Tag Archives: anxiety reduction techniques

Using Anxiety to Avoid Depression: Part 4

A reader’s comment on the third post in this series has led me to rework the post that I had planned for today. In essence, I was asked if I thought that all persons with anxiety were using that as a defense or screen against depression. The short answer to that is: No, not at all.

In fact, I am not at all certain how often anxiety is a screen over depression. I do not know of any statistical studies of this phenomenon. My thoughts on this matter come from on my own clinical observations.

I have a confession to make. Sometimes it takes repeated exposure and then being slapped in the face with it before I recognize the importance of an issue.

What happened was that a cluster of these cases occurred over the span of a few months. I did not have a good explanation of it for the patients or myself. This process of anxiety followed by depression was not new to me. Right now, off the top of my head, I can think of at least a dozen times that I have seen anxiety lead to depression. Its previous occurrences, though, were sporadic. At those times, I shelved the process as an unimportant anomaly. Not until the cases came in a group did I start to look for common threads and a decent explanation.

To repeat myself, I do not think that anxiety necessarily covers over depression nor that anxiety must lead to depression. That has not been my clinical experience at all.

My sense is that anxiety guards against depression in a limited number of cases. It seems to happen mostly to people with long-standing anxiety problems. These persons are in difficult life situations. In addition, they have difficulty separating anxiety-generated worries from objective concerns and thoughts. Further, it also appears that due to either other factors or the anxiety itself, there is a damaged self-esteem.

However, it also can happen abruptly. Imagine, for instance, a person who unexpectedly finds some evidence that his/her spouse is having an affair. This could lead to anxiety and doubt. On a level not quite conscious, the person could choose to remain anxious and doubtful rather than openly talk to the spouse about their suspicions. If the spouse confessed to the affair, it would be too depressing and painful for that particular person to bear. The anxiety is seen as the lesser of two painful situations. Recall that in anxiety some hope remains. In depression, hope is no longer present.

Allow me to start with the treatment of a “pure” anxiety disorder. This will show the types of anxiety cases that are not engaged in a defense against depression or some life event. Let us assume that the person obtained a thorough psychological evaluation. There is no suggestion of an underlying depression. The person expresses confusion about why they are anxious since there are no major stresses in her/his life. There is no history of trauma or substance abuse. Recent medical examinations found the person to be in good physical health. Anxiety or panic is the only clinically significant finding.

In such a case, I would proceed straight to cognitive-behavioral treatment. Any thoughts of anxiety shielding a depression are aside unless new clinical evidence called for their return.

In these instances, the following is the treatment that I have found most often to be helpful.

Before going further, let me emphasize that this does not substitute in any fashion for treatment or diagnosis by a professional.

There are five cornerstones in my approach. Each is critical in the reduction of anxiety, although some are harder to achieve than others.

1. Good sleep habits. To keep this post brief, allow me to suggest a page from the University of Maryland Medical Center. That will help explain the basics of good sleep hygiene.

2. Good diet. Caffeine, sugar, missed meals, highly processed foods are all gasoline to the fires of anxiety. While not exactly a food group, at least for most folks, alcohol and other intoxicants as well as nicotine can also ignite anxiety. For more details on good eating habits, you can go to MentalHelp.net’s article “A Healthy Diet.” It’s hard to overemphasize how much of a role diet plays.

3. Light exercise. This means nothing more than a 20-minute walk around the block. Any kind of physical activity that involves your whole body will do the trick. However, it does not include competitive sports and similar events where there are goals and high expectations.

There is a way to cheat on this if you absolutely cannot fit 20 minutes of light exercise into your day. But I have found that it is not as effective as exercise on a regular basis. For the sake of brevity in this post, I’ll direct you to another post on MentalHelp.net: “Progressive Muscle Relaxation for Stress Reduction” by Mills, Reiss and Dombeck. There you will find detailed instruction and explanation of this stress relief practice.

