How do you help a friend with extreme anxiety in the moment?
November 9, 2021 2:58 AM   Subscribe

How do you support a friend with extreme anxiety in the moment?

I have a very close friend with diagnosed anxiety and OCD. She has been trying out different therapies (both medical and talk therapy) for years and so her symptoms wax and wane. She openly talks to me about her issues and what she's doing to tackle them and I always want to do what I can to support her.

This is not a question about how to connect her with resources to support her--she is continuously exploring her options. This is a question about what I can do as a friend when symptoms are presenting themselves in the moment.

A lot of her anxiesty stems from how her behaviors might negatively affect others. Examples:

-She used to be a pre-school teacher years ago, but after reading about non-inclusive practices in education, she's now anxious about how she has potentially irreparably harmed children because she didn't have the same knowledge of best methods we have now. She now thinks that her lessons making paper bag hand puppets for two year olds is tantamount to child abuse.

-She accidentally walked into a corner store without a mask on (completely forgot) and cried for a week because she potentially exposed the guy working the counter to covid and she knows he has a family and what if he died and it's her fault that his children have no father.

-Just yesterday we were cheering on runners at the marathon and afterward she was physically upset because she had yelled 'Great job guys, you guys are doing great' and now she's upset that her gendered language could have been triggering/upsetting to women or non-binary runners.

My friend is a truly angelic person, her intentions are always selfless. This is not performative, she is truly debilitated when she thinks she could potentially have caused someone harm. And yes, there is the smallest kernel of truth in everything she thinks (sure, someone could have been offended), but she inflates it to a degree that is unreasonable and that causes her acute and sustained pain.

My question is how do I best respond to her in the moment she's telling me these things, like when we had coffee after the marathon and she kept turning it over and over in her head then she texted me later that night saying how horrible she is and so many people heard her saying 'you guys', etc etc? Saying 'of course not, I'm sure everything is fine and no one was hurt' is not very helpful to someone with disordered thinking (I say this as someone who used to have depression and knows a generalized 'everything is fine, what do you have to worry about' is the opposite of helpful).

Obviously she's not looking to me for solutions, and I'm always present to listen, but as an active listener, what should I be doing/saying in the moment to help or, at the very least, not exacerbate the problem?
posted by anonymous to Human Relations (12 answers total) 12 users marked this as a favorite
Could you talk about it at some point when she's not in an anxiety tailspin and ask what would be most helpful to hear in those moments?

I think distraction is super-useful. Not instead of listening - let her explain her worries through, being reassuring. But after going through it once, then suggest a form of distraction, preferably something physical.

Maybe 80% of her brain will still be worrying about The Thing but even if you can get 20% of her brain onto walking the dog or doing some crafts, that 20% is some relief. And she'll at least get to the end of the day and be able to look back and know she did something with that day, instead of surrendering it entirely to her mental health gremlins.

That's useful because it reduces the negative feedback loop that says "This must be a huge problem because I spent the entire day with 100% of my mind on it". It's a little better for your subconscious to get the message that "This must be a moderately large problem because I devoted 80% of my brain power to it today and for five minutes while I was throwing the stick for the dog, I actually forgot about it and the world didn't end." If you're not with her, helping her decide on something practical to do with the next hour or two rather than sitting ruminating could be helpful.

Depending on your friendship you could maybe agree ahead of time a phrase that you can use as shorthand to indicate to her that this is "one of those times" that her anxiety is swinging in, helping her to recognise that what she's going through is a pattern of anxiety thinking, not a genuine disaster. Don't use it to cut short listening to her, but once you've heard her worries once through, you can respond with "I'm sorry, that sucks. I think this might be one of those sherbet dip situations. I know it feels terrible, but I really think it's going to be OK. Shall we go and feed the ducks?"
That might not work for everyone though, depends whether she's someone who would welcome having that thought pattern pointed out to her, or whether she'd find it patronising/feel like it was you trying to close down the conversation. Ask her.
posted by penguin pie at 4:03 AM on November 9, 2021 [6 favorites]

