[Dr Nicola McDonald] So in the next part of this discussion, we’re going to talk about strategies for managing anxiety. Okay, and it’s presented like a smorgasbord. I’m going to tell you about a whole different heap of different ways that you can manage anxiety. And what I want you to do is treat it treat it like a buffet. I’m going to lay it all out in front of you, and you might pick different ones that you want to try right and you might have something that you save on there for later, and you might have some that you go. Oh,
I’m pretty sure that would be that wouldn’t work, you know and until you leave that. For me, that’s the fish! You know at a buffet I leave that alone because I know I don’t like it, you know. But pick and choose around what you think could be useful and hopefully it will just help fill out some of the things that you already doing.
So just going to go through them one by one. The first one to be really aware of is that our nervous systems talk to each other. That’s why we amp up when someone else is anxious. That’s why we find ourself feeling on edge or upset or having a reaction right, it’s because our nervous systems are designed to seek information from other people’s behaviour. And from their nervous systems.
So our job when a young person is anxious, even though it is really hard, is to be as calm as we possibly can. You’ll know what it’s like to ring someone in a bit of a flap and be feeling really nervous about doing something, and then have that person get nervous about doing the thing with you too. You know, it doesn’t help, it makes it bigger, you know, and you’ll leave that conversation off and feeling more amped up than you were when you got there, which is why our job when we’re supporting someone with anxiety is to try and model calm.
And I don’t care if you’re faking it till you make it. You know, it might be that you can be genuinely calm if you can all power to you that’s often not a service I offer when someone is really anxious, you know, but it’s about deliberately slowing myself down.
Deliberately, you know presenting what I want them to see which is that I’m calm and I’m not bothered by the situation. Okay, and that is what can help drop people’s nervous systems back down.
That’s why it’s really important. I really like this kind of diagram, and I don’t want to for a second suggest that anxiety is catching but you’ll notice that if you’re around a bunch of people and they’re in a bad mood.
You know often we’ll find ourselves getting a bit irritable as well. If we’re around someone who’s super worried, it can be really hard to maintain a sense of calm, but that can be the most useful thing that we can do for our young people when they’re anxious.
The other thing that can be really helpful is when you think about kids and young people right? They’re still learning how the world works, and they’re learning how their body works in the world and how their mind and how they’re feelings work.
And so they often need us to help coach them through what’s happening in their brain and their body. If you imagine that I suddenly clicked my fingers now and when I clicked my fingers you all of a sudden experienced all those body signs of anxiety, but you didn’t know what was going on. That’d be really scary. Why is my heart beating so fast? Why am
I sweaty? Why am I feeling really tense? Why am I breathing so quickly all of those things, you know to help give people the words for what is happening to them can be really really helpful. And so
I think about that sometimes as being a bit like an emotion narrator, you’re almost narrating what is happening for them, saying things like, “it’s really frustrating when things don’t go the way we plan”. You know giving that word frustration.
You look like you’re feeling really māharahara, which means sort of unsettled about dress-up day and they might go I’m not māharahara, I’m hōhā! I’m not worried. I’m angry! you know, or whatever. Kids are really great at, kids and young people are really great at correcting us if we’ve got it a bit wrong. Okay, but what we’re doing is kind of offering a suggestion for what might be happening for them.
And sometimes naming and validating a feeling can actually be enough. We feel heard. And we can move on.
You’ll know what it’s like to talk with someone who it just feels like they don’t get it. You know, you might be talking about how worried you’re feeling or how sad you’re feeling about something and they’ll say “Oh buck up”, you know, and they’ll give you a strategy about how to manage it going forward, that can just be profoundly unhelpful because we feel like they don’t get it.
They might be giving us the best strategy in the world about what we should do next, but we won’t be able to hear it because we don’t feel heard by that person.
Just using the naming word for that emotion can be really helpful and you might read those examples and go. Oh, that’s not how I’d say it my child would think I was really weird if I said, oh, look, it’s really frustrating when things don’t go to plan. Take this idea, tailor at the way you want to do it, use your words. Okay, but often it can be really helpful and just in helping young people feel like you get it.
