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Hello, friends!

We have a nice question and answer session for you today. Please be forewarned that one of the questions mentions the topic of suicide, so if you are particularly vulnerable to that topic, feel free to skip question #2.

Before we get into the questions, just a quick update on my dementia book “Does My Mom Have Dementia?” – it’s nearing completion and we’re hoping to get it out there in the next couple of months or so! Keep tuned to my social media or make sure you’ve signed up for the newsletter to stay updated!

Hello doctor. I have been reading through your website/blogs/listening to podcasts and love what you do as well as your style and approach. I also bought your book which is the best help I have received in a while in my search for a better self. I appreciate you. Now enough of the hippie shit . . . I have an issue that is a bit different than anything I have read on your site (obviously might have missed it) and I would love your thoughts. The first time I ever had extreme anxious feelings and panic attacks was when I was pursuing my career as a teacher. It was during the end of my schooling while doing student teaching (internship) at a school I was miserable at. I dreaded the idea that I had spent all this time working on something and then hating it. I started having panic attacks and ended up having to quit that internship. Thank the fates that my next one was way better and I found my love for teaching again. Fast forward to my first job as a teacher and it was not a good fit, but probably could have worked out . . .my thoughts drove me into another series of panic attacks and I ended up leaving this short term job early by lying about being sick.

One more fast forward to now. I have been teaching for 15 years in the same district and love my job and the people I work with. However, after a medical procedure recently I had another panic attack episode and going back to work scared me more than anything. Any time I would think about work the attacks grew stronger. I am working on the exposure techniques you write about, but here goes . . . Finally my question . . . Is there any other/further technique for losing my association of work with my first anxiety attack? I feel like life would be so much better if I could still go into work even when going through anxiety ridden/panicked episodes.

That’s so frustrating and I understand why you are worried about this. You have a pattern over time of feeling like you need to abandon tasks due to your anxiety. The thing is, that’s exactly what anxiety wants you to do. One way to think of it as anxiety is trying to be your protector. In the wild, it will help you quickly notice danger and react to keep yourself safe. In daily life, you don’t often need that kind of response, unless there is some big emergency. So anxiety tries to keep you safe, but it’s misguided. It tells you that situations are threatening or dangerous when they really might not be. As a result, you avoid the situation. Every time that happens, you are basically feeding your anxiety. You are saying thank you for keeping me safe, carry on and get bigger so that you can notice more danger in my environment to help me stay away from.

Start with exposure

Having said that, sometimes you need to bail out because it is just too much. Like you are in danger, you are in extreme discomfort, or it’s just not realistic. That’s okay. That needs to happen sometimes. But we want to move toward stopping that avoidance kind of behavior. You said that you have been working on the exposure techniques, which is great. Exposure exercises are definitely important in a situation like this.

As a refresher, exposure exercises mean you are doing some approximation of the situation that causes you anxiety. In this case, it might start from the bottom with imagined exposure – so not actually doing anything, but being in your own space imagining going back to school and teaching and work your way through that imaginary scenario. If that’s enough to cause you significant anxiety and discomfort, but without causing a panic attack, then that is the perfect place to start for exposure. You use this as a starting place and keep going through this, allowing the anxiety to wash over you and keep moving forward with the imagined scenario. Eventually when that imagined scenario is not enough to result in that peak in anxiety, then you can step it up by going to campus but not teaching, eventually doing maybe a shortened day.

For each step, you are focusing on sitting with the anxiety and working through it rather than avoiding it and trying to get relief from the sensations. You are trying to build a tolerance to anxiety, rather than avoiding it completely. The feeling of anxiety usually isn’t the problem. It’s your reaction to it. It sucks to feel all of the physical symptoms and have swirling thoughts, but that’s not inherently dangerous and you don’t necessarily need to escape. You need to get better at being anxious and doing what you need to do, at the same time. As you give yourself the chance to stand up to your anxiety and don’t let it limit you, you get the happy side effect of getting less anxiety from a situation that used to knock you down.

You said that you know about exposure, but I just wanted to make sure I clarify a little bit because a lot of people think they are doing it, but actually go about an exposure hierarchy the wrong way. I cover exposure in a previous podcast, but if you want a full in-depth guide, check out my online course.

Work on your thoughts

Aside from building a tolerance to the experience of anxiety, I think there is probably some room to work on your thoughts here. There are some assumptions that you have about the situation that you may need to challenge. I think there is a bit of catastrophizing going on. Meaning you are taking a little nugget of badness and turning it into an end of the world scenario. But, if you were to go to work and end of having a panic attack, that’s not the end of your story. It’s not like that is the end of your job, you will never be able to teach again, and you should just pack it up and go home. There are always options, even if the scenario you are dreading comes true. There are options. Try not to be so black and white about it.

As I mentioned, maybe there is a way to ease yourself in by having a reduced schedule or giving yourself the option to cut lectures short if you need to. You can also communicate with others about what is going on. You said that you love the people you work with, so maybe you could reach out to them for support. I’m sure they know you had a medical situation. You could tell them that you have been having these panic attacks since your procedure. This would simply help you not feel like an idiot if you act in a way that is different from what they are used to. They can take your behavior in context.

