Anxiety Disorders and Phobias: Aaron Beck
Contents
ContentsChapter 1 Turning Anxiety on its head: an overview 9
The Paradox of anxiety 9
Changing Concepts of Anxiety 9
Distinguishing Anxiety, Fear, Phobias and Panic 9
Anxiety and Fear 10
Phobias and Panic Attacks 10
Realistic and Unrealistic fears 10
Hoch’s paradox 10
Future Danger and present dangers 10
The function of anxiety 10
Adaptational aspects 10
Anxiety as a strategy in response to threat 10
Survival mechanisms 10
Summary 11
Chapter 2 Symptoms and their significance 11
Systems and Symptoms 11
Symptoms and functions 11
Major Reactions: mobilisation, inhibition, demobilisation 12
Free floating anxiety, fact or artefact 14
Normal versus pathological anxiety 14
Thinking disorder in clinical anxiety 14
Attention, concentration and vigilance 14
Alarm systems and automatic thoughts 14
Loss of objectivity and of voluntary control 14
Stimulus generalisation 14
Catastrophising 15
Selective abstraction and loss of perspective 15
Dichotomous thinking 15
Lack of habituation 15
Classification of Anxiety disorders 15
Summary 16
Chapter 3 The Cognitive model of threat reactions 16
The Role of Context 17
Primary appraisal 17
Secondary appraisal 17
Estimate of danger 17
Hostile Response 17
The Nature of Cognitive Processing 17
The relation of behavioural activation and inhibition to motivation 18
Distinguishing between behaviour and emotions 18
The vicious cycle 18
Primal Responses to threats 18
The anergic and the energic systems 18
Changes in cognitive content and physiological reactions 19
The relation of anxiety to other defensive responses 19
Summary 19
Chapter 4 Cognitive Structures and anxiogenic rules 20
Cognitive Schemas 20
The function of the cognitive set 21
The continuous Cycle 21
The Modes 21
Syndromes and modes 21
Assumptions, rules and formulas 22
Rules in problematic situations 22
Rules in Anxiety Disorders 22
Summary 22
Chapter 5 Vulnerability: The core of anxiety disorders 23
The Concept of vulnerability 23
The role of skill deficits 23
Self-doubt 23
The role of context and experience 23
Interference with effective performance 23
Catastrophic predictions and vicious cycles 24
The function of dysfunctional behaviours 24
Physical danger 24
Psychosocial danger 24
The domains of vulnerability 24
Sectors of the domain 24
Threats to the domain 25
Threats to sociality 25
Threats to individuality 25
Specific fears 25
Summary 25
Chapter 6 Generalised anxiety disorder and panic disorder 26
General View of the Etiology of Anxiety Disorders 26
Precipitating psychological factors 26
Interaction of precipitating factors with previous problems 27
Do Cognitions cause anxiety disorders 27
Generalised Anxiety disorder 27
Symptomatology 27
Types of Generalised Anxiety Disorder 27
Specific Fears 29
Self-Concept in Generalised anxiety disorders 30
Self-Criticism in Anxiety and Depression 31
The difference between anxiety and depression 31
Panic disorder 32
Description 32
Meaning of Panic Attacks 33
Functional Analysis of panic attacks 33
Precipitation of panic attacks 33
Summary 33
Chapter 7 Simple phobias 34
Definition of Phobia 34
Differentiating phobias from fears 35
The refractoriness of phobias 35
Content of fears and phobias 35
Classification 35
Traumatic phobias 36
Fixation phobias 36
Specific phobias 36
The Meaning of Phobias 37
Multiple phobias: Conceptual continuity 37
Relation of fears to Phobias 37
Self-Confidence versus vulnerability 37
Dual belief System 37
Visual Images 37
Identification with Victim 37
Evolution, Rules and Phobias 38
Summary 38
Chapter 8 The Agoraphobia Syndrome 38
The Riddle of Agoraphobia 38
The Development of Agoraphobia 39
Predisposition and precipitation 39
Onset of symptomatology 39
Panic 39
Attribution of causality in panic attacks 39
Cognitive set: vulnerability 40
A Synthesis 41
Summary 41
Chapter 9 The Evaluation Anxieties 42
The Essence of Evaluation Anxieties 42
Before the fall 42
Common features of evaluative threats 42
Vulnerability 42
Status and ranking order 43
Self confidence 43
Rules and formulas 43
Automatic protective reactions 43
Social phobias and social anxieties 44
Paradoxes of Social anxiety 44
The fear of being evaluated 44
The primal defences 44
Differentiating Social Phobia from Agoraphobia 44
Situations that provoke the phobic symptoms 44
Somatic symptoms 45
The phenomena of Social Anxiety 45
Shame and social image 45
Fear of loss or love or abandonment 46
Public speaking anxiety 46
Test anxiety 47
A Synthesis 47
Summary 47
Chapter 10 Principles of Cognitive Therapy 48
Principle 1: Cognitive therapy is based on the cognitive model of emotional disorders 48
Didactic Presentation 49
Levels of fear 49
Principle 2: Cognitive therapy is Brief and time limited 49
Principle 3: A sound therapeutic relationship is necessary condition for effective cognitive therapy 50
Principle 4: Therapy is a collaborative effort between therapist and patient 50
Principle 5: Cognitive therapy uses primarily the Socratic Method 51
Principle 6: Cognitive therapy is structured and directive 51
Principle 7: Cognitive therapy is problem oriented 51
Conceptualisation 52
General strategies 52
Principle 8: Cognitive therapy is based on an educational model 53
Learning to learn 53
Principle 9: The theory and techniques of cognitive therapy rely on the inductive method 53
Principle 10: Homework is a central feature of cognitive therapy 53
Summary 53
Chapter 11 Strategies and Techniques for Cognitive Restructuring 54
Developing Self Awareness 54
Directing Patients 54
Strategies and techniques 55
Counting Automatic thoughts 56
Questions 56
Three basic approaches 57
Where’s the evidence 57
What’s another way of looking at it 58
So what if it happens 58
Summary 59
Chapter 12 Modifying Imagery 60
Induced Images 60
Delineating maladaptive patterns 60
Pinpointing cognitive distortions 60
Modification of induced images 60
Techniques for modifying images 60
Turn off technique 60
Repetition 60
Time projection 61
Symbolic images 61
Decatastrophising the image 61
Images and thoughts 61
Facilitating change in induced images 61
Substituting positive imagery 62
Substituting contrasting imagery 62
Exaggeration 62
Coping models 62
Imagery to reduce Threat 62
Escaping a worse alternative 62
Mixed Strategy 62
Future therapy 62
Goal rehearsal 62
Summary 63
Chapter 13 Modifying the Affective Component 64
Accepting the feelings 64
Reducing anxiety about anxiety 64
Reducing shame about showing anxiety 65
Normalising anxiety 66
Active Acceptance 66
Identifying Emotions 66
Action strategies 66
Activity schedules 66
Increasing tolerance for anxiety 67
Alcohol, stimulants, diet, stress 67
Maladaptive coping behaviour 67
Self-Observation 67
Positive Self instruction 68
Graphs and diaries 68
Concentration (or distraction) exercises 68
Relaxation methods 68
Emotional Review 68
Imagery methods 69
Metaphors 69
Repeated review outside the office 69
Owning ones emotions 69
Sequential reasoning 69
Correlational reasoning 69
Analogical reasoning 69
Emotional reasoning 69
The Payoff 70
Summary 70
Chapter 14 Modifying the behavioural component 72
Identifying Protective mechanisms 72
Motivation 72
Explaining the therapeutic approach to the patient 72
Blocks to learning 72
Educational devices 73
Futility of self-protection 73
Experiments 73
Graded steps or a gradual approximation 73
Hierarchy 74
Aids to exposure 74
Initiation technique 74
Self-instruction 74
Behavioural rehearsal 74
The use of significant others 75
Technical aids 75
Cognitive avoidance 75
The critical-decision technique 75
Surprise 75
Choice 76
Behavioural thought 76
The As if technique 76
Shame and other feared experiences 76
Developing self confidence 76
Agreeing 76
Disagreeing 77
Doing the unexpected 77
Making a mistake part of the show 77
Summary 77
Chapter 15 Restructuring a patients assumptions and major issues 78
Identifying Assumptions 78
Major issues 78
Identifying Major Issues 78
Positive and negative reinforcers 79
Psychological double 79
Development of major concerns 79
Acceptance 80
Competence 80
Control 80
Motivation and Major Concerns 81
Summary 81
Book Summary 81
Chapter 1 Turning Anxiety on its head: an overview
The Paradox of anxiety
One of the paradoxical things about anxiety is it seems to
bring on what a person fears the most, so the person presenting is anxious so
they stammer their words which is what they most dread. When anxiety is
mobilised every part of the body responds, the physiological system, heart
racing and sweating, cognitions, oh god I’m going mad, emotions pure terror and
the behaviour of trying to escape. Why
does it give us these false results when we are merely speaking in front of
people?
Here are some possibilities:
1.
We overestimate the importance of the event as
about life and death
2.
Prehistorically this is how we acted
3.
Evolution favours anxiety and false positives
The idea is that before the initial stimulus, a thought or
an image appears that then stimulates an anxious response. Thus if I my heart beats quickly and I think I’m
going to have a heart attack and die, then an anxious response is appropriate. We
often have these thoughts and images too quickly to notice.
