Coping With Anxiety, an interview with Sarah Khan
May 12 , 2021
What is a forensic psychologist and what is your role?
Forensic psychologists work with people who have committed offences and will usually work in a prison setting, conducting risk assessments and working on offender behaviour programmes, both group and individual. My work has been in hospital settings in secure care with people who would be in a prison but are mentally ill or have difficulties meaning they can’t be in prison. I’ve worked with both adults and adolescents in hospitals and communities and would do assessments, as well as treat and help manage inappropriate behaviour. I have worked in private practice, seeing clients privately for about 8 years.
I did a psychology degree, then a post graduate diploma in criminology and then a forensic psychology Masters. I worked as a trainee for about 6 years under supervision of a chartered psychologist before becoming chartered myself. In 2011 I started work for the parole board, that’s half of the work I do now. I do assessments on lifers who have reached their tariff and are referred to the parole board who then make the decision as to whether they should be released.
TWP: That must feel like a lot of responsibility on your shoulders?
SK: Yes, luckily, I share that, there’s 2 or 3 of us who make the decision based on lots of oral evidence and written information. It’s really interesting and very worthwhile work.
The other half of my work is seeing private clients, anyone who contacts me with mental health difficulties, usually around anxiety and depression. I did an EMDR course a few years ago because I wanted to specialize more in trauma. EMDR is very useful for trauma but also very useful for anxiety and depression as well as OCD and various phobias. It’s very applicable and you can also use it for addiction, to alcohol, drugs or anything that you are addicted to.
TWP: What does EMDR stand for?
SK: It stands for Eye Movement Desensitization and Reprocessing.
All our experiences form part of a memory network that all fit together. So when you talk about your holiday you may remember the people you were on holiday with and the things you did and that may trigger another memory of doing something similar with another group of people, and the memories all kind of slot together. When we experience trauma we don’t always process the trauma related information adaptively and so these memories don’t integrate into the memory network, so it kind of floats on top.
So I explain to clients, it’s like when you get a takeaway curry and you peel off the lid and you get a layer of oil on top of the curry it’s almost like that. This is why traumatic memories and experiences can be triggered by lots of different things, smells, sounds, particular places and/or people, causing the person to feel as though they are back at the time of the trauma and reliving the experience. This can take the form of flashbacks, intrusive thoughts or sometimes nightmares. People who have experienced trauma may avoid certain places and/or people because it triggers intrusive thoughts or flashbacks from the original trauma. They may also experience high level emotions or very flat emotions. In EMDR you process the trauma related information so that it allows you to access adaptive information that is there but you’re not accessing very well because the intense memory of the trauma gets in the way. This allows the integration of information.
EMDR is a 3 pronged approach, it looks at the past, the present and the future. In EMDR the trauma is processed using bi-lateral stimulation, where you stimulate both brain halves at the same time, and this is usually done by eye movements, so that’s the eye movement part of it. The therapist will move their fingers horizontally and you will follow it with your eyes. You can also use tapping or buzzers, which you hold and get a little electric current in your alternate hand. Having to move online due to Covid we’ve been doing ‘butterfly tapping’ to create the bilateral stimulation. So, it’s any form of bi-lateral stimulation to allow the brain to process information more adaptively. It has an incredible effect and people really do feel relief.
TWP: So are you talking throughout it to pull anything out or is it just that?
SK: No, we don’t talk throughout the bilateral stimulation. You start by identifying what the worst part of the traumatic memory is, the target image, and then you explore what the negative belief is about yourself as a result of that. We then work towards a positive belief about yourself that you prefer to think about when you remember the traumatic experience. We explore the level of distress, what the emotions that you experience are and where you feel that in your body. So, when somebody feels very anxious, they may feel sick or get that horrible feeling in their tummy, or they might feel sadness in their chest. So, it’s identifying where in your body you feel it, focus on that and the target image and then you do the processing. You do the bi-lateral stimulation for about 30-40 seconds and then you stop and ask what they noticed. So you are encouraging the client to notice what happens and to be an observer. I it’s like just sitting on the train, looking out of the window and seeing what goes past, and that might be thoughts, emotions or memories, images, anything like this. You’re just observing what’s going on, there’s no judgement, no right or wrong, you’re just observing it. And every now and again we’ll stop and I’ll say ‘what did you notice?’ And they’ll process the information and access other information around it to allow them to incorporate the traumatic memory into their network, making it less distressing in the here and now.