I’m not sure what age students you teach, but it could even be cool to let them know. If it was a college class that I was teaching, I might say “So I had xyz operation and ever since then I’ve had these brutal panic attacks again that I used to get when I was younger. So I need your guys’ support. If I space out for a sec or have to take a few minutes to get some fresh air – bear with me. We’ll get back in the groove eventually.”

You might also make some plans for coping. Say you are there and feeling extremely anxious. What can you do about that? You could excuse yourself to the restroom for a moment. You could have some videos or non-intense activities on standby that you can turn to so that you aren’t in the spotlight as much. Same goes for worksheets and that type of thing. This might help you get used to being there without having to instruct quite as much. Brainstorm some of your likely pitfalls and what you can do about them.

Are you on medication? If you use an emergency medication like Xanax, it would probably make sense for you to have it on hand or even take a half/quarter dose prior to class to help bring you back down to earth. Talk to your doctor about that.

Take advantage of your anxiety

You can also use the anxious energy to your advantage. When you think about it, the feelings of anxiety, like having rapid heartbeat and being short of breath, are also present when you are really excited or amped up. If you can interpret your internal state as excitement maybe you could try to bring the energy with you and be a little wild in your teaching. Alternatively, you could exercise really hard before going in to try to get some of it out of your system.

If you have a panic attack, that doesn’t have to be the end of everything. The panic attack will pass and your body will be tired from it afterward. Even if you have to lose a few minutes of your day to it, you can come right back and keep teaching afterward.

I think it makes sense for you to start working toward being back at work. Letting this linger longer probably will just build up more anticipation and anxiety. Dip your toe in, have a plan for coping, and realize that there are many ways to go about this. You will be great.

I hate myself, I think I’m ugly and the worst, just because I’ve dated guys who only used me only for sex. I was believing in their friendship. Before anything happened between us, we were talking a lot for months, we were friends. In the beginning, I was fine, you know, guys are immature, they don’t want to settle. I was glad that I’m physically attractive. But since a few weeks, I’ve been having these intrusive thoughts that are coming out of nowhere. “You’re worthless, if you were prettier they would like to stay with you. None of them did, kill yourself”. It is so bad that when I look in the mirror I hate what I see. 200% of hate. When I’m in public, I look at other girls thinking that the guys for whom I fell would definitely love them. In my head, all the girls around me are attacking me like some evil creatures in an old Disney cartoon. I’m now 22 years old. 3 years ago I won a photo session, I always thought I was pretty. But now the self-hate is killing me. Other problems I’m having are clearly a product of anxiety. But this one is not. It is not a typical girly low self-esteem. I know that not everyone can be Penelope Cruz, but it is getting out of control. I’m going to listen to your podcasts, and read your other books. But this is kind of a fresh problem of mine so for the time being, I’d be very grateful for some words of explanation… Currently, I am going to therapy, but my psychologist is making me even more confused. Basically, the problem of anxiety in Poland is like a taboo, that’s why I’m looking for your help… I’m really afraid, and I’m sorry for the chaotic language.

Man. This one hurts my soul. You don’t deserve to feel this way. Unfortunately, a lot of people can probably see themselves in this question, especially ones that identify as female. I have never been to Poland and I am far from an expert on the culture there, but in the US, there are a lot of underlying patriarchal concepts that can really convince you that your worth is based exclusively on male-driven concepts of beauty or your body’s ability to procreate. You are worth much more than that, and I hope to help you realize that a little bit.

Before that, I’m glad to hear that you are seeing a psychologist. You did throw around the concept of suicide. “Kill yourself” can certainly be an intrusive thought that is out of place and scares you, but would never turn into the actual action of harming yourself. However, you need to continue being honest with your healthcare providers and your supports. If it turns out that you are actively considering harming yourself, something needs to be done about that.

This is only from a quick google search, but it looks like these are the details for suicide and crisis hotlines for Poland:

• 116 111 – Telefon Zaufania dla Dzieci i Młodzieży
• 116 123 – Kryzysowy Telefon Zaufania
• Internetowy Telefon Zaufania “Anonimowy Przyjaciel”
  
  

You also said that the topic of anxiety seems taboo there. I’ve said this before, but it can be helpful to continuously flood yourself with positive content. Even if you feel like you are getting mixed messages from your care providers, keep listening to podcasts, reading books, and watching videos about these topics that you are trying to get help with. You may not be able to force the negative thoughts out of your mind, but if you constantly have your headphones in listening to positive, helpful content, the negative thoughts will at least have to compete for space in your brain and they may become less powerful.

Changing your self-perceptions

Okay, so let’s talk about how to work toward changing your self-perception. There is a lot that we can work with here.

First off, you are falling into a lot of thinking traps. Illogical ways of thinking that serve to make you feel even worse. One major one is emotional reasoning. Just because you feel a certain way, you assume it’s true. This can turn into a sort of confirmation bias. You feel a certain way about yourself, whether that’s rooted in reality or not, you start to interpret everything through the lens of that belief. Since you think you are worthless, you are going to interpret what happens around you as proof that your feeling is true. So you want to try to incorporate other perspectives and any evidence that helps to unprove your hypothesis about yourself.

