Psychotherapy of Anxiety: Value Oriented Approach

The article outlines the principal theses of the concept of psychotherapy of anxiety disorders, based on changing the client’s perception on his problem and revising the system of values. Model of “anxiety-centered” behavior is reviewed and ways of transformation of client’s self-evaluation and lifestyle that are to manage the anxiety are described. Changing the “reference system” as core element of recovery is reviewed. Material is illustrated with case studies and excerpts from therapeutic sessions.

Introduction

There are plenty of psychotherapeutic approaches to anxiety. Many of them proved their efficacy and are being widely used. During my work with clients suffering from phobias, fear and anxiety I noted that successful recovery depends not only from client’s positive goal-setting, which is well-known and widely implemented, but from, so to say, “emotional reference system” too.

I wanted to call this method “quest therapy” first (in accordance with the basic techniques and metaphors), but this name has long existed for a completely different technique. So I decided to call it “value oriented approach”.

A client suffering from panic attacks, anxiety, a periodic feeling of fear, helplessness, or periods of a sharp drop in mood - in general, any mental and emotional disorder characterized by periodicity - is often inclined to consider these pathological manifestations as the most significant factors of his life. It is quite understandable - such affects break down the life of a person for a long time, especially if they occur unexpectedly and happen often. Moreover, unpleasant events, including physical symptoms are, in principle, remembered longer and recalled easier, than the “good” ones. After several repetitions of these episodes, which for brevity we will call “accidents”, a model of behavior is being formed, in which the accident moves to the center of the perception of the world as something inevitable and so important that it is impossible to ignore it. In the future, a person begins to build his life in accordance with the primacy of an unpredictable and dangerous accident, so that, in the end, all life is made dependent it. There is a change in behavior (the desire to avoid potentially stressful situations, avoiding contacts with people, communication with which is fraught with accidents, taking preventive security measures, including taking medications on the threshold of possible accidents, etc.). Up to some limit, such a tactic can justify itself, especially in cases of specific anxiety episodes, that is, those that can be precisely related to a particular situation, which in principle can be changed without affecting the client’s daily functioning. But the peculiarity of accidents is that, due to various reasons, their connection with external situation is not decisive, and, in any case, not the only one.

The beginning of accident is a complex process, including several factors, one of which is, so to speak, the person’s inner readiness for anxiety. Let us suppose, for convenience, that the pathological manifestations which we are talking about are occurring at regular intervals. Then the life path of the client looks like that (Figure 1).

Figure 1:

The life period between the accidents is shown in the lower part of sinusoid. Why the accident is depicted on the crest? Because, client for the moment of visiting the doctor, it is the most significant issue for a person (Otherwise he would not address to a specialist). Below, we will talk about clinically significant accidents, and not about the level of problems that a person manages to cope on his own - this is a topic for another study.

Let us say some words about the person’s “inner readiness” for anxiety. Very often you hear from clients about “waiting for a fear”. Consider, for example, an agoraphobic panic attack. The person is going to go out on the street – to visit the doctor, for example. He often experienced panic and a fear of losing consciousness in crowded places before. Or, for instance, the panic often occurred during the descent along the escalator in the metro. He remembers this very well and, accordingly, begins to feel fear long before he finds himself in a situation that was the source of anxiety last time he experienced it (the client thinks so, in any way). What happens? He leaves the house being already fearful and tense, and even in the event that a panic attack did not occur, a long time is waiting for it, not believing that this time everything went well. In fact, the stress persists until he returns home. And if the panic attack really happened, then the person received additional confirmation to his fears and became even more entrenched in his illness. Thus, our sine wave has acquired the following form (the new data is highlighted in red) (Figure 2).

Figure 2:

That is, the periods of well-being are getting shorter, while the problems related to accidents, on the contrary, occupy more time, strength and thought of a client, so that he practically does not have a place in his life for good health. Moreover, the life of such a client in this case is a the path from one accident to another, and the period of well-being is not only clenched in time, but also loses its significance and value, which was not initially too large (in any case, from client’s point of view ).

Now let us analyze in more detail the proposed mechanism for the development of this system and the formation of the behavior of the person following it.

