Anxiety is a modern concern

Anxiety is the most searched-for mental health issue and has been growing in prevalence for years - especially amongst the social-media generation, which was blatantly obvious in the teenage circles of my own children. Go back a few generations and anxiety was barely known. Yet today, according to Champion Health, in 2023, 67% of 16 to 24 year olds suffered anxiety at work.

It doesn't matter how illogical someone knows their anxiety is, the feeling is real to them. In our evolution, it needed to be. The fight/flight response is a fundamental part of our survival. Tiger in the trees? Don't think about it, flee or grab a weapon. Anxiety is like a prolonged, drawn-out version of that response and can lead to all sorts of negative life impacts - from simply feeling a bit anxious to avoiding work or even society itself.

This week, a client finished their therapy for anxiety after eight weekly sessions. When they first came, they were being repeatedly signed off work. So, you can imagine the smiles, for clearly the approach wasn't just working but improving - my norm is 12 sessions.

What approach? A form of exposure therapy. Confession - as an instinctive therapist, I wasn't actually conscious this was the approach being used until tried explaining it in a book, by comparison with beating arachnophobia (fear of spiders), and had a lightbulb moment. “Ohhh. That is what I'm doing.”

Exposure therapy for anxiety

So, how does it work in practice? In my sessions, on two fronts:

1. In the now

We need to help clients feel better in their day-to-day lives, so give them a different focus to anxiety. If they feel anxious about going to work, get them to focus on something good at work, instead of the dreaded lead-up to it. If anxious about meeting strangers at a party, focus on just enjoying being at a party - no pressure to do anything but be there.

Breathing is important. We all do it but the way we breathe also has a real impact on our physiology. Make clients mindful of breathing to a count - slow four in, slow four out to start with. The only rule is not to have the intake count longer than the out-take count. I say rule, but in yoga, we use Ujjayi breathing - long in, very short out, as if fogging a mirror. This also takes the mind off issues but, for the purposes of this article, let's stick to the traditional slow in, slower out.

A count to aim for is about seven in, 11 out, which is harder than it sounds. So, five in, seven out is a good compromise target. In any case, by breathing to a count, clients are not just physiologically regulating their bodies, they are also taking their minds away from the anxiety itself, allowing the levels of damaging stress hormone, cortisol, to come down.

As for the exposure therapy part, we start small and work our way up. Important to point out there is no such thing as failure, just new ways to learn what not to do and go forward from. Retrain the brain. For someone with social anxiety, a first step can be just saying hello to a cashier in a shop - no expectations of anything in return. If they say hello too, then great. If they don't, it does not matter. It is an exercise for the client - their way of learning new habits and behaviours. After a week of this, we progress to basic small talk:

“Having a good day?”
“How are you?”
“Been busy?”
“Cold/warm out.”

Little, positive steps that help their brain reframe how it interacts with the world. Making basic communication without anxiety becomes second nature.

According to a client's individual needs and situations, we give them further small steps that begin to directly expand them there - steps they can make larger if they want.

Going back to the shop example, if they decided they felt confident enough to try, they could ask for help choosing some product. No need to buy, just fun and enjoyment - polar opposites to anxiety and stress - are a key focus. It goes without saying that life is more enjoyable when it's fun.

“I'm anxious about letting the team down,” they might say, to which a response could be:
“Just enjoy playing and do what you can. What happens, happens. You'll learn from it and go forward.”

If we didn't push ourselves to failure, we would never progress in anything. How many times do toddlers wobble and fall down when learning to walk? Do they get anxious about it? No. They just try again. It's society that teaches us to be anxious - mostly screen-focused modern society.

On screens, most people pretend to be better than they are - human nature to want to be well received and perceived. While some people do post epic fails, most post brags and boasts of how wonderful they and their lives are. Holidays, post-make-up beauty sessions, being the king/queen of the party, even just a colourful ice cream - nothing that shows them below the surface. Nothing that allows positive discussion of insecurities, hopes and needing help. Far too much fear of ridicule by 'trolls' for that.

The flip side is the amount of posts relating to mental health labels. Labels that the insecure can cling to as a way of finding any identity and avoid needing to face their inner selves. I am depressed, anxious, suicidal, have ADHD, etc - often worn like badges of honour or self-diagnosed protective shields.

