15 psycho-educational  topics that i think are important   for everybody to have in a foundation treatment  program if you’re not familiar with some of these  
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tools or techniques that i’m using that’s okay  i’ve linked to longer videos that i’ve done on   each one of them in the notes to this video so  just scroll down look at some of those videos   and you’ll be up to speed so let’s start out with  the intake assessment or the diagnostic criteria  
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remember anxiety is a feeling it’s an emotion  so the first criteria for diagnosing generalized   anxiety is excessive anxiety that’s difficult  to control on most days for at least six months   about a variety of things it’s not about one  specific thing it’s about a variety of things  
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it’s also important to recognize that just  like you wouldn’t wait to go to the doctor   until you had a pneumonia you also are likely  going to do better if you start addressing anxiety   when you notice it instead of waiting until  you’re at a crisis point or until you accurately  
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and completely fulfill diagnostic criteria just  because you haven’t had it for six months or more   doesn’t mean it doesn’t need to be addressed so we  start out with this first symptom and i ask people   about what triggers their anxiety what causes  them to feel anxious what things do they think  
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about when they’re feeling anxious and  i make a list of these things as we talk   and then we examine those triggers for themes are  they related to things like loss or abandonment   or rejection or failure or loss of control and we  start trying to group them together a little bit  
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to help the person get a better understanding  maybe of where their anxiety might be coming from   then i asked them about their  anxiety vulnerabilities now   remember vulnerabilities are different  than triggers triggers are things that  
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kick off the anxiety response vulnerabilities  are things that make people more likely   to be triggered when they encounter certain  stimuli so being over caffeinated being unrested   being sick being in a strange environment all of  those may be vulnerabilities for people’s anxiety  
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and i go through each one very systematically  we look at physical vulnerabilities   such as being over caffeinated or having low  blood sugar having poor sleep being in pain   then we move on to affective vulnerabilities  if the person’s already feeling stressed out  
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or overwhelmed about things maybe they’re just  starting to feel burned out then that may make   them more vulnerable to react to things with with  anxiety then we look at cognitive vulnerabilities   when they are in a particular mood perceiving  the world as either optimistic or pessimistic  
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does that make them more likely to feel anxiety  and then we’ll look at environment are there   particular environments that contribute to their  anxiety like i mentioned earlier being in a   strange place or maybe being in an environment  where there’s lots of activity like your kid’s  
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preschool classroom or a very busy restaurant as  opposed to your home or the library and finally   we’ll look at relationship vulnerabilities if  you will and that is people in the person’s life   that may make them more vulnerable to  react with anxiety are there people that
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make the person feel on edge that may contribute  to them being a little bit more hyper vigilant so   they’re more likely to become anxious and notice  for example micro expressions after we go through   the themes the triggers and the vulnerabilities  then we go to effective coping strategies what  
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is the person doing right now that helps them  either a little bit kind of take the edge off   their anxiety or maybe it helps them relieve their  anxiety even if just for 5 10 minutes 30 minutes   those are things that we can build  on and that helps me understand  
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the types of tools that might  be effective for that person   the next characteristic or criteria for diagnosis  of anxiety disorder is feeling restless keyed up   or on edge now this is different than anxiety this  is having difficulty sitting still and this is a  
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common symptom of adhd so the person may have  anxiety but they also may have concurrent adhd   or concurrent ptsd that is contributing to their  sense of restlessness so no matter how much of the   anxiety that we treat this particular symptom may  continue to be present unless we also address it  
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so again i asked them about what triggers your  restlessness what triggers your inability or   difficulty sitting still and are there any  vulnerabilities that make it more likely that   you will have difficulty sitting still or that  you you will feel more keyed up a lot of these  
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often overlap with the anxiety triggers but  it’s still helpful to take a look at them   then i asked them about their strengths and  coping strategies for dealing with feeling   restless or keyed up what do you do when you have  to sit still and you feel restless maybe it’s in  