4. Fun. This simple activity is often the most difficult for people to be able to do. Whatever you consider fun, schedule it into your week. Fun is an antidote to the buildup of stress and anxiety.

5. Get out of the house and socialize, do things with your friends and family. Yes, even if you don’t feel like it or think that you won’t enjoy yourself or worry that you’ll spoil everything because of your anxieties.

If those are the cornerstones, then the ground upon which they rest is air. Or, to be more specific, it’s a type of breathing. For a host of physiological reasons, breathing is an essential element in both the kindling process of anxiety as well as in reducing anxiety.

Breathing by using your diaphragm is the simplest and most effective anxiety reduction technique that I know (excluding medications). The main problem with this method is that it is so easy, most people don’t think it can be effective.

There is another post by Mills, Reiss and Dombeck, entitled “Methods of Stress Reduction” that explains how to breathe in this fashion. You’ll find the instructions near the bottom of the page.

If you prefer a visual instruction, a YouTube video demonstrates the process. The video is from the Center for Hindu Studies and is called “Diaphragmatic Breathing.”

Once you learn how to do it, you can breathe this way everywhere you go and no one can tell. It does not need to be as formal as in the video. With practice, you can breathe with your diaphragm while walking up the stairs or sitting in a chair at dinner. It works best as a preventative measure and is only minimally effective if you wait until a panic attack to use it. So breathe with your belly regularly and often for best results.

Once these are accomplished, the cognitive aspect of the treatment comes into play. Here I listen for distortions, generalizations and other effects anxiety upon the thought process. We can then look at those assumptions and objectively assess them.

The following is a typical anxiety-ridden statement. “Whenever I try something new, I make a mess of it.” This can be challenged gently. I might ask if there really have been no successes ever in the person’s life. There has to be one in there somewhere and I build on it. That patient’s sentence is also loaded with anticipatory anxiety. One believes that “a mess” will be the result. To get past the dreadful anticipation, a mess is made sooner rather than later. It then helps to discuss ways to recognize when you’re setting yourself up for failure through anticipatory anxiety and how to substitute in thoughts that are more constructive. These and other strategies improve the thought processes and minimize anxiety.

In a thumbnail, that summarizes my initial treatment plan for dyed-in-the-wool anxiety disorders. I also offer to refer the person to a psychiatrist to see if medications can also be of assistance. Most of the cases that I treat fall into this category. The anxiety disorder stands by itself. Here, anxiety does not cover or shield a depressive disorder or a painful life circumstance that is being avoided.

I hope that this post has clarified that my focus in this series is on a limited sub-set of anxiety disorders. In the next post, I plan to look at the treatment of persons who do have anxiety standing guard against depression and painful life events.

Using Anxiety to Avoid Depression: Part Two

When we left off, it was with Donovan Campbell, in Joker One, trying to establish measures to deal with the stress faced by 150 Marines trying to gain control over an Iraqi city of 350,000.

As a refresher, he was trying to act as a calm leader. As he phrases it: “Frantic-sounding lieutenants lose everyone’s confidence immediately…Calm-sounding lieutenants make everyone believe that the situation is well under control…” At the same time, he attempted to establish activities to bolster esprit de corps and rituals for the unit so that they formed a cohesive identity.

A golden rule in dealing with anxiety of unknown dangers is to turn it into a fear of a specific threat. Once that is accomplished, plans can be made to deal with the threat. Campbell spent a lot of time planning his missions and identifying specific goals and means to reach those goals. He did this despite the full knowledge that conditions could quickly change and make his plans and goals irrelevant. As Campbell writes of a detailed plan he made in early April: “Like most of my plans, this one didn’t survive very long.”

Nonetheless, a key part of his strategy was to continue identifying concrete goals and clear-cut plans.

