Our emotions are vital to survival, but sometimes dwelling on them makes things worse. This is especially true for anxiety. When we face something that makes us scared or anxious, we feel uncomfortable. This activates our sympathetic nervous system. We call this the fight or flight system because it causes us to want to do something to get rid of this uncomfortable feeling.

Both fighting and fleeing can reduce this anxiety. Either response may even be the right choice at times. Using animal models, a cornered racoon may get a dog to flee by fighting. An antelope’s chances of survival are greater by choosing to run away from the lion. With humans this may help for fighting off or fleeing from someone trying to kidnap you.

On the other hand, using these strategies may not be good for us when the anxiety is about tasks in our daily life. Examples of these include going to school, speaking in front of an audience, or asking someone out on a date. In these situations, avoidance causes some interesting things to happen. First, avoidance causes a level of immediate relief.

Congratulations! You avoided the bad, scary thing.

Was this a good thing?

Avoiding something you need to do causes two bad consequences. The first consequence is the natural consequence from not doing the thing you needed to do. This could include missing an important lecture, having a zero on an assignment, or even missing out on the love of your life!  Second, through classical conditioning, the dread or anxiety becomes stronger over time.  If this pattern continues, the anxiety can become almost crippling.

Prevention Strategies for Anxiety

Sometimes we can help patients with a history of anxiety to prevent problems before they occur. Two of the most common examples are young kids going to school for the first time and college students taking a class in public speaking. Although not exhaustive, here are a few strategies I use. Please note that strategies for prevention and treatment can overlap, but I divided them this way to make it easier to follow.

Create a script for success

Being able to visualize yourself being successful can help reduce anxiety about the situation. This is particularly true for situations that are new. One common intervention for the first day of school is to create a social story in which the child is the main character. In a few cases, I have even had parents and schools use services such as Shutterfly to create professional-looking picture books with captions. The pictures include the child ready for school. The child arrives at school. Various activities are enjoyed during the day by the child. The child returns home to tell the caregiver about their fun adventure.   

Plan ahead

Information and having a plan can help reduce anxiety. To continue with a school example, for kids transitioning from elementary to intermediate/middle school it is helpful to walk the hallways a few days before school starts. The child can plan out the best routes to get from class to class. As a parent, I did this for a child who moved away for college. Another example is obtaining all needed supplies. For individuals with fears around eating out, checking the online menu in advance can reduce anxiety. This helps navigate the options and make decisions about what to order in advance.

Role play/practice

Although some people feel awkward doing this, role playing or practicing is very helpful. In session, we have done role plays for things including talking to a spouse about a difficult topic, asking for services in the school, giving a speech, getting a shot, and getting a haircut. For things such as getting a shot or a haircut, I sometimes bring in props, including a syringe or hair clippers. In each case it was neat to hear the success stories from those sessions.

Plan what to do if things go wrong

Planning what to do if things go wrong is helpful. Sometimes just the mental exercise of thinking about the worst thing that could happen realistically is enough. Most of the time the most likely worst thing that could happen is not as bad as the thoughts in our heads. At other times we have made larger plans like what if I get picked on at school or what if my partner doesn’t accept my apology. Other plans could include what to do when/if you get overwhelmed with emotions (e.g., what specific self-calming strategy will you use or who you can contact for help).

Treatment Strategies for Anxiety

More often, I help individuals after a pattern of avoidance has started. The individual may be experiencing severe anxiety and is having difficulty moving forward. Thankfully, there are strategies that can help these individuals. Sometimes we only need one strategy. At other times, we need multiple strategies over time.

Use relaxation & mindfulness techniques

The first step to reducing anxiety is decreasing emotional activation. One of the most established ways to do this is through traditional relaxation methods. I teach box breathing, grounding, and progressive muscle relaxation in therapy. There are multiple apps available to assist with these exercises. The Mindfulness Coach is an app I reference, made by the Veterans Administration. I like this app because it is free, and it provides helpful psychoeducation, guided practice, and methods to track progress.