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a staff meeting or on an airplane or something  else what strategies can you use that help you   cope with that sense of restlessness and edginess muscle tensions sleep disturbances and being  easily fatigued are all additional symptoms  
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and they can all be caused by a variety of things  muscle tension can be caused by poor ergonomics   and pain for example that is completely unrelated  to anxiety so again we can treat the anxiety   and we can address the stress related muscle  tension but if there’s also muscle tension for  
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other reasons we need to pay attention  to that too because muscle tension is   perceived by the body as a stressor and  that is going to trigger the stress response   which is going to make the person more  vulnerable to anxiety so i ask about  
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different triggers for their muscle tension and  what’s an effective coping strategy whether it’s   progressive muscular relaxation or massage or  heat or stretching what is it that helps them   reduce their muscle tension in terms of sleep  disturbances sleep can be disturbed for a lot of  
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reasons your circadian rhythms can be out of whack  your hormones can be out of whack you’re you could   be experiencing pain that is impacting your sleep  none of those are necessarily directly related to   the anxiety but they could be contributing  to maintaining the symptoms so i asked about  
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what are triggers for sleep disturbances for  example watching particular movies before going   to sleep or checking their email before going  to sleep and what vulnera vulnerabilities exist   for sleep disturbance what things make you  more likely to have difficulty going to sleep  
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and what are some effective street sleep  strategies that the person currently uses   sleep hygiene is a big focus of early treatment  for dare i say just about every disorder that i   treat because when a person is sleep deprived  when they’re not getting good quality sleep  
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it contributes to a whole bunch of symptoms  physical symptoms cognitive thinking symptoms   emotional symptoms as well as emotional ability  and difficulty regulating their emotions   so sleep strategies are important and i generally  provide people in the initial intake a link to a  
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video on sleep hygiene and a handout on sleep  hygiene so they can evaluate their own sleep   and then if they’re easily fatigued why is this  is it because they’re not getting good sleep okay   that could be it is it because their nutrition  is poor if you’re not getting good b vitamins  
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or if you’re stressed all the time so your body  can’t use the food that you are eating nearly   as effectively or if you’re eating foods that  don’t provide all the nutrients for your body to make energy available then nutrition may be a  cause of fatigue or a contributor to your fatigue  
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over and above fatigue caused by poor sleep  and being anxious or stressed out all the time   tension can contribute to fatigue even  though you may not notice that you’re   holding a lot of muscle tension holding that  tension keeping those muscles clenched takes  
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energy and that contributes to fatigue and finally  deconditioning people who are anxious and people   who are depressed often feel overwhelmed and  exhausted because of life so going to the gym   that’s a pie in the sky thought they feel like  they barely have the energy to get through the day  
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they can’t imagine mustering the energy to work  out but even deconditioning in terms of not being   able to spend as much time cleaning the house or  working on the yard just doing regular activities   of daily living may seem completely overwhelming  so they’re not doing them and after a period of  
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time the body loses its conditioning it loses its  stamina the good thing is stamina can be rebuilt   but it’s not something that comes back overnight  it’s something that has to be gradually rebuilt   and what helps the person improve their  energy when they’re feeling fatigued  
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you may not be able to go from feeling completely  exhausted to ready to go to the gym but if you’re   feeling fatigued is there something that can put  a little pep in your step besides caffeine and i   ask people about music are there particular songs  or playlists they listen to that can give them a  
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little boost music can actually help increase  dopamine and norepinephrine which make energy   more available to us so music’s one maybe deep  breathing or just getting up and moving around   or going outside into bright light those are  all tools or techniques that help some people  
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get a little bit of energy like i said it’s not  going to be a panacea but we want to look at   any strategies that work for the person at least  a little bit and then we can build on those two more criteria for anxiety disorder include  difficulty concentrating or your mind going blank  