Another helpful stress and anxiety management tactic is to simply take stock of the changing conditions and the results of earlier efforts. Do this with a neutral eye. It is decidedly unhelpful to harshly criticize oneself for plans made with the best of intentions and efforts. That leads to self-doubt which in turn brings back anxiety of unknown and uncontrollable bad outcomes. Instead, no matter what the outcome, it’s good to recall that you made the best decision possible available at the time.

For instance, Campbell, with very limited information, had to make a decision on whether or not to have a sniper shoot a man. He considered the situation for about thirty seconds and then ordered the sniper to fire. Months later, he learned that the dead man was in fact an insurgent and so the decision to have him killed was correct. However, Campbell did not revisit that earlier decision. As he puts it: “on the front lines, there are no great options, just bad ones and worse ones, so you do what you can…Then you live with the results…”

Sometimes, chronic exposure to severely stressful conditions will outmatch well made, rational plans and stress management techniques. Let’s recall the conditions these soldiers lived with. The temperature was often in the 130’s. There was insufficient water for regular showering and toileting. Sleep was often interrupted and too brief. Meals were mainly prepackaged rations. Fun activities, while highly prized, were in short supply. They were strangers to the culture. Mortars and small arms were routinely fired into their base. Their families and friends were continents away. 150 soldiers were tasked with winning an urban war fought on foot in a city of 350,000. Fellow soldiers were being killed and wounded in other units. “For many members of Joker One, death took on a very real persona…”

It should come as no surprise, then, that a weak spot in Campbell’s thoughts developed. It can be most clearly seen in his intensified beliefs in the powers of the pre-mission prayer ritual. At one point, his platoon was the only one not to have suffered a single wound. Some magical thinking crept into to his beliefs. He began to believe that due to the prayers, the lack of injuries to his platoon was a “clear sign that…God would certainly bring all of us home safely.” As explained in a Psychology Today article, “Emotional stress and events of personal significance push us strongly toward magical meaning-making.”

In a phone call to his wife, Campbell told her that the prayers were keeping his soldiers safe and that prayers would bring them back alive. His wife tried to inject some clear thinking. “She was glad that no one was hurt, she said, but she reminded me that God wasn’t a cosmic slot machine that came up sevens every time for the pious believer….All He guarantees you is your relationship with Him in the next. They were hard words of truth…And I completely ignored them.”

In retrospect, Campbell has good insight into his overemphasis on the power of his religious beliefs. “I didn’t recognize yet that my steadfast dismissal of the idea of casualties in my platoon stemmed not so much from a belief about God’s grace but from a refusal to consider the very real possibility that someday I might be responsible for the death and wounding of the men I loved so much.”

There are many reasons for avoiding the idea that he might have to order his men into situations that could lead to their and his death or injury. As he says, he loves his men. It is rational to want people you love to remain safe. Yet beyond that, Campbell has mistakenly tied his relationship to God, his idea of himself and the safety of himself and his men to events and circumstances that are clearly beyond his control. This is a formula for anxiety. To protect against the full, crippling nature of anxiety and panic, he forms unrealistic beliefs.

At the time, this symptom of anxiety, magical thinking, guarded him against both the overwhelming reality of his situation and feelings of futility and depression. “I thought that if I was just good enough, that if we just prayed hard enough,” then God would intervene and protect them and allow for victory.

The symptom of magical thinking kept a distorted form of hope alive. Hope that God would love him enough to keep him safe. Hope that he could prevent his men from being killed.

Hope that he, as a man, was just simply good enough.

The contrary of those thoughts are extremely painful. God does not love him. He cannot keep his men safe. Campbell is simply neither a good man nor a good soldier. If these statements proved to be true, basic trust in one’s surroundings, beliefs and one’s self crash. The result can be anhedonic depression.

So, with the apparent choice being between the alluring hope and belief that one is good and deserving enough for God’s love and protection, on the one hand, and despair, desolation and damning self-blame, on the other hand, which would you choose? However, because this alternative is based on magical premises, it is a false dilemma.

