Video discusses how most people experience minor emotional reactions when first quitting, but also how people with pre-existing mental health issues may need physician assistance in dealing with problems that seem to be exacerbated after quitting.
Comments lifted from my string Normal depressive reaction or a real organic depressive episode on Freedom from Nicotine Support Board:
I see we had some recent issues with quitting and depression and anger at the board. The fact is everyone who ever quit smoking faced these issues to some degree. I am creating a string here that covers depression from a number of angles. Some of these letters were written to my clinic graduates and others were specific answers to people who wrote questions with background histories. I think they will give everyone an overview of different physical and emotional issues around depression while quitting.
Again, some of the emotional reactions are a simple adjustment period. But some people have histories of emotional problems that may take more than the individual alone to overcome. The people involved may need to be working very closely with their doctors and medical professionals. These articles should give a little overview of those issues too.
The first letter here is in response to someone who wrote me a question regarding depression who had a past history of depression.
I take it from your post that you had been on medication for depression prior to smoking cessation. While becoming depressed upon smoking cessation is common, this depression normally subsides over time. But, when depression is a preexisting condition there are special considerations that need to be addressed. First, you may have been on a medication that initially took time to adjust, to find the right dosage for you. Now, when you quit smoking and stay on that dosage you can initially become depressed as part of the normal separation process from smoking, in a sense, feeling bad but not thinking anything is wrong. But when it doesn’t subside over time you may assume that nothing can be done, its part of not smoking, you are already on an adjusted dose of depression medication and you just have to put up with it. This is a wrong assumption. Chances are even though you are on your normal dosage of medication, that dose was set while you were a smoker. This may not be the proper (normal dose) for you as an ex-smoker.
This dosing issue is not just about depression. People with many conditions may find that after cessation they must find what is normal for them. A person who is diabetic or on thyroid medications often find that the dose required as a smoker needs to be adjusted after quitting. Anyone who is on various medications that effect mood, hormonal and blood sugar levels needs to pay special attention to symptoms. Once through the first few days, and especially into the second week, if physical symptoms normally attributed to withdrawal are still manifesting, it is advisable that their doctor checks out those individuals.
I have put a few articles on the board here that I suspect you saw. There are others that I am not sure I put here or not, they were written to individuals who wrote with specific questions. While they may not apply to your specific situation, they cover a range of different depression issues. I am going to attach a string of letters here that were written to a few such individuals. If you have read part of them, keep going further down there may be more that you hadn’t seen yet.
One other thing I would like to note that applies to emotions when quitting. If anyone lets emotions solely dictate actions, nobody would quit smoking. Part of the skill needed by all ex-smokers is the ability to override normal emotions, desires, impulses or urges, whatever we want to call it, the individuals wanting a cigarette or just a puff. Everyone feels it from time to time. It is going to be your intellect that is going to override the craving. That is where keeping your ammunition and focus of why you quit smoking is paramount. You have to keep remembering what smoking was doing to you making you sick and tired enough to go through initial quitting. Then you have to remember what continued smoking was capable of doing to you in the future, thoroughly capable of robbing you of your health and your life. When in emotional turmoil it is harder to keep that perspective. It is hard for everyone when in such turmoil but it is a skill that has to be honed day by day by everyone. Life will throw curves throwing people into despair. But smoking won’t solve any of these curves. Smoking can cause problems that will throw your life further into despair and if left unchecked will throw your loved ones life into a premature loss of you.
Keep focused on this fact that quitting smoking is a fight for survival. It may be hard at times, but it is worth the effort. Bad times may make it harder to see this, but bad times will pass. You’ve experienced them before and you know they got better. Hang on to those memories that they do get better.
Again, talk to your doctor letting him or her know you have quit and have questions on the medications. Keep focused on your quit. One other thing to consider too, considering you were on medications before, you were depressed as a smoker. Never delude yourself into thinking life was always perfect before. Smoking didn’t cure your depression before and it won’t do it now either. For you, other medications were necessary to help with those feelings, smoking was not able to do it. Anyway, the following articles deal a little with the medication issues. Again, they may not all apply to you but kind of covers a range of reactions.
Hope this helps.
The following is another article written to a specific person who was experiencing a longer-term depression. This person was being encouraged by his or her doctor to go on an antidepressant but was resistant to the idea of needing medication.
