Anxiety Training Tips

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By: Bridget Eickhoff

Anxiety, worry, and panic are felt by many of us at some point in our lives. After attending a training by David Carbonell, Ph.D. on chronic anxiety, I picked up some helpful tools that I would like to share.

The more you oppose unwanted thoughts, feelings, and sensations the worse they can become

A big reason behind anxiety symptoms is self-protection. People often interpreted anxiety as a signal for danger, meaning fight, flight, or freeze; but what if that was a false signal. What if this feeling is intense discomfort that will eventually pass if it is not forced to be silence. Next time you are experiencing anxiety check-in with yourself and if you indeed are in danger or is this discomfort? If it turns out to be discomfort allow yourself 5-10 minutes to worry, you may be surprised how different it feels to allow the worry to have its time rather than continue to suppress it.

 

The Rule of Opposites

Think of yourself swimming and trying to avoid a large wave coming your way. You may ask yourself “what is the best way for me to avoid this wave?” Your instincts may say to swim away from the wave and hope you can be faster, but in reality the easiest way to avoid the wave is to swim under it. The same can apply to feelings of anxiety and worry. During a panic attack your gut may tell you to hold your breath or take in more breaths at a time, when what is shown to help is taking deep belly breaths. Next time you find yourself beginning to feel anxiety or panic, try to recognize how your gut tells you to react and think about what the opposite might be.

 

The next time you are experiencing high anxiety or a panic attack be AWARE

Acknowledge and accept the feelings

Wait and Watch – recognize what the sensations in your body and your thoughts (this could be a good time to try doing the opposite of your usual)

Action – make yourself comfortable while waiting for it too pass

Repeat – go through steps a-c and try to think to yourself it will end no matter what I do

End of intense anxiety or panic attack

 

Our therapists at CARE Counseling are trained and competent in working with those experiencing symptoms of anxiety. Your counselor will be able to help explore with you common patterns of negative thinking, help you develop successful coping skills, and teach calming strategies.

 

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Eating Disorders: An Overview

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When you become so preoccupied with food and weight issues that you find it harder and harder to focus on other aspects of your life, it may be an early sign of an eating disorder. Without treatment, eating disorders can take over a person’s life and lead to serious, potentially fatal medical complications. Eating disorders can affect people of any age or gender, but rates are higher among women. Symptoms commonly appear in adolescence and young adulthood.

Symptoms

Eating disorders are a group of related conditions that cause serious emotional and physical problems. Each condition involves extreme food and weight issues; however, each has unique symptoms that separate it from the others.

Anorexia Nervosa. People with anorexia will deny themselves food to the point of self-starvation as they obsesses about weight loss. With anorexia, a person will deny hunger and refuse to eat, practice binge eating and purging behaviors or exercise to the point of exhaustion as they attempts to limit, eliminate or “burn” calories.

The emotional symptoms of anorexia include irritability, social withdrawal, lack of mood or emotion, not able to understand the seriousness of the situation, fear of eating in public and obsessions with food and exercise. Often food rituals are developed or whole categories of food are eliminated from the person’s diet, out of fear of being “fat”.

Anorexia can take a heavy physical toll. Very low food intake and inadequate nutrition causes a person to become very thin. The body is forced to slow down to conserve energy causing irregularities or loss of menstruation, constipation and abdominal pain, irregular heart rhythms, low blood pressure, dehydration and trouble sleeping. Some people with anorexia might also use binge eating and purge behaviors, while others only restrict eating.

Bulimia Nervosa. People living with bulimia will feel out of control when binging on very large amounts of food during short periods of time, and then desperately try to rid themselves of the extra calories using forced vomiting, abusing laxatives or excessive exercise. This becomes a repeating cycle that controls many aspects of the person’s life and has a very negative effect both emotionally and physically. People living with bulimia are usually normal weight or even a bit overweight.

The emotional symptoms of bulimia include low self-esteem overly linked to body image, feelings of being out of control, feeling guilty or shameful about eating and withdrawal from friends and family.