Anxiety and its varied symptoms can, temporarily, protect against depression. That is why, in some cases, the successful treatment of anxiety leads to a depressive state. We have taken away the shield against depression and not treated the underlying problem. And, if we just treat the depressive symptoms and not the underlying defense against the reality of one’s situation and the accompanying distortions in thought, then anxiety can rekindle.

This is an insidious problem. The anxiety or depression in these cases is a defense against the full truth of one’s situation. The person may not consciously be aware of the root of the problem. So, even taking a careful history and assessment of a patient may not reveal the psychosocial stresses that are being guarded against. For example, if I ask an anxious woman how her marriage is, she may adamantly present a picture of a warm relationship and loving husband. Ruling out real stressors, I might view the condition as a biologically-based anxiety or depression. I start to treat the symptoms and try to extinguish them.

Only later do I discover that the anxiety covers a depression which in turn covers an abusive husband.

But let’s go back to the book and see what happens to Campbell and his Marines.

Anxiety, even with Campbell’s stress management skills and magical thoughts, still managed to poke through intermittently. And anxiety struck him particularly hard on the morning of one very tragic day. He writes: “I woke up to a horrible feeling of dread. I can’t really properly put that heavy sense of impending doom into words…I had been scared before other missions, of course, but never before had I felt such a deep certainty that something bad would happen to my men if they left the Outpost that day.”

The Ox, which is the nickname for Campbell’s commanding officer, was to be in charge of a mission that day. The Ox had proven to have flawed judgement on a number of previous occasions and this was a particularly difficult mission. On most missions, Campbell was in direct control of his men. That was not the case on this day. The Ox would lead them and one more element of control was taken from Campbell. The balance tipped and he was acutely anxious.

Part of the mission involved having the Ox inspect repairs that were made to a local school. This would subject the men to a relatively long period of remaining in one place with little or no cover from the enemy. Campbell objected to the plan on the grounds of it being unsafe for his men. He was overruled.

As Campbell feared, his men became sitting ducks and came under fire by insurgents’ guns and rocket propelled grenades. In the first round of the battle, “the rocket had missed us. Instead it had impacted squarely in the middle of the crowd of small children. Dead and wounded little ones were draped limply all over the sidewalk…”

Campbell then had to make a quick decision. He could leave the area and get his men to relative safety. Or he could stay and tend to the wounded children until ambulances arrived. But this latter alternative came with the certainty that the Marines would continue to be at risk from enemy attack.

“I wish,” Campbell writes, “I could say that I stepped back and cooly and dispassionately evaluated the situation, but if I said that, I would be lying. The fact of the matter is…we were United States Marines and a bunch of dying children needed our help. It was just that simple.”

Tragically, there was an unduly long delay in getting ambulances to evacuate the children. In the meantime, there were more attacks by the insurgents. During the firefights, one of the Marines was horribly, severely wounded. The soldier died a few days later at a hospital in Germany.

The immediate emotional consequence for Campbell was depression.

“I found that my hope, built so painstakingly over the past eight months, had been ruthlessly extinguished in one terrible moment…I fell into a deep depression. For a week, I didn’t want to eat, and I didn’t want to leave my bed, even though I found no respite in sleep. Instead of sleeping, I spent my time endlessly replaying the scene…wondering where I had gone wrong…”

The defense against anxiety through planning and strategy and a prayer ritual had failed. Anxiety led to some magical thoughts. Those thoughts took Campbell beyond mourning and into a hopeless state of depression.

Our initial question of how anxiety protects against depression and how resurrecting hope might lead back to anxiety is now mainly answered. And with that we will leave Campbell and the rest of the Marines of Joker One except for some brief references in future posts.

I wish them well.

Why People Might Use Anxiety to Avoid Depression

[A quick administrative note. I recently entered into an agreement with MentalHelp.net to provide blog posts for them. Some of the entries made here will also appear in their blog. This is the first such post.]

