Crisis & Trauma Resource Institute: Anxiety – Practical Intervention Strategies
As I pursue looking on the internet for free continuing education opportunities, I came across the free training resources that are provided by the Crisis & Trauma Resource Institute. After viewing their webinar on children and Covid-19, I was impressed with the perspectives and practical interventions that were suggested. This led me to seek out the Anxiety workshop, which can be found here. I will warn ahead of time that the provision of an email address will add you to a mailing list, so be mindful of that when signing up for the course. In advance, I would like to note that I write as a student summarizing the key learnings from this learning opportunity, and in no way am an expert in anxiety or endorse any specific educational program or training platform. This summary is for demonstrating my participation in and use of the information in social work practice. For those looking for continuing education credits, the workshop produces a certificate for 4.5 continuing education credits.
Key Learnings:
Understanding Anxiety
Anxiety can be broken down into four key domains. These include physical sensations, emotional states, thoughts & perceptions, and behaviours. These inter-connected pieces can be looked at as a cycle, as behaviours can influence physical sensations (Crisis & Trauma Resource Institute Inc, 2015). What is key to keep in mind is that anxiety brings forward signals that grab our attention, and allow us to try and deal with the situation. This means that anxiety is not inherently good or bad, but that it depends on the context of the individual within their environment, and if the anxiety is adaptive or maladaptive.
The discussion of stress, fear, anxiety, and worry are very thoughtfully discussed, and fit in quite well with other free online learnings such as the Brain Story (which can be found here). Stress is outlined as a physical response generated by the nervous system and is given operational flexibility through recognition of real and perceived threats and internal or external sources. Fear is outlined as an emotional response that includes a physical state, a psychological sense of doom, and apprehension (though it is not limited to these components) that arises in response to an immediate threat. Anxiety is viewed as an emotional response that can include physical stress. In anxiety, this response can take place before or after the threat or challenge. Its purpose is to alert the individual to possible danger. The last component of the stress response is “worry.” Worry is viewed as a cognitive component of anxiety that is comprised of circular, repetitive thinking that is repetitively re-reviewed. This can be an attempt to problem-solve or perseverate. An important consideration here goes back to the concept that neurons that develop repeated associations are more easily accessed in cognition – “neurons that fire together wire together” (for Hebbian theory see Doidge 2007; Mischel, 2014).
The stress response system is framed by the Crisis & Trauma Resource Institute (CTRI) as having multiple components of the brain working together to produce a response (2015). The lower brain (the brain stem) serves the most basic functions of sensory perception, with the sensory information being sorted on the basis of relevance to survival and passed onto the limbic and adrenal systems. The reaction patterns within the limbic and adrenal systems are patterned, instinctual and reflexive. The presenter, Vicki Enns, also makes note of the flow of information between all levels of the brain, and the impact this has on the gut of individuals with anxiety.
The middle brain (the limbic system) is characterized by the CTRI (2015) as the emotion and social centre. The middle brain houses the amygdala, which scans for threats, and modulates if the information is emotionally significant. Working closely with other brain areas associated with memory, the information is shared with the right orbitofrontal cortex. Doing so allows us to socially engage and connect with others. The connections with the hypothalamus allow for there to be a connection with the autonomic nervous system – providing the fight/flight/freeze responses. These responses are influenced by the release of adrenaline and glucocorticoids from the adrenal glands.
The higher brain (the prefrontal cortex) is categorized as the part of the brain that recognizes and maps responses. The higher brain integrates information from the various components of the brain and works with short-term memory. Connections with the insula and anterior cingulate help the brain decide the significance of a “threat.” This is communicated back to the amygdala, which then influences the emotional and autonomic reactions. CTRI (2015) notes that this influences the role of imagination and social cues in the response system. These cognitions influence the activation of the sympathetic and parasympathetic nervous system(s).
Anxiety can be looked at in terms of the communication between the lower, middle, and higher brain, and the impacts that this has with the body. CTRI (2015) describes this as a disruption from the lower systems, moving to the higher systems. When we think of previous experiences, memories can influence the interpretation of threat. So if the amygdala has been activated over a similar event of the past, it can increase the chances of activation in a new, but similar, circumstance. Our response systems are able to categorize and judge the levels of stress/threat, however. So it is the association between the events we have experienced and fear/anxiety/threat that we need to be mindful of. The memory areas of the brain may misattribute threat to circumstances. This leaves the individual open to patterns of obsessions, compulsions, and ruminations.
Since there is a strong physiological response to anxiety, people may also begin to associate those sensations with a heightened experience of anxiety. Associations of anxiety with activities that arouse different bodily systems (such as exercise) may develop. This can alter the individual’s association of healthy behaviours with distress.