Avoid the reassurance trip. One of the tricky things about anxiety right is that we have a really natural response where we want to just help it be okay. We want to be really reassuring we want people to, understand from their interaction with us that it’s going to be okay, and what that can look like sometimes as being way too reassuring which can actually grow anxiety rather than shrinking it.
So say for example, imagine I don’t know, imagine that you are you’re at work and there’s a new guy going to be starting on the staff tomorrow. Okay, let’s say his name is Mark. I really hope your name’s not Mark watching the video.
So let’s say that Mark’s coming tomorrow and your boss comes and said, oh, you know Mark’s starting tomorrow. Mark’s really great. He’s really really good. I think he’ll be really good. He’s never had any complaints made against him. I think it’d be a really good collar. You guys will get on really really well, you know, I wouldn’t have any concerns about his work.
He’s got really good referees. I think Mark will be great addition to the team. I think you’re really enjoy working with Mark, no need to worry about him. It will be great. Pretty soon we start going why is all this reassurance necessary? Just how long is Mark’s list of prior convictions or how many jobs has he been fired from, or whatever.
We start to go, if this was just a normal day at the office, I wouldn’t be being this reassured about this thing happening.
And I think it’s useful to think about that when we’re thinking about our young people, when we’re overly reassuring it can actually amp up anxiety rather than amping it down, and I think of it as being a bit like a pendulum okay. So, sometimes people would just go with “oh for God’s sakes, harden up”! No reassurance. No validation. No nothing.
Or they might be the other end of the pendulum. Oh, it’s gonna be fine. Don’t worry about Mark, it’ll be totally fine. But you know and reassure too much. To manage anxiety best.
We want to sit somewhere in the middle. Okay having just enough validation, having just enough reassurance, for the child to know, we get it, without kind of amping things up, and that’s what I mean by the reassurance trap. Reassuring too much which actually grows anxiety. So just keep it simple.
You’ll know lots of people will have said to you about breathing to regulate anxiety. Right and I used to as a kid. I thought this was happy drippy rubbish. So I would fall over I’d bang my knee and my mum would tell me to take some deep breaths, and I did not want to take some deep breaths. I thought that was a waste of time and I just was completely overwhelmed with how upset I was right.
But what we know from the science around how our bodies work is that breathing slowly calms our body down. Okay, so when you breathe out your heart rate actually drops.
So if we breathe in slowly, don’t worry about deeply, people used to think it was about getting as much air and your lungs as you possibly can, that’s not it, it’s about slowing the process down. That can help regulate those physiological signs of anxiety we’ve talked about before.
There are loads of different breathing exercises you can do. If you talk with your young person, chances are, they’ve learned some at school. It might be three four five breathing. For example, you breathe in for three seconds, hold for four seconds, breathe out for five seconds, that kind of thing.
And it can be really useful to use apps, there are lots of apps that you can you know, you can follow a bubble that goes up, and then you hold it, and then you breathe out as it comes down. Those kind of things can be really helpful. Really important to know with breathing, and with relaxation, which we’re going to talk about in a minute, when someone is really anxious, and you might know this in yourself, it can be really hard to slow your breathing down in that moment.
So it’s not necessarily a thing you do in the middle of a crisis, but it can be something that you do regularly throughout your day, to try and help balance your nervous systems.
We’ve got we’ve got three nervous systems. I won’t take you through it in any great detail, but one of them is fight flight. One of them is rest digest. Okay, when we’re really anxious, often fight flight is the one that’s getting most of the airtime. So strengthening that rest digest system with a bit of breathing, with some relaxation regularly, can just help them operate together much better, and help you experience the world and I guess in a more relaxed or in a calmer kind of way.
In terms of relaxation, right? You might hear that word and think about a wine and the bathtub, with the kids somewhere else. That might be what relaxation feels like to you. Or, that might sound like your personal version of hell, and relaxing for you is about going for a run, or it’s about going fishing, or it’s about gardening, or it’s about tidying.
Okay, and that’s because we all have different ways of relaxing we might be really active, you know, active relaxers, who want to do things while we’re relaxing, or we might be passive relaxers, where we just want to do nothing, and have a breather, right? Or we might go both ways.
I think, relaxation for young people kind of gives them a bit of a break from feeling worried. And so we’re going beyond, it’s really important to know what does relax your young person, that’s really cool.