Like anorexia, bulimia will inflict physical damage. The binging and purging can severely harm the parts of the body involved in eating and digesting food, teeth are damaged by frequent vomiting, and acid reflux is common. Excessive purging can cause dehydration that effect the body’s electrolytes and leads to cardiac arrhythmias, heart failure and even death.

Binge Eating Disorder (BED). A person with BED losses control over their eating and eats a very large amount of food in a short period of time. They may also eat large amounts of food even when he isn’t hungry or after he is uncomfortably full. This causes them to feel embarrassed, disgusted, depressed or guilty about their behavior. A person with BED, after an episode of binge eating, does not attempt to purge or exercise excessively like someone living with anorexia or bulimia would. A person with binge eating disorder may be normal weight, overweight or obese.

Causes

Eating disorders are very complex conditions, and scientists are still learning about the causes. Although eating disorders all have food and weight issues in common, most experts now believe that eating disorders are caused by people attempting to cope with overwhelming feelings and painful emotions by controlling food. Unfortunately, this will eventually damage a person’s physical and emotional health, self-esteem and sense of control.

Factors that may be involved in developing an eating disorder include:

  • Genetics. People with first degree relatives, siblings or parents, with an eating disorder appear to be more at risk of developing an eating disorder, too. This suggests a genetic link. Evidence that the brain chemical, serotonin, is involved also points a contributing genetic and biological factors.
  • Environment. Cultural pressures that idealize a particular body type place undue pressure on people to achieve unrealistic standards. Popular culture and media images often tie thinness (for women) or muscularity (for men) to popularity, success, beauty and happiness.
  • Peer Pressure. With young people, this can be a very powerful force. Pressure can appear in the form of teasing, bullying or ridicule because of size or weight. A history of physical or sexual abuse can also contribute to some people developing an eating disorder.
  • Emotional Health. Perfectionism, impulsive behavior and difficult relationships can all contribute to lowering a person’s self-esteem and make them vulnerable to developing eating disorders.
  • Eating disorders affect all types of people. However there are certain risk factors that put some people at greater risk for developing an eating disorder.
    • Age. Eating disorders are much more common during teens and early 20s.
    • Gender. Women and girls are more likely to have a diagnosed eating disorder. However, it is important to recognize that men and boys may be under-diagnosed due to differences in seeking treatment.
    • Family history. Having a parent or sibling with an eating disorder increases the risk.
    • Dieting. Dieting taken too far can become an eating disorder.
    • Changes. Times of change like going to college, starting a new job, or getting divorced may be a stressor towards developing an eating disorder.
    • Vocations and activities. Eating disorders are especially common among gymnasts, runners, wrestlers and dancers.

Diagnosis

A person with an eating disorder will have the best recovery outcome if they receive an early diagnosis. If an eating disorder is believed to an issue, a doctor will usually perform a physical examination, conduct an interview and order lab tests. These will help form the diagnosis and check for related medical issues and complications.

In addition, a mental health professional will conduct a psychological evaluation. They may ask questions about eating habits, behaviors and beliefs. There may be questions about a patient’s history of dieting, exercise, bingeing and purging.

Symptoms must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in order to warrant a diagnosis. Each eating disorder has its own diagnostic criteria that a mental health professional will use to determine which disorder is involved. It is not necessary to have all the criteria for a disorder to benefit from working with a mental health professional on food and eating issues.

Often a person with an eating disorder will have symptoms of another mental health condition that requires treatment. Whenever possible, it is best to identified and address all conditions at the same time. This gives a person comprehensive treatment support that helps insure a lasting recovery.

Treatment

Each person’s treatment will depend on the type of eating disorder, but generally it will include psychotherapy along with medical monitoring and nutritional counseling. Family-based treatment is especially important for families with children and adolescents because it enlists the families’ help to better insure healthy eating patterns and increases awareness and support.

Many people receive treatment for an eating disorder without needing an intensive treatment setting. However, for some people, an inpatient or residential eating disorder treatment center or partial hospital setting is best when they begin treatment. Others may need hospitalization to treat serious problems caused by poor nutrition or for care if they are very underweight.

Support groups, nutrition counseling and medications are also helpful to some individuals.