Working with Anxiety
Practitioners want to be able to distinguish between anxiety that is adaptive and healthy, and unhealthy or “dis-ordered” anxiety. One sign to consider includes examining the pattern of anxious emotions over time and looking for a repeat or escalation in anxiety. Another consideration is if the pattern of anxiety is disproportionate to anxiety expected for the individual’s developmental stage (such as separation anxiety). The last consideration would be how the stressor escalates in the context of the individual’s life circumstances. Does anxiety become a stressor in and of itself that spirals out of control? CTRI (2015) explores the use of whole-brain approaches. This means that the practitioner would look at the state of the body, the state of the mind-body connection, the status of the mind, and the social skills that are present. Externalization of the anxiety (naming it and attaching metaphors to it) is one possible option to provide a means to discuss anxiety more openly.
The focus on the body examines aspects such as nutrition, activity, sleep, breath, sensation, and movement. They go quite in-depth with a number of possible interventions, so I will cover the ones that stood out for me:
Nutrition: Be aware of substances that can impact neurotransmitters (alcohol, nicotine, and other substances), and changes in hormones that take place throughout the life-cycle.
Activity levels: Increases inactivity may reduce anxiety, help in new brain-cell production in the amygdala, and regulate blood-glucose levels through normalization of cortisol. Be aware of the associations between somatic changes in exercise and panic attacks and discuss this with clients if necessary.
Sleep: sleep deprivation can put us into a state of “dis-ease”. Getting enough quality sleep can reduce the stress response. If there is sleep anxiety, it may be helpful to discuss that quiet resting is about 80% as restorative as sleep.
Breath: Breath is directly impacted by the sympathetic nervous system. Consciously slowing down the breath activates the parasympathetic system. Breath rhythm allows higher levels of functioning to reactivate and counter fear/anxiety. Mindfulness breath exercises may be useful in this instance. This can include belly breathing, guided imagery, and beats for breathing, Some buy-in may be necessary to get clients on board.
Sensation: Can immerse the client deeply into one of the senses. Includes sight, sound, smell, touch, and taste. We can explore what are the sensations that go with the feelings, or have the clients uses metaphors of their senses to describe feelings. It can be useful to practice this with the client in sessions. Questions that help the client more richly describe the experience of calming through sensation awareness can be useful. The 5-4-3-2-1 grounding technique may be useful.
Movement: The body naturally increases muscle tension as a response to stress and fear. Stretching exercises help stimulate the parasympathetic system. Neck rolls/stretches, and progressive muscle relaxation may be useful here as well. Rhythmic movement also can aid in anxiety reduction. Matching walking to the pace of breath helps the mind settle as can dancing/swinging or other forms of physical movement. Movement can be combined with the senses to deepen activation of the parasympathetic system. Somatic quieting activities may be aggravating to some, but helpful to others. It is important to look at interventions from the client’s perspective and seek their input on what may help them become more regulated.
Mind-Body Connection
Anxiety naturally may lead an individual to avoid situations associated with anxiety. This can reinforce the anxiety response. Providing information on how these components intersect may be helpful. Exploration of the barriers present to engage in mind-body activities may help make interventions more accessible through modification. The practitioner wants to ensure the client has autonomy, and that they can face it in small, but manageable steps. Looking at anxiety as a skewed perception of the environment, and allowing the client to put it into context may be helpful. This needs to have a self-compassion piece to it. Decisional balance sheets of inaction and action on addressing anxiety through this process may be useful!. The practitioner wants to help the client overcome the all-or-nothing experience of anxiety. Bringing awareness to different degrees of anxiety may be a useful strategy. This can be done by journaling the situations and scaling the experiences to raise awareness of variances in anxiety levels. Interventions can be paired with the events and before/after scaling questions can then monitor the changes of anxiety as a result of the strategies utilized.
Working with the Middle Brain
The middle brain signals the right orbitofrontal cortex. This connects conscious awareness with physical states and can be utilized to strengthen our ability to self-regulate. This part of the brain also works with our capacity to socially connect with others. Mindfulness techniques can be used here by building awareness around our cognitions without struggling to change them. the goal is to allow the client to benefit from learning how to train the mind to settle. It is useful to begin with breathwork, and move towards other dimensions of our experience. We want to find an anchor with the client that they can place their attention on. Because clients are very perceptive to our own state, we want to ensure that our own body, voice, posture, and thoughts are settled as well. This allows for co-regulation to take place. Guided imagery is another technique that can be used here.