But, also being able to use particular strategies to deliberately reduce anxiety and sort of deliberately relax your rangatahi’s body, can be really important. So when I talk you through one called progressive muscle relaxation, or as one of the dads I work with called it “goodnight toes”.
And the idea with progressive muscle relaxation is, at the moment my hands feel relatively relaxed, you know, but if you were to put you know sensors on my muscles, and have me squeeze my muscles for a short time, not so hard that it hurts, just so hard that I can feel it.
And then have me let them go, my muscles would be more relaxed, after being tense and relaxed, tensed and released, sorry, than they were beforehand. Okay, so we can take deliberate steps to relax our muscles, that can be really helpful in preparing us, you know to just drop down a little bit.
So with your young person, this might look like you get them to lie down on their bed at night time, you pull it into the bedtime routine for example, that’s what lots of my whānau do.
And you talk them through it. First of all they scrunch their toes up for 10 seconds
And then they relax them and they notice how much more relaxed they feel and then you look up, through the calves through their knees, through their thighs, through the bottom, through the tummy, all the way up.
And if you pull this into your bedtime routine, often what young people find is just helps them sort of switch off of it before bed. But, also doing muscle relaxation throughout the day and other realisation things during the day rather than at crisis point is really important.
If your child is super anxious because camp letters come home, lie them down the bed and get them to do progressive muscle relaxation probably isn’t gonna be your way to go, right? But actually, building this in as another way of strengthening that rest digest system, that can just sort of quiet and things down that little bit more, so a useful one to have in your kete.
Exercise, this is generally like the top strategy that my children and young people talk to me about an our sessions. And you might hear the word exercise and go “oh god”, she wants me to run 10 kilometres every day. No, I don’t, not one bit. Exercise is purely about getting moving above your baseline, and that could look like going for a run, or it might look like a dance party in your living room.
It might look like you parking further away from school than you normally would. Saying, “oh, sorry, I couldn’t get a car park”, you know and just you know, having them scoot a little bit further. Being on the trampoline, I work with a psychiatrist who used to prescribe certain amounts of time on the trampoline alongside any other intervention that he was doing, because for particularly for kids who are sensory, and you might be watching this because your child gets really anxious when sensory things are overstimulating for them. All of the sensory profiles and ways of being in a sensory world, most of them are regulated by movement. Okay, so generally adding more movement works pretty well for most people. So absolutely getting moving, doing some exercise is really helpful in managing anxiety, and it can be more helpful with managing mood than some medications and some other interventions. So absolutely get moving, however, way you can.
Distraction is one you’ll probably have used an awful lot, right? And that might be about using distraction and lack sensory tools like in the picture. It might be talking about other things, just trying to get your child’s mind off it. It might be about YouTube, or outside play, or it might be about listening to music, anything that just pulls their brain in a different direction, right? You might pay deliberate games like A for Aardvark, B for Bat, C for
Cat, you know working your way through. What most people find with restriction is that it’s kids go to strategy, distraction and exercise, and it can work really really well until it doesn’t, okay. So I’m thinking about young people for example, who I might be supporting to have a blood test, for them, distraction works really really well, until the needles in the room, at which point actually the fear is too big, their brain is too smart to be distracted, and they focus on the needle, right? So that’s why you need these other strategies in your kete as well. But, distraction can be really helpful for young people.
One of the strange things about anxiety, and you know, you’ll know this through watching a young person, is that anxiety makes us live in the future an awful lot. What if this happens tomorrow? What if camp next week is difficult? What if my friends aren’t kind to me when I go to an after school program? What if he doesn’t ask me out? All these kind of things, things that might happen in the future, generally in the moment, we’re okay, and we’re safe. Okay in this moment, I’m a bit nervous about doing a video, but I’m perfectly safe.
And so it’s about using strategies which help us connect with the present moment, without letting our brain pull us into the future to worry about what’s going on there. So grounding can be one really useful way to do that. And what grounding is about is, it’s just about, trying to pull your attention to where you are right now. Okay, so you might go through a grounding exercise like this one, the five senses exercise, where you go through and you think about five things you can see in a room.
Then you go through and think about four that you can hear. Three that you can touch or feel outside of your body. So, for me that might be I can feel my bottom on the chair.