Depression is normal in the cessation process. Almost everyone feels it to a degree, and the period of time that it lasts varies from person to person. Unlike the physical withdrawal, which is quite predictable in duration, the psychological reactions have tremendous individual variability.
I am attaching a letter here about the emotional phases of cessation. But since your reaction has been going for so long now, I would advise checking with your doctor. While quitting can be causing depression, it is possible that you do have an organic basis for depression that in a sense you were self-medicating with cigarettes for years.
If your doctor feels this is a possibility he or she may want to prescribe something for it. There are a lot of medications out there that are effective. As for safety or side effects, considering you may have been using smoking for this therapeutic purpose, a product that kills 50% of its users, the prescribed alternatives will pose minimal risks in contrast.
Or, the other hand, there may be some emotional conflicts in your life that have never been adequately addressed that are manifesting for the first time since quitting. I am attaching another letter I wrote to another person a few weeks ago that had some serious losses and was having some exaggerated reactions since quitting. I had more of a history on this person making me able to write this with some feeling that it really applied to this persons situation. I don’t know if it applies to yours, but maybe in reading it you will see if it strikes a chord.
Anyway, hope this helps.
Understanding the emotional loss experienced when quitting smoking
In her 1969 book, On Death and Dying, Elizabeth Kubler-Ross identified five distinct phases which a dying person encounters. These stages are “denial,” “anger,” “bargaining,” “depression,” and finally, “acceptance.” These are the exact same stages that are felt by those mourning the loss of a loved one as well.
Denial can be recognized as the state of disbelief: “This isn’t really happening to me,” or “The doctor doesn’t know what he is talking about.” The same feelings are often expressed by family members and friends.
Once denial ceases and the realization of impending death is acknowledged anger develops. “Why me?” or “Why them?” in the case of the significant others. Anger may be felt toward the doctors, toward God, toward family and friends. Anger, though, doesn’t change the person’s fate. They are still in the process of dying. So next comes bargaining.
In bargaining, the person may become religious, trying to repent for all the sins that may be bringing about their early demise. “If you let me live, I will be a better person, I will help mankind. Please let me live, and I will make it worth your while.” This stage, too, will come to an end.
Now the patient, becoming aware he is helpless to prevent his impending fate, enters depression. The patient begins to isolate himself from his surroundings. He relinquishes his responsibilities and begins a period of self mourning. He becomes preoccupied with the fact that his life is coming to an end. Symptoms of depression are obvious to anyone having contact with the patient in this stage. When the patient finally overcomes this depression he will enter the last stage, acceptance.
The patient now reaches what can be seen as an emotionally neutral stage. He almost seems devoid of feelings. Instead of death being viewed as a terrifying or horrible experience, he now peacefully accepts his fate.
As stated above, these stages are not only seen in the dying person but likewise in the family members mourning the loss of a loved one. However, on careful observation we can see these same stages in people who lose anything. It doesn’t have to be the loss of a loved one. It could be the loss of a pet, the loss of a job, and even the loss of an inanimate object. Yes, even when a person loses her keys, she may go through the five stages of dying.
First, she denies the loss of the keys. “Oh, I know they are around here somewhere.” She patiently looks in her pockets and through her dressers knowing any minute she will find the keys. But soon, she begins to realize she has searched out all of the logical locations. Now you begin to see anger. Slamming the drawers, throwing the pillow of the couch, swearing at those darned keys for disappearing. Then comes bargaining: “If I ever find those keys I will never misplace them again. I will put them in a nice safe place.” It is almost like she is asking the keys to come out and assuring them she will never abuse them again. Soon, she realizes the keys are gone. She is depressed. How will she ever again survive in this world without her keys? Then, she finally accepts the fact the keys are gone. She goes out and has a new set made. Life goes on. A week later the lost keys are forgotten.
What does all this have to do with why people don’t quit smoking? People who attempt to give up smoking go through these five stages. They must successfully overcome each specific phase to deal with the next. Some people have particular difficulty conquering a specific phase, causing them to relapse back to smoking. Let’s analyze these specific phases as encountered by the abstaining smoker.