The main problem with relaxation strategies is getting the person to do them. I often explain it by breaking individuals into three groups. For the first group, it works like magic in session. Among those, a small number do well in difficult situations without more practice. A larger number need added practice to get better at it on their own, particularly when they need it most. The second group takes a while. Years ago I read it often takes 4 to 6 weeks on average. The third group thinks the exercises are too silly and give up before giving them a chance. Based on these groups, most people can benefit from practicing this type of exercise.

Daily practice is important. It is easy not to realize the amount of residual stress we carry around all the time. One way to put it is that “getting used to the stress” might be more accurately defined as our body not recognizing the level of distress it is under as a coping skill. The long-term damage is still being done (Mayo Clinic, 2023).

Find and refute negative thinking patterns

For ingrained patterns of avoidance, the individual often has strongly held negative beliefs. These beliefs must be refuted to move forward. These beliefs are often reinforced by things others have said or by prior attempts that were not successful. The thinking errors can vary greatly but there are common ones. Examples include I am lazy, it is too hard, or bad things will happen. Talking about them openly builds more adaptive and accurate ways of thinking. This takes time, but it is an essential step. Sometimes this is where the real “work” in therapy occurs.  

Getting rid of negative thinking alone isn’t enough. Multiple patients have told me their parents say there isn’t anything to worry about. The patient says they realize that, but it doesn’t make the fear go away.  In fact, sometimes this creates greater distress and other thinking errors (e.g., negative thoughts about themselves).

I tell patients sometimes our head realizes we are safe before our body does. The other important truth this teaches is sometimes we trust our emotional reality more than actual reality. We have to teach the body it is actually okay. This leads to the next step.

Start small and celebrate small successes

A common thinking error relates to how fast a patient should improve. For example, some patients have missed multiple years of school due to severe anxiety. Others have been almost exclusively confined to their own home. We must start with progress that may seem small at first. This is called systematic desensitization.

To explain this, I will use the example of a fear of bugs. Living in Texas, bugs are simply a part of life. We can reduce the number we see, but we cannot completely avoid seeing a cockroach or other insect from time to time. Avoiding all places you have seen one in the past (e.g., bathroom, classroom, kitchen) has negative consequences. In this scenario, we may start by talking about bugs. Then we may introduce pictures of bugs. Then I pull out my collection of realistic-looking toy bugs. My mom gave these to my daughter years ago, and my daughter didn’t want to play with them. I started using them in therapy, and my mom was tickled to learn I use them for this purpose!

Sometimes, we use guided imagery. We imagine a bug being in the room with us without bad things happening. Finally, I will introduce real bugs.  The key is to start small enough that the person is not likely to escape. This process allows the person to experience manageable doses of their fear and slowly teaches the body they are still safe.

Work with the system to make reasonable accommodations

Sometimes we may need to set up special accommodations to help individuals transition from prolonged periods of avoidance to more “regular” functioning. In school, we have made a behavior intervention plan that allows the student to go to a quiet place. We have also included in the plan for the student not to be reprimanded for sitting with their head down in class. In these cases, I am currently not worried about grades. The most important goal is to get the kid back in school and acclimated to this environment.

Sometimes the school resists asking for this accommodation. As part of the negotiation, I try to set adequate expectations for progress (e.g., several months). I also find potential signs this accommodation is being abused, which is what schools worry will happen. Strangely enough, I have almost never seen a student abuse this accommodation. Almost always the student starts doing better on their own. Typically, if the anxiety is this bad, the student has their own level of shame and is as motivated and excited to see improvement as everyone else.

Conclusion

Anxiety-related avoidance is a common issue that has large negative consequences. Despite this, there are many ways to prevent and reduce negative thoughts, difficult emotions, and the behavior. Please note there are many other ways to address this issue. The examples given in this article are just a brief sample.

If you or your child needs help with anxiety, please contact our office.

Post written by Dr. Gordon D. Lamb, Licensed Psychologist and Clinical Director

Please note posts are educational in nature and are not intended to replace psychological services when needed.

References

Mayo Clinic. (2023). Chronic stress puts your health at risk: Chronic stress can wreak havoc on your mind and body. Take steps to control your stress. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-20046037