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and irritability when you’re stressed when you  feel anxious you’ve got that fight-or-flight   system going on you’ve got your brain in rescue  mode if you will so your brain is paying more   attention to all the threats because it doesn’t  feel safe it’s paying attention to more things  
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that are going on around you because it doesn’t  feel safe which means if you’re in an environment   where there’s a lot of distractions maybe in a  busy restaurant or even at work if you work in a   open area with lots of other people moving around  it may be more difficult to maintain your train of  
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thought because you’re thinking and then all of  a sudden your hyper vigilance makes you go over   here to pay attention to that person that just  walked in or over there to pay attention to sally   who just dropped something on the floor and  then you completely lose your train of thought  
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so it’s important for people to  recognize when they’re feeling   anxious what environments what situations  what conditions make them more vulnerable   to having episodes where they can’t concentrate  or their mind goes blank and what can help them  
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a lot of people find that in this particular  situation having noise cancelling headphones on   sitting in a quiet environment at work  maybe in a carol or in a private office   can help them focus more effectively and  what effective coping strategies do they have  
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to help them deal with this difficulty  concentrating in their mind going blank   making lists is a big one if they have a bunch  of stuff to do at work but they’ve got a lot   of anxiety it may be hard to remember okay what is  it that i’ve got to do next but if they make lists  
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that can help them keep track and  follow along with what they need to do   and irritability is that sense of being  short-tempered if you will and it’s important   for people to recognize what makes them irritable  irritability is sort of you can think of it as a  
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mild form of anger and anger just like anxiety  is a response to a threat when a person feels   anxious when a person feels exhausted when  a person feels vulnerable for some reason   then they’re more likely to respond to  any sort of outside input especially  
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stressful outside input with irritability it’s  like i just can’t take one more thing go away   it’s important for people to  recognize that and recognize   what their triggers are for irritability when  they’re angry i’m sorry when they’re anxious  
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what things tend to trigger their short fuse  if you will and what makes them more likely   to be triggered for example being too hyped up  on caffeine or being exhausted or being in pain then i move on to ruling out no matter how much  work a person does on their anxiety and their  
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thoughts and cognitions about their anxiety   if there are underlying physical issues or other  mental health issues that aren’t being addressed   there’s only so much progress the person can  make it’s important to recognize that people are
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not just a bunch of independent parts everything  interacts so if somebody’s in pain physical pain   that’s going to trigger their stress response  which is going to make them more vulnerable to   anxiety in order to make them less vulnerable to  anxiety helping them address anxiety is great but  
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we also have to address that pain so the stress  response system the hpa axis isn’t always turned   on we want to rule out thyroid imbalance hyper  or hypothyroid estrogen fluctuations lyme disease   nutritional deficiencies food sensitivities excess  caffeine or stimulants and that can come from the  
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form of energy drinks or diet pills or other  herbs that somebody may be taking that have   stimulatory effects medication side effects some  medications have in their list of side effects can   contribute to anxiety it’s important to recognize  that when serotonin gets too high for example  
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it can contribute to anxiety some people  when they start taking antidepressants   feel anxiety for the first couple of days  because all of a sudden their body’s being   exposed to more serotonin than it was prior  to taking the medication now eventually  
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it all balances out but it’s important to  recognize that that is a potential side effect   alcohol and benzodiazepine withdrawal also  contribute to feelings of anxiety now alcohol   related anxiety tends to be much shorter than  benzodiazepine withdrawal when you withdraw from  
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alcohol usually it’s two or three days that the  person experiences high blood pressure increased   anxiety etc and then things start to level out  i’m not going to say their anxiety goes away   but it levels out quite a bit with benzodiazepines  or anti-anxiety medications it can take a lot  
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longer for the anxiety to go away a lot  of people also experience rebound anxiety   when their anti-anxiety medication starts to leave  their system so if they’re taking a short acting   anti-anxiety medication it may start helping them  feel better real quick but then as it starts to  