The first question asked of the group during the smoking clinic was, “How many of you feel that you will never smoke again?” Do you remember the underwhelming response to that question? It is remarkable for even one or two people to raise their hands. For the most part the entire group is in a state of denial-they will not quit smoking. Other prevalent manifestations of denial are: “I don’t want to quit smoking,” or “I am perfectly healthy while smoking, so why should I stop,” or “I am different, I can control my smoking at one or two a day.” These people, through their denial, set up obstacles to even attempt quitting and hence have very little chance of success.
Those who successfully overcome denial progress to anger. We hear so many stories of how difficult it is to live with a recovering smoker. Your friends avoid you, your employer sends you home, sometimes permanently, and you are generally no fun to be with. Most smokers do successfully beat this stage.
Bargaining is probably the most dangerous stage in the effort to stop smoking. “Oh boy, I could sneak this one and nobody will ever know it.” “Things are really tough today, I will just have one to help me over this problem, no more after that.” “Maybe I’ll just smoke today, and quit again tomorrow.” It may be months before these people even attempt to quit again.
Depression usually follows once you successfully overcome bargaining without taking that first drag. For the first time you start to believe you may actually quit smoking. But instead of being overjoyed, you start to feel like you are giving up your best friend. You remember the good times with cigarettes and disregard the detrimental effects of this dangerous and dirty habit and addiction. At this point more than ever “one day at a time” becomes a life saver. Because tomorrow may bring acceptance.
Once you reach the stage of acceptance, you get a true perspective of what smoking was doing to you and what not smoking can do for you. Within two weeks the addiction is broken and, hopefully, the stages are successfully overcome and, finally, life goes on.
Life becomes much simpler, happier and more manageable as an ex-smoker. Your self esteem is greatly boosted. Your physical state is much better than it would ever have been if you continued to smoke. It is a marvelous state of freedom. Anyone can break the addiction and beat the stages. Then all you must do to maintain this freedom is simply remember, NEVER TAKE ANOTHER PUFF!
© Joel Spitzer 1982
The letter to the other person mentioned above.
Dealing with emotional loss has similarities to dealing with anger in regards to smoking cessation and its aftermath. When a smoker encounters a person or situation that angers them, they initially feel the frustration of the moment, making them, depending on the severity of the situation, churn in side. This effect in non-smokers or even ex-smokers is annoying to say the least. The only thing that resolves the internal conflict for a person not in the midst of an active addiction is resolution of the situation or, in the case of a situation which doesn’t lend itself to a quick resolution, time to assimilate the frustration and in a sense move on. An active smoker though, facing the exact same stress has an additional complication which even though they don’t recognize it, it creates real significant implications to their smoking behavior and belief structures regarding the benefit of smoking.
When a person encounters stress, it has a physiological effect causing acidification of urine. In a non-smoker or non-nicotine user, the level of urine acidity has no real perceivable effect. It is something that internally happens and they don’t know it, and actually, probably don’t care to know. Nicotine users are more complex. When a person maintaining any level of nicotine in their body encounters stress, the urine acidifies and this process causes nicotine to be pulled from the blood stream, not even becoming metabolized, and into the urinary bladder. This then in fact drops the brain supply of nicotine, throwing the smoker into drug withdrawal. Now they are really churning inside, not just from the initial stress, but also from the withdrawal effect itself. Interesting enough, even if the stress is resolved, the smoker generally is still not going to feel good. The withdrawal doesn’t ease up by the conflict resolution, only by re-administration of nicotine, or, even better, riding out the withdrawal for 72 hours totally eradicating nicotine via excretion from the body of metabolizing it into bi-products which don’t cause withdrawal. Most of the time, the active smoker more often uses the first method to alleviate withdrawal, taking another cigarette. While it calms them down for the moment, its effect is short lived, basically having to be redone ever 20 minutes to half hour for the rest of the smokers life to permanently stave off the symptoms.
Even though this is a false calming effect, since it doesn’t really calm the stress, it just replaces the nicotine loss from the stress, the smoker feels it helped them deal with the conflict. It became what they viewed as an effective crutch. But the implications of that crutch are more far reaching than just making initial stress effects more severe. It effects how the person may deal with conflict and sadness in a way not real obvious, but real serious. In a way, it effects their ability to communicate and maybe even in someway, grow from the experience.
