Understanding & managing anxiety with Dr. Richard Rakos – Podcast

By LifeStance Health on May 19, 2020

Nicolette Lienza: (00:00)
On today’s episode, we’ll be talking to Dr. Richard [Rakos 00:00:06] on how to understand anxiety and how to manage it. So, Dr. Rakos, tell us a little bit about yourself.

Dr. Rakos: (00:13)
Thank you. Yes, I’ve been at Psych BC since 1995. So I’ve been here for quite a while. For almost 38 years, I taught psychology, clinical psychology to graduates and undergraduates at Cleveland State University. I retired from there in 2016 and expanded my practice at Psych BC considerably, where I specialize and work with a lot of anxiety problems and clients with other related disorders.

Nicolette Lienza: (00:45)
Oh, great. It sounds like you have a lot of experience with this topic, then.

Dr. Rakos: (00:48)
It’s a population and a problem that I’ve done a lot of work with.

Nicolette Lienza: (00:53)
It definitely sounds like that. So, let me jump in and just kind of start with tell us what is anxiety exactly?

Dr. Rakos: (01:02)
Anxiety is probably one of the central experiences of the human condition. You look at the personality theorists from Freud, and some of the humanistic ones and some of the so-called Neo-Freudians who came after Freud, everybody has anxiety as a central concept in personality development. So anxiety is a ubiquitous human experience that we all have to learn to understand, but most importantly, manage. Life without anxiety’s not possible.

Nicolette Lienza: (01:33)
So true.

Dr. Rakos: (01:33)
The issue is, how do we deal with it, manage it, and keep it under control so that it doesn’t impact our life negatively.

Nicolette Lienza: (01:43)
Right, excellent point. Which… yeah?

Dr. Rakos: (01:46)
Let’s take a break here.

Nicolette Lienza: (01:46)

Dr. Rakos: (01:51)
So, anxiety being one of the central experiences of human existence, it’s really one of our pre-potent responses, one of our main responses to a stressor. A stressor is when we perceive a threat and it doesn’t have to be something that’s real. A stressor is perceptual. If we see a threat, it’s a threat, and then our sympathetic nervous system starts secreting cortisol, maybe adrenaline, and we start feeling tension and that sense of either anxiety or sometimes we feel anger or sometimes we act aggressively. But one of the main responses to stress is anxiety, and that’s what I really wanted to focus on today.

Nicolette Lienza: (02:31)
Yes, for sure. So tell me, how can a person tell that their anxiety might be so much that they actually need help with it?

Dr. Rakos: (02:40)
Okay. That’s a great question, because as I said, we all experience anxiety. So, anxiety can be transient, it could last just for a short while. We all worry, we all have tension, we all feel unsettled at times, and that’s normal. Anxiety becomes a problem when it becomes too intense, too frequent, lasts for too long a period of time or we start worrying or focusing on the anxiety and sort of get into a vicious circle where we intensify it ourself with our own reactions to it instead of understanding it and accepting it as something that we need to live with, we try to eliminate all vestiges of anxiety and live anxiety-free. And that’s really where we often get into a lot of difficulties.

Nicolette Lienza: (03:32)
Yeah. Yeah, I bet. Can you give a specific example about how one can get in a bit of a difficulty with it?

Dr. Rakos: (03:39)
Yeah, well, we all have anxieties about somebody or somatic symptoms, or we all have situations that we handle less well or that are less comfortable for us. And we still force ourselves, we manage to go through a social situation or deal with a situation where we have less comfort like with an object we’re mildly phobic to let’s say, a snake or a spider.

Dr. Rakos: (04:14)
But we still are able to deal with the animals in and around our house, our yard. But when we can’t, when we find that our behavior is disrupted, that we’re avoiding or ruminating or stewing, or getting elaborate protective rituals or equipment, then we know that it’s disrupting our behavior, our smooth functioning. And we’re not getting our life tasks done, because what we’re doing is starting to in a very rigid fashion, organize our life around minimizing, avoiding anxiety. And so when your lifestyle starts revolving around it or being really influenced by it, that’s a cue that you want to start looking at it.