Changing Concepts of Anxiety
Much clinical work has focus on the feeling of anxiety,
presumably as this is the thing we most want to get rid of as it’s a very
unpleasant feeling. However it’s the
cognition that follows immediately after the initial stimulus that creates
anxiety. The effect of anxiety is the one that we want to get rid of the thing
that motivates us to action but it is not the locus of the treatment it is the
symptom, rather like pain is for a nail in the foot
Distinguishing Anxiety, Fear, Phobias and Panic
Fear: the feeling
evoked by a judgement something dreadful will happen. It is a cognitive
process. It is directed to the future.
Anxiety: this
comes from the Latin word to choke and is the feeling similar to fear but
without the object. Anxious is on the anxiety spectrum which ends up in panic.
Anxiety seems like the affective aspect of fear without the appraisal aspect.
Phobia: An
exaggerated fear of something. Come from Phobos which is Greek for flight
Panic: sudden
overpowering fright and a frantic desire to find safety, it is a high state of
anxiety
Anxiety has had useful responses, where it freezes us from
further action, i.e. stops us going over the ledge or into the woods at night.
It is useful where there is a real danger and an inability to cope with that
danger. Thus it changes as we grow up, we are less anxious about strangers the
bigger we get.
Anxiety and Fear
Fear is the judgement something terrible will happen,
anxiety is the affective response to something terrible happening
Phobias and Panic Attacks
Phobia judges something as highly dangerous that others see
as safe. The outcome of a phobia is anxiety or panic. Phobias are fears of the
consequence of something.
Realistic and Unrealistic fears
You can apply the words realistic and unrealistic to
cognitive processes like fears, but not to affective ones like anxiety. Freud
saw anxiety working in two ways one to external threats which he saw as normal,
and one to internal threats, i.e. repressed desire becoming manifest which he
saw as pathological.
Hoch’s paradox
Why does anxiety impair our ability to perform, it seems to
make things worse, when we get fight or flight responses this seems adaptive
but freezing doesn’t seem so.
Future Danger and present dangers
Fear is future based something terrible will happen, anxiety
is something terrible is happening.
The function of anxiety
Adaptational aspects
In the development of our species anxiety has been useful.:
1.
Fear and anxiety prevent risky behaviour, so
freeze before stepping over the cliff
a.
Childhood has a lot of anxiety making events,
strangers, roads, the dark, leaving mummies side
Explanation of current distresses
1.
Agoraphobia: could have had roots in being
vulnerable to attack away from the pack or the covers
2.
Public speaking: roots in the dangers of being
socially alienated
Anxiety as a strategy in response to threat
Anxiety gets attention and we really want to stop the
feeling of anxiety. It helps us move away from dangerous situations and from
taking careless action. In anxiety disorders we have a misinterpretation of a
danger signal that is causing the anxiety, so there is nothing to get away from.
Survival mechanisms
There are different classes of fast reaction to feared
situations. The more volitional they are the slower their response is:
1.
Anxiety reactions
2.
Reflex reactions: gagging, coughing, blinking,
ducking, dodging, loud bangs
3.
Defensive patterns: tightening muscles, shallow
breathing
One of the problems of anxiety disorders is the lack of
flexibility to stop being anxious when the danger has gone.
Summary
Anxiety is a very strong feeling that makes you want to get
the feeling to stop. Anxiety is the current affective response to being in
danger, like pain is the current response to being in pain. Fear is the
judgement that something bad is going to happen, anxiety is the feeling that
something bad is happening, or just about to happen.
Whilst fear is a cognitive response and anxiety is an
emotional response, an anxiety disorder stems from a cognition. So something
happens, my heart beats fast, then there is a cognition I’m having a heart
attack and going to die. Anxiety is then the response to the feeling that I’m
dying.
The evolutionary purpose of anxiety is to stop a person
adopting risky behaviour and also to be able to pass on rules through the ages,
so the tribe says don’t go to the woods at night or bad things happen, as they
have found this out and taken this as an accept rule. Obey rules or you lose
social support, so anxiety polices the rule to say don’t go to the woods at
night.
Chapter 2 Symptoms and their significance
Systems and Symptoms
Anxiety can be understood in terms of its function to the
overall system. Evolutionary master
objectives are self-preservation, feeding and breeding and subsystems are said
to be adaptational when they fit into that. Each subsystem reacts differently
to different situations and to different master plans and it is the cognitive
system that controls this. Our cognitions sees the relationships between
things, between perceptions. The things most vital to our interests are
survival and sex, thus it is likely that anxiety disorders have some relation
to sex and survival in them.
When cognition selects anxiety as the affective response
this have the effect of speeding up the system. One of the problems however of choosing
anxiety is that it isn’t that flexible and you can’t switch from one subsystem
to another and turn it off. Even when the danger goes, then anxiety doesn’t
switch off. There are many aspects to fear and danger, from getting a sense the
situation is dangerous to perceiving the dangerous aspect, to understanding
what coping mechanisms are available to selecting and implementing them. There
are a variety of subsystems involved in this process thus the reaction to fear
and danger is not a simple one. You can
also get clash of strategies fight and flight that adds complexity to the response.
A person can be in a situation where
their wishes and fears clash. I wish to speak, speaking is a danger to me. The
danger response is a primal.
Symptoms and functions
Anxiety affects 4 subsystems
1.
Cognitive
2.
Affective
3.
Physiological
4.
Behavioural
Anxiety is from a primal subsystem and can overtake more
mature responses.
Cognitive Symptoms in Anxiety disorders
1.
Sensory
a.
Mind hazy, cloudy foggy
b.
Objects seem blurred
c.
Environment seems unreal
d.
Self-conscious
e.
Hyper vigilant
2.
Thinking difficulties
a.
Can’t recall important things
b.
Confused
c.
Unable to control thinking
d.
Difficulty in concentrating
e.
Difficulty in reasoning
f.
Loss of objectivity and perspective
3.
Conceptual
a.
Fear of
i.
Losing control
ii.
Going mad
iii.
Not being able to cope
b.
Frightening visual images
Whilst the above cognitive symptoms are experienced by most
people some of the time, they generally ignore them. With people with anxiety
disorders then they are taken as symptoms of an anxiety disorder or madness etc.,
but certainly the symptoms fuel the symptoms.
Thinking difficulties may be because all attention is there
for dangerous items and no energy is left over for other ways of attention
however this seems unlikely as the cognitive functions just seem impaired
rather than good in some areas and bad in others.
If anxiety is immediate and severe it is likely to be
experienced as panic, if it is long lasting then it is more likely to be
experienced as unease or a wound up feeling.
Anxiety behaviour can either be a freezing or the tremors of restless
activity.
Major Reactions: mobilisation, inhibition, demobilisation
Three types of reaction to danger
1.
Mobilisation
a.
Prepares the individual for active defence
b.
Cognitive: Hypervigilant for danger
c.
Affective: edgy, tense and terror
d.
Behavioural: increase in muscle activity, restlessness
continual movement
2.
Inhibition
a.
Curtails risky behaviour buys time to aid
decision
b.
Cognitive: functions are impeded a sense of
passing out
c.
Behavioural: inhibition of spontaneous movements, face therefore may
appear blank
3.
Demobilisation
a.
Deactivation of defences in the face of
overwhelming threat
b.
Symptoms are weakness and fainting
Affective adjectives for anxiety
1.
Edgy
2.
Impatient
3.
Fearful
4.
Scared
5.
Uneasy
6.
Nervous
7.
Tense
8.
Wound up
9.
Anxious
10.
Frightened
11.
Alarmed
12.
Terrified
13.
Jittery
14.
Jumpy
Behavioural symptoms of anxiety
1.
Inhibition
2.
Tonic immobility
3.
Flight
4.
Avoidance
5.
Speech dysfunction
6.
Impaired coordination
7.
Restlessness
8.
Postural collapse
9.
Hyperventilation.
Free floating anxiety, fact or artefact
When questioned the anxious person always has a feeling that
something bad is going to happen. His
attention then becomes selective to only those things that show that he is in
danger. Anxiety only appears free floating or without cause as we do not
understand the clients world. If a client doesn’t get what they are anxious about
then they don’t understand their world either.
The psychological core of anxiety is a fear of
1.
Physical disaster
a.
Death
2.
Mental disaster
a.
Going mad
3.
Social disaster
a.
Making a fool of yourself
Normal versus pathological anxiety
If there is a real danger and the level of anxiety accords
to that and diminishes when the danger goes then anxiety is deemed normal and
pathological outside of that realm.
However the boundaries are unclear and pretty much sociocultural
constructs.
Thinking disorder in clinical anxiety
Attention, concentration and vigilance
Attention is reduced, concentration is impaired. However all
cognitive systems are pointed to one thing, thinking about danger, possible
danger and actual danger. Thus using his cognitive system to be hypervigilant
for danger then he has less energy left for any other tasks.
Alarm systems and automatic thoughts
Anxiety disorders can be conceived of as a hypersensitive
alarm system. Negative automatic thoughts tend to keep the feeling of danger in
focus and keep the alarm system on hypersensitivity. It can be difficult to be
aware of some of these thoughts, they can sometimes be so fleeting that the
only thing you are aware of is the anxiety generated. Likewise they have been
thought so often you don’t pay attention to them and again just act on them.
Loss of objectivity and of voluntary control
Objectivity can be lost a client logically can say they
don’t believe their thoughts about danger but they act as if they are true.
Another aspect of anxious thinking is there’s a large degree of involuntariness
about it, which adds to the out of control feeling.
Stimulus generalisation
The original cause of anxiety can be generalised to things
associated with the original, so the effect of anxiety moves to more things, is
associated with more situations and more antecedents.
