Reappraising Anxiety
It is extremely common and normal to feel anxious before therapy. Whether it’s the first session ever, first session with a new therapist, or 50th session, people can feel apprehensive for any number of reasons. Jennifer Yeh, a therapist at Seattle Anxiety Specialists, PLLC, notes that “prior relational traumas, shame, and general fears of being judged” may all contribute to worry about upcoming sessions. Yeh also recommends offering oneself compassion about the process, validating that “the work of therapy is intensely vulnerable” and therefore it is natural that the mind might be vigilant in defending against the possibility of threat.
Reappraising anxiety as excitement can be immensely helpful for calming down one’s nervous system. Alison Brooks, a psychology researcher at Harvard Business school, investigated the efficacy of reappraising pre-performance anxiety as excitement across situations like karaoke singing, public speaking, and math performances. She found that saying “I am excited” can quickly and easily prime the mind toward searching for opportunity and then in turn, improve performance.[1] Brooks (2014) notes that people “tend to adopt threat mindsets when they are in negative affective states,” so the replacement of anxiety with a positive emotion like excitement can prime an opportunity mindset.[2] In the case of therapy, one may benefit from this reappraisal of anxiety if they are able to replace fear-based thoughts (e.g., “I’m nervous I’ll break down and be judged by my therapist”) with more opportunistic and positive ones (e.g., “I’m excited to see how my therapist will react when I share something vulnerable. Their response will be super helpful for figuring out if we’re a good match.”)
Brooks’ self-talk strategy has been shown to be more effective at calming the mind and body than simply telling oneself to calm down, due to arousal congruency (see Figure 1). The logic of this effect is that “reappraising one high-arousal emotion (anxiety) as another high-arousal emotion (excitement) is easier and more effective than trying to shift from high arousal (anxiety) to low arousal (calmness).” One caveat is that Brooks found significant reappraisal when her participants stated “I am excited” out loud. Thus, it might be most helpful and successful if this technique is practiced aloud, perhaps in the car or somewhere private before therapy.[3]
Figure 1
Secondary Emotions Categorized by Arousal and Valence Levels
Note: This model was produced by Walinga in 2010, summarizing secondary emotions.[4]
Rumination can be one of the most distressing harbingers of anguish before a stressful situation, as the repetitive nature tends to only exacerbate symptoms. The coupling of reappraisal with mindfulness holds even more powerful potential at relieving anxiety and ruminative thoughts than reappraisal alone.[5] In 2007, Jain et al. conducted a randomized controlled trial demonstrating that mindfulness meditation (compared to other types of relaxation training) “may be specific in its ability to reduce distractive and ruminative thoughts and behaviors, and this ability may provide a unique mechanism by which mindfulness meditation reduces distress.”[6] If one is in their car before therapy, fretting about how the session will go, paying mindful attention to thoughts and bodily sensations can be useful for breaking off a cycle of repetitive thought.
As the level and fervor of one’s pre-therapy anxiety increases, a greater variety of techniques might be necessary for relief. Research has found that cycling through the aforementioned methods of 1) self-compassion, 2) positive, excitement-based self-talk, and 3) mindfulness tend to be effective at reducing cyclical worries. The usefulness of these strategies lies beyond simply mitigating momentary distress. According to findings by Fredrickson and Joiner (2002), positive affect and positive coping mutually build on each other, creating an upward cycle of enhanced emotional well-being and positive emotions.[7] Theoretically, the more one can switch into a positive affective state, the more likely they will be able to cope, and the more one can cope positively, the more easily they will be able to switch into a positive affective state. Over time, this self-reinforcement may lead to a significant reduction in anxiety before a potentially stressful situation, such as therapy.
Q&A
SAS Therapists Discuss Pre-Therapy Anxiety
1. How would you describe a first therapy session?
“First sessions can be exciting and overwhelming. Clients often feel like they have to justify their needs, and often resort to explaining every step leading up to the session. They may also want reassurance or a prognosis. From the therapist's perspective, there is the clinical pressure to conceptualize, diagnose, and develop a treatment plan. I try to defuse these pressures by explicitly designating initial sessions as conversations, and enlisting clients' help in structuring them. I invite clients to ask questions of me, and show my interest in them as people. This doesn't mean that we avoid the urgent themes above, but that they can surface organically rather than being overt frameworks. This is also my way of showing, rather than telling, what my overall therapeutic approach is. Thus, clients hopefully get a sense of what it means to be present together in a session.” (Jerome Veith, Ph.D., LMHCA)
“A first session is often about getting to know each other, with therapists' task being to try to understand their new client and what is holding them back, and the clients' task being to see if there is a good personality/ style fit with this clinician. Fit is important, and having a good working relationship is one of the most important foundational pieces for good clinical work, so paying attention to that is important. If you're nervous going into a first session, seeing it this way (therapists are working to understand and not judge, the power of judgment is in your hands) may be reassuring.” (Case Lovell, LMHC)
“A lot is happening in a short period of time. The therapist is likely working to listen deeply to understand how they can most be of support to the person in front of them. The therapist may already have a helpful clinical blurb from intake paperwork, but nothing can replace the power of spending time hearing (and vicariously experiencing) the client's story, in their own voice. On the client's end, the first therapy session is a window into whether they might be able to be fully themselves with this particular therapist. This is not necessarily a simple thing to feel through. It can take time within the session itself, and possibly even the week(s) after to reflect on how the connection resonates for them.” (Jennifer Yeh, LMHC)