Nicolette Lienza: (05:07)
Because it seems like to me, it can be very paralyzing for some people, especially if they’re putting a lot of protective factors, that that could very much interrupt and paralyze their life.

Dr. Rakos: (05:16)
Exactly. It can interrupt, it can paralyze, it can immobilize. It’s something that if we can’t learn to live with it, then we spend our life trying to avoid it, and that’s where we wind up missing out on a lot of other things in life, a lot of other rewards, we prioritize the main reward of avoiding anxiety, and that’s a short term gain and a long term loss.

Nicolette Lienza: (05:49)
Right, and we’re going to take a break. Thanks, Dr. Rakos. Tell me a bit about the different types of anxiety.

Dr. Rakos: (05:56)
Okay, so there are different kinds of anxiety disorders that clinicians and mental health professionals see typically in practice. Some of them are specifically anxiety disorders, and some disorders have anxiety as a prominent feature. So some of the main anxiety disorders, there’s separation anxiety, which is usually with kids but could also be with adolescents and adults who have difficulty detaching from a safe base essentially. In terms of other kinds of anxiety disorders, there’s several kinds of phobias.

Dr. Rakos: (06:38)
There’s specific phobias where a person is intensely afraid of some identifiable stimulus or object in the environment. Blood, an animal, thunder, very specific concrete stimulus. More generalized is something called social phobia or social anxiety disorder and that’s where somebody is incredibly anxious when under the scrutiny of somebody else, and they usually feel an evaluation pressure.

Nicolette Lienza: (07:11)
Like a judgment, feeling judged.

Dr. Rakos: (07:13)
Like a judgment. And it’s often something like giving a performance in public or talking at a work meeting, but it can also be test anxiety. Some people have trouble eating in public, some people have trouble writing in public, can’t sign a check if anybody still uses checks, they’ll have trouble signing a check in public.

Dr. Rakos: (07:39)
So, anything that has that kind of scrutiny, and that can be very disabling at work or school, or social situations where somebody is so uncomfortable they can’t talk to anybody but people that they know really, really well and know won’t judge them negatively.

Nicolette Lienza: (08:01)
Well, let me ask you this. Is there a type of anxiety that’s just very broad in general, where it’s just maybe that person who’s constantly worrying and that worrying is floated through their entire day?

Dr. Rakos: (08:12)
And there is. It’s one of the other anxiety disorders. It’s called General Anxiety Disorder, Generalized Anxiety Disorder, GAD. And the central feature there is a constant worry about some identifiable feared happening, a parent worrying that his or her children will be hurt, maimed in some way in an auto accident, get an illness, be accosted, be mugged or something along those lines. Worry about being fired or losing a job, or worried about a partner leaving, but it’s a constant worry. It occurs day in and day out, and it is never far from consciousness.

Nicolette Lienza: (09:04)
Got you.

Dr. Rakos: (09:04)
Other kinds of anxiety disorders, there’s agoraphobia where somebody is really uncomfortable in a closed space or an open space. Public transit or really in any place where they don’t have control over the surroundings.

Nicolette Lienza: (09:19)
Got you.

Dr. Rakos: (09:19)
They can’t get out of a bus or a train or they have to be in line with other people, or be in an enclosed, noisy, poorly-lit restaurant. So that’s another major kind of anxiety.

Nicolette Lienza: (09:37)
Yeah, sounds to be very debilitating.

Dr. Rakos: (09:39)
Panic disorder is another one. That’s where a person has repeated panic attacks or episodes of panic where there’s a sharp and sudden increase in intense anxiety that usually only lasts a few minutes, but it’s very, very frightening because it feels like your body is out of control and a lot of people report they feel they’re going crazy or having a heart attack.

Nicolette Lienza: (10:04)
Feel like they’re going to die, right. Right.