Catastrophising
Anxiety sufferers catastrophise quite a lot, they see events
in dangerous, so sees a negative outcome and an inability to cope with it.
Selective abstraction and loss of perspective
Selective abstraction: people only see part of the picture,
the dangerous part, they blank out aspects of a situation that would mean that
there is safety, that you can cope
Dichotomous thinking
Dichotomous thinking: again anxious folk see black and
white, dangerous or not, there is no space for ambiguity or uncertainty. As
they get closer to the danger then the level of absolute, catastrophic thinking
increases.
Lack of habituation
After repeated exposure to anxiety normal people become
habituated to it where as people with anxiety disorders don’t. The thinking
being that a normal person will understand that an event isn’t threatening, so
even if it could be, it is understood that it isn’t, whereas an anxious person
sees that as it could be a threat then it probably is.
Classification of Anxiety disorders
1.
Panic disorder
a.
Recurrent anxiety attacks happening at possibly
unpredictable times
b.
Feeling of nervousness between attacks
2.
GAD
a.
Ruminates about a wide range of things
b.
Can’t better be described by one of the other
classifications
3.
PTSD
a.
Follows a
psychological experience outside of general human experience
4.
Atypical anxiety disorder
a.
this is
the miscellaneous when none of the other fit
5.
Phobic disorders
a.
Irrational
fear of an object/activity. The fear is recognised by the individual as
unreasonable.
6.
Agoraphobia
a.
Fear of being alone or being in public places
from which escape in case of incapacitation might be impossible
7.
Social phobia
a.
Avoid situations where you can be under the
scrutiny of others. Fear of being humiliated or embarrassed
8.
Simple phobia
a.
Fear of spiders, heights etc., can’t really see
the difference between phobic disorders apart from the individual sees them as
irrational.
Summary
So anxiety is an affective response which can be used as
part of a cognitive appraisal of a situation. Choosing it, if that’s what we do
speeds up the components of the system.
Anxiety as a response is deemed to be adaptive if it reflects the level
of danger, and our ability to cope with it poses. The anxiety response is quite a primal
response to danger, and is likely to be related to some of our base needs
survival and sex. Anxiety disorders
happen when there is a misinterpretation of the signs of danger, so it’s like having
a hyper sensitive alarm system. Thus all the various subsystems go into a state
of hyper vigilance. The attention is only aware of possible danger, hyper
vigilance of perception can be to look at the body for signs of impending doom,
or the environment for signs that disaster is on its way. Cognitions only
respond to thinking about dangerous things.
Anxiety is a powerful feeling that we want to stop. The thing is that
like pain we need to find the cause of pain and get rid of that rather than
find a way that we can stop feeling pain, or as soon as that balm wears off it
will come back again.
The anxiety response does a number of things:
1.
Speeds up response
2.
Can close down systems so that all attention is
given to danger
3.
It can inhibit systems so that no danger is
created through activity
4.
It can play dead so that the beating that will
come can be ridden
I do wonder if the propensity to anxiety attacks is similar
to the level of avoidant behaviour. It seems that to stop is an aspect of the
anxious reaction to danger.
Chapter 3 The Cognitive model of threat reactions
Perception is like using a camera you trade of features of
the scene to make the shot. People have
first impression to a scene that determines if the situation is of interest and
if it requires a critical response. The
emergency response is to a clear and present danger
When we first do our appraisal of what a scene means then we
include possible dangers which on subsequent reappraisal are ignored, in
anxiety disorder this isn’t the case.
Thus we have primary appraisal, secondary appraisal and
reappraisal
Example of Primary appraisal would be:
1.
Is the current situation a threat to me?
2.
Use general perceptual engagement, perception if
you like rather than reflection
Secondary appraisal would be
1.
What are the resources I have to deal with it
2.
What method of attention should I give to the
scene
3.
What is the likelihood of the danger happening
Fight, flight, freeze or faint. As the primary and secondary
appraisals happen they are not intentional but happen very quickly
If the danger is coming from a situation that the client
thinks they have the power to overcome then there can be a hostile response,
shouting, staring down, and attacking.
Fighting can also be done as a last resort, as a way of slowing the
predator down.
The Role of Context
Appraisal is broken down into primary, secondary and
reappraisal, which is a process of progressive scanning of finding specific
focus within a scene. Primary appraisal is about vital interests
Primary appraisal
This provides information that either reinforces or modifies
an existing cognitive set, and concerns whether something concerns someone’s
vital interests, if this is a perception of vital interest then this calls for
a critical response. So vital interests are survival, individuality,
functioning, if there is a threat to these then this call for an emergency
response. The type of response is global, absolute and arbitrary; it is
therefore very fast. Actual threats use primary appraisals to generate
emergency responses, although there are also possible threats which in anxiety disorders
are where the problems are. So false alarms from possible threats are not
turned off either because a reappraisal doesn’t happen or it does and the alarm
still isn’t turned off.
Secondary appraisal
Secondary appraisal is working out what resources you have
to deal with the threat, which can be internal or external. As this secondary appraisal happens there is
also a sum that is made that relates the level of danger to the ability to cope
which then produces the intensity of one’s response. Primary and secondary appraisals
happen at such speed we may not even be aware of them, or if we are then they
can be fused into one.
If the threat is low compared to his coping mechanisms then
he may fight, if they are high then he may flight, freeze or faint.
Estimate of danger
On the size of the danger and size of your coping responses
you work out if you will fight or flight. The degree of mobilisation and of
subjective anxiety is relevant to the degree of danger perceived. The degree of
fear is relevant to the estimate of potential damage anticipated and the
probability of it occurring. So there is
a decision point whether to fight or fear something. Then there is the estimate
of the level of danger to self, i.e. threat less coping. Then there is the
probability.
Hostile Response
We can fight if we think we have a chance of winning and our
resources are greater than the threats, we can also increase our feelings of
our own resources by self-confidence, and contextual items, e.g. helper. If we
are back into a corner and have nothing left to lose we can also fight but this
is on the basis of anxiety, and we are trying to minimise expected damage.
The Nature of Cognitive Processing
Bowlby states that before we are aware of a stimulus coming through
our senses we have already done much processing of selection, interpretation
and appraisal that excludes much of the incoming material as we only have
limited capacity on our senses, so we have to reserve this for the good stuff.
The nature of this pre conscious selection is on the basis
of what is best for us. When you are hungry you will see the world in food
terms, when horny in sexual terms etc. In an emergency response all that is
seen is danger, which is odd as what about means to cope with danger, or safety
etc.
The relation of behavioural activation and inhibition to motivation
Primal responses seem to operate on the automatic scale of
things. Motivation is therefore applied to volitional areas.
Distinguishing between behaviour and emotions
How come people see venting your anger is good, but venting
your anxiety is not so. The emotion of
anxiety as opposed to its behaviour, i.e. the feeling can only be created
involuntarily so you have to recall a certain anxiety provoking situation to
get anxiety, whereas you can act anxiously. As we encounter a fearful situation
we judge it as such as fearful, then we get anxious about this, and this
anxiety reinforces the judgement of the fearful situation. We are behaviourally
activated and motivated
The vicious cycle
The vicious cycle is where a response to a dangerous
situation is seen as a threat itself, then as the danger increases so does the
threat. So the feeling of anxiety may reinforce
the feeling of vulnerability and therefore increase its intensity. So if you
have your situation and anxiety, and anxiety disorder interprets the levels of
anxiety as the levels of the problem, not the levels of the situation. People
who have to be in control are more susceptible to anxiety disorders as they can’t
accept not being in total control and paradoxically this makes things worse.
Primal Responses to threats
1.
Fight which can be defensive or aggressive
2.
Flight instigated mainly by anxiety
3.
Freeze, just prior to attack, gives time to
appraise the situation and decide best course of action, also prepares the body
to absorb the impact, it can also be to prevent continuing dangerous action
like walking off a cliff
4.
Faint, happens when someone is overwhelmed, it
is a play dead response, in the hope that the threat will pass them by
5.
Duck\Dodge\Jump: evade missiles
6.
Clutching\Clinging: helping to maintain balance
7.
Reflexes: gagging\blinking\coughing
8.
Calling for help
The anergic and the energic systems
Sympathetic nervous system relates to fight\flight
Parasympathetic relates to rest and digest relates to
feint\freeze
There is a sense when one system can be activated and can be
the predominant response, fluid movement between the two doesn’t seem to happen,
but rather on the basis of a primary appraisal then one system is activated.
Changes in cognitive content and physiological reactions
The choice of nervous system response is determined between
the fight or fear response. If the former then you get a sympathetic response
if the latter then a parasympathetic response.
If you are injured then you can get a parasympathetic
response where systems close down, this is the shock reaction to minimize
activity to prevent further injury.
People can also imagine that something is going to happen,
so they will be injured or such like and you can get a strong parasympathetic
response in this instance. This is where the response isn’t adaptive as the
problem hasn’t happened.
The relation of anxiety to other defensive responses
There are other responses to reduce anxiety, but they can
appear also without anxiety being there, they may well happen when anxiety is
low:
1.
Counterharm strategies
a.
gagging
2.
Ducking, flinching
a.
Reflexive behaviours work quicker than intentional responses
which are the domain of anxiety. Anxiety calls up volitional movement,
reflexive movements but as the plan master it is slower than reflex.
Summary
Perception works on a funnelling aspect where there is a
pre-conscious filtering\interpretation of the world at quite a low level. It is
done on the basis of our bodily engagement with the world and our desires, so
when hungry, tired, etc. you see the world differently to when you aren’t. The
reason this happens is there is so much bandwidth in the senses so you have to
be selective with what you offer to them. On the basis of this pre-conscious
filtering then we see, hear, smell etc.
