There are many approaches to contemporary psychotherapy: for example, psychodynamic, existential, cognitive, or top-down/bottom-up. With the top-down approach, interventions begin with the mind and target its interpretation of data or information. By contrast, the bottom-up approach begins with information acquired from the senses and sensations in the body.
Since my practice in Seattle welcomes individuals, couples, and families, I work with people of all ages. Many of my clients struggle with anxiety that interferes with their ability to live their lives in a fulfilling way. Because of this, a bulk of my practice focuses on evaluating and treating anxiety.
When a new client makes an appointment, I attempt to understand how they are experiencing the anxiety. In many cases, they are over-thinkers. They get stuck in their heads and think about the future or even the past; they plan for and obsess over future interactions, or torture themselves with regret and how they could have handled things differently in the past. In my practice, I call this past or future obsession "chewing and grinding." It tends to keep my clients up at night, interfering with their sleep and making their anxiety worse. I also see clients whose bodies experience the anxiety: upset stomach, pounding heart, shortness of breath, or pain in their neck, shoulders, or back. My client's experience of anxiety helps me choose my intervention techniques for treatment.
The Four Parts of Evaluation That Help Me Construct Treatment
My initial evaluation includes four parts:
- How often does the anxiety happen? Multiple times per week, per day, per hour?
- How intense is the anxiety? I first ask clients to rate their anxiety levels on a scale from 1 to 10 with 1 being not very anxious and 10 being most anxious. Next, I ask the client to give examples of when their anxiety has made it difficult to fulfill everyday responsibilities or to enjoy life.
- How long does the anxiety last? I am particularly interested to know whether my clients can pinpoint an exact moment that ended the anxiety. If they can clearly articulate the cause of the anxiety as well as the moment it ended, then they may have already developed some coping skills to help themselves though periods of anxiety.
- When did anxiety first become problematic? Did it start with a life event? Is anxiety a long-term coping strategy gone awry?
This last question is a good way to explore the client's background in greater depth; the areas that I typically cover during an initial evaluation are trauma history, family of origin, substance use, and nutrition:
- Trauma history: Unresolved trauma can keep the nervous system activated, and clients experience this as anxiety.
- Family of origin: What was the client's experience of anxiety as a child? Did a parent have anxiety and show it? How did they observe their parents managing anxiety?
- Substance use: Anxiety can be severe with use of or withdrawal from alcohol, marijuana, amphetamines, cigarettes, and caffeine. This information helps to clarify the diagnosis and treatment plan.
- Nutrition: Nutrition can play a big role in the management and experience of anxiety. I am particularly interested in the amount of carbohydrates vs. protein that my clients are eating. Protein helps stabilize blood sugar level, but carbohydrates get converted to sugar and cause blood sugar spikes and crashes. When blood sugar is low or people don't eat frequently enough, the brain acts as if the body is starving. The brain tells the pancreas to release adrenalin into the blood stream. The adrenalin provides a burst of energy. That burst can make a person feel jittery, and clients experience it as anxiety.
Interventions I Use When Treating a Client
Working with the client, we establish whether there are patterns or triggers of the anxiety. While we are examining patterns, I explain the nutritional benefits of protein and recommend that my clients increase their protein intake (roughly eight grams every three hours in addition to meals). The goal is to stabilize blood sugar and reduce the amount of adrenalin released into their bloodstream.
The second aim is to establish orientation, a concept and practice from Peter Levine's Somatic Experiencing. Orientation is connecting to the environment through the senses, usually vision. I ask a client to assume a comfortable position and let their eyes wander where their eyes want to go. During this activity, I ask that clients make a mental note of what their eyes want to see. After a few minutes, I ask what drew their interest and why. The process of orientation helps settle the nervous system and offers a tool to help manage anxiety. Giving the eyes the opportunity to look where they want to confirms safety for the client. In animals, the orientation process can demonstrate that there is no danger or that danger has passed.
A third way that I intervene with clients is with two mindfulness practices. They can do both or I may choose one based on their personalities or present capabilities. For the first type, I suggest setting an alarm for sixty seconds, finding a quiet space, and counting ten breaths (in/out being one breath) until the alarm goes off.
The second practice I teach in session is called a body scan. Starting with the feet and moving up the body, I have client's imagine breathing through that body part: toes, feet, ankles, calves, knees, thighs, hips, abdomen, shoulders, upper arms, elbows, hands fingers, neck, head, and face. A majority of my clients have forgotten what it means to relax, and to have that experience in session is an accomplishment for them.
Every Patient has the Tools to Take Control of Their Anxiety
This represents the tip of the proverbial iceberg in treating clients with anxiety, helping clients to get some order out of their chaos and provide some helpful tools for their journey. My long term goal is for my clients to be able to coach and nudge their own biology and nervous systems towards health, to access the body's own capacity for wellness, to be able to be present and expect and know that moments of anxiety that were once debilitating will now pass and they become more free to live in the world.
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Date of original publication: December 16, 2014
Updated: March 04, 2016