Dr. Rakos: (10:06)
And a lot of people wind up in the ER with anxiety-

Nicolette Lienza: (10:08)
Mm-hmm (affirmative), very true.

Dr. Rakos: (10:09)
… or panic attacks, thinking they have a heart involvement of some sort-

Nicolette Lienza: (10:15)
Right, right.

Dr. Rakos: (10:15)
… and it turns out to be intense anxiety.

Nicolette Lienza: (10:18)
Right, for sure.

Dr. Rakos: (10:18)
So, those are some of the anxiety disorders per se. Other disorders have anxiety as a prominent feature of them. Some of the eating disorders like-

Nicolette Lienza: (10:27)
Okay, good point.

Dr. Rakos: (10:30)
… anorexia, adjustment disorders, could be with anxiety, could be anxiety and depression. It could be anxiety, depression, and conduct kinds of problems. There’s other anxiety disorders revolved around the body, there’s somatic anxiety where you’re worried about a particular body symptom and there’s more general illness anxiety disorder where, used to call that hypochondriasis where we’re worried about not maintaining our health. That we’re going to be ill, that we’re going to get sick, that we’re going to be exposed to something that our body will not be able to fight off, and that’s another kind of generalized anxiety because we’re worried… persons with that issue are worried about that almost all the time, that something’s always threatening.

Dr. Rakos: (11:17)
And there are plenty of other disorders that have a lot of anxiety attached to it. One other I’ll just mention is trichotillomania, hair pulling.

Nicolette Lienza: (11:27)
A mouthful to say, too.

Dr. Rakos: (11:30)
And obsessive-compulsive disorder, the rituals of compulsions are designed to reduce the anxiety that’s prompted by the situation, the disorganization or perceived lack of cleanliness.

Nicolette Lienza: (11:45)
Got you. So one thing that’s interesting is that as clinicians, we may specifically diagnose anxiety disorders and everything that falls in that family, but also recognizing that anxiety can be attached and infused in many other different diagnoses as well, or just what people navigate. So it’s really interesting because I’m not sure if people maybe always recognize that if you’re diagnosed with an eating disorder or something else, that anxiety could be just a whole component of that as well and I think that’s very interesting.

Dr. Rakos: (12:18)
Exactly, and think about it. Many of the eating disorders where people are either compensating, let’s say if they’re binge eating or trying to restrict calorie intake, they may not always call it anxiety, but it’s often driven by this tension, this urge, this experience of really being emotionally off-center and a lot of people experience that as anxiety. The person with anorexia is feeling… is anxious that they’re going to gain weight, is fearful they’re going to gain weight.

Nicolette Lienza: (12:47)
Yes, yes.

Dr. Rakos: (12:47)
Is anxious about how their body looks, is anxious that they don’t look as well as they would if they lost another half a pound.

Nicolette Lienza: (12:56)
Got you.

Dr. Rakos: (12:56)
So the anxiety is just embedded in a lot of these-

Nicolette Lienza: (12:57)
Yeah, good word, embedded. Mm-hmm (affirmative), for sure.

Dr. Rakos: (13:01)
… problems in living.

Nicolette Lienza: (13:05)
Dr. Rakos, let me ask you this. What are some tips that people can use to navigate anxiety? I guess maybe because there’s so many different types and it can be embedded in so many different things, maybe just general anxiety, some tips on how to navigate that?

Dr. Rakos: (13:20)
Sure. I think the first, the very first step is to accept that anxiety is inevitable because if we don’t accept that, then we’re always trying to eliminate anxiety. Even so-called normal or just typical or just daily living tension and anxiety and if we focus on that and try to eliminate that, then we’re likely to make it worse. What we want to do is just accept it and manage it, not elevate it.

Nicolette Lienza: (13:49)
Got you.