Psychotherapy should be provided by a mental health professional with experience in treating eating disorders. Because of the complexity, therapy needs to address both the symptoms and a person’s psychological, interpersonal and cultural influences which contributed to the disorder.

Cognitive behavioral therapy (CBT) is often successfully used in the treatment of eating disorders because it helps people understand the relationship between their thoughts, feelings and behaviors. CBT that is developed for the treatment of bulimia is very effective at changing the binge-purge behaviors and eating attitudes.

Wellness and Nutrition Counseling involves professionals helping a patient return to a normal weight. Dietitians and other health care providers can help change old habits and beliefs about food, dieting and exercise with healthy nutrition and eating information and planning. Sometimes planning and monitoring responsibilities are shared with mental health professionals or family members.

Helping Yourself

Although you may realize that your behaviors are destructive it may be difficult to control them. Treatment can teach you ways to cope. Here are some examples:

Lifestyle. It’s important to begin making changes in your life and remove the reminders and stop negative behaviors associated with the disorder. Resist the impulse to check yourself in the mirror frequently or weight your several times a day. Fight the urge to diet or skip meals.

Steer Clear of troublesome reminders. Identify the triggers–a certain place, challenging situations, some friends-for old behaviors or symptoms and prepare a plan to deal with them.

Accept yourself. Your healthy weight is your ideal weight. Don’t be tricked by ultra-thin models and actresses. Look for healthy role models. Focus on activities and interests that make you feel good about yourself.

Partner with your health care providers. Develop trust and communicate openly. Give your healthcare provider the information they need to help you recover. Don’t skip therapy sessions, and be consistent with meal plans. Ask about vitamin and mineral supplements and which type of exercise, if any, is appropriate for strengthening and rebuilding your body.

Complementary therapies. Alternative and complementary therapies and medicines can have negative or positives effects. Always discuss with your health care providers anything you would like to add to your treatment plan. Weight loss supplements, diuretics, laxatives or herbal remedies are commonly unregulated, and often misused. Other treatments generally considered safe and helpful, including acupuncture, massage, yoga, chamomile tea and biofeedback.

Learn all you can. Read self-help books that offer practical, credible advice. Research helpful topics online, but don’t visit websites that promote dangerous eating habits or showcase very thin, unhealthy bodies, as it could trigger a relapse. For men with eating disorders, check out the National Association for Males with Eating Disorders (N.A.M.E.D.).

Find emotional support from others recovering from an eating disorder. Share your thoughts, fears and questions with other people who have dealt with an eating disorder. Connect with others on online message boards or peer-support groups like NAMI Connection Recovery Support Groups.

If you live with a mental health condition, learn more about managing your mental health and finding the support you need.

Supporting Your Family Member Or Friend

Discuss your concerns. If you have concerns about a friend or family member and suspect an eating disorder may be the reason, learn about the different disorders, symptoms and warning signs. When you are knowledgeable, talking with them in a loving and non-confrontational way about your concerns is best. Tell the person you care.

Suggest they see a doctor, counselor or other health professional. This may be tricky, as your loved one may not want to admit or even realize there is a problem, but sometimes seeing a professional who is knowledgeable about eating disorders is the first step in recovery.

Avoid the traps. Conflicts and battles are hurtful. If a person is not ready to acknowledge a problem, you can be a supportive friend. Avoid placing blame, guilt or shame on them about behaviors or attitudes related to the eating disorder. Remember that giving simple solutions minimizes the courage and strength a person needs to recover from an eating disorder.

Be a good role model. Reflect on your attitudes and actions. Do you maintain sensible eating and exercise habits? Also, focus on the other person’s successes, accomplishments or personality.

Parenting. Having a child with an eating disorder places significant responsibility on parents, making them active partners in treatment planning and implementation. Your family needs to feel comfortable and confident in the professional’s approach and abilities, and in discussing the disorder. Finding a mental health professional with experience treating young people or children with eating disorders and their families is important.

Find emotional support. Family support groups provide people with a chance to share thoughts, fears and questions with other people who are in similar situations and understand.