One level of low level automatic filtering that happens is
whether something is of interest to us, to our concerns, if it is it takes our
interest. On the basis of this, then there is the estimation as to whether it
is a threat to our concern or a boon. This is called the primary appraisal,
which determines is something of interest to us, what is the strength of this
interest and is it positive or negative. If something is a threat to a vital
interest, then this elicits an emergency response.
A secondary appraisal happens at that time which looks at
the level of resources that you have to deal with that threat.
On the basis of the primary and secondary appraisal then you
work out:
1.
Level of vital interest
2.
Probability of happening
3.
Ability to cope
The relation between these three factors produces the level
of anxiety response. Anxiety tends to speed up processing as we want the
feeling to go away. If we think our
resources are greater than the threat level then we adopt a hostile response, i.e.
we fight, if not we adopt a fear response. The fear responses are:
1.
Flight
2.
Freeze
a.
This gives time to make a decision
b.
Prepares the body for blows
3.
Faint
a.
This plays dead and hopes the threat won’t take
interest in me
So standardly anxiety functions as the outcome of a threat
appraisal, it is the motivation to act quickly to respond to the threat. The
type of response that is called for with anxiety is a volitional one. Anxiety
isn’t as quick as reflexes which are the quickest to respond and aren’t
volitional, whereas anxiety is not as fast but is volitional.
On the basis of anxiety, then this is a prompt to deal with
that which you are afraid of. The
difficulties with anxiety come when
1.
You are not sure why you are anxious
a.
This can lead to thinking there’s something
wrong with you
2.
The signals for anxiety become something you are
afraid of
a.
This means that your response to fear increases
fear
Chapter 4 Cognitive Structures and anxiogenic rules
Predominantly we act on rules, interpretation and judgements
rather than perceive fresh each time. Past experiences therefore impact on how
we perceive, and can be reified as rules, or as cognitive structures. Cognitive
structures contain rules, beliefs, memories and the like that guide
interpretation, relevance and action. Sometimes a person oversees, so he more
responds to his cognitive structure rather than what is actually there.
Cognitive Schemas
Cognitive schemas are there to label, classify, interpret,
evaluate and provide meaning to objects and events. They are derived from
experience and instruction and contain, rules, beliefs and memories. When a
schema is activated it can block out information that isn’t allowed by that
schema, so if someone is hungry that can block out ideas about diet or
exercise. With psychopathology then the anxious person can only see danger not
safety, the depressed person only see negative things not positive things. With anxiety that’s kind of weird as if the
cognitive appraisals are correct, i.e. threat, coping resources=anxiety, then
the perception for coping resources is already there. But with anxiety
disorders, there’s the sense that the symptoms are a sign that something is
wrong with me, I will go mad, or that will be humiliated.
When the symptoms of anxiety become something that is feared
then this can make anxiety become worse to the point where fainting is the
order of the day or freezing as the fear is so high now, that the client thinks
they are either under attack now, or that they just can’t cope with the level
of attack.
The content of the schemas will determine the affective and
behavioural response.
The function of the cognitive set
Once a schema is invoked it can rapidly process data which
is its point. I wonder what it’s like when we are between schemas or there is
no active schema. Schemas are adaptive in that they allow us to processes the
most amount of data that we can in the shortest of times. A schema can often increase the number of
false positives but decrease the number of false negatives, so in a danger
schema, then there will be more times that something which isn’t frightening is
identified as such but fewer times something that is frightening is identified
as such.
Schemas can sometimes be turned on and off at will, so I
decide to study and the studying schema is evoked. More than one schema can be
evoked at any one time, so that the playtime mode maybe activated with the
study schema which can create a clash of desires.
The continuous Cycle
Schemas can have cognitive, affective or behavioural
content. So you might judge something as being sad, so that you then invoke the
sad affective and behavioural schemas. You can also get a behavioural schema
operating under a fear schema you aren’t that conscious of, and when you spot
it happening, you can deliberately invoke a less fearful schema. Thus you can get a behaviour that is
activated then controlled, this you can usually see as not all of the behaviour
can be controlled and it certainly doesn’t look like its desired outcome, so a
nervous person forcing themselves to look relaxed doesn’t look like a relaxed person.
Anxiety is used to prompt for action which when taken should
reduce the fear and signal the all clear signal, it is this latter aspect that
doesn’t happen with people with anxiety disorders.
The Modes
Problems can occur when there is prolonged activation of
fear and anxiety and this occurs when a person perceives his vital interests
are at stake. If danger schemas are
activated for too long then you get distress, tremors, muscular tension, sleep
disturbances. If a schema is often used
then it becomes habituated and it becomes the superordinate schema. These
superordinate modes, can be narcissistic, depressive, erotic, fear or hostility.
These dominant modes then effect specific schemas, so if you are taking a test,
and you are in hostile mode, then you think bloody test, or if you are in
depressive schema, then you think, "Oh my God, " I’m going to fail. S
Syndromes and modes
Various syndromes can be conceptualised in terms of the
dominant schema
1.
Depression
a.
Self-constricting mode is dominant
2.
Anxiety
a.
Vulnerability of danger mode is dominant
Dominant schemas produce bias, both attentionally and in
terms of recall. So cognitive processing
is biased by the dominant schema both in terms of perception and in terms of
recall.
Assumptions, rules and formulas
Rules can operate at a preconscious level where they direct
our attention and our interpretations, they have been used so many times that
we are not aware of ourselves doing it.
Rules can be grouped in terms of theme, much like schemas can around
modes. Many rigid rules are there for
rapid response, they seem too organised as a basic matrix of cognitive response
and therefore hard to change.
Rules in problematic situations
Problems occur when you use rules in the wrong situations,
or you don’t adjust your rules to suit your outcome. Rules say how you should act, and how you
interpret, thus rules are the basis on which we confer meaning to our world. As much as there are rules, there are also
assumptions which are standardly conditional if someone is nice, then they want
something. Often rules and assumptions guide our interpretation of a situation
and we are as unaware of them as of the rules of grammar that guide out language
Rules in Anxiety Disorders
Each distress has its own set of rules associated with
it. In anxiety the rules are about
danger and vulnerability and are generally conditional if x happens then
dangerous y which I can’t cope with.
Summary
We need to interpret the world in a certain way and judge if
what is of interest, if it is positive or negative. We cant do this every time
as otherwise we would be very slow in our actions. So what we do is to have
schemas which is the congealing of rules, assumptions, beliefs, and memories,
that determine how we respond behaviourally and affectively in a situation,
they determine our perceptions and our interpretations on that which lead to
action, behaviourally and emotionally.
Schemas have modes where they have certain aspects. Likewise
schemas have different content type so cognitions, behavioural and emotional.
You also have dominant schema so we might have a cognitive shcema in charge,
saying I must study, and this may be in battle with the play schema that needs
to have fun. The modes are the descriptions of schemas as depressive, hostile,
loving, caring etc. When a person
habituates certain modes of schemas then they can naturally adopt these and
they become quite inflexible. The problems with this is where the schema
prevents sight of anything to dispute it, the rules which are used are used to
prove themselves with evidence from the world rather than looking at the world
to see if they are true.
Rules and assumptions are used so habitually to interpret,
guide action and evaluate action that we forget the rules that we have much
like we don’t the rules of grammer we use, just the impact
Chapter 5 Vulnerability: The core of anxiety disorders
The Concept of vulnerability
There is a paradox when anxiety prevents the simplest skills
from operating at a time when we need them most, the clue to this is the
concept of vulnerability, the feeling when
you are threatened.
Vulnerability is the person’s perception of himself as
subject to internal or external dangers over which his control is lacking to
afford him a sense of safety. Where this
sense of vulnerability is pathological is where there is a minimization of
perception of personal strength and a maximisation of the sense of danger.
There is minimisation, selective
abstraction and catastrophising to get to this point. A person minimises their personal strengths,
perceives the world as only threantening, selective abstraction and each slip a
slide towards oblivion, i.e. catastrophising.
When in vulnerable mode, recall is of times that they have
been weak, past successes are forgotten. A vulnerable person only counts failures
not successes. A positive appraisal of yourself and ability to handle threats
gives you self confidence.
The role of skill deficits
A person feels vulnerable if he lacks the skills to deal
with a threat. Inceaseing skills decreases vulnerability.
Self-doubt
When the vulnerability mode is active then processing
happens in terms of the clients weaknesses. There’s a sense of uncertainty with
each act, oh my god, its going to go wrong.
The role of context and experience
As long as a person
has a firm belief in competency he is protected from the sabotage of
uncertainty. When we have more skill and experience then we can have more
mature and less primal responses. The more skill the more coping resource, the
more experience the more coping resource.
There is a strong aspect of context with skill. In private
we can play the fiddle, walk a straight line, make people laugh, but do this in
public, or walk a straight line over a 100 foot drop. The context provides
consequences to failure, and the higher the consequences the more we question
our ability and the greater the vulnerability we feel. A more experienced
person directs their energy towards problem solving rather than escape
behaviours, or protecting himself in the
face of threat. If you enter an evaluative situation then this can increase the
likelihood of your vulnerability set being shown, so speaking in private, or
speaking in front of a room of people.
Interference with effective performance
A person perceives themselves not to have the skills to
manage a threat, they then can actively block themselves from achieving it, eg
mind going blank, rigid muscles etc. A
person inhibits themselves in this way as they want to stop themselves going
into the danger zone. Thus it becomes self defeating when on one hand your
anxious, and your anxiety is trying to stop you doing something and on another
hand you’re thinking I shouldn’t be anxious I’m going to do this anyway.