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leave their system their anxiety rebounds and it  feels like it’s even stronger than it was before   they took the pill in the first place and it’s  important if that’s occurring to talk with your   doctor about whether there are more longer  acting options that would reduce the rebound  
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anxiety or if there are other treatment options  which there are in in lieu of benzodiazepines   pain as i mentioned can also contribute to  keeping that stress response that hpa axis   turned on keeping the person hyper  vigilant when you’re in pain you tend to be  
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kind of guarding because you don’t want to hurt  anymore you don’t want to get injured anymore   and it can make people more likely to respond with  anger or anxiety so we do need to address pain   whether it’s chronic pain like from fibromyalgia  or intermittent pain like from frequent migraines  
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we still need to address what’s going on for  people who have intermittent pain they can also   experience anxiety because they dread having  another episode for people with chronic pain   they can have anxiety related to the chronic pain  worrying that it’s going to get worse and worrying  
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that it’s going to keep them from having the life  they want ptsd post traumatic stress disorder has   a lot of anxiety related symptoms however people  can have both generalized anxiety as well as ptsd   ptsd symptoms are focused mainly around triggers  reminders of the trauma whereas generalized  
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anxiety the anxiety is about more things but if  a person has ptsd they are going to likely be   hyper vigilant which is going to make them more  vulnerable to anxiety about a variety of things   obsessive-compulsive disorder has an anxiety  component people have these obsessions  
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that they are they can’t get out of their head  and they’re worried that if they don’t do if they   don’t do x if they don’t engage in a compulsion  then it is going to end up causing bad things   or they may just have this repetitive intrusive  thought that they ruminate on that contributes to  
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their anxiety and social anxiety remember i said  generalized anxiety the person is anxious about a   multitude of things in social anxiety the anxiety  is specifically about being negatively evaluated   by people can you have both yes potentially but we  do need if somebody has a social anxiety component  
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we need to make sure that we’re addressing  that in addition to the generalized anxiety the general treatment flow that i go through  with general with generalized anxiety   in this initial meeting we have talked about  triggers vulnerabilities and current effective  
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strategies that the person uses so i take all  of those and i put them into a spreadsheet   and we look for themes and i give them to the  per give the spreadsheet to the person so they   are more aware they can start identifying  vulnerabilities and triggers that they  
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want to address i also refer people to their  primary care to rule out physical causes and   contributors like hormone imbalances nutritional  deficiencies chronic pain if they need to be   or they want to be referred to a nutritionist  or a sleep specialist i also make a referral  
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to those particular people at that point in time i  also have people start keeping a daily anxiety log   in which they note the date the time the trigger  or triggers for their anxiety the intensity   of their anxiety on a scale of one to four one  being yeah i noticed it but it wasn’t a big deal  
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two is i felt anxious but i was able to get  through just fine three is i felt really anxious   but i managed somehow to get through it and  pushed through but it was really really hard   and four the anxiety was overwhelming i just i  couldn’t i was paralyzed so date time triggers  
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intensity duration did it last five minutes or  five hours and what interventions what things did   they do that helped to either reduce their anxiety  or help them recover after the anxiety episode and then henceforth each week we review their  anxiety logs that’s like the first thing that  
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i do with people after i ask them you know  how’s your week been we look at the anxiety   logs and i evaluate it for repeating triggers and  repeating themes for their anxiety then we process   at least three of their triggers for their anxiety  and i use the fcp method what are the facts for  
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and against your belief about this situation what  aspects did you have control of in this situation   and based on the facts and your ability  to control the factors you had control of   what’s the probability that this  actually would have ended up being  
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a catastrophe would have actually ended up  being a notable threat that’s where we start   a lot of times helping people move away from  emotional reasoning into factual reasoning gives   them a sense of new perspective and a greater  sense of mastery over the situation they may not  