Here is simple example of what I mean. Let’s say you don’t like the way a significant other in your life squeezes toothpaste. If you point out the way it’s a problem to you in a calm rational manner, maybe the person will change and do it a way that is not disturbing to you. By communicating your feeling you make a minor annoyance basically disappear. But now lets say you’re a smoker who sees the tube of toothpaste, get a little upset, and are about to say something, again, address the problem. But wait, because you are a little annoyed, you lose nicotine, go into withdrawal, and before you are going to deal with the problem, you have to go smoke. You smoke, alleviate the withdrawal, in-fact, you feel better. At the same time, you put a little time between you and the toothpaste situation and on further evaluation, you decide its not that big of a deal, forget it. Sounds like and feels like you resolved the stress. But in fact, you didn’t. You suppressed the feeling. It still there, not resolved, not communicated. Next time it happens again, you again get mad. You go into withdrawal. You have to smoke. You repeat the cycle, again not communicating and not resolving the conflict. Over and over again, maybe for years this pattern is repeated.
One day you quit smoking. You may in fact be off for weeks, maybe months. All of a sudden, one day the exact problem presents itself again, they annoying toothpaste. You don’t have an automatic withdrawal kicked in pulling you away from the situation. You see it, nothing else effecting you and you blow up. If the person is within earshot, you may explode. When you look back in retrospect, you feel you have blown up inappropriately, the reaction was greatly exaggerated for the situation. You faced it hundreds of times before and nothing like this ever happened. You begin to question what happened to you to turn you into such a horrible or explosive person. Understand what happened. You are not blowing up at what just happened, you are blowing up for what has been bothering you for years and now, because of the build up of frustration, you are blowing up much more severe than you ever would have if you addressed it early on. It is like pulling a cork out of a shaken carbonated bottle, the more shaken the worse the explosion.
What smoking had done over the years was stopped you from dealing early on with feelings, making them fester and grow to a point where when the came out, it was more severe than when initially encountered. Understand something though, if you had not quit smoking, the feelings sooner or later would manifest. Either by a similar reaction as the blow up or by physical manifestations which ongoing unresolved stress has the full potential of causing. Many a relationships end because of claming up early on effectively shutting down conflict resolution by communication between partners.
As I said, anger is not the only emotion effecting urine acidity. Sadness does this too. The losses of your family members likely increased your smoking consumption at the time. By smoking you too may have suppressed numerous feelings and emotions during the losses. In a sense, not only did smoking impact your communication with others, but also maybe with yourself, coming to grips with certain feelings. In a sense, you may have interfered to some degree with your own personal growth at the time. And now, by quitting, these feeling are manifesting. While it may hurt at the time, it may be essential that these feeling are coming out. Beneficial in fact, making you face feelings in a way more constructive than smoking and suppressing them. And again, understand, if they are there deep seated all this time, if they didn’t come out now, they were going to come out eventually. In what manner no one can predict. But the sooner you deal with the feelings, the less severe the reactions will generally be.
This above text doesn’t resolve the feelings, it may just help you understand the possible problem. Talk with people here if that helps. Maybe there are more personal issues, you may find it more helpful to talk to a local professional, a doctor or therapist. Whatever you do and who ever you work with, understand, everyone will have greater interest in helping you than cigarettes will.
I know people who are afraid to take medications for mood disorders but will smoke in its place. No matter what drug would be prescribed for them, none of them would carry the risk that self-medicating oneself by nicotine carries. Smoking is lethal. Don’t give cigarettes the legitimacy to treat feelings. They don’t. They make them worse. They in effect minimize your ability to communicate and grow. Growth may hurt, but it beats carrying on unresolved feelings that slowly may deteriorate the quality of your life.
Hope this helps explain why it hurts so much but also helps you to understand why it is still so important not to smoke.
Will talk to you again soon.
The following “Depression Basicis” article was
created by the Tobacco Control Research Branch
of the National Cancer Institute.
NOTE: This information is not meant to tell you for sure if you have major depression. It cannot take the place of seeing a mental health professional.
It is common for people who are feeling bad to think about hurting themselves or dying. If you or someone you know is having these feelings, they are in crisis. Get help now. Call 1-800-273-TALK (8255) or 1-800-SUICIDE (1-800-784-2433) to reach a 24-hour crisis center or dial 911.
Both 1-800 numbers are open all the time to give free, private help to people in crisis. The Substance Abuse and Mental Health Services Administration (SAMHSA), a part of the U.S. Department of Health and Human Services, runs both crisis centers. For more information, go to http://www.suicidepreventionlifeline.org.
