Post 107: 3 CBT (Cognitive Behavioral Therapy) Strategies to Try During Those Moments of Anxiety

We have all been put in a position where we had to wait for big news or a serious discussion, often anticipating “the worst.”

“Mom and Dad want to talk to you.”

“Let’s reserve a time to discuss your 360 evaluation.”

“Your husband’s ICU team asked that we set up a family meeting with you and your family to discuss your husband’s overall health condition and potential next steps depending on your and family’s wishes.”

One of my current tasks as an in-hospital palliative care specialist (read Post 1: What Exactly Does a Palliative Care Specialist Do?) is to set up the family meeting involving the patient [if they are of sound mind (read Post 10: Four Simple Questions to Determine if a Person is of Sound Mind)] and/or whomever they consider family to discuss their overall health picture, realistic trajectories, prognosis (read Post 67: The Difference Between “Potential” and “Likely” and Post 15: What’s My Heaven ETA? - The Who, What, Where, When, Why, and How in Asking About Prognosis), and potential paths moving forward when there is no straight-forward path. 

Upon learning that a healthcare clinician wants to meet with the family for an hour to put together a loved one’s various diagnoses and hear their concerns and questions [read Post 79: Doctors Can Hide Behind Technical Terms and Ambiguous Words – 4 Tips For Getting Clarity and Post 100: The Other Half of the Doctor’s Conversation (that Often Does Not Occur)], many family members express eagerness to meet.

However, some family members do express hesitation about meeting.  “Are you going to talk about bad news?”  they ask. Sometimes, they say they will get back to us with a meeting date and time, and then never answer our calls again (read Post 13: Sometimes It’s Denial, and Sometimes It’s Just Really Bad Timing and Post 70: It’s Not Cowardly to Not Want to Know).

Anxiety often presents as dread or worry along with physical symptoms such as racing heart, tightness in the stomach, or restlessness.  Specific types of anxiety, especially those that paralyze us from performing day to day activities, should be evaluated by a healthcare clinician and may require expert guidance from a psychiatrist, psychologist, or counselor depending on the particular diagnosis.

This blog attempts to address the anxiety that is significant enough to impact day to day functioning, but not severe enough to paralyze us.  In the world of living with serious illness, declining health, or unexpected prognosis, these moments may occur while anticipating test results, a doctor’s appointment to discuss potential treatment plans, a procedure or surgery, or a family meeting with the doctor.

“I’m trying to focus on my son as he tells me about his school day, but I’m so anxious about the upcoming meeting, I can’t focus.  I know I’m distracted.”

“I wish I could enjoy this family barbeque, but I have a ball of stress in my stomach, and I can’t eat.  I’m hoping for good test results, but I keep worrying.” 

The following suggestions are techniques or strategies you can try at home (that does not involve taking medication) to reduce anxiety overwhelm so that you can be as present as possible with loved ones and for yourself.  The first set of strategies are simple and straightforward and would likely not require practice; in fact, you have probably heard variations of these in the past:

·       Distract yourself to take a break from the anxiety.   Some may consider embracing distraction as a form of "being in denial" of the seriousness of a situation, and "being in denial" often has negative connotations. However, denial can be a necessary form of the brain’s coping to allow time for the brain to process a catastrophic event, situation, or news.  (Denial becomes potentially harmful when it prevents someone from taking necessary action or making time-sensitive decisions.)  “When I feel anxious about something and I can’t concentrate and get anything done anyway, I lie in bed and watch anything lighthearted on Netflix.  Eventually, my body calms.”

·       Consider a mantra or phrase to re-center.  Sometimes, a certain phrase can be a source of comfort.  “When I feel anxious, like waiting at the doctor’s office, I say the Serenity Prayer.”

·       Consider talking to the person whose voice is calming.  This person of trust may be a spouse, family member, or good friend.  You may want to talk about how you feel or simply avoid the topic and use their voice and conversation about unrelated subjects as a form of soothing distraction.  “I call my husband.  Even if there’s really nothing he can do, I usually feel better.”

·       Take deep breaths to cut through the anxiety spiral.  Effective meditation and breath work often takes practice.  However, if we can deliberately take a moment to take deep breaths to pause a negative thought or emotional spiral, we may be able to stop that spiral. “One day I was driving, late to a meeting, and I started feeling too anxious, like heart and thoughts racing about being late, and I knew I needed to calm down.  I remembered reading when you take deep breaths, you want the exhale to be longer than the inhale.   But I made it really exaggerated, like I took a deep breath in, and I then pursed my lips and blew out the air for as long as I could.  It was really exaggerated and really loud, like I was trying to blow out my anxiety.  I did it again, and by the 3rd time, I didn’t feel overwhelmed – still a little stressed, but I could think rationally.” 