 

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Everybody Knows Somebody: Eating Disorder Awareness

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Eating disorders are some of the most challenging mental illnesses and are serous, life-threatening conditions. Affecting one in 20 people during their lifetime, eating disorders frequently occur in people with other mental illnesses, including depression, anxiety disorders and substance abuse issues and as with other mental illnesses, early identification and early intervention are keys to recovery.

NAMI joins NEDA this week in support of the aim to ultimately prevent eating disorders while reducing the stigma surrounding these conditions and improving access to treatment.

NAMI recently spoke with Andrea Vazzana, Ph.D., a clinical psychologist and eating disorders specialist, to learn more about eating disorders and how to help a friend or loved one living with one of these conditions.

NAMI: What is the current prevalence of eating disorders in America?

Vazzana: Overall, over 10 percent of young women currently meet criteria of one of the eating disorders, anorexia nervosa, bulimia nervosa or eating disorder NOS (not otherwise specified). The new Diagnostic and Statistical Manual (DSM5), set to publish in May this year, includes binge eating disorder as a mental illness. Men can also live with eating disorders. While the prevalence of men to women was previously thought to be a ratio of 1-to-10, it is now believed that the ratio is closer to 1-to-6, meaning that six times more women than men have the condition. Although not as common in men, it is important to recognize that more men are now being treated for these mental illnesses.

Some believe that eating disorders are more prevalent in women because of what is called the “thin-ideal”. Biology and environment are both contributors to this condition, and researchers have found that the cultural pressure to equate thinness with beauty, as well as some sports that encourage low body fat and thinness, are factors. It is not always the ideal cultural “think” to equate thinness in men and therefore that social factor is often removed. Still, there are some sports and cultures where being thin is idealized and therefore a contributor.

What are the types of eating disorders and are there any recent changes in prevalence and conditions?

Vazzana: Eating disorders NOS, will be changing with the new DSM, to be published in May. The criteria and diagnosis will change. Binge eating will be a full-blown disorder all on its own. Binge eating disorder is similar to bulimia in that it includes the binging, but not the purging, aspect of the condition.

What are the most common co-occurring disorders (mental health conditions)?

The most common is depression and dysthymia, what some consider a less-severe but often longer lasting condition than depression. Half to three-fourths of those with eating disorders meet the criteria for depression in their lifetime, and there is a direct relationship to malnourishment and depression.

In addition to depression, the other most common co-occurring conditions are anxiety disorders, specifically social phobias and, with people living with anorexia, OCD, which impacts about 25 percent of individuals with this condition.

Substance abuse, particularly alcohol abuse, is co-occurring in about 5 percent of people living with anorexia and from 25-40 percent of people living with bulimia.

Personality disorders are also common co-occurring conditions, particularly for people living with bulimia.

What are current treatment options available and what are likely outcomes?

Recovery from eating disorders is possible. The right treatment choice depends on the type of eating disorder, but treatment approaches are often similar for the various conditions, and coordination of care between mental health care providers, nutritionists and medical professionals is important, depending on the individual’s treatment plan. Nutritional guidance, as well as individual and family counseling, is an important treatment options to consider.

The best rates of recovery for people living with bulimia involve cognitive behavioral therapy (CBT) where the focus is often on normalizing weight and eating behaviors and challenging distorted thinking patterns that are usually associated with this condition. One of the goals is to interrupt the thought pattern that leads to individuals evaluating themselves in terms of shape and weight. Individual therapy is often another key to recovery.

The best rates of recovery for people living with anorexia include treatment plans that incorporate family-based therapy, often the Maudsley Method, which is often used for adolescents and children with Anorexia still living at home. This intervention involves parent coaching to encourage feeding their children to help restore their weight—eating meals with them and encouraging eating. With anorexia, it is important that the individual restore their weight as soon as possible; the longer they are in a danger zone of thinness and malnutrition, the worse the outcome. Early intervention is key; people living with anorexia (about 5 percent) have the highest probability for mortality, including death by suicide.

In addition to psychotherapies, medications, specifically, selective serotonin reuptake inhibitors, SSRIs, a type of antidepressant medication, are sometimes used in patients that are responding to CBT as an adjunct therapy.

What myths are the most common and what stereotypes exist that create barriers to understanding and treatment?