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feel like they can control it yet but they’re  feeling like they have a better understanding   eventually as we go through the treatment process  people will learn about cognitive restructuring   dialectics living in the and purposeful action and  hardiness and we’ll apply each one of those tools  
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as they learn them when we process their  triggers i also look at their anxiety   logs for potential vulnerabilities and i and i  identify mitigation strategies include setting   and maintaining boundaries assertiveness  and trigger management so for example  
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if one of their common triggers was interacting  with their boss or interacting with their   sister-in-law then i would say okay what  mitigation strategies could we use how can   you effectively set and maintain healthy  boundaries and manage this trigger in a meaningful  
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way may not be able to completely prevent the  anxiety but how can we help you move from a four   where you’re completely paralyzed by your anxiety  to a three where you can start you can get through   it it sucks but you can get through it and  then eventually we’ll get down to a one  
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we discuss what tools have been effective  in the past week it’s really important in   my mind to help people identify and build on  their strengths and realize the power that   they already have realize the resources that they  already have that they may be taking for granted  
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and then i provide a video handout and worksheet  on a particular psycho-education topic and it’s   important for a lot of people to have a video  that kind of explains it and walks them through it   and then a handout or worksheet to apply  it why do i do this for in between sessions  
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because i feel that people’s money is best  spent when they’re in session with me actually   processing stuff the psychoeducation component i  think is something in most cases is something that   people can spend their time learning between  sessions i don’t want to waste their money
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lecturing them when they could watch a video on  it i want to spend their time in session actually   using what they’ve learned  and applying the information so the psycho-education topics that i  think are important for everybody to  
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learn about the function of anxiety its connection  to the stress response and the impact of fight or   flight on perception and problem solving and i  mentioned that several times in this video that   when we’re in fight-or-flight mode we don’t pay  attention to the good stuff we are actually more  
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aware of more of the threats in the environment  because we are on high alert so to speak   which means we tend to perceive the world as  more dangerous and because of all that because   of the glutamate and the norepinephrine and  everything else in our brain it makes it harder  
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to think clearly our brain is has tunnel vision  adrenaline haze whatever you want to call it that   is geared towards helping us fight or flee  not think about all the possible options   and problem solving so until people can get  into what linehan called the wise mind until  
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people can get out of that high anxiety state  it’s going to be difficult to problem solve   then we talk about distress tolerance  skills which are the skills that people   need when they feel anxious to help them  remember that they can tolerate the distress  
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so they don’t feed into it by saying oh my  gosh this is going to overwhelm me i’m not   going to be able to handle it these distress  tolerance skills help people feel more empowered   even in the face of anxiety and can  help them get into their wise mind  
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we talk about circadian rhythms and sleep  hygiene because it’s so important for developing new skills for learning new things  as well as for helping the hpa access the threat   response system recover that people are getting  good quality sleep then i talk about nutrition  
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and neurotransmitter support what we eat is  broken down to make neurotransmitters to make   hormones to repair the body so if we’re eating  like crap we’re probably going to feel like crap   a lot of people want to get straight down to the  nitty-gritty of how can i improve my serotonin  
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my dopamine my norepinephrine and ultimately  everything is in a fine balance so if one goes up   one happy chemical goes up the other ones are  likely going to go up too but that requires   a healthy diet for example making serotonin to  break down tryptophan we need to have vitamin  
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b we need to have calcium we need to have  zinc we need to have iron we need to have   tryptophan itself and then to break down it goes  from tryptophan to 5 ht then to break that down   even more we need even more vitamins and  minerals so it’s important that people  
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understand the importance of a healthy diet but  also understand the regular foods that they can   eat to support their body’s ability to make those  neurotransmitters like spinach and bananas and   cocoa and tea and colorful vegetables it’s not  anything that’s really weird wild and radical