TWP: It actually sounds like something that would be hugely beneficial for so many people who are just muddling through and aren’t aware that EMDR is out there and is so effective.
SK: Yes. And another one of the real attractions about EMDR is that it can be quite quick. So, you can get a level of relief quite quickly. Even somebody who has experienced quite significant trauma can have that emotional relief quite quickly. The other part of attraction is that you don’t really have to talk a lot about the trauma.
TWP: Which is good because some people can’t handle the thought of talking therapy.
SK: Yes exactly. And you don’t have to do any homework like with some other therapies where you may be asked to keep diaries and various other tasks and think about things. And also, you don’t have to expose yourself directly to stimuli as you would in for example exposure therapy, something people often feel reluctant to do.
TWP: Because that could just put you off doing it, because it may be traumatizing
SK : Yes, absolutely. So where as other therapies people may be put off doing it, with EMDR you are allowed to just process things in your own head. Your therapist is just there taking you through that journey, sitting in the passenger seat while you do all the driving. The client is the expert on themselves. It’s very beneficial for those with anxiety and depression, although it has not yet been included in the NICE guidelines for those conditions, there is mounting evidence that it works really well and I’ve used it a lot for a lot of people.
TWP; So, is it ok and safe to use EMDR for anxiety and depression but that isn’t publicised yet?
SK: Yes it’s just that there haven’t been big enough clinical trials but there is lots and lots of evidence.
TWP: Arguably a lot of anxiety and depression stems from underlying trauma that maybe is unaddressed and is then quite deep rooted? And also trauma is quite a broad term in the sense that you can have quite acute trauma like being in a car accident, or you can have more accumulative traumatic experiences over time. Could you have even experienced trauma without even being aware that you had, perhaps as a young child?
SK: People think about trauma as something that’s life threatening and as being a big event, like a big car accident or being in a war. But there is also something we call small T trauma, which are events that are life changing but not necessarily life threatening. So, for bullying, developmental trauma where someone may have lived in a family where there was lots of neglect or emotional abuse. There may not have been one traumatic event but it’s on-going. When you think of the term ‘Death by 1000 paper cuts’ it can help to explain. There are relationships that might have been abusive, not necessarily physically, but emotionally and psychologically, that people don’t think of as necessarily trauma but it has had a profound effect on their lives and how they live.
TWP: And so they may put it in a box and put it away?
SK: Yes, it’s like a closet. The more stuff you cram in there and then try to shut the doors, at some point the doors won’t shut. So, with EMDR it’s like taking the stuff out of the closet, having a look at it and giving it a good old shake then folding it up before putting it back in a neater way. And then you can shut the doors, you can still come back and look at the stuff in the closet but you can choose when you do rather than being accosted by the content through intrusive thoughts or flashbacks.
TWP: We’ve heard the term box breathing as a way to help cope with anxiety, could you talk us through it?
SK: Box breathing is basically breathing in a square. Breath in for the count of four, hold it for the count of four and then breathe out for four. And then you start all over again. That’s basically what box breathing is.
TWP: So you don’t hold at the end of the exhale for four? Because that can be quite anxiety inducing, right? People would feel like they needed to catch their breath.
SK: Absolutely. So no, you don’t hold at the end of the exhale. And the idea of the breathing is that the brain, as clever as it is, can be fooled into thinking all is well. So if you breathe slowly, the heart will then slow down and therefore you will feel calmer. If you can do that maybe four/five times really slowly and very deliberately breathing, you can use it in any situation. Even if you are in a meeting and feel quite anxious or ahead of a presentation, it’s good for calming you.
TWP: That sounds like a good exercise to do on the train or a bus, if you're anxious on a commute and it’s really busy around you.
SK: Absolutely.
TWP: It’s interesting because in yoga I’m finding that some practices are really not helpful for anxiety. So when you start to look at the breath, some practices will be really helpful in affecting the nervous system and then triggering that relaxation response by slowing the breath down and signaling to the body. For me finding that pause and holding the end of the exhalation is really relaxing because it’s like a stillness. Then for people who are maybe more anxious and holding their breath a bit more, it’s going to be really tricky. Also meditation can be quite tricky for people with anxiety because they can feel quite isolated and in their own mind, rather than grounded in their body.