The myths surrounding eating disorders are vast and include myths primarily around race, age and social economics.

When people think of anorexia, they often mistakenly think of young, white, high social status females. This is not the case. There are 5-10 million people in America who have eating disorders, and one out of 6 are men, who more deeply experience the negative aspects of stereotypes and have unique barriers to treatment and acceptance.

We also know that eating disorders do not just affect white women. The rates are as common in young Hispanic and Native American women as they are in Caucasian women. With African American and Asian American women, however, there does seem to be a lower prevalence, with the exception of pre-adolescent African American girls. With Caucasian girls, the prevalence is lower and rates increase with puberty and continue to increase as into early adulthood.

Age is another myth; eating disorders do not just affect teens and young adults. More and more are being diagnosed for the first time in middle age. And unless effectively treated, eating disorders will last into adulthood for many.

How can someone help a friend or loved one who may have or one who is living with an eating disorder? How should they/could they intervene if needed and how can the provide support?

Regarding intervention, the key to remember is that the earlier the better. In terms of identifying a problem, it is important to know that it is common to have body dissatisfaction. Most women are more critical. However, when they go beyond dissatisfaction and they are harshly critical and disparaging of their bodies, and when there is noticeable evidence of over-thinness and over concern about food and weight, there may be a problem.

Some people mistakenly wait to intervene, thinking that the individual may grow out of their condition. The best thing to do is to let them know about your concern. You have observed behavior—talking poorly about their body, other signs—and you just want to be honest. Saying something like, “I have noticed these things and I am concerned about your health,” without being judgmental, can be the most natural first step. Because individuals living with eating disorders are generally already self-critical, it is important to so separate the illness from the individual. Try not to focus comments on appearance but rather focus comments on health by expressing concerns and the need for further medical evaluation. Recognizing that people with eating disorders often consider being thin with success, being persistent and consistent while avoiding criticism and comments on thinness, is important.

After an individual is in treatment for an eating disorder, one of the best things a family member or parent can do is to get family-based treatment or therapy. During meals, families and friends should try not to be angry even if they see their friend or loved one struggling with eating. Working to avoid impatience can be challenging, but neutral and supportive reassurance offer the best outcomes.

It is important that friends and family strive to avoid commenting on appearance. Avoid comments like, “You’re gaining some weight, that looks great!” Compliment other things, perhaps superficial aspects of clothing, conversations, other activities and contributions, but avoid mentions of size or appearance if possible.

What do you think is the most important thing for people to know about eating disorders?

The importance of intervening early! Treatment works best the earlier you can begin it. The longer the condition persists, the more deadly it becomes with more physical complications to manage.

Andrea Vazzana, Ph.D.,is a clinical assistant professor of child and adolescent psychiatry at the NYU School ofMedicine and a licensed psychologist at the Child Study Center.

 

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February is Eating Disorder Awareness Month

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Eating Disorders Awareness Month

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In Many Minneapolis Schools, the Therapist is Just Right Down the Hall

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When Cathy Moen’s son, Elijah, was in first grade, he was diagnosed with attention deficit hyperactivity disorder. She took him to the pediatrician, who put him on medication and suggested therapy.

The medication part was easy. But getting him therapy proved more difficult — not because Moen couldn’t find a therapist or didn’t have insurance, but because of logistics.

The appointments were always during the day, and between her work schedule and the traffic, it was nearly impossible for them to make it.

But she soon learned Elijah was able to see a therapist in his Bloomington school. More than 15 years ago, Minneapolis Public Schools helped pioneer a national model of bringing community mental health care directly to its students. Today, most of the public schools in Minneapolis — more than 50 of them — have a therapist on site, and many other districts, like Elijah’s, have followed suit.

These days, Elijah’s therapist simply walks down the hall and pulls him from class.

“This is like a godsend,” said Moen.

The family’s health insurance pays for the care the same way it would if the student were being seen in the clinic. The school program was designed so that no student in need will be turned away for lack of insurance.

The Minneapolis program has also provided a road map for schools across the country as more administrators realize that mental health is as important to students’ future success as academics. Studies have shown that students are more likely to show up for appointments when the therapists are on-site.