Catastrophic predictions and vicious cycles
As predictions of danger change so does the sense of
vulnerability. Walk across a plank 6 inches up and 600 feet up. This can lead
to catastrophic predictions when any sign of wobbling can lead to the image of
catastrophe, which again makes the levels of anxiety higher, and performance
decrease.
The function of dysfunctional behaviours
Physical danger
There is active interference with performance with anxiety
which aims to curtail risk taking, and abandon the current plan. The higher the
amount of effective danger, i.e. level of danger vs. coping ability plus a
factor in of probability, leads to the level of anxiety, which will curtail the
action.
The cognitive system evokes caution by putting out thoughts
about self-doubt, possible catastrophic outcomes. What the anxiety is trying to
do here is to stop what you are doing as doing it more will cause more harm or
conceivably if you are under attack stop the body so as it can better respond
to a pounding, also there is play dead which is a possible outcome. So where anxiety becomes an issue is that you
want to do the anxiety provoking activity.
Levels of self-confidence in ability to cope lower the
levels of anxiety. This is where the a protective person, a helper, I can’t think of the right word, the human
safety blanked enables anxiety levels to
drop and why people cling to people, to raise their self-confidence, lower
anxiety. This safety blanket to raise self-confidence, can be seen in social
circles by getting people to smile and laugh and therefore like you. That means
they are less likely to criticise you.
Anxiety is a primal defence system.
Psychosocial danger
Again as with physical danger, the result of the sum danger
level, coping level, and probability=level of anxiety. Here the anxiety makes
the problem worse. Anxiety provides physical immobility and inhibits speech. A
common social fear is that of showing weakness or impropriety and being
devalued. If a person’s self-esteem is tied up with his performance then it can
matter greatly to him if he performs badly, so the danger levels are very high.
Anxiety says I cannot cope with this danger, so I must be cautious against any
slips. This means increased vigilance,
this means selective attention for dangers, never mind looking for safety I
must see the dangers that are out there, as I must increase my anxiety levels
to stop what’s going on, until I don’t see any more danger and my coping levels
feel fine again. So why when you start getting anxiety, does it build up on the
basis of your active interference, well you are still active in an anxious
making place, you haven’t heeded the warnings so it’s turning up the volume.
The domains of vulnerability
Sectors of the domain
The domains where there is vulnerability are social or
personal.
The social domain are those areas where close relationships
are vital for success. Thus there is dependency on the other for help and
support. Goals such as intimacy,
sharing, understanding, approving and so on. Individuality are goals that advance a person’s sense of
identity, mastery and independence, so these are about status and power, in
these instances other people are involved but they are not the goal merely the
expedient.
Threats to the domain
Any event that impinges on a domain is either going to be a
gain, a maintenance, or a threat. You can also understand the personal and
social domains in terms of Public and private.
1.
Sociality
a.
Public sector deals with a person’s strivings in
reference to his social group. These strivings include group belonging,
support, approval and physical closeness.
b.
Private sector a gratifying relationship with
another, intimacy, empathy
2.
Individuality
a.
Private sector: Striving for power, knowledge,
wealth, health etc. is similar privately and publically
b.
Public sector: uses others to compare levels of
individuality against to measure success levels. Here social roles will be used
to succeed, rather than to connect with the group
Threats to sociality
In the public sector threats to sociality are loss of group
identity, acceptance and conviviality. So the threats are exclusion and
isolation.
In the private sector, then exclusion and isolation are the
end game of threat with rejection and disapproval the threat.
Threats to individuality
In the public sector then threats to identity, status or
power are threats, which cash out to devaluation, depreciation. In the private sector then the threats are to
health, so disease or death, losing bodily functions, going mad, anything that
threatens self-mastery.
Specific fears
If you look at most standard complaints they can be mapped
against societal\individual public\private
1.
Panic
attack
a.
Fear of going mad: private individual
2.
Social anxiety
a.
Fear of being judged by the group: public
individual
b.
Being rejected by the group: public societal
Summary
Vulnerability is at the core of anxiety. It says that I am
under threat to a danger which I have no power to cope. This inability to cope
suggests that with more skills and more experience then there would be a higher
ability to cope. Likewise if there are people to support you then this could
increase the power to cope. Likewise how significant the danger is will
influence the level of vulnerability. If you whole life will be defined by a
piano recital then an awful lot is at stake.
Therefore the ways that you can work with anxiety, is to
increase coping skills, decrease the sense of danger, also get the client to
look at what is causing the anxiety not thinking the anxiety itself is a
problem or a sign of something else.
Anxiety then tries to stop reckless behaviour by making you
not want to go any further or continue your actions, it can also enable you to
ride blows or get the enemy to ignore you by playing dead. These responses are
fast and primal
The domains of vulnerability are societal and individual.
The former are goals with people the latter are goals by yourself. So the
former is acceptance, belonging, intimacy, the goals for the latter are
mastery, power and status. You can use the public, private realms to understand
most pathologies in terms of individual or societal.
Chapter 6 Generalised anxiety disorder and panic disorder
General View of the Etiology of Anxiety Disorders
The predisposing factors to anxiety disorders are:
1.
Hereditary
2.
Physical diseases
3.
Development traumas
4.
Inadequate coping mechanisms
5.
Cognitive difficulties, unreasonable goals
values etc. learnt from others
Three are also precipitating factors
1.
Physical disease
2.
Severe external stress
3.
Chronic external stress
Standardly it is the composition of genetic, developmental,
environmental and cognitive that predispose one to anxiety disorders.
Precipitating psychological factors
These are going to be things that increase the danger of an
event and decrease coping resources. To increase the danger of an event, it can
be an existing event that increased in quantity\quality, or your valuation of
that event.
1.
Increase in demands
a.
If a person has increased demands and if those
demands are highly related to personal worth, i.e. a vital interest be it
individual or societal and there is a depletion of coping resources then
anxiety will loom, so promotion, new parent etc.
2.
Increased amount of threat in a life situation
a.
New boss at work, who threatens to fire you, new
mother whose baby is susceptible to infection
3.
Stressful events that undermine confidence
a.
Fail at something significant to vital interests
that undermines confidence
Interaction of precipitating factors with previous problems
Precipitating factors are only an issue as they highlight
vulnerabilities which are a result of the composite of hereditary, physical
diseases, development etc.
Do Cognitions cause anxiety disorders
Dysfunctional cognitions are a symptom of depression and
anxiety not a cause.
Beck proposes there is an upset in the regulatory functions
of the cognitive system that misinterprets dangers. There is usually a
self-righting mechanisms amongst emotions. Hostility is usually counter
balanced by anxiety. Elation by criticism. So this means that you cant be held
in the grip of a single emotion for too long.
What seems to happen with pathology is that the turn off mode has gone,
so with anxiety, this would be turned off by seeing that there is no longer any
danger. It is possible that some modes become used so often that they prevent
the hearing of the usual feedback that would turn them off.
In mania there is an attentional bias to self-inflating
ways, in anxiety an attentional bias to danger, these modes are not turned off
and then create secondary problems, somatic generally plus also the feeling
that this isn’t a mode but this is life.
So the cognitive system actually is the turn off mechanism
for anxiety, depression etc. as much as as symptom of them. When the cognitive
system starts seeing coping resources, then threat levels reduce and anxiety
reduces. When the cognitive system starts seeing achievement then self-esteem
increases and depression reduces. The
cognitive bias maintains these maladies either always seeing danger, or always
seeing whats wrong with me and the world.
Generalised Anxiety disorder
Symptomatology
The symptoms in anxiety disorders are overactivity of the
cognitive, affective and behavioural systems.
An important feature of GAD is an inability to concentrate\mind blurry
and fear of being rejected. Also uncontrolled somatic symptoms, shaking,
wobbling etc. are prevalent.
Types of Generalised Anxiety Disorder
Two types of GAD:
1.
There has been a traumatic event, this tends to
be more acute
2.
An extension of early developmental experiences,
this tends to be more chronic.
Acute anxiety state
the belief you are actually in a life threatening situation, where the
sensation, images etc. are so vivid that you believe you are there. The
response system is reflexive and there is hallucination which are responded to.
1.
Traumatic anxiety disorders
The first major class of GAD could be labelled traumatic anxiety
disorders, i.e. PTSD. A previous event was so traumatic that it hasn’t been
possible to assimilate it, so in some ways its undigested but still in the
stomach, an introject that hasn’t circulated into the body but remains awaiting
digestion and the message that comes from this process is you cant cope.
The event is traumatic as it highly threatening to something of value and
the person felt helpless. Autonomous images: people see images of disasters
that creates anxiety, so you have the original event, then separate images that
recreate a similar situation. These images are outside volitional control, they
can be evoked by certain experiences, or they can come by themselves. Once an
image has started it continues until a person is distracted or they go to
sleep, it continues or repeats itself, they cannot turn it off. The person
re-experiences the original trauma as if it’s in the present. The person cannot
see that the image is not the actual event, they quite literally relive their
experience
2.
Traumatic psychosocial event, e.g. threat of breakup
of relationship, sudden increase in demands of new job, or new parent. This
jeopardizes certain values, such as relationship or career success.
On the basis of this there is
high anticipatory anxiety and a shutting down of the coping mechanisms which exacerbates
the problem. Thus the immediate danger responses then constitute a problem and
this is why the anxiety responses escalate, the constant state of anxiety then
produce physical symptoms which are then seen as signs that something is really
wrong and again there is an escalation.