I can feel my feet in my shoes. I can feel a little bit of air circulating in the room on my face, you know, those kind of things. Two things I can smell and one thing I can taste. And going through and doing those things to just help your child connect with their senses about what’s happening right now can be really helpful.
Mindfulness is a word that you’ll have heard before. And mindfulness I think can be misunderstood really easily. But all it’s about is focusing on the present moment, similarly to grounding, pulling your brain back from what might happen, and going what’s happening right now, okay.
And mindfulness like realisation can be passive or active. It might be something like, you’re sitting in a chair, you’re listening to a recording encouraging you to focus on your breathing, right. Or it might be something that you’re doing actively, mindful eating for example, people can find really helpful.
For me, the most mindful thing that I do is when I go fishing, right and any of you who do this, you’ll know that you go you cast you click your reel over, and you wind.
And you look at the tip of your rod, and that’s what you’re doing, that whole time. Because if you take your eyes off the tip of your Rod, you might miss a fish right? And so you find yourself you find I find my attention just going [focusing type noise from Nicola] into what I’m doing in that moment, okay.
This doesn’t have to be [that]. It might be around listening to a recording with your young person, that can work really well for lots of young people. Or it might be pulling mindfulness into what you’re doing normally.
There are great scripts and apps available online for this. Chances are a young person will have been doing some of this [not understandable] at school. But yeah, just have a have a play around with it, I know lots of people who play mindfulness recordings in the car on the way to school and they find that helpful. And it might as
I say just be focusing on things that kids already do, like colouring, or like you go for a walk together, for example, and you notice the different greens and the trees, all of those kind of things can be really helpful too, to be mindful while you’re doing them.
We’ve talked a little bit about the wave of anxiety, right. And we’ve talked about how it comes, and it peaks, and it goes. And we’ve talked about the fact that one of the keys to managing anxiety is just being able to go with the wave, just being able to tolerate the fact that it feels like we will go on forever. But then it breaks and then it drops away. And there’s a really great whakataukī, which I think captures this really well and it goes like this.
Āta tirohia te ngaru nui,
te ngaru roa,
te ngaru pae whenua
Notice carefully the great wave,
the long wave,
the shoreward wave.
And it speaks of, there will be a time where the pull of that really big wave starts to drop away. Okay, and that wave will give way there’ll be a sense of change and it will give way to smaller waves, that are easier to navigate, where we can find, you know a way back to shore, and we can get a sure footing, that’s what distress tolerance means to me. Getting a hang of the feel that the wave will come, it will feel awful.
But, the wave will come, and then it will go, and then it will drop away, and the more we learn to go with that wave without fighting it, and just let it happen, and then move forward, the better off we are. So I think the stress tolerance is really important both for young people and for adults.
Another hugely important thing is self-talk. What we say to ourselves matters, and this cartoon I’m sharing with you is one of my favourites, it’s called heart and brain understandably.
And you’ll see in that cartoon, you know hearts the optimist, in the cartoon and he’s trying to pull brains attention onto the good things that his butterflies resting on, but brain can’t pay attention to the good things, its busy trying to analyse a bad thing. Okay, and this is what our brains do. We’re designed to attend to threat.
We’re designed to notice the things that aren’t going well and try and fix them.
And you’ll know this from it might be a school report from yonks ago, or an appraisal at work, or even just having coffee with a friend who talks about all the things that they really like about you and thinks are really great about you, and they have one small criticism, and we find our attention is going to [Nicola makes focusing noise] into that criticism.
I can absolutely remember, you know my last appraisal, [it was] really really great, and one thing I could improve on. I couldn’t tell you what the really great things were, but I could tell you almost word for word, what the thing I could improve on is.
And I think when we notice how our self-talk is in our minds, you know, we can talk to ourselves that really critical ways which can be really unhelpful. And I think we often hear young people self-talk in their speech. I could never manage that that we’re far too difficult. What if, what if, what if, what if, what if I do that it will go really poorly. There’s no way if I ask him out that will go. Well, I won’t manage camp. I can’t you know, I won’t be able to read this book. It’s too hard. I’m too stupid, all these kind of things that’s kind of like hearing how they’re talking to themselves in their minds coming out through their mouths.