The next set of strategies are exercises of cognitive behavioral therapy (CBT), a type of psychological therapy based on the premise that our behaviors stem from our emotions, which themselves stem from our thoughts about a situation. 

SITUATION FACTS

(cannot change)

↓

THOUGHTS ABOUT THE SITUATION

(changeable)

↓ 

EMOTIONS

↓

BEHAVIOR

The following is an example of how changing the thought can change the emotion and behavior:

I am eager to hear from my older son about his weekend with friends.  He does not respond the two times I greet him while picking him up from his friend’s house. 

↓

I think, “That’s incredibly rude, especially since I had to rearrange my schedule to make this happen. Where’s the gratitude?”

↓

Initially, I feel annoyance and irritation...which festers into insult and anger.

↓

When we arrive home, my younger son asks what’s for dinner.  I yell at him, “I just got home! Be patient!”

 or

I am eager to hear from my older son about his weekend with friends.  He does not respond the two times I greet him while picking him up from his friend’s house. 

↓

I think, “I wonder if something’s bothering him?  Was he bullied?”

↓

I feel worried and unsure.

  ↓

At the next red light, I ask my son, “Hey, you seem deep in thought.  What’s on your mind?”

The following CBT strategies may require a pause in the anxiety overwhelm (perhaps with one of the above "simple" techniques) to actively change a thought process:

·       Change the thought, considering other perspectives and possibilities.  This strategy can be highly effective, though it may require some practice.  It involves stating the objective facts of a situation and realizing that feelings of anxiety is stemming from subjective thoughts about the situation. Therefore, we would change the subjective thought about the situation to change the emotion.  For example, a fact may be that the scheduler at the front desk of the doctor’s office was curt and abrupt in answering your question.  A subjective thought such as “I was treated so rudely” may result in feelings of anger or resentment (and subsequently actions of impatience and irritability, such as yelling at your daughter for loudly exclaiming).  Or, a subjective thought such as “She must be having a rough day, probably really busy or maybe dealing with an upset patient” may result in feelings of solidarity or empathy (and subsequently actions of benevolence or patience, such as letting the scheduler’s tone roll off your back).

·       Step back and look at the big picture of your life.    Sometimes, in certain situations, it may help to remind yourself that that actual moment is really not that big of a deal.  “When I start to feel very stressed, sometimes I ask myself, ‘Ok, 5 years from now, will any of this matter?  3 years from now?  1 year from now?  Heck, will I even remember much of this 3 months from now?’”

·       Keep your mind on the Now. Be mindful of your senses and your environment in the present moment.  A technique suggested by Dr. Delia Chiramonte from The Institute for Integrative Palliative Medicine is being mindful of whether thoughts are focused on the Past, the Future, or the Present. 

Often when we focus on the Past, we ruminate.  “I used to be able to run up the stairs like that.  I’ve lost so much.”  “I’m angry at myself.  I regret not stopping smoking.”

Often when we focus on the Future, we worry.  “I’m anxious about what the test results will show.”  “What if the doctor says my child needs surgery?”

Catch yourself, and redirect the mind to the Present.  “I’m RIGHT NOW sitting on the deck and feeling the breeze on my face.”  “I’m RIGHT NOW sitting next to my daughter sharing a bowl of ice cream."

PAST

(ruminating)

(cannot change events)

FUTURE

(worrying)

(what if’s are not controllable)

PRESENT

(what you are at this moment doing, thinking, seeing, smelling, tasting, hearing, holding, touching)

(agency is possible over the PRESENT) 

Finally, the last set of suggestions is taking action.  As the saying goes, “action is the antidote to despair.” 

·       Take an action step to address the specific source of anxiety.  Taking an action step, even if it is as small as scheduling an appointment and even if an opposite direction is decided later, often gives people a sense of control. This is especially true if anxiety is stemming from uncertainty over the future and/or loss of control over more and more aspects of one's life.  “That dementia diagnosis was scary.  Then I finally decided to check out some books on it, and I felt less anxious after reading about it.  I mean, there’s stuff in there that doesn’t sound good, but at least now I think I know what to expect.”

Life, especially one in which you and your family are trying to make the most of living with serious illness, will have many potentially anxiety-inducing, stress provoking, or worrisome situations. Hopefully, at least one of the above strategies resonates with you so that you can include it/them in your coping arsenal.