Back in March of this year, I was listening to NPR while driving around town doing errands. Terry Gross was interviewing Donovan Campbell, the author of Joker One. His book is about a platoon of Marines stationed in Ramadi, Iraq. Campbell was talking to Gross about a soldier under his command that was killed in Iraq. Campbell began crying while talking about the death. I found it remarkable that a battle-hardened Marine officer who served three tours in the Middle East and had written a book on the topic could still allow himself the candor and authenticity to cry on national radio about a man who died several years earlier.

I bought the book. I was not disappointed.

Joker One

Around the same time, I was puzzling over a clinical question that was happening frequently enough to catch my attention. In some cases, when treatment of anxiety symptoms was successful, depressive symptoms emerged. The reverse of that seemed also true: alleviation of depression sometimes led to resurging anxiety symptoms. I spent a lot of time thinking about the psychological and social conditions that might be at work in these instances.

Patients sadly asked me why it should be that now that the anxiety attacks were gone, instead of being happy they had become depressed. I had some stock answers to the problem. However, they no longer satisfied me. More importantly, I don’t think my answers were helpful to them.

This process occurred both in individual and marital therapies. Anxiety symptoms apparently were defenses against becoming depressed. And if someone was previously anxious and then became depressed, the depression-in part-served as a defense against a return of anxiety.

Further, the symptoms themselves guarded against fully coming to terms with the reality of the person’s or couple’s situation.

That all sounds complicated and I will attempt to unpack it as we go along.

Hope, I believe, also plays a pivotal role. Hope, that is, in both its manifestations: an alluring, sweetly promised desire and as an unfulfilled, tormenting, scoffing longing. But we’ll get to that later.

In subsequent posts I will also provide clinical examples of anxiety as a defense against depression (and vice versa) for individuals and in marriages. I will also try to work out some of the dynamics involved.

But to get started, let’s return to Donovan Campbell’s Joker One. It was while reading this work that I began to formulate an answer to the clinical questions that were dogging me.

Some caveats before I begin. This is not a review of the book itself. Nor is this intended as an analysis of the book’s author or the other Marines. Nor am I making any comment on America’s current wars or politics.

Rather, I simply want to look at some of the psychological effects of exposure to urban warfare.

I deeply respect and admire Mr. Campbell and the other Marines in this book. Nothing that I write below is intended as a slight or criticism of those men. I strongly recommend that you read Joker One. It is a work of art and love birthed in one of earth’s many hells.

Okay, now to the book.

iraq-ramadi

The setting is Ramadi, Iraq in 2004. In Campbell’s words, the city “contained roughly 350,000 people…one of the highest population densities on earth…its alien nature struck me almost like a physical blow. No amount of training at abandoned U.S. bases could have prepared us…” Add to this that none of the 150 Marines spoke the local language. The city was home to unknown numbers of well-armed insurgents who did not wear identifying uniforms. Mortars were fired routinely into the Marine’s base. Their job was to “walk the city on foot” where “trash and human waste littered every street” and for the 150 Marines to secure and stabilize the city of 350,000.

If that is not a recipe for anxiety or panic, then I have never heard one. Obviously, a platoon’s commander cannot afford to have anxiety spread through the troops. Therefore, they would need good anxiety reduction strategies. I have written elsewhere on this topic and won’t repeat my views here; a number of them would not apply to his battlefield conditions anyway. So, let’s see how Campbell devises a real-time strategy for anxiety reduction and stress management in the midst of a hostile chaos and in the fog of war.

For one, he acts in the fashion of a true leader. Here’s how he writes about it:
“I had a responsibility to my men to provide for all their needs…Marines will only listen to those who have suffered alongside them, and if you want any credibility as a leader, you not only have to bear the same burdens as they, but you also have to try, to your utmost ability and every single day, to transfer those burdens from their shoulders onto yours.”