Dr. Rakos: (13:50)
As for second, to me, the core concept of anxiety is what is called experiential avoidance. When we experience anxiety, we try to avoid that discomfort both in terms of our thinking and our feeling and our action. So, the notion of experiential avoidance is instead of accepting and dealing with anxiety, we go to all sorts of lengths to avoid it. And so we engage in avoidance behaviors, we engage in distraction, we engage in repetition, and then we start developing in some cases rituals or compulsions and what that does is reward the avoidance of the anxiety, all those behaviors.

Dr. Rakos: (14:49)
But what it does is make those avoidance and ritual behaviors even stronger, and so what we wind up doing is starting to develop a lifestyle around avoidance and ritual so that we don’t experience the discomfort of the anxiety. So experiential avoidance, and I think in terms of understanding anxiety, that’s for me the core concept that to deal with anxiety, you have to experience anxiety.

Nicolette Lienza: (15:12)
Yeah, yeah.

Dr. Rakos: (15:14)
To manage it, you have to experience it. I tell clients to think of it not as an illness or a disorder that can be cured in an analogous fashion to say, getting an antibiotic. It’s much more akin to a chronic condition like diabetes where you have to look at diet, exercise, medication, stress management, social relationships, being able to resist peer pressure, a whole set of skills to manage that condition.

Dr. Rakos: (15:52)
And I think anxiety’s in a sense the same way. There’s a lot of different ways that we can manage it through very much the same kind of things, exercise, diet, stress management, social relationships, and if we look at it as managing our lifestyle, then it’s not getting rid of it.

Nicolette Lienza: (16:09)
Right, and I think that’s often the misnomer of like, someone might want no anxiety at all and that’s not realistic. It’s about managing it and maybe containing it and not letting it run your life, for sure.

Dr. Rakos: (16:21)
One of the things I try to teach my clients early on is what I call the anxiety mantra, and that’s just really a very simple way of reminding yourself of three key elements of anxiety. I have clients learn and recite when they’re anxious practicing, “Anxiety is temporary, tolerable, and copeable.” And those three characteristics are absolutely true. Anxiety is temporary. It doesn’t last forever. Even a panic attack is only a few minutes.

Nicolette Lienza: (16:57)
Right, right.

Dr. Rakos: (16:59)
Anxiety can become chronic, but in the daily course of life, it tends to be temporary and if you work through it, it tends to go away if you stay in the situation. So it’s temporary, it is tolerable. We say that I can’t tolerate anxiety, what we’re really saying is I don’t want to. I don’t want to exert the effort, I want it to be smoother. And that makes sense, we all want that, but sometimes we don’t get in a sense what we want. And so instead of saying, “I can’t deal with it,” let’s say, “It is tolerable, how will I deal with it?”

Dr. Rakos: (17:36)
And the third aspect is copeable, and if you look in the dictionary, copeable isn’t a real word but it follows nicely and clients remember it. But basically what that’s saying is you can deal with anxiety, you can manage it. You can’t get rid of it, but you can learn to live with it, cope with it, moderate it, make it in some ways work for you because sometimes, you have to keep in mind, anxiety in low controlled amounts can be a powerful and effective constructive motivator.

Nicolette Lienza: (18:12)
We forget about that too.

Dr. Rakos: (18:13)
We do. It’s a famous inverted U-curve that we all learned in school that there’s a middle amount of anxiety that leads to most productive performance. Too little anxiety and we’re unmotivated. Too much anxiety and we’re immobilized or our smooth behavior is undermined. So a moderate amount, and I mean a modest amount, can help motivate us. But too much disrupts behavior, too little can lead to lack of energy of behavior.

Nicolette Lienza: (18:50)
Right. So, Dr. Rakos, how do you approach it with your clients? How do you help them with their anxiety?

Dr. Rakos: (19:00)
I approach it through cognitive behavior therapy, which is one of the most well-researched and effective approaches to working with excessive anxiety and disruptive anxiety. And cognitive behavioral therapy has several key features, and I’ll be real brief with these. Although it emphasizes cognition and behavior, it’s holistic. It deals with feelings. Feelings are critically important and the cognitive behavior therapist will be really looking to understand how his or her clients experience anxiety and deal with their feelings.