3.
Chronic anxiety disorder, this is where a
legitimate although ungrounded fear is continually worried about, e.g. that I
may fail an exam, so I worry before class, during and after. This type of
anxiety is often following on the back of a developmental pattern. These
patterns are those around societal or individual fears and anxieties. When you
have the skills to do something you still don’t lose the fears that you had of
not having those skills, weird hunh? When we’re growing up there is both the
fear of abandonment from primary care giver and at that transitionary point
fear of independent incompetence. The price of autonomy is the decrease of a
primary care giver. The fear of disaster combined with a fear of distancing
from a caregiver is seen in agoraphobia. There are two modes self-confidence
and vulnerability, where each will cancel the other out. Vulnerability was
greatest when we were young and self-confidence is greater when we are older. A
person fears that they will be ridiculed, they will lose the support of their
care-giver, they will not have the competence to reach their needed goals.
Generalised anxiety disorder may derive
from a reactivation or extention of developmental fears regarding a persons
ability to master new skills and his acceptability to other people.
The difference between GAD and social anxiety
is that with the latter there is a skills deficit, but with the former there is
an active interference with performance that makes the dangers he fears become
more likely.
Specific Fears
There is anticipatory anxiety prior to an event, and
retrospective anxiety after an event. Generalized anxiety often have a general
fear such as dying, being rejected or attacked, whilst there is no specific
situation that cases GAD there are themes that unite the various situations
Social anxiety or interpersonal anxiety appear to be the
corner stone of most GAD. The general fear in GAD can also be somatic, so fear
of death, madness, etc. The difference between GAD and phobia, is that GAD
situations must be attended to, so I want to go out because its fun but I’m
terrified I will be rejected whereas with the spider, you just want to avoid
it. With phobias I just don’t want to see the spider.
Anxiety can be useful, if you experience it in a social
situation, it can be a spur to develop good social skills so you can increase
socialization and decrease depression which will occur if you get rebuffed by
your social group. Anxiety is therefore a spur to safe behaviour, be it
socially or individually. Where anxiety works is where the skills deficit that
it shows is remedied, or the dangerous situation is avoided. An immature person
will seek instead of making good the deficit take someone or something to lean
on.
Loss of control can be an imperative that can cause GAD
people are so frightened about it that it creates anxiety.
Proximal fears and ultimate fears
Three types of fear, the first 2 proximal or anticipatory
1.
Fear or a situation
2.
Fear of an unpleasant affect
3.
Fear of the outcome or 1 or 2
Thus there is a proximal fear, the anticipation of being in
a situation, the unpleasant situation where you might fear the ultimate fear
then the ultimate fear. So your boss calls you into his office, you have fear
of having to go into the office of being in the office, and ultimately of being
fired, as it is the ultimate fear that colours the other fears.
How this works is that the antciipatory fear of situation
can stop you going into the situation, so is preventative. Children are frightened of the dark, but this
is a proximal fear, it’s what might happen in the dark, i.e. be attacked that
is their ultimate fear. So fear can keep you away from the bad places, places
where bad stuff happens. You may not know what happens in there anymore,
because either this is a social truth or you have forgotten, but you know it’s
bad. Thus the fact that the situation is understood as dangerous provokes
anxiety.
You get afraid of the
anticipation of anxiety. This is when you are in the situation and you are
anxious about what may happen. You can be afraid of this anxiety and back away
from it.
Finally there is the ultimate fear, here the knowledge of
the danger associate with the outcome of risky behaviour is enough to keep the
person away from doing it.
The initial physical judgement of the situation is a simple
primal judgement and operates quickly but is likely to contain a lot of false
alarms.
In a study of 32 people, all were seen to fear psychological
or physical harm, but this is self evident, for a patient seeking treatment
those do so as they are being harmed! Just before a GAD episode there would be
thought such as I’m having a heart attack. Most had a distressing image , prior
to attack. Most GAD patients can trace their fears to a speficic incident in
their life that frightened them, fear of death\madness\rejection\embarrassment
are all the likely candidates.
When someone has PTSD say to being raped, when they
experience terror in a similar situation, they do not believe they will be
raped there, but that something terrible will follow the terrible, anxious
feeling.
GAD with panic attacks is usually around threat of physical
problem
GAD without usually psychological problems.
Self-Concept in Generalised anxiety disorders
Concepts of people with GAD are concerned with inadequacy of personality, or
a skills deficit in a particular situation.
People with anxiety problems have problems around
vulnerability, this can lead to a shutting down of normal goals which then
leads to depression. Vulnerability can focus around some key problem areas:
1.
Confront an authority
2.
Confront a group
3.
Subjection to immediate evaluation of ability
4.
Confrontation with a stranger
In all these situations there is the competence in dealing
with a problem and getting respect and acceptance for his individuality and
rights as a person.
The GAD client is different from the depressive patient in
that he can see the positive aspects of his personality and can separate the
consequences of inadequate behaviour from the durable concept of himself. Self_image of the GAD person is contextual,
when in an unthreatening situation they are fine, and contrariwise.
Thus GAD people have different views of themselves, one as
competent one as GAD/not competent. Therefore they have multiple senses of
self.
Self-Criticism in Anxiety and Depression
Even in anxiety provoking situations e.g. a test, GAD people
will criticise themselves for not preparing better, etc.
The depressive criticises themselves in much more global
terms, I am a failure, I have always been, the GAD criticises themselves
contextually., GAD criticisms produces anxiety as if they were warning
themselves of the dire consequences of failure.
The anxious person blames themselves for behavioural flaws,
you should have prepared, the depressed person has characterlogical self blame.
People with GAD are often depressed, and people who are
depressed are quire often anxious.
The difference between anxiety and depression
The anxious person thinks something will go wrong and they
can cope. The depressed person thinks something has gone wrong and it’s my
fault as I’m bad.
Depression vs. Anxiety
1.
Depressive criticisms are global I am bad,
anxious criticisms are specific, I can’t play tennis
2.
Anxious people see there being a future, they
can see their good sides
3.
Anxious person doesn’t see problems as
irreversible
4.
Anxious person is tentative in negative
evaluation depressed person is absolute
5.
Anxious people anticipate damage to objects,
self and relations. Depressed people regrets that he has lost sources of gratification,
that he has been deprived of significant other people, that he has been
defeated in his objectives and that he is incapable of doing anything to resolve
this
6.
Depressed person sees nothing will turn out
right for him and he feels regretful and sad, anxious people only predict
certain events going badly
Avoidance: depressed people have given up on tasks, routine
or otherwise. Anxious people only give up on specific ones. As an anxious
persons capacities grow so their avoidance lessens.
Motivation and energy: depressives lack the energy to carry
out tasks, where anxiety people have the energy but are inhibited by fear. Anxiety
is themed by paralysis, being locked in position.
Depressives lack the energy to carry out tasks, a loss of
will power.
The inhibition of someone suffering from anxiety is lifted
on the basis of a change of circumstances, whereas with a depressive person
then they have given up on a whole range of objectives before they have event
started. So an anxious person’s outlook is contingently troubled whereas the
depressed persons is absolute and they expect failure. They feel the failure of
the task not yet completed.
The anxious patient is afraid of failure in the future and
tries to stop it happening, the depressive sees that it is going to happen. The
anxiety patient is not concerned unless a vital interest is threatened.
The anxious person thinks they have something inside them
that stops them, they feel a fear for that which will go wrong in the future,
whereas a depressed person already feels sadness for the fact that it does go
wrong.
Self-concepts. The anxious person thinks they have specific
problems, weaknesses, etc., the depressive thinks they have character flaws.
The anxious person is contextual,I cant do x at y, whereas the depressed person
is absolute I cant do x, period.
Panic disorder
Description
5 aspects of a panic attack
1.
Internal experiences seems strange
2.
Loss of control of cognition, perception,
rationality and action
3.
Feels confused and disorientated
4.
Uncontrollable anxiety
5.
Faintness
The most frightening thing about panic disorders is losing
control of those things you take for granted, focussing, concentrating,
attention, action. It is rare to lose consciousness. There is a dazed and
confused feeling that is derealising.
The striking feeling of a panic attack is the feeling of being engulfed
by uncontrollable anxiety and the suppression of reasoning power. During the
onslaught of symptoms there can be no reasoning that the last time this
happened it was innocuous. Whilst cognitive faculties are lost there is still a
hypersensitivity to certain noises. There is also a feeling of weaknesses and fainting.
There can be signs of a panic attack such as NATS and inexplicable
physiological sensations. Panic attacks seem to signify helplessness in the
face of serious danger. The fear of his own vulnerability interacts with
psychological and affective responses to produce a vicious cycle.
The panic disorder, has cognitions, I’m going mad, physiological
affects that and fear of derangement that almost seem designed to be self-supporting
and increase this problem.
The crucial devastating symptom is the inability to control
ones mental, physical and affective symptoms, when this happens the client
starts to catastrophise.
In simple phobias, i.e. fear of height, animals etc., if
escape isn’t possible then a panic attack is possible. Beta blockers reduce tremors
and a tight throat but don’t deal with any other symptoms of panic. Valium has
an effect on GAD but not on pd. Beta blockers deal more with physiology whereas
valium deals with affects.
Meaning of Panic Attacks
A person feels vulnerable backed into a corner and then they
take their anxiety reactions as a sign of internal derangement and the real
explanation of what is happening.
Panic attacks can be treated with beta blockers. They are a
response to an emergency situation whereas anxiety is in response to a danger
situation.