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next we talk about mindfulness the difference  between focused mindfulness so you’re focusing   on something like a candle flame or open  awareness mindfulness where you’re walking through   a park for example and you’re not focusing on  any one thing in particular you’re just noticing  
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quote everything as you walk down the  path that open awareness encourages you to be mindful be in the moment instead of  thinking instead of being in your own head   and then mindfulness in terms of the self scan  mindfully scanning your your head heart and gut  
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so to speak how am i feeling emotionally how am i  feeling physically what am i needing emotionally   what am i needing physically right now the next  lesson is on compassion and loving-kindness   developing compassion for yourself as well  as other people a lot of times anxiety  
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comes from fears of being rejected  fears of being criticized fears of   not being good enough and sometimes that comes  because your own inner critic is just harsh   and hateful so developing self-compassion  recognizing that it’s okay to be imperfect  
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can be helpful to encourage people to move towards  self-acceptance as opposed to self-abandonment   and loving-kindness meditation is helpful to   inspire compassion for others even  others that are being kind of difficult
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the next unit or topic is cognitive distortions  what they are their function and restructuring   them cognitive distortions include think  things like all or none thinking mind reading   and catastrophizing and over personalization so  we talk about how those thinking errors are likely  
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thinking strategies that formed in childhood  before you could think more critically so to speak   and often remained unchecked then we talk  about alternatives such as looking for   alternatives instead of thinking it always  happens or it never happens looking for exceptions  
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you know when has this happened if i if i say it  never happens is that true or are there exceptions   if i’m taking things too personally instead of  saying it’s all about me or the person’s mad at me   or hates me what are three other explanations  for why they may have given you a dirty look  
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besides you you were they even did they even see  you or were they caught in their own thoughts   then we move on to optimism and i  have in here tragic optimism because   unbridled optimism can be just as unhealthy as  unbridled pessimism tragic optimism includes  
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an element of dialectics and living in the  and in tragic optimism we recognize what is   but we have hope that it can get better we  recognize the good and the bad and the present   and we have hope that we can make a difference  to move towards a more rich and meaningful life
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unit 9 looks at schema schema  are our brains cliff notes   our brain shortcut to help us interpret what  to happen you have schema about everything   stop lights i’m assuming everybody who’s  watching drives and so you have a schema  
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when you see a stop light that’s on yellow  you have a schema that tells you how to react   if you think that yellow lights are really long  and you’ve got plenty of time to get through   then you’re going to keep on going or maybe even  floor it if you think that yellow lights tend to  
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change really quickly and you don’t want to run  the red light then you’re probably going to stop   so based on your past experiences with yellow  lights you’re going to react in the current moment   probably without thinking about it you’re  not going to sit there and go okay well the  
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last three times i came to this light it changed  really fast it’s just sort of an automatic process   that’s the beauty of schema it helps us do some  of our things in default mode or on autopilot   unfortunately if somebody’s been exposed to trauma  or has been anxious for a long time then their  
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schema may have been altered to expect that  the world is going to always be a dangerous   disempowering un unpleasant place so it’s going  to be important to evaluate their schema back then   that may have been true in the current context  at the current time is this schema still accurate  
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if so okay how do we deal with it if not how can  you adjust your schema relationships are the same   way if you’ve been in multiple bad relationships  you may expect that people aren’t trustworthy   but that really sets everybody else up to be  at a loss because you’re just expecting they’re  
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going to behave badly if you adjust your schema  and you say okay in this context at this time   with this person are my beliefs about  what’s going on are my expectations true   or am i just assuming based on other  people’s behaviors and past experiences
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number 10 is creating a rich and meaningful  life vision board helping people visualize what   things are important in their rich and meaningful  life what things do they currently have that are   important in their rich and meaningful life and  instead of using their energy just holding on to  