Guided imagery works with imagination, but also vulnerable to rumination and anxiety. Overactivation of the imagination can be suppressed through learning the technique and expand the individual’s problem-solving capacity. Imagery works by stimulating the limbic and emotional brain structures alongside the cortex. This brings opportunities for awareness, possibilities, and choices to collectively work together for the client. use of multiple senses can work across multiple brain regions to strengthen components of the whole neural system. The client should be able to choose an experience they would like to experience in guided imagery, explore when they embodied the quality, notice the changes in their body, alter the intensity of the senses, reflect on what they see/feel/sense, reflect on similar situations in their life, and reflect afterwards on the experience as a whole.
Focusing on the Thinking Mind
We may have a distorted understanding of what we do and do not have control over. Our brains tend to filter out the options we do have control over if the brain does not see it as important. This is because our brain is geared toward seeking safety. The prefrontal cortex works with the limbic system to decide how intense a “threat” actually is. This can take place by observing the sensations, actions, thoughts, and emotions that come up for an individual in an experience. Working with clients, we can explore how anxiety shows up, what it sounds or looks like, what it feels like, what it does to grab our attention, how it impacts our beliefs, and how it changes our experience. Dan Siegal’s “name it to tame it” was shown in this session (which can be found here). So it is useful to help name the emotion the individual may be feeling, and check-in with the individual to help them find their own description as a way to calm the amygdala.
Another strategy, interrupting the loop, appears to be a good way for a client to remove themselves from an anxiety spiral. This is where the client actually catches themselves in the spiral and can either say “stop” or use visualizations that represent a need to stop. Other strategies mentioned earlier can be combined with this technique, but practice will help the technique become more impactful. The goal is to have the client become more aware of what is going on with their body, and put it in context with the situation and possible interventions. Other strategies such as “containing” the anxiety may be helpful, by carrying out other activities to lower the stress so that anxiety can be more manageable in a less-heightened state. The client does not, however, want to use this as a way to ignore the anxiety. The goal is to promote better self-regulation of anxiety.
Another technique that can be used is reality checking. In this technique, the individual identifies the situation, explore the thoughts/beliefs, scales the level of worry, looks for evidence to see if the worry fits with the situation. Scaling anxiety before/after can help the client discern if distorted thinking has adversely influenced the worry initially, and then help quantify how much of a change exploration has on reducing anxiety. This helps the client critically think about the evidence that fuels anxiety. The practitioner’s role in this situation is to help the client check to see if the evidence is true or distorted.
A similar technique, the worry well, progresses the same as reality-checking through the thoughts/beliefs, and evidence for anxiety fitting with the situation. What differs is the response to anxiety. In this intervention, the client is encouraged to explore what they do and do not have control over. From these insights, the areas the client has control over can be further explored, prioritized, and broken down into smaller components that are more manageable for the client to work with. This empowers the client to create their own path forward.
Expanding Social Skills
One of the nice things in this workshop was the understanding of the interconnectedness between individuals, and the role interconnection plays on our own anxiety. This fits well with the social work concept of person-in-environment, as well as reciprocity in relationships (Miley, O’Melia, & DuBois, 2017; White, 2008). This is nicely broken down by the CTRI (2015) into getting connections and giving connection. Ecomaps, genograms, and other assessment tools to explore the nature of relationships may be useful here.
If the client experiences anxiety as a result of social interaction, skill-building may be beneficial. CTRI (2015) explores the usefulness of exploring social interactions that are a regular part of the client’s day, interactions that are necessary for the functioning (school/work), and interactions that are a part of recreation. Skills that may be useful to develop include understanding and building tolerance for the physical components of anxiety, enhancing capacity to maintain conversations, practicing boundaries (saying no), learning to make efficient decisions, becoming an assertive communicator, and the development of conflict resolution skills. What is key to these skill areas is to develop a skill goal, and break it down into manageable pieces (make it SMART).
Conclusion
In summary, there are 4 broad strategies that can be used sequentially or inter-woven together to empower the individual’s response to anxiety. There are body-based strategies, middle-brain strategies, thinking brain strategies, and social skill strategies. While the practitioner wants to allow the client to take direction in what and how they address anxiety, we also want to gently guide the client from the comfortable and familiar to the areas where more growth can take place. Moving from the small worries outward to the greater worries helps build resilience against anxiety.
References
Crisis & Trauma Resource Institute. (2015). Anxiety: Practical intervention strategies. Retrieved from https://ca.ctrinstitute.com/free-on-demand-workshop/?type=workshop
Doidge, N. (2008). The brain that changes itself: stories of personal triumph from the frontiers of brain science. Toronto, ON: Penguin Books.
Miley, K.K., O’Melia, M.W., & DuBois, B.L. (2017). Generalist social work practice: An empowering approach (8th ed.). Upper Saddle River, NY; Pearson Education Inc.
Mischel, W. (2014). The marshmallow test: Mastering self-control. New York, NY: Little, Brown.
White, M. (2007). Maps of narrative practice. New York, NY; W. W. Norton & Company