More and more states are making mental health care in schools a priority. At least two states have recently passed laws that require schools to teach mental health. And more are considering it.

But the benefit of having a therapist on-site goes beyond just getting students to see a therapist. In Minneapolis, it’s also helped make mental health a school-wide priority — and helped get counselors, teachers and others more involved, said Mark Sander, who helped start the district program.

A man wearing a button down shirt.
Mark Sander is the director of school mental health at Hennepin County and Minneapolis Public Schools.
Christine T. Nguyen | MPR News

“Those teachers start learning more and more [about mental health],” said Sander, who directs school mental health for the district and the county.

He said as they learn more about mental health, teachers are feeling like, “‘OK, I get it. And now, you know, I’ve got this other student who’s not diagnosed with anxiety but has some of those anxiety features. And now I know how to better support them.”

At South High School in Minneapolis, the therapists sit in the school clinic, the same one where students go if they feel sick during the day or to get a physical so they can play sports.

The issues the students bring to the therapist run the gamut from stress about grades and colleges to anxiety related to a bad situation at home.

Farah Hussein is a therapist at South. She said it’s hard being a teenager, and she tries to help.

“There’s a lot of conversations about, ‘Who am I? Where do I fit in the world? Where do I belong?’ and just a lot of distress in exploring that,” she said.

All of this has important implications for the students’ well-being beyond just their mental health.

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A group of people sit around a conference table in a school.
Collaborative mental health meetings at South include the school’s social workers, counselors, nurses, psychologists, school-based clinic therapists and occasionally administrators.
Christine T. Nguyen | MPR News
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A sign reads "Mental Health" on a wooden shelf with books.

 

Sharon Hoover, who co-directs the National Center for School Mental Health at the University of Maryland School of Medicine, said more schools are collecting data on outcomes of in-school mental health programs, and the results are clear.

“They are more likely to have good attendance and to graduate and to get improved grades. We even have documentation of having better standardized test scores when you put universal systems in place like classroom-wide social emotional learning,” she said, all of which makes for happier, better adjusted students.

Cathy Moen, the mother whose son, Elijah, is in therapy in school, said she doesn’t know if it’s the medicine, or the therapy, or just that he’s growing up, but she — and his teachers — are already seeing a difference.

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In International Falls, the last psychiatrist for 100 miles just retired

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When Dr. Jeff Hardwig started his job as a psychiatrist in his hometown near the Canadian border, he wasn’t sure there was enough work for him.

Pretty soon, it became clear that there was, in fact, plenty of work in International Falls, Minn., a town of 6,000 people. He split his time between a group family practice and community mental health center and also saw patients in nearby communities.

“Within two or three years, it was clear I was too busy to go out of town anymore,” he said.

After nearly 30 years working as the town’s sole psychiatrist, Hardwig retired in September, leaving no psychiatrists for more than 100 miles around. His departure underscores a difficult reality: A national shortage of psychiatrists is much more acute in rural and remote areas, which leaves many people without access to the kind of services they need.

And the demand for Hardwig’s services has never let up.

Wendy Dougherty, the nurse who worked with him at the clinic, said his calendar was always full.

“He never ever … in the five years I worked with him, ever had an empty slot,” she said. “And one thing about his patients, if they called and canceled, that empty slot was filled by somebody that had been waiting two months to get in.”

But, she said, he was also the kind of doctor who would always find a way to squeeze in somebody in a crisis, even if it meant missing lunch or canceling his own meetings.

‘You take all comers’

The clinic where Hardwig worked is a primary care center on the outskirts of town, part of the Duluth-based Essentia Health system. It’s a low-slung building across the street from a Menards and a Dollar Tree that offers all the basic services, including annual checkups and mammograms.

Hardwig and others agree that the need for a psychiatrist in town was there, but until he arrived, people mostly counted on their primary care doctors to handle it.

His patients’ diagnoses over the years ran the spectrum of diseases, including anxiety, depression, bipolar disorder and schizophrenia.

“I had to take care of people of all ages — all the way through to the nursing home,” he said. “You can’t really specialize if you’re in a small town. You take all comers.”

