Daily practices

Studies show that some form of regular exercise has overall health benefits, including reduced anxiety and depression. A systematic study of exercise effects on depression demonstrated large antidepressant effects in long-term (nine weeks, average 45 minutes, three times per week) and even short-term (four weeks) interventions across a variety of settings for outpatient and inpatient groups (Morres et al., 2019). Exercise is an effective method of reducing self-reported symptoms of anxiety and has been used as an option for the treatment of anxiety in clinical groups.

We encourage people to develop a habit of exercise and to begin by focusing first on becoming consistent. Low goals and expectations can kill motivation—but too much enthusiasm to get into great shape can, too. We often recommend nonexercisers to start with a five-minute walk. If you have a treadmill or exercise bike in your house, it might seem that it should be easy to get on one of those machines for a daily five-minute walk or ride. It seems logical—but it’s maybe not as logical as you might think.

It’s often not simple and straightforward to maintain a consistent exercise behavior. Negative reinforcement rules the day in many health behaviors, especially when effort is involved. Negative reinforcement occurs when we engage in a behavior that is associated with a decrease in discomfort. Thinking about the effort needed to get on a treadmill or exercise bike or put on a pair of running shoes to go outside (it’s cold or it’s hot out there) raises the level of emotional discomfort a bit. If we think, “I’ve still got time to do that. I can do it later. I can start tomorrow,” the discomfort drops, and the behavior we call procrastination is reinforced. We don’t see procrastination as a character flaw, but a commonly reinforced pattern developed through experience; humans work to avoid discomfort. Negative reinforcement is the problem to overcome.

What if we minimize discomfort as much as we can and work on “wiring in” a pattern to increase the likelihood of stepping on the treadmill or riding a bike? At first, what I’m about to suggest may seem ridiculous, but stay with me. When you walk through the room where you have the treadmill, walk over and step on it. Stand there for a few seconds and then go about your day. But try to step on that machine every time you go through the room. Maybe just step on it and think about walking on it for a minute, and then go ahead and do whatever it was you were going to do. I’m sure you can now see why we suggest this and why it’s not really ridiculous, after all. Each time you step on the machine, you’re getting exposure, which reduces the discomfort of starting to exercise, and at the same time, you’re engaging in the very activity we’re trying to prime: stepping onto the treadmill or bike.

Sleep is fundamental to good mental and physical health. Sleep is the first item on our symptom checklist when you come to our office to complete paperwork. Sleep deprivation affects working memory and attention and makes it difficult to manage stress, anxiety, and depression.

Mindfulness is the practice of redirecting your conscious attention to the present without judging where your thoughts were before the redirection. This includes the active acceptance of how we are feeling. Less anxiety occurs overall if we refrain from judgment about our own unhelpful thoughts and negative feelings and instead redirect our attention to our thoughts or behaviors in the present. Mindfulness posits that instead of trying to change something about the situation, we accept the situation exactly as it is.

There are many ways to utilize mindfulness as it relates to anxiety and OCD. Some of these, such as mindful meditation, breathing exercises, and progressive muscle relaxation, are used primarily as standalone methods to reduce anxiety symptoms. Some can be used in conjunction with other therapeutic skills like active awareness and redirection of thoughts, or understanding and acceptance of anxiety and obsessions, and the urge to engage in compulsions to reduce these uncomfortable feelings.

Cognitive restructuring is one example of where mindfulness can be used in combination with other techniques. We'll address cognitive restructuring in depth in Chapter 8, including ways to use the Relabel, Reframe, Redirect (RRR) tool. Mindfulness can be beneficial in the “relabel” part of the RRR exercise because it is about active awareness of what is occurring in the present. For example, we recognize that we are triggered/anxious in the moment and make a conscious effort to acknowledge that it is directly related to our anxiety or OCD. Mindfulness may also serve the “reframe” piece of RRR because the accurate assessment of the current situation necessitates being more present and more rational about the way we are thinking. Finally, mindfulness might be helpful for the “redirect” part of RRR because often we are worrying about something that might happen in the future; we are worrying about something uncertain (“what if…”). If we redirect our focus to something we are doing in the present, especially a helpful/therapeutic behavior, we pay attention to what is happening minute-to-minute rather than fretting over what may (or may not) occur later on.

One situation to be aware of is the concern that mindfulness to reduce anxiety can “undo” the practice of exposure. We do not want clients to utilize mindfulness techniques during an ERP session to calm themselves down or to reassure themselves that their fear will never happen. The central idea of exposure is to confront the fear and tolerate the anxiety that comes with it; therefore, we don’t want to introduce an “anxiety-neutralizing” technique in the middle of that process.

