When pitcher Zack Greinke left the Kansas City Royals during spring training in 2006, it wasn’t because of a sprain, a break or a torn muscle. Something less visible was threatening his promising baseball career: clinical depression and social anxiety disorder.

With the help of counseling, Greinke was able to work through the issues that plagued him and returned to the mound a few months later. Fast-forward three years, and Greinke is now a star pitcher who has appeared on the cover of Sports Illustrated.

Greinke’s story of recovery from social anxiety disorder is particularly amazing when you consider that each time he reports for work, he’s performing in front of thousands of fans. But he’s far from the only person struggling with anxiety. Anxiety disorders are the most common mental illness in the nation, affecting 40 million adults or 18 percent of the adult population.

Social anxiety disorder is characterized by an intense fear of social or performance situations and the feeling that others are scrutinizing you, often leading people who struggle with the disorder to avoid being with others. When those situations can’t be avoided, these individuals are consumed by how others are viewing them.

“People with social anxiety often have this magical kind of thinking that they know what the other person is thinking about them — and of course, it’s negative,” says Stephnie Thomas, a member of the American Counseling Association who has worked at the Anxiety and Stress Disorders Institute of Maryland in Towson for 12 years. “Most of us have periods of shyness, but (social anxiety goes) beyond shyness.”

Blushing, feeling hot in the face, sweaty palms, a racing heartbeat — all can accompany social anxiety, Thomas says. People who struggle with the disorder are consumed by the feeling of needing to say or do the right exact thing so that people will like them. “Remember those awkward adolescent years where you felt like you had two left feet?” Thomas asks. “Social anxiety disorder is kind of like growing up with two left feet. It’s like they’re forever stuck in that adolescent gawky phase where they just don’t feel like they fit in with the rest of the world.”

Thomas says the disorder has both a genetic and a behavioral component. The family root aspect is so common that Thomas recommends counselors ask the client if there’s a family history of social anxiety. “Sometimes it’s Uncle Charlie who didn’t like going to the family picnics and always kept to himself,” she says.

The treatment Thomas most uses to combat social anxiety is exposure. She encourages her clients to put themselves in social situations and investigate their negative feelings — first acknowledging those feelings and then looking at the reality. In most instances, she says, no one is staring or disapproving.

On a recent Friday night, Thomas took a group of clients struggling with social phobia to a nearby mall. Each person first attached a few pieces of toilet paper to the bottom of his or her shoe, then walked around the mall to see if anyone noticed. Of the six people in the group, only two said someone had spied the toilet paper. “It really helped them see, ’You know, maybe people aren’t always looking at me,’” Thomas says.

Worry without end

Another anxiety disorder counselors say they commonly see is generalized anxiety disorder, characterized by at least six months of persistent and excessive anxiety and worry. Beverly Snodgrass, who works in private practice in Austin, Texas, says people struggling with generalized anxiety disorder have difficulty controlling their “worry thoughts.” They may feel fidgety and have difficulty sleeping. “It becomes so overwhelming that they’re unable to complete the things they need to complete,” Snodgrass says. And it can become a vicious cycle. “If they’re worried about job performance,” she says, “they may become so overwhelmed that they can’t do the things they need to prepare for that or to have satisfactory performance. Therefore, the problem becomes worse. It becomes a self-fulfilling prophecy.”

Snodgrass says some people have a “biological vulnerability” to anxiety. “They may be more sensitive than other people. They may have inherited a nervous temperament,” she says. Experiencing a painful or traumatic event (even a low-grade trauma) can make anxiety even more likely for the person, says Snodgrass, who adds that anxiety serves as a kind of protective shield against experiencing the trauma again.

One effective treatment for generalized anxiety disorder is cognitive behavioral therapy, Snodgrass says. “What we’re focusing on here is bringing awareness to the thoughts that are contributing to anxiety,” she says. Snodgrass asks her clients to challenge the anxious thoughts and replace them with more realistic thinking, such as, “Yes, this is painful, but I’m going to live through it,” she says.

Another technique Snodgrass uses is mindfulness. “The client is taught how to observe thoughts with a healthy distance — being aware that thoughts are events of the mind and they have a beginning and an end,” she explains. Snodgrass helps her clients notice their physical symptoms, such as a quickly beating heart or shaky hands, and acknowledge that they aren’t in any immediate danger. Mindfulness techniques are more helpful with people whose anxiety levels aren’t extremely high, she concedes. When anxiety reaches a certain level, it’s hard for people to effectively manage their thinking, she adds.