And working in a small town, he also couldn’t avoid running into his patients frequently. It might have been hard for some doctors — psychiatry is a profession that particularly prizes its discretion — but Hardwig says he didn’t mind.

“I just had sort of an agreement with my patients if they say ‘hi’ to me, I’ll say ‘hi’ back, but I won’t otherwise out them. And my wife knew not to ask, ‘How do you know that person?’” he said.

He said his patients were respectful of him, too, and didn’t try to squeeze in consultations in line at the grocery store or when he was out to dinner.

One of his longtime patients was a man named Daniel Carr, whom I met at a clubhouse run by a community mental health center where people with serious mental illness can spend their time. The cozy house has battered couches and an armchair in the living room. A Christmas tree sparkles near the front window.

Carr, who has paranoid schizophrenia, was Hardwig’s patient for 25 years. He says he misses Hardwig.

“He knew exactly about how to treat me,” Carr said.

“I had some trouble with my medicine changing a little one way or the other, but he usually knew what was best. I’d tell him what I was experiencing and he knew what to do.”

Hardwig wouldn’t talk about specific patients, including Carr. Carr said his psychiatric care has been transferred back to his primary care doctor, and that it’s been going OK so far.

But Wendy Dougherty, the nurse who worked with Hardwig, said some of the primary care doctors have been less than enthusiastic about taking on the psychiatrist role.

“Jeff took care of the hard ones,” she said. “The schizophrenics, the bipolars … these docs kind of put up their hands and say, ‘Oh, my God, I don’t know what meds to give them.’”

The psychiatric nurse practitioner Hardwig worked with is still at the clinic and handles some of the harder cases, but she’s planning to retire soon, too.

A shortage in nearly every county

International Falls is hardly alone in not having a psychiatrist — particularly in remote areas.

More than 90 percent of psychiatrists only work in urban areas, even though more than 20 percent of Americans live in rural areas. In Minnesota, nearly every county — aside from the Twin Cities metro and Rochester area — is considered to have a shortage of mental-health professionals as determined by federal guidelines.

Hardwig said the hardest part of working in such a remote area was that he didn’t have a continuum of care to work with.

“There just isn’t that inpatient bed when you need it. We have only one crisis bed and we haven’t had that the whole time I’ve lived here. We don’t have residential treatment,” he said.

And International Falls is luckier than some places because there’s a community mental health clinic in town. (Hardwig partnered with it until his retirement, and the nurse practitioner still does.) The clinic is looking to expand in the near future. There’s also a mobile crisis team in town that can help with emergencies.

Still, recruiting mental-health care providers, even those who aren’t psychiatrists, to remote areas is challenging. Paul Mackie, a professor at Minnesota State University, Mankato, has studied the problem. And he said the only way to recruit and retain people in remote areas is to grow them from scratch. That is how Hardwig, who grew up in International Falls, ended up there.

Mackie said there are already physical medicine programs that train people for practice in rural areas. And he said now we need to do the same for mental health, too.

“We need to be a lot more thoughtful about who we’re recruiting and how we’re recruiting them,” he said. “We can have that conversation around what does a rural practitioner look like and look for that person and encourage them.”

But that takes time. People who graduated from high school this year won’t be done with medical school until 2027. And then they still have to complete their residency and any other specialty training.

So in the meantime, International Falls — and communities like it — are doing what they can. Hardwig’s old clinic has hired a child psychiatrist who sees her patients remotely over Skype-like technology.

Finding people to work on-site is proving much trickier, though. It was two years ago that Hardwig told the clinic he was planning to retire. It’s been looking for a replacement since then. But nobody has applied for the job.

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Holiday Tips

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I recently saw a meme on social media that said “It’s almost time for my normal anxiety to turn into my fancy holiday anxiety.” I had to chuckle when picturing anxiety showing up in a glittery ugly sweater or draped in all things sparkly. Humor aside, it shows that during the holidays, our existing anxiety (or depression) does not just “take a holiday” but rather increases due to stress and societal pressures.