Ask her what her coping strategies are (or possibly what she has been advised to try). A person I know with anxiety actually does find that logic works to relieve her anxiety, and she can talk herself down and it is not at all difficult to support that by questioning her disordered thinking in the moment. But I wouldn't try that on everyone, as I don't know that it is a good coping strategy for everyone.
posted by plonkee at 4:04 AM on November 9, 2021 [3 favorites]

So, what you're describing can also be classed as *extreme perfectionism.* I also suffer from this and actual anxiety. I don't know about your friend but I was raised with an absolute terror of ever making mistakes, and my identity was very closely tied to being "good," that is, "perfect."

So for one thing, you and I know that being perfect (always wearing your mask, having perfect omniscient knowledge of best pedagogy practices, never fucking up and using the wrong pronouns) is not within reach. (Maybe you've always known it but I had to learn it.) Your friend, in addition to treating her anxiety which you indicate she is doing, needs to learn that perfectionism is not something that is attainable and is, rather, a torture device foisted upon us by the patriarchy.

I would gently suggest, when she gets into these holes, that what is actually at play here is a distortion, that it is not possible to be perfect, and I would encourage her to understand that mistakes make up part of how we learn. Everyone makes mistakes. Whom does she admire most? That person has made mistakes, I am sure they are documented somewhere. You? You make mistakes, all the time. People on the news? Definitely make mistakes.

Super Basic "People make mistakes" Resources:
1) It's OK to Make Mistakes (YouTube of a kids' book, this makes me laugh at myself and gets me out of my head)
2) An Essay from the Bolthole (Short)
3) The Gifts of Imperfection (a book)
posted by Medieval Maven at 4:21 AM on November 9, 2021 [8 favorites]

Really, you've got to ask her. Find a good moment, one where she's not actively underwater with anxiety, and just ask. "Hey friend, I was wondering if there's anything specific you'd like me to do for you when you're dealing with intense anxiety in the moment. Is there anything I could do that would be helpful?"

Be aware that sometimes you can't fix something like this -- the best you can do is to be there with the person.

Emotional validation may also be a helpful technique for you to learn about. Basically, you let go of any focus on the "facts of the case" and you simply validate her feelings, which are very real. So for instance, instead of saying, "Well, I don't think the marathon runners even heard you, and even if they did, I don't think they'd be upset," (focusing on the facts of the case), you would say something like, "I can see you are having a really hard time with this right now," (validating her emotions). This can be surprisingly helpful, both for her -- she may feel seen and heard -- and for you -- it takes the pressure off of you to "solve" her feelings by trying to figure out the right way to convince her not to feel them.
posted by ourobouros at 4:24 AM on November 9, 2021 [6 favorites]

I’m no expert, but when I’m listening to someone in a place like that, the first thing I do is listen—let them get the whole story out, with active empathy, engagement, etc. But if they pause to check in with me for validation on something I don’t think is true—I.e. to confirm saying “guys” in public was harmful to non-binary people the crowd—I might say something like, “Maybe! But it’s also possible that they saw you cheering and smiling and knew you meant well!” or something like that. And if they push back, I don’t argue, but go back to active listening, But of they seem open to alternatives, I’ll try to find a story in my past that can help me identify (“I remember once when I misgendered someone and it felt awful, but here’s what I did to make it right…”) A strategy that can sometimes work to break a pattern of irrational thinking is to talk about parts: “It seems like part of you is being really hard on yourself—is there a part of you that has more empathy for what you were trying to do in that moment?” It’s a bit therapy-talk-ish (I learned it from my therapist!) but it can sometimes be very effective. And then, if it really seems like they’re stuck and not getting anywhere, there can come a time to gently but firmly set a boundary: “I feel for you, I really do, but you’re being incredibly hard on yourself and I don’t think it’s helpful for you to keep beating yourself up. Do you mind if we change the subject for a little while?”
posted by Merricat Blackwood at 4:49 AM on November 9, 2021 [2 favorites]

If it's about regrets and concerns about mistakes in the past, we do the best we can and that regret can be a nudge to positive change. Many of your examples are in the "oops, sorry" category.