When you find yourself making assumptions about what other people’s behavior says about you, it may be helpful to try the best friend trick. Think of someone that you care about deeply. If the situation were happening to them, would you make the same conclusion? Like if your best friend told you that it seems like all the other girls are out to get them and would rather sleep with someone else because they aren’t pretty would you let her get away with saying that? Most people would not. You’d probably tell her that’s bullshit, she is beautiful and worth being treated well. So using the best friend trick can give you a little bit of clarity about the situation.

Beauty is subjective

It can also be helpful to shift the focus away from physical beauty. Right now the way that you are judging yourself or the metric you are judging yourself by is physical beauty, some physical criteria for beauty. When you base your self-concept on something like that, of course it is going to be risky. There are so many things that matter more than physical beauty, especially since physical beauty is something that is so subjective. So rather than attacking the feelings of being ugly head on, maybe you could try to increase the feelings of being competent, a good person, productive etc.

You can do this through positive affirmations. They may sound cheesy, but research does indicate that you can change the way you perceive yourself through positive affirmations. Not things that are way out there and unrealistic, but things that are true. A good exercise is that when you are feeling negative or have bad thoughts about yourself, write down 5-10 positive affirmations to balance it out. The more the better. You can also place these affirmations in prominent locations or make a point to read them every day. This is basically directly fighting against the negative bias that you already have.

Remember that your negative self-talk isn’t necessarily true. Thoughts are just thoughts. Just because you think you are ugly or unworthy does not make it so. We don’t have that kind of power with our minds. You also want to try to focus on giving yourself credit for your accomplishments. I usually have people integrate this into daily journaling practices. It can be a challenge, but you need to practice it. You can also ask other people for feedback. What do they think is good about you aside from looks?

An entirely different strategy is to try to work on taking the focus off of you. Rather than focusing so much on your worries, place some of the focus on other people. Do some volunteering or make a point to go support your friends and family much more often. Let the negative thoughts exist in the background. They don’t always have to be the most important thing.

I’m wondering if you have any advice for how to decide if you should stay with a therapist when a change makes continuing very inconvenient? Mine is moving her practice about an hour away, but I’m sure this would be applicable to others whose insurance has changed or who have had some other big life event occur.

For background, I’ve been seeing a trauma therapist for about six months now. I’ve only recently become stable enough to really start digging into processing my trauma, and am feeling set back and defeated at the prospect of having to start over with someone new. I’ve made a lot of progress with my current therapist. She has said I’m welcome to continue with her if that’s what I want to do, but my abandonment issues have me concerned about my ability to trust her anymore anyway.

Thanks again for all you do.

It’s allowed to be a bummer. That’s never going to be a fun thing to deal with. But you have options.

It’s particularly unfortunate that this is happening in the context of trauma treatment because that can take a while to build up trust and a good working relationship. This is something that you probably need to keep processing with your therapist. Her moving her practice has nothing to do with you personally. You likely won’t get a full answer as to why, but there could be factors like the office rent price, life changes for your therapist, or other things that are just purely circumstantial.

You’ve got this!

Whether or not you decide to stay with your current therapist, it is important to realize that your current treatment has been a proof of concept. You are able to get into the murky shit with someone. You are able to trust someone with your burdens. You are able to stand up to your trauma without letting it force you into hiding all the time. That’s powerful. You know you have it in you to do this. Will you have a bit of a dip and have to get over the disappointment if you find another therapist? Probably yeah. That’s part of the deal. But you know that you can do it now. You have seen the potential there.

You may also not be stuck in such as bind. An hour away is pretty far for regular sessions. But maybe you could get creative with your therapist to bridge the gap. For instance, maybe you go into the office in person once per month and on the other weeks have phone or video sessions. If you are in the US, it is perfectly legal for your therapist to have sessions with you over the internet. I have several patients that I exclusively see online and we are able to make fantastic progress regardless.

Plan with your therapist

You could also plan on finding a more local therapist, but continue with your current therapist as a bridge and have her help you create a plan for transitioning. So maybe you go travel an hour to see her regularly for the next month or two, but then your plan is to make a transition to someone else. If you do stop with her, I think it would be good for you to have some sort of closure with her and wrap up the work that you have done together. She was never going to be the only resource or tool to solve your trauma, so at some point your chapter with her would end. So you could spend some time together and even on your own just looking at the progress you have made, writing down important lessons that you have learned, or even quotes from session. Working on a project like this together can help you feel less abandoned because it’s not an abrupt end. It will also help you recognize the work that you have put in and the progress that has been made, even if it’s only one step along your journey.

So you definitely have some options here. Give yourself permission to have mixed feelings and grief about it. Keep processing it with your therapist. Try to work on your thoughts of abandonment and realize that it isn’t personal. Be collaborative if possible with any transition you make. And see if you might be able to continue seeing her, just in a modified way. And remember, you’ve already proven to yourself that you can do this, which is amazing! 

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