The teenage years are when young people really try to find their adult identities and all many are learning are false identities - to fit in with the fake world of social-media hype and unrealistic expectations constantly thrust in their faces. They either get depressed that they can never achieve or try and get depressed because they aren't instant millionaires, pop stars or managing directors. My children are just emerging from their teens and we've seen it all - including a very pretty 15 year old girl who would dress up for a pose and feel ugly/depressed if she didn't get a hundred likes that day; ending up anxious about trying again.

This is what I see as the background to the boom in anxiety today but, regardless of background, the therapeutic approach is the same - only the individual client details are different. Removing the fear of failure by manageable small failures (exposure therapy) doesn't just remove the driver for the anxiety, it also makes life more fun. As I've said, fun is important. Our inner child needs it.

We all get things wrong on a daily basis and need to learn to accept it as a normal part of life. Just look at Elon Musk and his SpaceX programme of reusable rockets. How many times did they get ridiculed for crash landing? Did they give up? No. With every crash, they learnt something and finally, they got it right.

2. In the past

How much we delve into this depends on client needs. Personally, I find up to 90% of my clients have adult issues due to things that happened in early childhood. These can be as drastic as direct abuse but are often based on something the client, in their adult mind, does not deem as drastic or as abuse - though to their child selves, it impacted them with fear, anxiety, anger, insecurity or low self-esteem.

Parents are all too often oblivious to such long-term impacts - just getting on with being parents and making sure their children and fed, clothed and kept physically safe. All important boxes to tick but what about little Charlie's psychology? We think little Charlie will forget about things when older - such as arguments, house moves, criticisms, put-downs, and even just fear of getting lost in a shop for a minute.

Indeed, little Charlie probably will forget this but little Charlie's subconscious probably won't. Emotional markers created in youth, especially in infancy, tend not to go away. When a client comes saying they don't remember anything before the age of 10, I take it as a sign, and before the age of 10 is exactly where we go next.

Timelines are a great way to build a clearer client picture. Take a sheet of A4, in portrait position, and write zero at the top left, five in the middle left and 10 at the bottom left - the client's first decade. On another sheet start at 10, middle 15, bottom 20 - and so on, potentially for each decade of the client's life, though a key focus is zero to 10.

Now they are invited to talk. Any key events that come to them, in any order that they come to their mind. Parent divorce/separation, moving house, a death, the arrival of any siblings, a bird being attacked in a tree, anything and everything that comes to them - all noted down on the timeline at the appropriate place, as best as they can remember the age they were.

Timelines are not an exact science and can need modification as other memories come along. It is important not to restrict clients to a very specific age but to allow memories to come as they come. Restrictions can restrict, and therefore limit, the creative process of pure recall. In the same way, a forgotten memory can be remembered by a song or a smell, they can be remembered by another memory. As the memories start to come out, because our brains work by association, more memories will come.

It can take a few weeks to get a clear picture but even after the first session with this, we can get a good feel for where the root cause of their adult anxiety lies. Often within the very first session, a 'key suspect' has been identified. Clients often mention the suspect event without even associating it with the issue - so normalised has it become in their adult minds, even trivialised but still impacting them subconsciously. For example:

• moving home = losing friends
• non-amicable parental separation = abandonment
• death = emptiness, abandonment and fear
• parental addictions = abandonment and fear
• abusive parents (to each other) = fear and stress
• abusive parents (to child) = fear; stress and low self-esteem, often leading them to become abusers or victims in adult life.

The above aren't by any means black and white results for such events - just probabilities. Each client's subconscious can interpret them differently and, as therapists, it is our job to understand how.

So, where does that lead us with the modern explosion in the anxiety state of mind? Apart from busy, as therapists, can we do more? Can we help spread the word about the importance and value of failure itself - pushing us out of our comfort zones to learn where our limits are and how to extend them?

According to the London School of Economics, mental health, of which anxiety makes up a large part, costs 5% of GDP - almost £120 billion in 2022. Wouldn't it be wonderful, as well as productive, if we could get the government to help tackle it, as a national priority? Over to you BACP, NCPS and UKCP lobbyists.