In the initial moment for myself and my close-anxiety-havers, we do the "standard" invasive thought/panic/anxiety mitigation stuff:
* Quick! Name 5 things you see, 4 things you hear, 3 things you smell... etc.
* Quick! Count backwards from 1,000 by 5s (or 13s if they're, like, really good at the 5x table).
* Go do that chore you hate-hate-hate; dishes or dusting or vaccuuming or whatever. You're moving and you're getting your mind off it, and you're productive

and there are great suggestions above in the vein of "mindfulness" and "gratitude" and "attention" and "focus." "Not freaking out" is basically "separating stimulus from response," which is a skill that can be practiced over time.
posted by adekllny at 6:27 AM on November 9, 2021 [1 favorite]

This might go against the grain, but I think tough love is the answer. Her relationship with herself is toxic. She is striving for some kind of moral perfection and that is impossible, we are all flawed. She is not angelic, she is human. It is OK. I think she beats herself up in these situations you mentioned to distract herself from her less than perfect thoughts. It’s absolutely performative. In the situations you describe remind her to get over herself. Because while we are all special, we are also not at all.
posted by Lucky Bobo at 7:41 AM on November 9, 2021 [2 favorites]

If I was in this situation with my friend who's in treatment for OCD, I would definitely say "Hey, what's your treatment goal here? How would you and your therapist like me to react to these situations?"

This is second-hand, and folks who have OCD themselves, please correct me if I'm wrong. But my experience through my friend has been that OCD treatment is very specific, sometimes counterintuitive, and often involves planning out in advance what kinds of exposure to take on and how to respond to them. Jumping into that with "Hey, friend, here's what I think you should do" would feel counterproductive to me. I'd at least want to check in first.
posted by nebulawindphone at 7:53 AM on November 9, 2021 [9 favorites]

Learn some ACT defusion techniques and walk through them with her when she's getting lost in her anxiety. There's probably a lot of intro-to-ACT material out there that would be helpful in this context.
posted by late afternoon dreaming hotel at 7:55 AM on November 9, 2021

I would recommend not engaging with the contents of her anxious obsessive thoughts at all. Whatsoever. Whatever you say will easily be construed to be used as further weapons for her to use against herself. You will not be able to say anything which won’t make things worse.

So in those tough moments you can soothe and distract:
- take her outside for a walk
- make her a cup of tea
- suggest you watch something together
- generally be calm and gentle and directing her away from her ruminations.
posted by Balthamos at 10:14 AM on November 9, 2021 [4 favorites]

Obviously she's not looking to me for solutions, and I'm always present to listen, but as an active listener, what should I be doing/saying in the moment to help or, at the very least, not exacerbate the problem?

Yeah a lot of this really depends, as nebulawindphone says, of what her treatment goal is. Because reassurance seeking at this level (i.e. texting you to rehash the horrible things her brain is telling her where you probably tell her it's not that bad) is itself part of the difficult cycle of OCD/anxiety and it may be worth talking through this with her in a time where she's not stuck inside it, because the last thing you want to be doing, I suspect, is being part of a bad symptom she is having. But you want to help which is a really good thing, you are a good friend.

Because I think it's fine (as someone who suffers from anxiety but not this level of OCD) to be empathetic and tell her that you are genuinely sorry for the negative feelings she's experiencing but at the same time not really engaging with the content of what she's saying. Because at the level that she's experiencing this anxiety, the crying for a week thing, may be normal for her but is way outside the bell curve for even normative stress reactions and this sounds debilitating. So tI think helping her focus on the fact that this is a non-normative reaction and help her focus on whatever her therapeutic approach to that kind of thing is, may be helpful.