P.K. Anokhin defined any behavioral act as an “anticipatory reflection of reality” [1]. That is, the action is not focused on what is happening at this particular moment, it is a reaction not to the event that is happening at the given time, but to the final aim, which is to be achieved in future. The indicator that the goal has been achieved is not the fulfillment of the action itself, but the fixation of the acquisition of emotional and physical state, indicating the satisfaction of the need for which the action was carried out. This is the result of the action. The moment of the beginning of the behavioral act is characterized by a combination of motivation, the current environment, memory of the experience of similar actions in the past and, finally, by the trigger that directly starts the action. On the basis of the synthesis of these factors, a person makes a decision and proceeds to execute a program that either ends when the desired result is achieved or adjusted if the original need is not satisfied.

Now let’s see what happens when the fear of accident (we emphasize - not the accident itself but the fear of it) is the main, we might say, system-forming moment of the client’s life. When a client falls into a potentially stressful situation, which is signaled by the environment and the memory of the same accidents that occurred to him before, a minimal incentive is enough to trigger the entire pathological mechanism of the system. By the way, there is always the signal that triggers, say, a panic attack, though it is often difficult to find it.

(Case: client experienced “panic attacks” in the form of unexpected fear episodes last for 30-40 minutes, accompanied by all the vegetative symptoms that occurred in very different situations, having nothing common with each other, and passed independently or after taking tranquilizers. In the course of interview and exercises addressed to body awareness in the moment of panic it turned out that immediately before the accident client always experienced an unpleasant feeling in the area of ​​the right ankle joint (due to wrong step, temporal immobilization, etc.). In the course of further work, it was revealed that at the age of two, when he was left by his parents for a long time at home (parents thought he was sleeping), he woke up, climbed on the table, fell down on his leg and spent two hours on the floor, waiting for the parents. After several sessions aimed on rethinking the actual meaning of body symptoms and improving client’s attention to his parents, panic attacks ceased).

A person can try to avoid the situation in which the accident occurred in the past in some way, but, firstly, the external situation is only one of the elements of the problem, and secondly, the memory of an unpleasant event, and most importantly the realization that he is EXACTLY TRIES TO AVOID PSYCHOLOGICAL TRAUMA (the category of trauma is always present in such a system, even in the form of its negation), already fully prepare a person for the launch of the functional system and unpleasant sensations. In this case, even if the accident does not occur, it is difficult to fully restore the good state, and this takes more time and resources (look again at the second sinusoid). In other words, it turns out that in order to feel better, client should either feel fear so that it will end and a moment of saving relaxation came, or practically wait for next anxiety episode in the case if it did not happen this time for some reason. This is due to the fact that in both cases fear is perceived not only as something fatal, inevitable and unexpected. And even most importantly, it can sound paradoxically, but fear becomes, a necessary part of client’s life - even in the form of self-absence. The evaluation of the result of the action is completely determined by the presence or absence of anxiety. All life in this case is divided into “life with anxiety” and “life without anxiety”, but it is impossible to exclude this category from the client’s attitude, at any rate, it is very difficult. It is present in the client’s system of values as a principal structure - it does not matter in what form. Fear becomes dominant. It should be noted, however, that fear is not the only content of the client’s life, moreover, it often, occupies a very small part of lifetime. A lot of events can occur in the life of the client, including those that are very important, pleasant and valuable for him, and even things that are not particularly positive but much more significant than those associated with fear, but because of the existing dominant of anxiety they are depreciated. It seems to be understandable - pathological symptoms at the height of its manifestation can scare anyone and remain in your memory for a long time. Russian poet Vladimir Mayakovsky was absolutely right when he wrote in his poem “Cloud in trousers”: «I know - a nail in my boot is more nightmarish than Goethe’s fantasy!” (Translated by Prof. James McGavran III). And here we come to the main principle of the proposed method: fear, although it is real, sometimes very traumatic and carries not only spiritual but also physical suffering, nevertheless, is not the only thing that is essential and necessary in the life of the client. And most importantly - fear is not obligatory. (Case: client with multiple sclerosis who experienced a panic attack every time the doctor injected her medication intravenously - after one case, when there was anaphylactic shock at the time of injection because of the mixed syringes - after a psychotherapy course, when the next injection went without any problems - I specifically monitored this from her neurologist, - said to me: “I forgot that I should be frightened”). The basis of the concept offered to the client is a statement (I emphasize - not modeling, not a guess, not a wish, namely a statement) of the fact that there are many other valuable and important things in his life. There are periods (often quite long) of well-being, relaxation and self-confidence, which are very important and useful for him, for it is during these periods that he creates, feels, works, loves, communicates - in general, lives . Did you notice that in this concept the word “fear” is absent? Let us return to it a little later.