SK: Absolutely and that’s a really good point. It’s transferring your attention from inside your head to being inside your body, grounding and really trying to feel yourself sitting on the ground or wherever you are, really experiencing what your body is feeling as opposed to what’s going on in your head. With anxiety the tendency is to turn inwards, you start feeling your heart beating a bit faster and feel uncomfortable, and then realize your breath is getting shallow and the more you focus in, the more you will notice the changes within your body, resulting in more anxiety. It’s very natural, like when you’ve got a pain and you focus on it hoping to make it get better but in fact it doesn’t, it just gets worse. In any situation like that really grounding and thinking about what’s going on outside of you rather than inside is helpful, like what can you see? Can you see 5 things that are blue/pink/ wooden/glass, 4 things you can feel like your feet on the ground/ the warmth of a cup of tea in your hand/ the breeze, 3 things you can hear like bird song/traffic/ dogs barking and 2 things you can either smell or taste like coffee/ flowers/ scented candles/food. Focus your attention outwards rather than inwards.
TWP: If I’m at home and I’m really anxious and have a racing heart, for me to just step outside and walk at my local park, after about 10 minutes I realise that I’m not even thinking about my heart beating fast anymore and I’ve distracted myself from the feelings in my body.
SK: Exactly, it’s that whole thing about just being present in the moment. We talk about distraction and avoidance, and people often get the two mixed up. With anxiety avoidance is your absolute worst enemy even though it feels at the time like your great friend. For example, if you think ‘well if I don’t go on the tube I’ll definitely feel a bit better’ but then of course you may start building that up and generalising it so you don’t go on the trains and then it may end up expanding to thinking well I don’t really want to go on buses either because that’s a similar kind of feeling. Then you might end up not wanting to go on planes anymore and your life can end up becoming smaller and smaller and smaller.
TWP: Yes, anxiety can make your life quite small can’t it.
SK: Absolutely, and people are fearful of exposing themselves to their fears. But I think that actually distraction is different, it’s taking yourself away from your head to doing something that you pay full attention to or are fully engaged with. People often find if they are very anxious leading up to something and they are worried about how it’s going to turn out, thinking things like ‘what will it be like when I get there’ or ‘are people going to look at me and make up their own minds about me’. That’s like time travelling into the future that we have no control over, because it’s in the future. But as soon as you start your presentation or you start to talk to people and go in to do it and are more present, you feel less anxious because you are focusing on what you are doing rather than your mind jumping ahead into the future and ‘what if’s’.
TWP: Yes that’s really annoying that that’s how it works. It’s interesting that you describe being present as a distraction, because it’s almost like it’s the opposite of a distraction because you’re just living in what’s happening now. And anxiety is really future oriented and imaginative. The interesting thing I was learning about when I researched a lot on stress is the fact that you can actually think your way to a stress response, which essentially accumulates to anxiety I guess. Is that right where it stems from?
SK: Yes, anxiety is an instinct and a bodily response to feeling threatened by something. It goes back to stone-age man who may have been in a situation where they were faced with a Sabre-toothed tiger and it’s the fight or flight response, so your body gets ready for either fighting or fleeing. And so of course now, even though we don’t often come up against physical threat to us, the body still responds in exactly the same way to a perceived threat, be it social, emotional or psychological, and that’s why people feel panic. In that moment when your heart’s racing, your breathing is really shallow, when you’ve gone sweaty and clammy and your mind’s gone completely blank because all the blood has drained from your mind to go to all the extremities so that you can deal with the fighting or the fleeing.
TWP: And you become hyper-vigilant as well and more worried and scared about things.
SK: Exactly, and a panic attack is like a fear of fear. You’re now fearful of becoming more fearful because it’s so uncomfortable. And of course, you’ve got to deal with the whole thing of your heart’s beating so fast that you may think you’re having a heart attack or going to die and then it just spins on. So yes, it is very much a stress response and adrenaline is produced because of how you feel under threat.
How your anatomy can change your life
Neurologically things will shift. So, there’s lots of research around ‘neurons that fire together wire together’. So the more times you do something, whatever that may be, the more times you respond in a certain way the more that becomes your habitual way of doing things, but you can change that. It’s like if you usually leave your house and turn left every morning along the same route and do it because it’s what you have always done, you can start to turn right instead and realize that actually after a while the right turn is much better for me, it’s a nicer walk that get’s you where you need to go and it’s much quicker. Then you start to make a new pattern of behaviour, but it takes time and it’s difficult to make the shift because it’s very entrenched, it’s familiar. With anxiety particularly we are so fearful of what’s going to happen that the world can become smaller and you do the same thing over and over, because at least you know it and you’re familiar with it. It may not be comfortable, you may not be happy with it but at least you know what it’s like, it’s a habit.