He also instituted “a pre-battle ritual…that we only performed every time we left the base’s confines…” The aim of this was to have “each of my Marines…think of himself first as a member of Joker One and only thereafter as an individual with needs and desires different from that of the team as a whole…a focus on the group and an overriding concern with the service and welfare of others.” The ritual was a recitation of the Twenty-third Psalm.

Praying Before Mission

So far, so good. Against an unknown, unseen force whose members were prepared to suicide if it would cause Marines to die, Campbell presents himself as a strong, competent and compassionate leader of a group of soldiers with an intense, common identity. Yet, within the recitation of the psalm was a paradox that ultimately threw Campbell into despair. But I am getting ahead of the story here.

There’s much more to Campbell’s campaign against anxiety and the dread of the unknown.

But this is a good place to take a break. I will continue analyzing his strategy in the next post. In the meantime, may I again suggest that you pass the time by reading Joker One.

Tips on Anxiety Management

The Atlantic this week has an article entitled Surviving Uncertainty: A Few Tips by Lane Wallace.

As part of her credentials on this matter, she notes that:

“I’ve flown small aircraft on five continents. I’ve been stranded alone on a glacier in shorts and tennis shoes. I’ve found myself in the middle of rapidly destabilizing situations in African countries.”

She finds it helpful to

  • Focus on the present.
  • Keep perspective. Ask yourself, “what’s the worst thing that happens here?”
  • Separate what you can’t control from what you can, and then focus on taking action on those items you can control.
  • Learn to prioritize what’s essential, and loadshed everything else.

Take a few minutes to read her informative article by clicking here.

Swine Flu Anxiety

miss-piggy

If the economy isn’t enough to give you agita (see my earlier post), then all the press about swine flu might do the trick.

Let’s recall the basics of anxiety: something bad, we’re not sure just what but it’s bad, may happen in the future and there’s nothing we can do about it. I discussed this in the third post in this series, last October. More formally stated, Wikipedia has it that “Anxiety is a generalized mood state that occurs without an identifiable triggering stimulus. As such, it is distinguished from fear, which occurs in the presence of an external threat.”

If you’ve been following along, those two sentences give a key to one of the ways to deal with anxiety. That is, turn anxiety into fear. We should get as specific as we can about the nature of the threat and then do what we can to prepare for it. After that, get on with your daily life, stop ruminating about the potential threat, enjoy the Spring.
tulips
In that vein, here are links to the most recent and reliable information I could find about swine flu.

In addition to the tips on what to do in those articles, here are some recommendations for general emergency preparedness.

Now, turn off the TV and do a bit of light exercise. Then make plans to go out and have some fun. And remember to get seven to eight hours of sleep per night and eat a sensible diet. Avoid caffeine, nicotine, alcohol and other drugs.

Long term stress suppresses the immune system. So by following these steps, you can reduce your stress levels and maintain a healthy immune system just in case you need it later.

Anxiety, Self-Esteem and Self-Soothing

If you have been following these posts, perhaps you will recall one entitled “The Experience of Anxiety and Panic.” In that essay, I briefly noted some of the thoughts people with anxiety disorders sometimes have about themselves. The self-attributions or labels that they attach to themselves relevant to today’s discussion include:

•embarrassment
•shame
•guilt
•a sense of personal failing
•being sure that one is flawed
•believing that you are inferior to others
•being harshly self-critical
•having low self-confidence

These are powerful, negative beliefs that some anxiety-ridden people have about themselves. They hold them to be as true as the sun rises in the East. These thoughts stem from the anxiety disorder. These anxiety-provoking thoughts are incessantly repeated, both verbally and sub-vocally, until they are soaked in apparent truth. Beliefs such as these can strongly influence a person’s behavior and interactions with others.
For instance, a person with social anxiety may repeat the phrase “I suck at meeting new people” over and over again. They practice this belief dozens of times a day. Socially anxious people may even imagine how horrible meeting someone new at school (or elsewhere) today will be. Practice, in this as in many other areas of life, makes perfect. Therefore, our socially anxious person believes that s/he “sucks at meeting new people.” S/he has visually imagined or practiced how poorly the next interaction will be.