Case: Michael (the name is changed - IZ) described his feelings as unmotivated (from his point of view) periods of anxiety, which took place in transport, crowded places and in general almost everywhere outside the house. Attacks lasted for 40-60 minutes, accompanied by shortness of breath and palpitations, passed independently (long) or after taking phenazepam (quickly). From the subsequent conversation it turned out that Michael began, by his own admission, to worry in advance and to worry before the supposed exit from home, and eventually became afraid, in the first, more often, in the second, stronger and longer. Moreover, returning home, for a long time he could not calm down and fall asleep.

Remember the “anticipatory reflection of reality” and the second sinusoid?

After a detailed discussion of fear and everything connected with it, I asked Michael what is good about his life, and when he feels the best. Michael thought it over and answered that the best time and place for him was at home, around 6-8 pm, when he returned home, drank tea and was reading a book or watching TV. I asked him to describe his condition at that moment, after which the exercise “accompanying in a pleasant memory” from the practice of Eriksonian hypnosis was conducted [3]. Exercise was performed successfully; Michael was able to largely reproduce his comfortable “evening state”. After that (more precisely, even during the session), I told him: “Now, being in this comfortable state, you are already starting the path to it again, you begin moving to the next good period in your life, and this movement is the instrument of achieving the goal - desired comfort. Your good, comfortable state is the most valuable issue in your life, alpha and omega, and it is in your power to make it even better and longer. Do you play computer games (Michael is a programmer by profession - IZ)? Yes? Then you know that there are quests where you need to step out of the castle, make a certain trip, and then return to the same castle. Your good condition is just your castle. And now you start the path to it, knowing that this is your goal and striving for it. Along the way, something may happen or not happen (who said that something must necessarily happen?). But even if it takes place, it does not matter on its own, it’s just a point on the map, on the way to your goal, and what is an indisputable fact, it is that you will reach the final destination of your journey (it’s also an initial one). I ask you to allow yourself, your body, and your feelings to remember and fix this good state, described by you. Your body remembers all the good things that happened to it, all the positive feelings and physical sensations remain in the muscular and emotional memory for ever, and all that is needed to awaken them is to let them remember and manifest themselves. This simple exercise can be done by yourself every time there is a desire or need to feel better and gain strength and confidence to achieve your pleasant, constructive goal. I ask you to please yourself before our next meeting, to make yourself something pleasant and useful, so that the light in the windows of your castle would become brighter, and so that you would better see the purpose of your journey, and would like to achieve it more strongly. Perhaps then you will find an easier and more convenient way, and that pleasant feeling will be longer and stronger. On this we parted. At the next meeting, Michael said that he went home with hope and expectation of something pleasant (and it really happened). He experienced several panic attacks after that, but gradually he managed to significantly weaken their intensity and duration, evoking a pleasant image of the house in his memory.

What is essentially important in this work: all the feelings and events discussed with the client are absolutely real, taking place in reality, moreover, in fact, quite every day. From the point of view of simple logic, a person does not go out of the house to ride a vehicle (with or without adventures), and even, ultimately, not to make any planned action, but in order to, having accomplished this action, calmly return to a comfortable home environment or an equally comfortable destination.

During the following sessions, Michael began to note such an interesting moment for him that did not happen before (in any case, he did not fix it): the panic sensations happened twice unexpectedly, BUT: the first thought that he had with it was I did not expect it” (did not expect the onset of fear, did not prepare the ground for it), and paradoxically, precisely because he was not already internally predisposed to the onset of total horror, as before, the attack was less intense and passed faster.

What happened? Absolutely important thing happened, on which this concept of therapy is based. Michael, speaking in physical language, changed the frame of reference. The starting point and the end point for him was not fear, as before, but a period of well-being. That is, he just turned the sinusoid upside down, putting a positive on the basis of his life, and not a disease (Figure 3).

Figure 3:

Over time, the values ​​on the second sinusoid also changed places.

That is, the perception of the system of values had been changed. The memory of a comfortable state took the place of memory of the fear and the motivation acquired a positive form (“return to the desired emotional environment” instead of “avoiding fear and overcoming it”). Also, the result was not a statement of the fact of dealing with anxiety (which previously, as indicated, was always present in the system, even in the form of, so to speak, its absence), but confirmation of the achievement of the desired level of self-awareness. It is a tipping point.