Mindfulness that is being used specifically to reduce anxiety symptoms can be employed effectively, and to the client’s progress, outside of an active ERP session. However, the principle of mindfulness that promotes staying in the moment and accepting it in total, exactly as it is, is beneficial to the practice of exposure. Realizing that you are triggered, accepting that you are feeling anxious, or that you are obsessing and thinking these thoughts, and allowing them to come and go are all applicable to exposure.

To reiterate, meditation and relaxation techniques are typically not to be used during exposure therapy. These skills are for reducing anxiety symptoms in specific situations and overall in day-to-day life. One relaxation technique that frequently uses mindfulness is meditation. Methods such as meditation can actually retrain your brain to make new connections and pathways that promote tranquility and rationality more often during times of stress. The UCLA Mindful Awareness Research Center website (https://www.uclahealth.org/uclamindful/guided-meditations) provides helpful free guided meditations.

Another relaxation technique is a practice called progressive muscle relaxation. Progressive muscle relaxation is the process of tensing parts of your body (such as clenching your jaw or making fists with your hands), and then slowly releasing that tension. This can be done as a full-body scan, starting with purposeful tension in your face and ending with your toes, or can be done by focusing on one specific area of the body—whatever feels most beneficial to you at the time.

We need fun so that life is more than just a “to-do list.” For anxiety sufferers, symptoms can greatly interfere with the enjoyment of life, especially without something to anticipate that is enjoyable to them. Engaging in recreational activities on a regular basis with friends and loved ones can be a source of hope and relief from anxiety.

Sometimes it is hard for people to find the right words to capture the amount of anxiety they might be experiencing. Some fear that saying their intrusive thoughts out loud will make them come true. Some may simply be more artistically inclined. Whatever the reason may be, utilizing various forms of art can be helpful and healing in the exposure process as it allows individuals to express themselves in ways other than talking. For example, one client used her artistic abilities to create her own character that represented her worries and unhelpful habits. By doing so, she was able to use her ability and love of creating characters to represent her struggle all while keeping it in perspective by doing what she already enjoys.

Perhaps someone may not be ready to write all that could go wrong when visiting a crowded mall. However, by utilizing art in the exposure process, he could draw a mall filled with a sea of people with himself in the middle of the crowd. A person may not be ready to touch a public doorknob due to contamination fears. She could begin by drawing herself covered in germs or even surrounded by people who are covered in germs. Art is not limited to drawing or painting. Art can involve a variety of activities such as music, poetry, sculpting, and acting. A person could even write a poem about their relationship with anxiety, or how they feel in the midst of a panic attack. Someone who enjoys music could compose a song about their thoughts and feelings that occur when resisting a compulsion. As with writing, the goal isn’t to produce a masterpiece, but to help individuals express and become mindful of their own thoughts and feelings.

Scientific research on spirituality has had a rocky history. It’s hard to define what “spirituality” actually is, and even harder to measure it. In the last few decades, we have been able to examine the effects of spiritual practices on the brain. Neuroscientists have used electrodes and MRI machines to examine what happens in the brain when we pray or meditate. These practices actually rewire our brains to make us happier and more resilient in the face of stress. Human beings are designed with a capacity for awe and wonder. Something in us responds to profound beauty, like a church choir, a concert, or a sunrise over the ocean. It also responds to quiet and attention when we still ourselves and contemplate something as simple as a drop of dew sliding down a windowpane, or a baby sleeping in its parents’ arms. If we pay attention, we can find moments of awe and wonder in our daily lives. Take a moment to ponder how you see: tiny photons of light, born in the furnace of the sun, travel eight minutes through space, ricochet off objects around you, and pass through your eye before slamming into your retina. They paint an upside-down picture there that gets chemically translated and sent to your brain, where they are interpreted as colors and shapes that somehow make sense. That whole process enables you to see the symbols on this page and translate them into thoughts that we call “reading.” This is so amazing that if we were to truly appreciate it, we would constantly be in a state of awe. Congratulations! You are a miracle!

Spirituality seems to be, in part, about bringing that capacity for awe and wonder into daily life, pausing to be thankful in the midst of ordinary existence. Brother David Steindl-Rast, who writes about gratitude, says that gratefulness is the core of spirituality. Pausing to give thanks, to rest in thankfulness, recalibrates how we approach our lives. People who give thanks tend to be not only happier, but they are also more likely to take care of their health and maintain relationships with other people. Gratitude has a domino effect of positivity in our lives, which increases our overall happiness and makes us more likely to do behaviors that maintain our happiness.