Just speaking from what has been helpful to me, an anxiety sufferer. I mostly have anticipatory anxiety, am very very convinced that whatever bad thing I think is going to go wrong is LOGICALLY OBVIOUSLY HAPPENING and it's not useful when people tell me "Oh that bad outcome won't happen" and very helpful when people are like "Hey you sound pretty scared, would you like to talk about that?" Sometimes, for me, fighting about how sure I am of the bad thing is actually like a maladaptive thing that I crave at some level but is actually bad for me to engage with.
posted by jessamyn at 10:40 AM on November 9, 2021 [3 favorites]

Hi, I have OCD and anxiety, and I've had symptoms very similar to what you're describing in your friend. Through both my OCD specialist's recommendations and through trial and error, I've found a few things that work for me in terms of how my friends can best help. Of course this is just based on my experience; I'm not your friend's therapist (or any kind of therapist at all). But I hope it helps you think about the situation. You sound like a wonderful friend that anyone would be lucky to have, FWIW. :)

-First, I absolutely second nebulawindphone's suggestion of asking your friend what she needs/wants, if you're close enough to feel comfortable doing this. I recommend asking her at a time when she doesn't seem to be in the middle of an anxiety spiral, if possible. (For me, anyway, it's much easier to believe and express what will *actually* be good for my long-term treatment during times that I'm clear-headed and not in the grips of anxiety and reassurance-seeking.) I've had several friends do this, usually by asking pretty straightforwardly (e.g. "Hey chaiyai, how's therapy going? Is there anything I can do to help when you're anxious?"), and it's always very touching and appreciated.

-Your friend might say that she'd like your support in avoiding enabling her reassurance-seeking behaviors (this is what my OCD specialist recommends his patients tell friends and family, so it's the approach I take). This is tricky but can be *so beneficial* for the relationship. Your response in this case will depend on your comfort level as well as hers. Here are examples of various ways friends have responded to me when I've come to them with something I'm anxious about (I try not to do this much personally as part of my treatment, but sometimes it happens):
---"It sounds like you're seeking reassurance from me. I love you and you know I'm not going to do that. I'm gonna change the subject so we can talk about something else." (Neutral, honest, straightforward.)
---"Yeah, sounds like [your worst fear in this situation] is probably gonna happen then. Sucks. I guess [everyone hates you/that mole is actually cancerous/you probably irreparably harmed those people]." (This is obviously an extremely blunt tough-love approach, similar to exposure therapy. It's what my specialist recommends as being most effective, but I personally haven't felt super comfortable asking most of my friends to do this, nor have most of them felt comfortable going this route, which I totally understand and would never pressure them to do.)
---"I'm sorry to hear that; it sounds tough. Want me to listen/hug/distract you?" Then, as you listen, continue saying some form of "that sounds tough" or "I'm sorry you feel so shitty", but don't weigh in on whether or not x anxiety is true. (This is the option I use with my friends who are being super anxious and seeking reassurance from me, but who haven't asked me explicitly to deny giving them reassurance, since I feel it'd be presumptive and boundary-crossing to basically exposure-therapy them when they haven't asked for it. This approach expresses sympathy for the real pain your friend is experiencing but avoids directly enabling the anxiety.)

-Often my friends do end up saying things that are technically not ideal for my recovery and enable my anxiety. This happens for loads for reasons, including that it's just a very normal human response to want to validate a friend's concerns and help them feel better in the moment. I emphasize that it's 100% not their responsibility to manage my anxiety - it's mine - and same goes for you and your friend, of course.

-I also like penguinpie's suggestion about distractions. This depends on the person - I know some people in OCD treatment who use distractions in unhealthy ways to avoid confronting their anxiety. But for me it works pretty well, for the reason that penguinpie mentioned (unsticks my brain from the tailspin, gets my brain used to the fact that it's possible to think about other things even when The Worst Thing is Happening).
posted by chaiyai at 2:01 PM on November 9, 2021 [5 favorites]

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