The next stage in our joint work with Michael was the consolidation of the result obtained and the transfer of the positive changes from the category of achievements to the category of habitual level of daily existence. You cannot demand that a person should feel good all the time, and at the same time, the well-being that really exists in the client’s life is ideally perceived as a habitual positive background. In the case of Michael, getting the job and systematization of the life schedule played a big role. As a result, emotional state gained during the psychotherapy, became habitual and relatively comfortable.

What happens with fear during this work? Of course, it does not disappear immediately (although it was once, in a client with a hysteric manifestation, the problem was in another area), but the attitude towards it changes. From the system-forming phenomenon, in the client’s mind, it becomes a) possible, but not an obligatory factor, and b) a technical, accompanying event, so to speak. I will comment it with a fragment from a conversation with one of the clients.

“Imagine that your good friends invited you to visit them a beautiful country house. You know that there are good, nice people waiting for you, your favorite music will play, your favorite dishes are on the table. But there is broken, dirty road that leads to this house through a dense forest, and the rain has recently passed. If your thoughts and aspirations are concentrated on this broken section, if it is the main issue for you, - not the place where you are expected, - then either you go home with grief and frustration, or try to overcome these obstacles in spite of everything, put the car on the bottom, come to the guests angry and irritated, and tell the master of the house everything, that you think about him and about the road, quarrel and have to go back morosely. If, instead, the main thing for you is the expectation of a pleasant meeting with friends and finding the best way to the house, then there is suddenly a place for a safe parking lot nearby, and a dry path leading to the house. Simply, while ruts and bumps were in the center of your attention, you simply did not see all this”.

This is by no means a rescue therapy. That is, fear is not ignored, it is not avoided (avoiding an anxious episode by changing the situation from traumatizing to another, usually does not work, anxiety arises on another occasion), but it is given a new meaning, its place and function in the client’s values ​​system is reviewed. I propose the term “devaluation” (it has nothing to do with the type of resistance in Gestalt therapy of the same name), that is, a decrease in the significance of the actual symptom by changing the attitude towards it in comparison with other, positive components of client’s system of values. In the concept of “anticipatory reflection of reality”, fear ceases to be such a reality, something positive that every client owns takes the place of fear in this scheme.

So, the main stages of the therapeutic process are:

1. Analysis and crystallization of symptoms.

2. Identification of positive entities in the life of the client. From this moment the main target of psychotherapy is not a symptom, but a comfortable state.

3. Reconstruction of a comfortable state and teaching the client its independent reproduction and improvement.

4. Transfer of the reference point to the positive period of the client’s life cycle and the construction of a new life scheme according to it.

5. Devaluation of symptom. Stages 4 and 5 are conducted more or less simultaneously.

6. Fixing a positive result and stabilizing a comfortable state as a background.

7. (The ideal one) Formation of a positive worldview of the client taking into account the newly developed system of values.

Reproduction and consolidation of a positive state can be carried out in different ways, depending on the preferences and professional experience of the therapist. I mainly use Eriksson’s hypnosis. It can also be cognitive-behavioral psychotherapy aimed at working with automatic thoughts and intermediate beliefs (in the framework of the concept of anticipatory reflection of reality, the downward arrow technique works, aimed at the final result, the reflection of which is the client’s behavior)[2]. Gestalt therapy techniques - sequential allocation of figures of fear and comfort and the formation of a positive ground - can also be useful here [3]; reframing techniques from the practice of neuro linguistic programming (I repeatedly applied the timeline to reconstruct a positive bodily response to a potentially traumatic situation and reproduce it at different life stages)[5], and much more. Analogies and metaphors illustrating the proposed material and reinforcing the achieved changes are widely used [4]. They can be used taking into account the cultural and educational peculiarities of the client and the sphere of his interests. Methods are working from the practice of positive therapy, with constant emphasis and reinforcement of any productive manifestation of client resources [6]. Client is being taught to be grateful for all positive issues in his life – both long and new, appearing in the process of treatment. Gratitude helps to evaluate and use all the positive and pleasant moments as an instrument of building positive background and strengthen new system of values based on well-being (see Gratitude as a Psychotherapeutic Intervention) [7]. If person is not grateful for good things in his life, he does not feel the value of them and, accordingly, cannot use them in full volume, because they are perceived as something regular and neutral. In order to help client to reap the benefits from his positive essence, which is to help to manage with accidents and possible bad state, the “Positive diary” is used, in which positive events are being noted, as well as people and events clients is grateful for them. Diary sheet is enclosed.