Tina Cannon, a Florida psychotherapist and the founder of onlinecounselingblog.com and thebestcounselingblog.com, finds guided imagery useful for helping clients manage their anxiety. Cannon asks clients not only to picture a place they feel relaxed but also to identify what they hear, smell, taste and feel. “I ask them to practice that one or two times a day,” Cannon says. “Then, when they do feel anxious, because they practice it so much, they’re able to use it during those times.”

In the wake of trauma

Post-traumatic stress disorder (PTSD) is another anxiety disorder that has garnered recent attention, mainly because of its prevalence among soldiers returning from the wars in Iraq and Afghanistan. But wartime experiences aren’t the only trigger for PTSD. Any traumatic event in which a person believes his or her life is in danger, such as a rape or a car accident, can open the door for PTSD. More than 7 million adults in the United States have PTSD, and the disorder is more common among women.

One of Snodgrass’ clients, a 25-year-old woman, struggled with PTSD after experiencing traumatic work situations that forced her to leave her job. The situation was so severe that she subsequently spent time in the hospital. After being released, she relocated to Austin to be near her sister.

When the client began seeing Snodgrass, the trauma of her past job, linked with her hospital stay, was causing the woman to avoid the job market. Searching for jobs and going on interviews made her extremely anxious. Together, Snodgrass and the client first worked on relaxation techniques and steps the woman could perform each day to remind herself of her competency. During the treatment, Snodgrass’ client landed a new job. But her anxiety level still ran high. If she made even one mistake at work, it triggered her past trauma, and she feared landing in the hospital again.

After the initial stage of treatment, Snodgrass used a technique known as eye movement desensitization and reprocessing (EMDR), which counselors are finding helpful in treating PTSD. EMDR requires the client to use focused eye movements while bringing to mind a traumatic episode. The idea behind the treatment is that by switching focus between the memory and eye movement, the client reprocesses the memory. In this case, the client kept her eyes on the movement of Snodgrass’ hand while calling to mind the worst memory of her job loss and hospitalization. After three sessions, Snodgrass says the client’s memories had become less disturbing to her.

“It takes away those intense feelings about whatever that trauma was,” says Cannon, who also uses EMDR in treatment. “They still remember it, but they don’t have that immediate connection of ’It’s all happening all over again.’ It doesn’t change the way they remember it; it changes how they feel about it. It changes the emotions associated with it.”

Plagued by panic

Panic disorder is another common anxiety disorder that some counselors treat. Panic disorder is sometimes coupled with agoraphobia, which literally means “fear of the marketplace.” When agoraphobia is present, people become afraid of being in a place or a situation in which it would be hard for them to escape or to get help if they had a panic attack. Cannon notes that panic attacks can happen in places as varied as a certain store that gets overcrowded or while driving in a car on the highway. “Clients usually describe (the panic attack) as an intense fear where they felt like they were going to die or lose control,” she says. “Then they get this urgent desire to flee the situation.”

Medication can often help a person struggling with panic attacks, Cannon says. Regarding therapy, she recommends first helping clients to identify the trigger for the panic attack, such as recalling a traumatic event or phobia. Then the counselor can assist clients in changing the thinking patterns that are keeping them from overcoming their fears and changing their reactions to anxiety-provoking situations. Cannon recommends counselors try desensitization techniques such as EMDR or exposure and response prevention. She adds that deep breathing exercises will aid in relaxation and anxiety management.

Thomas also sees a large number of clients with panic disorder. When she began working at the Anxiety and Stress Disorders Institute of Maryland, she says the institute’s professionals concentrated mainly on cognitive behavioral therapy. Now she uses “third-generation” cognitive behavioral therapy, focusing more on acceptance. Many counselors still teach distraction and relaxation techniques to clients. Although those techniques are good in the short term, Thomas says, they can lose their potency after a time. Thomas teaches her clients that they can be OK with their feelings of anxiety, which essentially separates the feelings from the perceived danger, she says.