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anxiety and tossing it around in their hands like  a hot potato how can they instead use that energy   to nurture the things that are important in their  life and what kind of a difference would that make   number 11 is acceptance purposeful action  and heartiness helping people recognize  
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that sometimes life just sucks it is what  it is so to speak but using their energy   purposefully instead of using their energy  to be angry about it and stew on it and pout   using their energy and saying okay can’t change  this situation but what can i change what can  
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i use this energy for that would help me  move closer to a rich and meaningful life number 12 moves into relationships and  interpersonal behaviors and i start out   with setting and maintaining boundaries a  lot of times people feel anxious because  
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they have never been taught how to set boundaries  and maintain them they have other people have   encroached on their boundaries and told them  what to think or what to feel or criticized them   for how they think or how they feel and so  learning how to set and maintain boundaries is  
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really important to helping people feel empowered  and safe in any relationship in section 13 we talk   about secure attachment positive self-talk and  the inner child so there’s a lot there hopefully   by this point in treatment people’s triggers  and anxiety experiences are a lot less intense  
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and a lot less frequent so they have more time  to spend on developing additional skills but in   order to feel safe in order to feel loved people  typically need to have some secure attachments   including a secure attachment with self feeling  like you can be there to respond to your own needs  
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so we talk about what secure attachment  looks like how secure attachment is developed   how to use positive self-talk to enhance  your secure attachment with yourself   and to help heal your inner child that may  have been wounded because of past things  
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in unit 14 we talk talk more about the inner  critic because the inner critic is huge and   contributes to a lot of people’s anxiety the  inner critic may bring up past stuff remember   back then you failed you’re going to fail again  which can trigger anxiety or the inner critic can
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bring up anticipatory things you  think you’re going to be able to   do this you’re going to fail and  then this is what’s going to happen   and the sky is going to fall so getting that  inner critic under control is really important  
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in 15 we talk about listening without  defensiveness because defensiveness is a   anxiety anger threat reaction when people feel  like they’re being criticized or when people   feel like others don’t necessarily agree with  them the automatic reaction for a lot of people  
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is to feel threatened and to get defensive  so we talk about how to hear other people’s   opinions maintain your own boundaries and not  get defensive you don’t have to agree with them   but it’s important to be able to listen and then  finally in unit 16 we talk about assertiveness  
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in order to feel safe and empowered which is what  you need to do to feel not threatened to feel less   anxious it’s important to be able to assertively  communicate your thoughts wants and needs   so we talk about any barriers to assertiveness  and how to assertively communicate what you  
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need to others while still respecting  their boundaries and maintaining yours that gives you a general overview of the types  of things that i go through in a 12 to 16 week   treatment program with somebody who presents with  generalized anxiety now remember every individual  
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is different so i may add things like a unit on  abandonment anxiety or a unit on grief and loss   for people based on what their the themes of their  anxiety triggers are but the skills that i have   already gone over the skills that i’ve highlighted  in this presentation i think are essential  
Source : Youtube

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Leaman Ralph

Really sugar is shaky because it originates from a straight stick see the play is Granny yes Grandma plus new style luv MaryJane so listen (Granny Apple last years blue ribbon production winner AKA) I, I, I ain't on the right side of my house Jane something or the other is in my room: finally after an extermination Grannie speaks once more "let my (old man) Pacman step on it". See it is home on the range so solo as it be truity speaks got a problem it is your own. But alter scenario: Z/n time; narcotics I got that candy s.p.ee..d360 Bar itch its' and Mickey Mouse for the Sultan 7 1 4er well a hem a hem, it went early in the morning like a smack chanting sugar structure 7 -one 1 +eleven and 4 do an ate 'er 8 eight 'er? Well that aint nice. NARCO says do you know them numbers change (response) Yes it is a FiX they are MF's Ope yeah Ope Douglas is it. Surrounded by Alkaloid is both Mary and Grandma in an never ending circle of membership. French mandates declare put up their dukes... ZEN Pepsi can talk half Chocolate and your ole man Pacman down in Cuba posing as the worlds one and only Coffee Wizard "back 1:1" tis Coffee time... ||