Functional Analysis of panic attacks
Primal automatic mechanisms take over in these conditions.
They are not volitional, they were designed to cope with physical danger but
are now used with psychological danger, and they can actually increase the
problem.
Primal physical reaction:
1.
Freezing
a.
to cope with ambiguous danger
2.
Immobility
a.
To prevent falling
3.
Gagging
a.
To prevent obstruction of the airway
4.
Ducking or jumping
a.
To avoid an object
Because these are automatic this creates a psychological
danger. These primal reactions often serve no use in mature adults who have
better coping strategies, but may provide some use to small children.
Panic attacks differ qualitatively and quantitavely to GAD
and anxiety in general. Panic is more intense. In a panic attack you may see
depersonalisation, derealisation that you may not in anxiety. You can also see
in panic attacks the loss of the ability to reason. Panic suggests an emergency
response whereas anxiety suggests a danger response. Panic attacks can be made
better by anti-depression drugs but not by anti-anxiety drugs which suggests
they are part of a different system.
Whilst panic attacks seem to be spontaneous there seems to be some
activation of a person’s alarm system, be it cognitively or physiologically.
These can be innocuous but are often accompanied by impaired faculties to
reason with himself, be it fatigue or drugs.
Precipitation of panic attacks
Whilst described as spontaneous there seems some
experienceses that activate a persons alarm system, feeling faint, or short of
breath. These are then misinterpreted. Psychological factors can also
precipitate an attack, for instance following the separation with a loved one.
Summary
Generalised anxiety disorders have two forms acute anxiety
and chronic. The former is based in PTSD
and has generalised the stimulus. The latter is the result of developmental
issues and whilst it will have a theme will be see in a variety of situations. Actue anxiety there is hallucination and a
re-experiencing of the original trauma.
For the GAD sufferer then there are aspects that predispose
people to respond in this way, that then make them more susceptible to certain
situations, e.g. levels of stress.
GAD is that a situation represents a danger and there’s a
feeling of not being able to cope with it and being vulnerable. The vicious
cycles of GAD are where the anxiety warning signals are interpreted as a danger
themselves and this is where they can escalate.
It seems that the anxiety systems were created predominantly for
physical danger but now get used for psychological danger and they actually
increase the levels of psychological danger through decreasing its performance.
The anxiety systems are primitive and primal and fast.
Within the anxious person then they see themselves as
contextually deficient, they can see their good aspects but struggle in certain
situations.
For people with anxiety disorders then there is a problem
with turning off the alarm system when the danger has gone, it is as if the
alarm has been working so often that its got stuck
The difference between GAD and panic attacks, are the former
are for danger the latter for emergency. You can see this as GAD and anti
depressents work and panic attacks and beta blockers work but not vice
versa.
The anxiety system are from a primal response to a danger,
there is a good chance that they were created in response to physical danger
but now are in response to psychological danger so are not adaptive.
The vicious cycle of anxiety is when the symptoms of anxiety
are seen as a problem, oops I said this above, oh must be getting tired. Anything more to say about GAD, no but the
clients that I have worked with have more complained about excessive rumination,
which whilst part of GAD doesn’t really do it justice. GAD is where there is
anxiety in numerous situations, rumination in numerous situations is different.
Now admittedly there might be anxiety that the rumination is seeking to reduce,
but that is the step that you need to take or be clear about.
Chapter 7 Simple phobias
Definition of Phobia
Phobia derives from the Greek Phobos which means flight,
panic-fear, terror and comes from the Greek god Phobos who could invoke fear
and panic is others. The sufferer of a phobia doesn’t accept the grounds of
their fear as reasonable.
A person facing their phobic object has a degree of anxiety,
and has what is akin to a medical emergency, pounding heart. The second
powerful urge is to escape or avoid contact with the object or situation of
fear. The third characteristic is that outside of the interaction with the
phobic object he sees his fears as exaggerated or ungrounded but despite this
realization it doesn’t change his reactions to it. A phobia magnifies a fear. A
phobic has anticipatory anxiety when he thinks he is going to meet his phobic
object, this is the same anxiety as can be seen in GAD.
The objects of phobias are objects that normal people fear
too, or archaically feared and the phobic merely magnifies this level of fear,
and the magnification of risk.
A phobic, who has anticipatory anxiety of encountering their
feared object, has similar symptoms with someone who has GAD. In fact what is
the difference, someone who had an acute trauma, will have GAD by generalising
the original trauma. Someone who has chronic GAD and who has developed with a
feeling that they won’t be able to cope and some things are very important to
their being. So I guess the difference is in terms of values GAD people have
something they value threatened and they don’t know how to defend against it, a
phobic merely fears the object, they don’t threaten directly a value object,
such as self-esteem, but rather the spider that will bite, or the birds that
will touch me, I guess the valued object is their health which with downward
arrow would probably show.
Differentiating phobias from fears
The difference between phobia and fear is the reasonable
factor, if generally people think someone’s fear is unrealistic, over
emphasising the danger, and the risk then it’s a phobia. So it’s a social
construct.
A person with a specific phobia, isn’t weaker on the
sensitive scale as often they can tolerate other situations that other people
are highly afraid of.
The refractoriness of phobias
You can’t change a phobia by educating the person about the
feared object. Intelligence or realising
that a phobia is unreasonable doesn’t diminish it, indeed phobics can be
powerful people in all other areas, Often the reason for the phobias
development is unclear. From a distance a phobic has a greater rational
appraisal of the situation, but closer this rationality goes.
Content of fears and phobias
Phobic objects have changed, gone are the fear of Satan, but
up comes the fear of radiation. The fears of phobics generally tracks the fears
of non phobics, just exaggerates the risk.
Phobias spread associatively, knocked over by a truck when
working, then get fear of working in road, then fear of driving on road. The
link is a similarity in type of danger.
There is rationality for the phobic about their fear, but
there is a chance that it has been being done for so long they have forgotten
what it is and merely act now on the basis of intuition.
Classification
Phobias can spread through a process of abstraction in a
similar fashion to OCD. However in phobia it is similar in type of danger, in
OCD then it can be other forms of relation, i.e. spatial, can’t touch the
handle, can’t touch the cloth that could have been placed on the handle, hmm,
that’s similar to the same type of danger. Maybe they are the same.
There are three major types of simple phobia:
1.
Social rejection
2.
Agoraphobia content, e.g. travelling alone,
being in crowded places, heights
3.
Being cut or observing bleeding
Traumatic phobias
Phobias often develop from a traumatic experience or a
childhood fixation, also continued exposure to danger can do it. People with a
traumatic phobia are often able to date the onset of their phobia to the event
that started it.
Fixation phobias
Common in childhood, e.g. fear of water, thunderstorms,
blood, doctors etc. Children have a lot of fears, and young children it focuses
on physical harm, and older children it focuses on psychosocial harm. Most
children outgrow these phobias but why don’t all of them? It is possible that
these are carried into adult hood as the child watches their parent’s avoidant
behaviour and copies it, or avoidant behaviour was reinforced by parents.
Alternatively there might have been an incident whilst the fear was active,
that created the avoidant behaviour.
Specific phobias
1.
Acrophobia is fear of heights.
a.
The sufferer can get somatic images where they
feel the fall, imagine the fall and this creates dizziness. The sufferer thinks
either they might jump from the height or that some external force will pull
them over the edge.
2.
Elevator fear is that the elevator will drop or
stop between floors.
a.
There can be those with this fear that have a
physical fear that they will go crazy or a social fear that they will faint and
then suffer embarrassment afterwards
3.
Claustrophobics, believe the walls will collapse
and they will be trapped, buried alive.
a.
They fear that they will suffocate due to
insufficient air, or be buried alive
4.
Air plane phobics believe they may lose control
due to tension in the plane, that they will run out of air, due to the planes
air con not working, oh yeah and the plane crashing.
a.
There is a a social fear going on, that they
will faint and be an embarrassment. There can also be a fear similar to agoraphobia
that there is separation from a caregiver who can help them if they have a
heart attack
5.
Blood phobias, they get squeamish at the sight
of blood, it’s not a fear but rather it creates a collapse response
a.
People phobic of blood usually have other
phobias and fears., the common denominator is passivity and a sense of
helplessness in the face of possible injury.
The Meaning of Phobias
Phobics who fear the same object, may well fear different
consequences. So same phobia different fear. They may well have the same fear
to different objects or events.
In general phobias tend to focus on:
1.
Physical harm
2.
Natural disaster
3.
Social embarrassment
Multiple phobias: Conceptual continuity
Many phobics have multiple phobias. Standardly with multiple
phobias there is a common link between them.
Relation of fears to Phobias
Sometimes difficult to tell the difference between fears and
phobias, as phobias always have a grain of truth within them. On the spectrum between fear and phobia is
phobia, standard fear, then counterphobia, where people do objectively fearful
jobs with no fear, e.g. soldier, tanker driver
Self-Confidence versus vulnerability
Why do some people have no fear when they should do? The
more often you do something dangerous the less anxiety you feel, e.g. driving a
petrol tanker. It is possible through
repetition of the feared activity you see that your worst fears will not be
realised.
Dual belief System
Phobics have a dual belief system, one belief in the phobic
situation one outside, one believes the phobia, one doesn’t. As much as you can have cognitive fantasies,
i.e. rumination, you can also have visual fantasies. When not near the feared situation they have
a standard objective probability of disaster, as they get closer to this, this
changes due to activation of cognitive distortions and visual images, and they
have a high probability of something very improbable happening. You’d wonder if
the warning signs that get created, e.g. visual distortions and somatic
responses, actually recreate the same situation as if there was danger,
Visual Images
Some people have acute visual images that create anxiety,
they seem to operate as a warning sign for an impending doom.