2. What tips do you have for people who are anxious about beginning therapy for the first time?
“It's totally normal to feel nervous before a first session. I certainly do! It might be helpful for clients to remind themselves that there is no way a session has to go, regardless of whether it's the first or fiftieth. Therapists are generally so eager to be there for the client that they will meet them however they show up.” (Jerome Veith, Ph.D., LMHCA)
“There is no need to worry about being 'a mess' or 'too anxious:' seeing how your anxiety manifests in the here-and-now of an interpersonal interaction is a valuable source of clinical information. Like an auto-mechanic getting to hear the weird engine noise in the shop and not just hearing the driver's description of it, they can get a clearer sense of what might be going wrong to make things not run smoothly.” (Case Lovell, LMHC)
“I really want to normalize experiencing anxiety when beginning therapy for the first time. It's such a brave thing to be authentic and dig into the vulnerable parts of your story. It can be so healing to begin sifting through and communicating these emotional pain points with another person, but it's not something that we've necessarily been socialized to do. Remember that it’s okay to go slow and take the time you need.” (Jennifer Yeh, LMHC)
3. What do you recommend for people who feel like they have nothing important to discuss before a therapy session?
“I know it's difficult, but I would say ‘trust in the process.’ That feeling, of not having important material to discuss, is itself worthy of discussion. The only justification one needs in showing up to therapy is a desire or need to connect.” (Jerome Veith, Ph.D., LMHCA)
“In terms of not having important things to talk about going into a session, some sessions are more exploratory than others, and that is OK. Having the space to connect with the feelings and concerns that are coming up in the moment (vs. needing to have premeditated topics) can lead to some very powerful and productive sessions. It can be helpful sometimes to show up with an agenda, but as long as you're showing up and being present in that session, there is a space to move forward.” (Case Lovell, LMHC)
“Know this can be a completely natural part of the therapeutic process, and it's completely fine, because topic content is actually only one part of the therapy session. The client showing up-- just as they are-- sharing the thoughts or emotions they're experiencing in the moment and seeing what emerges from there, can also be very healing. Remember that if the dynamic is a fit, you can also trust the therapist to guide you towards uncovering what emotional needs might be unmet or need tending to.” (Jennifer Yeh, LMHC).
Cognitive reappraisal is defined by Gross & John (2003) as “a form of cognitive change that involves construing a potentially emotion-eliciting situation in a way that changes its emotional impact.” Across several studies, their research found that “reappraisal was related positively to sharing emotions, both positive and negative.” In the context of therapy, an outcome of increased transparency should only improve the effectiveness and productivity of a session. Additionally, Gross & John (2003) found that people who regularly reappraise their emotions show fewer depressive symptoms, contrasted with people who habitually suppress their emotions and exhibit increased symptoms of depression.[8] The evidence supporting not only the efficacy of the reappraisal technique itself, but also the positive impact on social and interpersonal openness and general depression, has direct applicability to pre-therapy nervousness. Even if the anxiety is minor, it serves one to reappraise anyway and prime oneself toward increased communication, rather than risk engaging in suppression of the anxiety and building a habit which is correlated with elevated depressive symptoms.
Contributed by: Maya Hsu
Jerome Veith, Ph.D., LMHC, Case Lovell, LMHC & Jennifer Yeh, LMHC
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
1 Brooks, A. W. (2014). Get excited: Reappraising pre-performance anxiety as excitement with minimal cues. Journal of Experimental Psychology: General, 143(3). https://doi.org/10.1037/e578192014-321
2 Ibid.
3 Ibid.
4 Walinga, J. (2010). The Experience of Emotion. In Introduction to psychology: 1st Canadian edition. essay, BCcampus.
5 Garland et al., (2011). Positive Reappraisal Mediates the Stress-Reductive Effects of Mindfulness: An Upward Spiral Process. Mindfulness 2, 59–67. https://doi.org/10.1007/s12671-011-0043-8
6 Jain et al., (2007). A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Annals of Behavioral Medicine, 33(1), 11–21. https://doi.org/10.1207/s15324796abm3301_2
7 Fredrickson, B. L., & Joiner, T. (2002). Positive emotions trigger upward spirals toward emotional well-being. Psychological Science, 13(2), 172–175. https://doi.org/10.1111/1467-9280.00431
8 Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348–362. https://doi.org/10.1037/0022-3514.85.2.348