TWP: Is this what is meant by being ‘set in your ways’ as it’s even harder to change because habits have become so entrenched.
SK: Absolutely
TWP: There has been talk in the last ten years or so of neuroplasticity where your brain is flexible and can change whenever you start to practice or behave in a different way. You can start to think differently.
SK: Yes this is a really important thing because people can feel like they’re trapped and that this is how they are going to be forever. Which makes you feel quite helpless and also quite hopeless, and that is another classic of anxiety. People can feel like they can’t really do something because of their anxiety and that they just have to put up with it, but there are ways of not having to live like that and things can be done differently
TWP: And EMDR is something that could be offered to people who feel like this because of the way it works
SK: Yes because it does allow you to process things very differently and allows the different neurons to fire and wire together to make the change. Anxiety is such a big topic in so many ways because everyone has to experience some sort of anxiety. People just want to be rid of anxiety but anxiety is a necessary emotion, it helps us survive, it protects us in some situations. But when the anxiety response has become unhelpful and the body responds with anxiety to situations that are not dangerous (like the sabre-toothed tiger) it’s more about managing it and living alongside it rather than getting rid of it. It’s also difficult because as soon as you start resisting something it can become more intrusive. Of course, it feels intuitive to avoid things that make us feel scared or anxious but when our bodies respond with a fight or flight response to a situation that isn’t dangerous the response is no longer protecting us. As soon as you start to try to not do something it seems to become harder so there is something about accepting how you feel and not over analyzing the feelings too much. Just noting that maybe you feel a bit anxious but saying ok, let’s leave it at that rather than delving into the possible causes. Easier said than done at times but like everything else it’s about practice.
The other thing with anxiety and the whole idea of trying to be present in the moment is that anxiety is about time travelling, it’s about trying to pre-empt how we are going to feel in a future situation. For example when you are going on holiday and have to fly you may say ‘well I know last time I felt really anxious so that’s how I’m going to feel this time’, and you’ve created a narrative for yourself. Then you’ll be looking out for it and perhaps will say to yourself that it was through security that you started to feel anxious and when you get there this time, you’ll get those same feelings and tell yourself “see, that’s where I felt anxious last time as well, now I’m feeling it again”
TWP: So it reinforces it
SK: Absolutely. So now you’re not feeling anxious about security at the airport, you’re feeling anxious about the memory of when you were last in that situation. So, it’s a bit like Pavlov’s Dogs where a bell is rung and a dog is given food, and so after pairing this many times an association between the bell and food has been made. If you take the food away but ring the bell the dog will still salivate because it has now connected the bell with getting fed, even when the food has been taken away. And that’s similar to anxiety in some ways. We say ‘well last time I felt like that’, the memory of feeling anxious has now made me feel anxious and I don’t want to go back and do that again, I’m going to avoid it. Then you’ve confirmed to yourself that flying makes you anxious and you’re not going to be able to do that again.
TWP: It’s like a lack of open-mindedness because you’re not allowing yourself to let there be a new experience, you’re almost reliving the same experience over and over again.
- Exactly. So the time travelling is about the future ‘How will I feel when I go into that situation?’ but it’s also about the past ‘when I was last in that situation I felt awful’ So you’re not allowing yourself to see what it’s like this time and you’re not open to that, and that’s why being in the present is so important in all of this.
So with regards to hospital appointments or going to the dentist you can spend several days feeling that slightly heightened anxiety because you are now waiting and spending all of that time worrying when actually you have no idea what it’s going to be like when you do go.
TWP: And so much time is wasted worrying, that’s what can be so frustrating. It’s so unproductive.
SK: So much time and so much effort. And this can be worked on in any therapy you choose. It’s about getting to know your triggers or when you know you start to feel anxious, being able to identify body sensations. It’s about getting to know what works for you and having that toolbox to help you manage your anxious feelings more effectively. Like the box breathing, the grounding work, the 5432, going out for a walk, cooking, meeting up with people or playing games, relaxation techniques. Whatever it might be, make it something quite engaging, something that you can do that keeps you in the present.
Your Questions Answered
"How do you find Clarity when anxiety brain fog hits?"