(Case: client complained of the fear of speaking to people and generally communicating to little-known persons. I suggested him to take some small thing that reminded him of well-being and comfortable emotional state next time he will go for a meeting. I underlined that this small object is not a talisman or amulet, but simply a reminder of a good condition and an instrument that helps client to recall the desirable emotional condition and to return to it. I asked him to put it in the same pocket where he wears pills, which he used to take to manage the anxiety. Client told me on one of the next sessions, that once he took out a keychain (for it was such an object), instead of tablets and he did not feel the need to take the medicine, because he managed to tune himself in to a positive background. In the future, key chain has ceased to be necessary to feel better, although he still carried it with him for a long time).

Another client, who initially complained of “panic attacks, from which my pills successfully rescue”, after a while said: “I carry out all your recommendations and medical prescriptions of a psychiatrist, but panic attacks continue to interfere with me.” I asked what exactly they interfere, and the conversation gradually passed to the life and everyday affairs of the client, with consideration of options for improving his existence. Later attacks began to disturb the client much less often. It would seem that the words “attacks interfere with me” contain a uniquely negative meaning. In fact, in the context of the dynamics of the client’s condition, they can be not only a positive, but also a very significant sign. In the first phrase, in which “drugs rescue from attacks “, attacks are clearly marked as the main, principal content of the client’s life. This phrase speaks about competently selected pharmacotherapy, but it does not testify to positive emotional dynamics. “Rescued from” idiom relates to rescue from enormous, terrible and threatening - in any case, from something most important and meaningful at the moment. From the other hand, things, that “interfere”, “disturb”, “bother”, “strain” and even “do not allow to live” may be very heavy and unpleasant per se, , but they are, so to say, extraneous, and not related to the main, central essence of client’s life, what they interfere with. Such a verbal construction indicates that a fundamentally important point has been reached in the described therapeutic concept - the accident has been moved from the dominant position in the system to the role of a concomitant, albeit extremely unpleasant, factor, and the focus of attention is shifted to the positive essence that accident prevents to function in the desired way. Such words demonstrate the change in the frame of reference, as discussed above. It depends on the concrete therapeutic situation, whether to say in to client immediately or wait for more convenient moment, taking in consideration the client’s possible reaction to demonstration of this evidence of change. But this point is to be fixed and used by therapist.

In general, the combination of the proposed method with pharmacotherapy and work at different stages of medical treatment is a topic for a separate article, but the basic principles remain unchanged. Equally, practice shows that this technique brings results with different genesis of anxiety states - both as an independent phenomenon, and as a symptom of other pathologies, which is also supposed to be described separately.

Conclusion

I want to conclude with one more phrase from a conversation with one of the clients:

“When you were a child, you probably have played a board game with a dice and chips, in which you were to go through a field or a forest from one point to another. So, you leave from point A, which is your comfortable good condition, and move to point B, which is characterized with similar comfortable state. The dropped dice can show a different number of points; you can skip a move or go back several cells back, as well as jump a lot forward. But one thing is certain: in any case, you will reach the place you are going to. The difference with the game is that you do not compete with anyone; you just move from one good state to another, it is your own journey. Have a good trip!”

Appendix 1

1. Anokhin PK (1978) Philosophical aspects of the theory of functional systems. Soviet Studies in Philosophy 10: 269-276. Link: https://goo.gl/A5tDAz
2. Clark D, Beck AT (2010) Cognitive therapy of panic disorder. Link: https://goo.gl/Gyd2gr
3. Ivana Vidakovic (2014) The Power of “Moving on” - a Gestalt Therapy Approach to Trauma Treatment. Link: https://goo.gl/ooDA9C
4. Weekes C (1974) Simple, effective treatment of agoraphobia. Am J Psychother 32: 357-369. Link: https://goo.gl/Y8f8hr
5. Leslie Cameron-Bandler, Michael Lebeau (1986) The Emotional Hostage – Rescuing your Emotional life. Link: https://goo.gl/OTjDU7
6. Nossrat Peseshkian (1986) Psychotherapy of Everyday Life: Training in Partnership and Self Help with 250 Case Histories. Link: https://goo.gl/Q6wcYY
7. Emmons RA, Stern R (2013) Gratitude as a Psychotherapeutic Intervention. J Clin Psychol 69: 846-855. Link: https://goo.gl/cExIh1