Thomas compares the physiological feelings involved in a panic attack to riding a roller coaster. “Most people get off the roller coaster and say, ’Oh, cool, that was fun. Let’s do it again,’” Thomas says, but people more prone to anxiety might say, “Oh, I didn’t like that, and I don’t want to do it again.”

“A lot of it is difference in attitude toward the symptoms,” she says.

Last year, Thomas flew with a group of five people on a day trip to the Rock and Roll Hall of Fame and Museum. They flew out of Baltimore in the morning and flew back from Cleveland later that evening. For most people, the trip wouldn’t have been a big deal. But for this group, it was an amazing feat because all, save for Thomas, were afraid of flying.

Thomas specializes in helping clients come face-to-face with the things they fear. During the past few years, she has developed a comprehensive program for clients who are afraid to fly. About two weeks before her group flew to Cleveland, she took them to the airport to talk to a pilot about flight safety. “They usually find it very reassuring,” Thomas says. The point of visiting the airport and then waiting two weeks before flying, she explains, is so clients will learn to cope with the anticipatory feelings.

Whether the situation involves experiencing panic attacks in an elevator, on the highway or on a plane, Thomas says helping clients practice those situations can assist them in overcoming their fear. In recognizing the sensations and feelings that accompany anxiety and panic, clients realize they can be in those situations and emerge unharmed. “They begin to habituate to the sensations and feelings,” Thomas says, adding that clients can then recognize the initial jolt of adrenaline. “This is a very normal reaction, but it doesn’t necessarily mean you’re in danger.”

Tips from the pros

These experts agree that no matter what type of anxiety disorder a client seems to be presenting with, a counselor’s No. 1 priority should be ensuring the client has had a full medical checkup. Medical conditions such as thyroid problems can sometimes mask as anxiety, Thomas says.

Expressing faith that the situation can improve is another helpful tactic, Snodgrass says, but be realistic with the client. Reassure clients that while things might not change overnight, they will get better. At the same time, she says, help clients understand that it’s not realistic to expect that all their anxiety will disappear or that they’ll never feel anxious about anything again.

Don’t be afraid of the anxiety, Thomas advises her fellow counselors. “Anxiety is not dangerous, and if you can sit there (with the client) and hold their anxiety and not be afraid, then that gives them courage that they can change.”

Snodgrass recommends counselors help clients see how they might be unintentionally reinforcing their anxiety and then assist them in eliminating those patterns. She offers the example of a person who has great anxiety about grocery shopping. The counselor should arm the client with techniques, such as breathing exercises, to use when he enters the store and begins feeling anxious. Leaving the store will only reinforce the sense of anxiety, she says. “It further enhances the idea that I can’t handle it — ’The last time I went to the store, I left.’ It makes them more anxious the next time.”

Counselors must also be careful not to reinforce their clients’ anxiety, says Snodgrass, recalling that she learned that lesson firsthand. One of her clients, a man in his mid-30s, was struggling with anxiety caused by feelings of social isolation and incompetence. Snodgrass allows her clients to set up a “coaching call” when they’re attempting to do something they’ve been working on in treatment. Although that approach is beneficial with many of her clients, it had a negative effect on this particular man. “He was calling me, but it was reinforcing his idea that he couldn’t handle (his anxiety),” Snodgrass says. She adapted the plan so the client would call her after he had utilized the relaxation techniques instead of before, and that change had a positive impact. Reinforcement and anxiety can be “tricky” topics, Snodgrass admits. Happily, she says the client is now reconnecting to his feelings of competency.

Although anxiety at the disorder level is neither healthy nor enjoyable, ACA member Neil Soggie, an assistant professor of psychology at Atlantic Baptist University in Canada, says some anxiety is necessary. He agrees with Snodgrass that total elimination of anxiety is neither realistic nor advisable. Soggie, who wrote the Professional Handbook for Mood and Anxiety Disorders, knew someone who struggled with anxiety and took medication to combat it. When on her medication, however, an antisocial tendency came to the fore that had been held in check by her anxiety of getting caught. “So while she felt fine, she left a wake of destruction a mile wide while on her antidepressants,” Soggie says. “This is a reminder that there is a positive role of anxiety and that we all need a little anxiety in our life in order to help it be meaningful and keep us sane and civil.”

Lynne Shallcross is a staff writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org.