I would say using the grounding techniques. Really focus and recognise the early signs. How do you recognise that you feel anxious? Is it that sinking feeling in your tummy or your heart racing? Start to observe what happens for you when you become anxious and then start to work early because often what happens is when you’ve got into a bit of a spin it’s more difficult to get out of it and it takes a lot more effort. So if you recognise it early and nip it in the bud it helps. But I would say the grounding and the breathing techniques but also just doing something and just focusing on that. Doing something that keeps your mind occupied, not something you do on autopilot so your mind still has time to ruminate. Even just changing position if you are sitting on the sofa worrying, you know get up, just stand up for a bit or go for a walk. Take yourself off somewhere to do something like water your plants or get yourself out and really notice what’s going on around you.
'I'm due to be going back into the office soon after a year of WFH. I'm not worried about Covid at all but I'm embarrassed about my appearance as I have gained weight during lockdown, and this is making me anxious about seeing my colleagues again. I keep thinking that they will judge me on how I look and it's making me not want to go back in"
I think that is so common and lots of people have got super, super used to be at home and we’re used to just not been around people. We’ve spoken about social skills that need practicing and this has only been happening in your house or with close friends and family. It’s keeping in mind that a lot of people will be feeling exactly like you and everybody will be feeling very conscious about coming back in again. Lots of people will have gained weight as they, and I speak for myself, have been unable to keep up with their exercise regime. And the important thing to remember is that people are very concerned about themselves, they are much less concerned about other people. So, if you’ve gained a bit of weight and are conscious about it, remember that other people will be thinking about themselves and won’t necessarily spot what’s happening for you. We don’t really have enough space to really think about too many other people at that time. So again it’s about bearing that in mind and realising that you are not alone in feeling like this. When you first get back into it, maybe the first or second time of going in, you may have that anxiety but it will feel better after a short while. It’s often the thought of doing it that is worse.
"If you are feeling anxious, what anxiety triggers should be avoided, if any?
I think avoidance is risky, so don’t avoid anything. Often people talk about caffeine and alcohol and those obvious potential triggers, and if you are feeling particularly anxious try not to do a big binge on alcohol. Try to slow down because the day after can make you feel quite anxious. Again, associating things with anxiety is not helpful either. So, if you associate drinking alcohol with anxiety, each time you have a drink you may be thinking, I really hope I won’t be anxious, and then you’re inviting it back in. Or drinking coffee as well, some people don’t like the way it makes their heart feel so they don’t drink it even if they like it. So I’m saying to avoid avoidance, try not to avoid things but keep things in moderation. Know your limits and stick with it.
Is there such thing as 'delayed' anxiety i.e. experiencing anxiety after the traumatic experience has passed"
Definitely sometime when things are judged and aren’t processed at the time for whatever reason, you end up carrying that. Sometimes you don’t realise very soon after because you are dealing with the aftermath of whatever the trauma is. Then it’s only when things settle back down again. So a child who may have experienced horrific abuse growing up might have a long spell of time where there isn’t a response to that, then once they are safe and feel more settled those feelings can come out.
TWP: So allow yourself in the aftermath of trauma to be kind to yourself and don’t assume that you are ok because you aren’t showing feelings straight away.
SK: Yes be compassionate and check things out with yourself and with other people. Very importantly seek support from other people because anxiety is very isolating, you can feel as if you are the only one. And sometimes people can see anxiety and mental illness as a bit of a character weakness, people don’t want to admit to being anxious in case they are thought of as a bit silly. But actually, many, many people feel it and the more we talk about it with each other and tell each other, the more we can share and feel less alone.
"I live with someone who is very anxious but doesn't really make any moves to address it or even acknowledge it. Their anxieties can end up controlling me and my day because they are powerful feelings for them and I'm quite easy going so end up letting it happen for a quiet life. How can I deal with this?"
This is difficult because the anxiety is being projected onto you from the other person, and your life is becoming smaller because you are living with somebody who is very anxious. One of the things is to talk about what prevents them from resolving this issue. And it might be fear, fear of having it resolved and then what happens? We create identities for ourselves and if somebody thinks of themselves as an anxious person they may worry about how they would be if they didn’t always feel that way. Have an open and honest discussion about it and don’t become co-dependent. For the person who isn’t anxious it’s important to be able to continue doing what they want to do and not feel restricted through someone else’s fear or worry. But it’s also about being understanding and compassionate, listening but not taking on the other person’s experience. That is hard because you want to help somebody but you can’t always do it, they have to want help and also to help themselves. And you still have to live your life as well and don’t want to feel held back because that’s not great for the relationship either.