And that gives us a really good opportunity to notice when how they’re thinking about something doesn’t actually match how things are in reality. Okay, it gives us a chance to notice when they’re catastrophizing, when that snowball is running down a hill, and it gives how to manage that is to go is to take what they’re thinking, and rather than just try and turn that into a positive, you know. It’s about seeing things in a more balanced way. So worry will be giving them all of the evidence that something bad might happen.
And our job with self-talk is to think about what else might happen instead. What other evidence do we have that things might actually be okay. And just gently bringing that into their seeing things in a more balanced way. We’ll talk about self-compassion in a while. But also we often notice that our self-talk in, our own minds, to ourselves.
So much harsher than how we would talk to somebody else if they’d made a mistake.
Oh for God’s take Nicola. This is really, you know, you’ve made a really poor job of this, and it’s not going well Nicola makes noise indicating ongoing self-talk]. Where there is somebody else is in the same situation you’d be encouraging.
You’d be forgiving of the fact that you’d made a mistake, or something wasn’t expressed as clearly as it hoped, or something like that. You’d just treat them really differently. I think it’s useful to keep in mind how we treat ourselves, and how we’re talking to ourselves.
I’ve put problem solving in here, and you’ll notice that its my second last strategy. The reason for that, is because if we jump into early with problem solving often, we’ll lose our rangatahi.
Often they’ll feel really misunderstood. Okay, because you know and you know, you have people in your lives who are absolute pros at this who will feel discomfort, when you’re anxious, discomfort when you’re unhappy,
And they want to jump in with a solution before you feel like they’ve actually properly understood what’s going on.
So this is why I leave this far far down in the background, you know, it’s a useful skill to have, but maybe don’t lead with it, lead with that validation, and then move to problem solving.
These are just five steps to think about how you might look at problem solving with your young person. The first one is thinking about what the problem is, you know. And you might actually write this out, often kids with anxiety are better solving a problem that’s on paper then a problem that’s whirling around in their minds.
So what’s the problem? What options have we got, and use all options. Some might be silly and ridiculous, others might be more sensible, but list all your options. Think about what the consequences of those options might be.
Choose the best one, try it out. And then at the end of that kind of come together and evaluate how it went, if you need to go around again, and try something different, do that. But this can just be a useful model for thinking about how you might encourage a young person to help problem solve.
Another strategy that’s really useful for managing anxiety is medication. Okay, and that’s often useful in situations with a volume of the anxiety is turned up so high, the other strategies that you’re trying to offer your young person are getting drowned out, and aren’t helping so young people talk about anxiety is being like there’s a radio on the corner of the room that is cranked as high as it will go and they, you know, you might be over here talking with them around breathing talking with them around problem solving using all your strategies.
The anxiety is too strong, you know, and you can’t get through. And I think you know medication, I’ve seen be a really useful strategy, when they’re volume is really high.
Over time with medication, usually it’s a short term-short to medium term prescription with anxiety. So it’s generally not something you’re on for the rest of your life. Okay, but the idea with it is that medication can turn that volume down a bit, to give the other strategies the air time that they need, and then with practice your young person starts to rely on those strategies more so that probably when they come off the medication, those strategies, those behavioural strategies become their primary way for managing anxiety.
Get a lot of questions about medication and my job, which I’m sure you’d understand. So I thought I’d summarise some of the best ones here, that I hear the most of, and run you through some of the answers.
So people will often ask me who they can talk to about medication. If you’ve listened to this talk and you’ve gone actually, I’ve been trying lots of those strategies for ages, we’re not getting anywhere and I think that anxiety is just too big. You can talk to your GP, or your case manager, or your paediatrician. They’re sort of your first port of call.
People worry that medication for anxiety will sedate their te tamaiti, their child, you know, and if it does that the dosage needs reviewed or the medication needs reviewed, [it] breaks my heart when I hear stories of people who trial the medication, found that it’s sedated them, and so just came off it, and they never tried another one again.
The dose was wrong. Or the med [medication] needed reviewed. You know, that’s the time to talk to your GP, if that’s happening. But usually what happens with prescriptions for young people. Is that a very low dose is prescribed, and it’s amped up very very very slowly to try and minimise the chance of that happening.