Dr. Rakos: (19:37)
It uses only best practices, research-supported interventions. It’s focused in the present. The CBT approach, and the research supports this, asserts that understanding what we would call the maintaining causes of the current situation of the anxiety is much more important than understanding the original causes how anxiety may have started 10, 20, or 40 years ago. So it’s present-focused. It’s a more active approach. The therapist, me, when I do it, is generally more active asking questions, engaging the client, sometimes even giving mini-lectures, because there’s information to be conveyed.

Nicolette Lienza: (20:27)
Can you give a very specific example of what would CBT look like in an interaction, if they’re worrying about getting the coronavirus or something like that? Very topical.

Dr. Rakos: (20:41)
Right. The action, the activity is because the CBT approach as I sort of implied earlier, it’s more of an educational approach rather than a curative approach. So clients are learning tools to manage their anxiety. They’re learning cognitive tools, relaxation tools, behavioral skills.

Nicolette Lienza: (21:03)
Got you.

Dr. Rakos: (21:03)
So it’s a skill-based approach. So it’s competencies. What competencies, what skills does this person need to learn to handle anxiety better? So there may be for example times when I have to instruct a client in what’s called deep diaphragmatic breathing or learning to think more rationally or learning to use self-instructions like the anxiety mantras and other more specific ones. So there could be these mini-lectures where information has to be conveyed-

Nicolette Lienza: (21:34)
Got you.

Dr. Rakos: (21:34)
… because it’s just more educational than curative. The last thing I’d mention about CBT and anxiety treatment is that discomfort is inevitable because what we know now is, you can’t talk somebody out of anxiety. They have to learn to work their way through it, and learn those tools and skills to manage it.

Dr. Rakos: (22:05)
So in CBT, what we try to do is break down the intensely problematic situations whether there’s a phobic stimulus or health anxiety or ritualized behavior in obsessive compulsive disorder, and do the equivalent of figuring out how do you dip that big toe into the ice-cold shallow end of the pool? Not in diving in or being pushed into the deep end of the pool.

Dr. Rakos: (22:34)
But clients have to understand that that toe has to be dipped in. You can’t stand on the edge of the pool and will away or wish away-

Nicolette Lienza: (22:41)
Right, right. Got to do it, got to take action.

Dr. Rakos: (22:41)
… anxiety. Exactly. So you put the toe in and then the foot, then the ankle. And we generally work systematically. What I call we start with the low-hanging fruit, and then move up to the more intense and difficult situations, and as a client learns to handle the low-hanging fruit, they gain confidence, they develop the skills-

Nicolette Lienza: (23:04)
Yes. I can see that.

Dr. Rakos: (23:05)
… and they develop what we call self-efficacy, or confidence in their ability to start handling the situation. And so in the CBT approach, we try to enact action first and that then changes how people think and feel about their abilities-

Nicolette Lienza: (23:19)
Got you.

Dr. Rakos: (23:19)
… and particularly, their ability to handle anxiety.

Nicolette Lienza: (23:22)
Wow. You are such a wealth of knowledge with all of this, Dr. Rakos. Thank you so much, in sharing your knowledge with everyone here today.

Dr. Rakos: (23:32)
Pleasure. Pleasure to do [crosstalk 00:23:33]-

Nicolette Lienza: (23:33)
We’d love to have you come back in. So, thank you again.

Dr. Rakos: (23:35)
Happy to.

Dwight Thompson: (23:36)
Hi, welcome to Reset Your Mindset by LifeStance Health. Myself, Dwight Thompson, and my co-host, Nicolette [Lienza 00:23:46], will bring you conversations with leading Lifestance Health professionals who will help guide you on your journey to positive mental health and well-being. At LifeStance, we believe in the three pillars of mental health, mental flexibility, mindfulness, and resilience.

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