This linking of an anxious presumption (I suck at meeting new people) with imagined interactions and outcomes leads someone to become successful at being unsuccessful in meeting new people.

Let me make an aside. When I was young, I played golf. I remember reading an article by the golfing hero of the day, Jack Nicholas. He described the technique he used to prepare for his next shot as he walked up to his ball. He visualized, from a first person point of view, making the back swing, exploding downward and striking the ball, following through and only then looking up to follow the ball on a perfect arch and direction to the exact point where he wanted the ball to land and then roll to.

At the time, I thought that was just something he came up with for the article. I tried doing it and had little success. Only later did I realize that I have a hard time visualizing such things. For me, verbal or auditory cues work much better. Years later, when I read books about NLP, I came to have a much better understanding of why Jack’s visualizations did not work for me, but talking myself through something did work.

Before getting too far afield, let me return to erroneous belief systems and self-soothing. Our socially anxious friend now has a rigid belief that they suck at meeting new people and have practiced poor outcomes in their imaginations. They have become as prepared for that bad interaction as Jack Nicholas was prepared for his birdie. In all probability, the socially anxious person will have a very upsetting encounter with the next new person.

This seems to prove the assumption that “I suck at meeting new people.” So, if anyone should ask why a person thinks she or he have difficulty meeting people, there is fresh, concrete proof. That is a fallacious line of argument.

The socially anxious person, in this case, would better be described as, due to the anxiety disorder, being successful at preparing and planning a disastrous first meeting with someone. It is not that they prepared and practiced to have a successful outcome. We do not know how the meeting would have turned out if the person had been at ease, comfortable in the setting, and had practiced a successful outcome to the meeting.

One way to try to combat negative, self-fulfilling beliefs involves my asking what seems to be a question dreaded by some of my patients.

Let me explain that a bit. Anxious and depressed persons often come to the first session well-versed and ready to discuss what is wrong with them. The descriptions of their purported flaws, shortcomings, self-criticisms flow easily.

At some point in the session, I ask them to “tell me three good things about you.”

There is usually a silence. Sometimes there are looks back at me that seem to say that I have asked a most impolite, hideous and foul question. It would seem easier to return to the lengthy list of negatives.

One of the reasons behind asking this question is to find traits that a person likes about him or herself for use in self-soothing and self-esteem. Another is to assess the constancy and quality of the person’s self-representation. The latter is relevant to this discussion but would take us into object relations theory and psychodynamic/analytic theory and is beyond the scope of this post.

With three good things about oneself in hand, many techniques become available. A simple one is to say to yourself something like the following:
“I’m a good person who is (fill in the blank with three self-positives). I am going through a difficult time (fill in the situation, e.g., meeting this new person). But I have gone through bad times before and made it through. And I’ll be able to make it through now because I’m a good person and (fill in the three self-positives). I’ll still have those good qualities even if this (meeting or whatever) goes poorly.”

In the above, I have suggested three initial strategies on building self-soothing strategies and positive self-esteem.

First, notice when you are practicing negative thoughts about yourself and preparing for self-fulfilling bad outcomes. Then attribute those thoughts and previous outcomes to the anxiety disorder. Stop those ruminations by getting up and doing a different activity, even if it is only getting up from the couch and going into the kitchen and washing dishes; if you are alone you can say “Stop those thoughts” out loud and switching your thoughts to any positive memory you might have; and similar techniques.
Second, try to picture a successful outcome to your next project, like Jack Nicholas. Alternatively, if visualization is not for you, talk yourself through the steps of the project. Imagine how one successful step will lead to the next.

Third, remind yourself of your good traits, at least as often as you rehearse the negative ones. In addition, in times of trouble, remind yourself that you will still have all your positive attributes with you through the difficult task and even afterwards.

I will return to these topics in later posts.