Will they have to be on this forever? Medications for anxiety are generally prescribed for a time limited period. Okay, so the vast majority of time when I’ve been alongside a psychiatrist prescribing for a young person.
They’re expecting that will be for a period of time, often sort of 6 to 12 months, because that depending on the medication can be a sweet spot where basically if you’re on it for that length, that makes at least like that your anxiety will occur when you come off it right. So generally, if you are trialling a medication for your young person, for anxiety, expect to be on it for more than a couple of months, but, it will be a time limited period.
Can medications be addictive? SSRI’s which is the most commonly common family of medication prescribed for anxiety aren’t addictive. Okay. They’ve been some anxiety medication in the past that from a very different family of medication, and they were really, sometimes people found them really hard to get off. SSRI’s, that’s not the case, generally. Will it change their personality? Generally not. Okay, but some people find that actually when the anxiety is damping down, but they start to see parts of the child’s personality that they used to see a lot more of before they were anxious.
More of a sense of humour, or just interests they used to love doing, that they’ve sort of dropped away from, those kind of things. So rather than be a personality change, often it’s about, you know, allowing space for the personality to show through a little bit more.
Will we need to tell anyone that they’re on medication not?
Nah! Absolutely not! You know, its your health information, and it’s your call. Um, obviously your
GPs gonna know, because they’ll often be helping prescribe, but then it’s actually your decision as a whanau about who you tell, about what. I’ve got lots of young people who will you know, go on sleepovers with their medication, and some people are really open with being on medication, and that’s fine for them. Others have the medication shoved in a sock somewhere, and they just take it subtly when they’re able to.
It’s up to you who you tell. Sometimes, it can be helpful for school to know, but that’s your call. And so no, you don’t have to shout it from the rooftops. How will it be monitored? By close review, from either a psychiatrist or you’re a GP, with the oversight of a psychiatrist. So it’s a medication trial in a young person is an important thing. It’s taking really seriously, and it’s really closely monitored.
So hopefully it’s helpful to have some of those answers for you. In terms of other strategies for our smorgasbord, writing stuff down can be really helpful for young people.
Having a worry box, writing it down, putting them in the box, and you might decide that once a week, or once a day, you open that box. You take out the worries, and you talk about them.
There’s this great story about someone who decided he worried an awful lot, and he decided that he was only going to worry on a Wednesday. And so he would write down his worries every day that wasn’t Wednesday. And he put them in the box, and every Wednesday, he would pull them out, pull them into the light, read them to himself.
And what he noticed was a lot of the time the worry that he might have had in a Monday for example, by Wednesday it was gone. The situation had resolved itself. And what he noticed that my scheduling a time for worry, it actually made the rest of his life more manageable. So that can be useful for some people.
Make a worry time and stick to it. Try not to make it just before bed.
It’s the hardest time to get off your worries, before you go to sleep. But it might be that you decide that you know at four o’clock you guys sit down and have a chat about how the day was, and is there anything that’s been difficult that day and sort of pull that time into a more manageable time.
And lastly, visualisation can be a really really helpful tool for young people. And that’s where you sit with them and you talk with them around, what actually makes them feel relaxed and calm. Can they imagine a place they could go to in their mind, which would make them feel relaxed and calm. That might be an actual place for them, or it might be a place that they make up, you know, and they are design and their mind. And help them, you know describe that to you really really richly in terms of the senses.
What they can see, what they can hear, all those kinds of things. So they have a place in their mind, that they can go to, almost for a bit of a vacation from their worries.
Some of my young people like to draw that place if they really artistic, or others like to write a poem about it, others just like to know they’ve got it in their mind, and they can go there when they need to. That can be really helpful particularly before bed.
So in summary, there are heaps of strategies we can use to managing anxiety. I’m sure if you were in front of me, you’d have even more to add to the list.
Try some, you know, try some, and see how you find them and you might find that some strategies will work well for a while and then they’ll sort of feel like they stop working. Change it up a little bit, you know, we need to be flexible, anxiety is a flexible thing. We need to meet it flexibly.
And also if strategies aren’t helping and you’ve been having a really good crack, you know managing things through strategies for a while, or just the anxiety seems far too big, medication can be a useful thing to consider. A lot of young people find really helpful.