Para obtener asistencia en español durante las 24 horas, llame al 1-888-628-9454.
What is depression?
Depression is more than feeling sad or having a bad day. People with depression usually feel down, blue, or sad, and they have other signs, such as:
- Feeling sad all the time
- Not wanting to do things that used to be fun
- Grumpy, easily frustrated, restless
- Changes in sleep—trouble falling asleep or staying asleep, waking up too early, or sleeping too much
- Eating more or less than they used to
- Trouble thinking
- Feeling tired, even after sleeping well
- Feeling worthless
- Thinking about dying or hurting themselves
You may have depression if:
- You have 5 or more of the signs listed above.
- These signs have lasted 2 weeks or more.
Use our depression screening quiz to see if you are depressed. You should consider seeing your doctor or a qualified mental health professional, especially if these problems are getting in the way of your life or are making you stressed.
What causes depression?
There are many things that increase a person’s chance of getting depressed. Everyone is different, but here are some common things that can lead to depression:
- Feeling lots of stress
- Going through a difficult life event
- A big life change, even if it was planned
- Medical problem
- Taking a medication that is known to cause depression
- Using alcohol or drugs
- Having blood relatives who have had depression
How is depression different from sadness?
Everyone has down days and times when they feel sad. Sadness could turn into depression, but depression and sadness are different in these ways:
- How long the feelings last: Depression is felt every day (or most days) and lasts at least 2 weeks, usually much longer.
- How bad the symptoms are (how much they get in the way of your life): Depression makes it hard for you to do things (like work or family duties) and it can stop you from doing the things you want to do.
How is this different from withdrawal from smoking?
Mood changes are common after quitting smoking. You might be irritable, restless, or feel down or blue.
Changes in mood from quitting smoking (withdrawal) usually get better in 1 or 2 weeks, and they are not as serious.
If you find that you are feeling very down after quitting smoking, then you should talk about this with friends and family, and also call your doctor. This is also true if you have symptoms from the list above. See “What is depression?” and the depression screening quiz.
Who gets depression?
In general, about 1 out of every 6 adults will have depression at some time in their life.
Depression affects about 15,000,000 American adults every year.
Anyone can get depressed. Depression can happen at any age and to any type of person.
But some types of people seem more likely to get depressed than others. For example,
- People with medical problems
- People who are stressed
Your race, ethnicity, or how much money you make doesn’t change your chance of getting depression.
Why is depression more common in smokers?
Nobody knows why smokers are more likely to have depression than non-smokers, but there a number of guesses. People who have depression might smoke to feel better. Or smokers might get depression more easily because they smoke. Other ideas are also possible. More research is needed to find out for sure.
No matter what the cause, there are treatments that work for both depression and smoking.
If I get depressed after quitting smoking, should I start smoking again?
No. You should look for ways to get help with your depression. Smoking does not treat depression. Remember that smoking is linked to many serious health problems for both the smokers and the people around them. Finding ways to help your depression and quit smoking are the best way to go.
How long does it last? Will this go on forever?
Everyone is different. For some people, it will only last a few weeks, some for many months if not treated.
For many people, depression is only a problem during really stressful times (like a divorce or the death of a loved one). For other people, depression happens off and on through their life.
But, for both groups of people, there are treatments for depression that can help reduce the symptoms and shorten how long the feelings last.
Is it worth getting treatment for depression?
Yes! Treatment almost always helps to reduce symptoms and shorten how long the depression lasts. A common problem is that too few people get help. Many people think that depression is not a real problem, can’t be all that serious, or is a sign that they are simply not tough enough to deal with life. None of these are true.
You do not need to feel shy or embarrassed about talking openly and honestly about your feelings and worries. This is an important part of getting better, working on ways to help your mood.
Many people benefit from treatment for depression, even if the symptoms are not serious. So you don’t need to have a lot of symptoms of depression before talking to your doctor or a qualified mental health professional (see “Who provides therapy?”) about getting treatment.
If you find that you have 5 or more signs from the list above (see “What is depression?” or the depression screening quiz), you should talk with your doctor or a qualified mental health professional. This is especially true if the feelings have lasted 2 weeks or more, are making you worried, or are getting in the way of your daily life.
What are the treatments for depression?