This time of year can be an incredibly stressful and frustrating time. On one hand, we fill our days to the brim with spending time with family and friends, social events, potlucks, baking, preparing meals, finding the right present within your means, and many other tasks guised in the name of the holidays.  All of this “fun” can turn to chaotic quickly. Then on the other hand, some of us may have unwelcome reminders or memories associated with the holidays or feel more alone during this time as we watch others join together and celebrate. Whatever the reason for your distress, here are some helpful strategies to help manage the rise of our fancy anxiety (or depression) in finding ways to relax during the busy time of year or help with our perspective on the season.

  • Self-soothe – Using all 5 senses, focus on what you notice. Cast any judgments away and focus on the experience in the moment. Here are some examples.
    • Taste – slowly eat and notice different flavors in a favorite holiday treat or dish
    • Smell – light a candle or smell a pine tree or cup of tea
    • Sound – listen to your favorite holiday music, point our different instruments or lyrics you might have over looked
    • Sight – watch the fireplace flicker with light or notice the holiday lights all around
    • Touch – when baking or wrapping gifts, bring attention to the different textures you feel
  • Pay it forward – doing something kind for others or contributing can make us feel good about ourselves and give perspective. This could be anything from holding a door open for someone, greeting someone with a smile, adopting a family for the holiday, or volunteering. It does not need to be a large act to bring a sense of contribution to your holiday.
  • Be intentional about breaks – Set aside 15 minutes to check in with yourself and pause from all of the holiday excitement. Read a favorite book, do a meditation, sit in silence, or snuggle up with someone you love.
  • Simplify and slow down – With your to-do list growing, it may feel like you need to be in multiple places at once; however, what we know about the brain is that it cannot think 2 things at once. So, focus your entire attention to the task at hand rather than jumping from task to task (aka multitasking).
  • Follow traditions (or make your own new ones) – Partake in something that brings you meaning for the season, whether this be a family tradition, baking Grandma’s cookies, or finding something new to do this time of year (i.e., sledding, ice skating, driving around to see holiday lights, etc).
  • Put down the phones – I know, I said it. Just hear me out. Often times social media can impact our level of stress by comparing ourselves to others, especially when those others seem to have it all together. They have the catalog ready decorations, Martha Stewarts holiday food spread, or gifts we cannot afford. This can lead us into a down spiral. So, try to limit your access to your phone and engage with those around you.
  • Reach out to someone– The holidays can be a lonely time for some. Sometimes we can still feel lonely in a room full of people, feel so far away and disconnected from others, or feel forgotten. Use all of your willingness to reach out to someone or connect. Whether that be grabbing a cup of hot cocoa with a friend, attending a service, volunteering, or making a phone call to someone you have lost touch with in the past. We are social creatures and need human connection.
  • Be real with yourself – This includes preparing to spend time with family or friends. You likely already know who is going to be the Grinch, who is going to over indulge in the holiday punch, who is going to bring up politics, and who is going to ask about your love life. Just because it is the holidays, does not mean we are going to change who we are or the roles we play. Have an action plan for how you are going to deal with the likely interactions or dynamics.
  • Life in moderation – Life is about balance. Enjoy the holidays by partaking in the indulgences and socialization. Moderation is key. Listen to your body and the signals it is giving you.
  • Gratitude– Research is growing on the importance and efficacy of practicing gratitude in daily life. Our brains are inherently negative so being intentional about shifting out of the holiday stress (and negativity) can help bring perspective and renew our enjoyment of the season.
    • Write down things you are thankful for in life. Focus on the small things (i.e., clean water, fresh air, etc). Nothing is too small to be grateful for in life.
    • Reflect one thing you believe you did well over the past year.
    • Compare yourself to a time in your past when you might have handled the holiday stress less effectively.
  • Permission grant yourself – The holidays are not always candy canes and sprinkles. Often times we hold ourselves to high expectations and forget we are in control of our own actions. Grant yourself permission to: take time outs/breaks, have fun, do things “out of order”, celebrate differently than family/friends/the past, start a project and stop, be honest with people (and yourself), or have days that are “humbug” or just okay.

 

Feel free to make these tips your own by adding your own personal flair to them. It is important to find what works for you and your fancy holiday distress.

 

Happy holidays,

Dr. Alison Dolan