There are many good treatments for depression, and more than 8 out of every 10 people who use them get better. Treatment usually means getting psychotherapy/counseling, taking medications, or doing both. Your doctor or a qualified mental health professional can help you figure out what treatment is best for you.
About therapy (counseling, talk therapy, psychotherapy)
Therapy has shown to be quite helpful and is often an important part of treatment for depression.
Getting therapy does not mean you will be in treatment forever. Most talk therapy is for a short time. Depending on how serious your feelings are, it can mean meeting only a few times with a therapist. Most talk therapy focuses on thoughts, feelings, and issues that are happening in your life now. In some cases, understanding your past can help, but finding ways to address what is happening in your life now can help you cope and be ready for challenges in the future.
Therapy is more than just telling your therapist about your problems. It means working with your therapist to improve coping with the things happening in your life, change behaviors that are causing problems, and find solutions. Your therapist may give you some homework in between meetings; things for you to think about and work on. This might include making a list of situations that give you negative thoughts and feelings, or looking at things in a different way.
Some common goals of therapy:
- Get healthier
- Get over fears or insecurities
- Cope with stress
- Make sense of past painful events
- Identify things that make your depression worse
- Have better relationships with family and friends
- Make a plan for dealing with a crisis
- Understand why something bothers you and what you can do about it
Who provides therapy?
There are many kinds of people who have been trained to give therapy and help you. These include:
- Psychiatrists (they write “MD” after their name)
- Psychologists (they write PhD, PsyD, EdD, or MS after their name)
- Social workers (they write DSW, MSW, LCSW, LICSW, or CCSW after their name)
- Counselors (they write MA, MS, LMFT, or LCPC after their name)
- Psychiatric nurses (they write APRN or PMHN after their name)
More important than their training, you should find someone you can talk with honestly and openly. Your therapist won’t have all the answers, but the key is to find someone you can work with as a partner to help you find answers.
Many people with depression find that taking medication is a useful tool in improving their mood and coping. Medications for depression are called antidepressants. Antidepressants cannot solve all your problems like magic, but they can help you to even out your mood and be more able to handle events in your life that are making your mood worse.
Antidepressants are prescription medications, so talk to your doctor if you want to take them. If your doctor writes you a prescription for an antidepressant, ask exactly how you should take the medication.
There are many medications, so you and your doctor have options to choose from. Sometimes it takes trying a couple different medications to find the best one for you, so be patient. If you are worried about cost, ask your doctor or pharmacist if the medication comes in a generic form. Generic medications can cost less than brand names.
When taking these medications, it is important to stick with them for awhile. Many people start feeling better a few days after starting the medication, but it often takes 1–2 weeks of taking it to feel a big difference, and 4 weeks to feel the most benefit. It is also common to have to change the dose, so you will want to work closely with your doctor.
How long a person takes antidepressants is very different from person to person. Many people are on them for 6–12 months, and some people take them for longer. Again, you and your doctor will want to talk about what is best for you.
Antidepressants are safe and work well for most people, but it is still important to talk with your doctor about side effects you may get. Side effects usually do not get in the way of daily life, and they go away as your body gets used to the medication.
If you notice that your mood is getting worse, especially if you have thoughts about hurting yourself, it is important to call your doctor right away.
Taking care of you
There are many things you can do to help lift your mood and improve feelings of depression.
- Exercise. Stay active. This can include something as simple as taking a fast walk or as involved as going to the gym or joining a team sport. The type of exercise depends on how fit you are, but any kind of activity can help. If you need to, start small and build over time. This can be hard to do when you are down or depressed because feeling down saps all your energy. But making the effort will pay off! It will help you feel better.
- Structure your day. Create a plan to stay busy. It is especially important to get out of the house whenever you can.
- Talk and do things with other people. Many people who are feeling depressed are cut off from other people. Having daily contact with other people will help your mood.
- Build rewards into your life. For many who are depressed, rewards and fun activities are missing from life. It is helpful to find ways to reward yourself. Even small things add up and can help your mood.
- Do what used to be fun, even if does not seem fun right now. One of the common signs of depression is not wanting to do activities that used to be fun. It may take a little time, but doing fun activities again will help improve your mood. Some people like to make a list of fun events and then do at least one a day.
- Talk with friends and loved ones. Their support is a key to your feeling better. Having a chance to tell them your concerns can help things seem less scary.