Identification with Victim
Some phobias happen by watching someone else in a dangerous
situation, e.g. hospital staff watching an operation. This happens through an
identification with the patient.
Evolution, Rules and Phobias
The rules for promoting immediate survival against an
immediate threat are fast rules, i.e. global, absolute, there is no question or
ambiguity. The rule is applied on the basis of a part object if it is that
terrifying, so the eyes of a hawk, for a mouse. It is good for children to use
absolute rules until they become mature enough to refine their rules. Pre
verbal rules are often in terms of images and conveyed by the expression of the
mother. The movement from an immature rule to a mature one is the realising
that the rule is too absolutist or that the fear is exaggerated most of the
time. Immature fears are not entirely got rid of, and when we are stressed,
tired etc., they can reappear, or maybe depression.
There’s seems to be some evolutionary benefit to these
phobias, fear of small animals, heights, open spaces. Whilst absolute fears
will generate many false positives again it seems that evolution favours the
nervous.
Summary
Phobias are an unreasonable fear of something. The root of
them is within either current or historic fears in society or in childhood and
are magnified. They have the form of
being an absolute rule about their fear, which is on the basis of a part object
and in no way allows proability to come in to their equation, in this way a
phobic response is like the response to an immediate threat. The base fears in phobia are:
1.
Physical harm
2.
Social embarrassment
3.
Natural disaster
Standardly a phobic has a dual belief system, one when
distant from their feared object and one when close. The movement between near
and far is represented by an increase in the danger signs system, i.e.
distorted cognitions, visual images etc.
There is a spectrum from phobia on one side, normal response
to counter-phobic, where people do dangerous jobs with no fear.
Phobias can be things that started in childhood, or from a
trauma and then fixated at that point. They are also things that can be more
prevalent under times of stress, depression etc.
Chapter 8 The Agoraphobia Syndrome
The Riddle of Agoraphobia
Why does a person develop agoraphobia in their 20’s when
they have no other psychiatric problems?
The Development of Agoraphobia
Predisposition and precipitation
Agoraphobia occurs after the age of 20. They say that
agoraphobics have panic attacks with regards to separation and that they have
had a lifelong fear of the ability to cope and that there has been a protective
figure there who makes it alright. So mum and dad and at the age of 20 then
they are separated from them agoraphobia can be brought on as the needs to be
more adult increase or the protection and coping mechanisms decrease, e.g.
death of a care giver, or birth of a child. There is also the sense that if the
client performs inadequately there will be disastrous consequences. In a
typical scenario then the client sees the person who supports them is also
suppressing them, then as demands increase there can be a reversion to an
earlier dependent state.
Onset of symptomatology
The fears of the agoraphobic are losing control, getting
lost, being bowled over and it seems like the salient aspect is not being able
to get back to the caregiver, get back home. These seem similar to the fears of
a young child.
Aspects of agoraphobia:
1.
Perception of unlimited opportunities to be
humiliated, crushed, attacked etc. and no reliable defence against these
threats
2.
Reflex produces panic physiology which is
suggestive of serious internal problem from which there is no escape
3.
Experience of malfunctioning and a decrease of
competence
4.
Loss of control over reactions, noticing that
they have no control over the external threat or in response to this the
internal threat, i.e. diminishing of functioning, and panic physiology
5.
Loss of sense of competence, fears of internal
and external disturbance means seeking assistance from the care giver
6.
Home or safe haven is safety from external
threat, internal threat caused by external
7.
Multiple inhibitions, submissive tendencies and
negative appraisal of self, undermine self-confidence and thus tend to
disequilibrium in relationships thus feeling dominated by other people
Panic
Attribution of causality in panic attacks
Some people believe that agoraphobia begins with clients
with a panic attack. Some people have
agoraphobia without panic, some have agoraphobia and then panic. In many cases
the progression to panic attacks follows a period of tension where a person
can’t deal with a novel problem. Without
coping strategies there builds up a sense of hopelessness and various somatic
and psychological symptoms. Rather than link this sense of unease to the novel
problem it becomes linked with a problematic internal state. You can also
sometimes see the preponderance for explanations that people have. If symptoms
are unexplained then it could be that people revert to their default
explanation of problems, such as a disease or a character defect.
Imagery plays a role in agoraphobia, where people imagine
malign events in public places. The panic attacks in agoraphobia are the same
as with GAD, some patients can head off a full blown attack by distraction,
cognitive restructuring, or seeing the symptoms as an emotional reaction not
the sign of a catastrophe.
Cognitive set: vulnerability
As a client approaches a phobic situation she locks into a
vulnerability set. Before the situation they are worried about an
uncontrollable reaction but they don’t see it as indicative of anything serious
but inside it they do.
The base cognition seems to be that when you are alone you
are vulnerable, this can be assuaged by somewhere or someone safe. So they can
have a minor complaint, can’t get to safety, this increases fear of not being
able to cope which intensifies the sensations which leads to feeling that
something serious is happening and they can’t cope. If they can’t get to a
place of safety or a caregiver then this sense of danger radically increases.
Again the danger signals suffered, give indication of the seriousness, and the
immediacy of the danger.
The agoraphobic operates on the following principles
1.
An overwhelming danger can occur
2.
There’s nothing I can do about this
3.
If I can get to a place of safety, or a
caregiver then I will be ok
4.
Any particular sensation can be a sign of this
5.
If I don’t stop this danger, or sensation then
it will increase into ultimate disaster
Specific locations cause problems as they block access to
safe havens and caregivers, the key feature in all of this is the sense of
being trapped. They can also be seen as having an element of danger it, that is
why they are so toxic, as they are dangerous and block access to safety. There
can be a whole host of dangers getting to the phobic place, e.g. driving to the
mall, the mall is the phobic place, but there are phobic dangers attached to
the drive too.
Opticokinetic reflex: where the geometry of a building can
both suggest being hemmed in and being engulfed by too much space, so can’t get
back to care giver.
Agoraphobics value mobility and means of getting to safety,
paradoxically one of the responses to this is immobility. Mobility is however a
need on its own and freedom, self-determination and individuality are all
aspects of it, and remind me about the feeling suppressed by the care giver.
There are often fantasies about being completely free, breaking loose from
conventional rules of behaviour by yelling, acting crazy doing destructive
acts. The conflict then is around on one hand dependency and need to get to
safety which mobility forms a part of and also a resentment of this and a need to feel free.
Thus they feel incapable of coping without the support but rue the loss of
freedom that is associated with this. This is important an agoraphobic not only
needs to escape the danger, but also they have a need for complete untrammelled
freedom. They need the caregiver but there is also a resentment of this,
possibly shown by the need for ultimate freedom. Thus the issues revolve around
danger, dependency, autonomy and control.
An agoraphobic has
1.
A strong emphasis on self determination
2.
A hypersensitivity to control or interference
3.
A tendency to react to threat with weakness or
escape
4.
A tendency to react to somatic complaints as a
sign of physical disruption
5.
A strategy of depending on a caregiver or a safe
place
An agoraphobic doesn’t want to be too close to their care
giver lest they get dominated nor too far lest they can’t cope, this is
mirrored in their relation to space where they don’t like things too narrow,
too close, nor to expansive.
A Synthesis
The following is a synthesis of the above material and is
based on clinical observation
1.
Agoraphobics have fears that were realities in
early childhood but not in adulthood. Susceptibility to these fears is
increased when under stress.
2.
With the background of reduced internal and
external resources the fear of being away from a safe haven may be activated
due to trauma
3.
A panic attack is taken as a sign of some
internal disorder, the patients reduction in cognitive faculties means that
they cant objectively assess the danger.
4.
The reduction of faculties, and the increase of
danger means search for a caretaker, who is seen as having faculties not
impaired. The caretaker is there to get the person to a hospital if there is a
physical danger or to reality test as they have lost their faculties
5.
There are a number of circumstances that can be
interpreted as dangerous
a.
Places where panic attacks have occurred
b.
Places which are relevant to latent fears from
childhood
c.
Experience of dramatic internal states
d.
Separation from caregiver or safe place
6.
Hypersensitivity to too narrow or too expansive
places
Summary
Agoraphobia generally has an onset in the twenties. This can
be a time when they have less support from their parents. It can be that there
are childhood fears of being abandoned or of being overwhelmed that have both
been supported and created by their parents. When they no longer have this
support or there is a critical incident you can see the onset of agoraphobia.
Agoraphobia can extend from a specific type of place to other places.
What you see in agoraphobia is a panic attack when they
can’t get access to their safe place or person. This comes from a feeling of
vulnerability in not being able to cope with danger. When a panic attack comes
from a dangerous place then cognition is impaired, somatic symptoms show danger
and there is a sense of high scale impairment of faculties that needs to access
the faculties of a caregiver to ensure there is safety from danger. Mixed in with this is a resentment of the
dominance of the other and a desire for complete freedom.
The agoraphobic is hypersensitive to internal signals of
impending disaster
Chapter 9 The Evaluation Anxieties
The Essence of Evaluation Anxieties
Before the fall
A person with social anxiety feels vulnerable unless his
performance is adequate. An adequate performance is according to certain rules
and procedures. The greater his confidence the greater the skill, if he has a
failure then he may have a primitive motor response. Social anxiety is a test
of maturity and ability. Smooth performance maintains his image and his status
and contrariwise. His performance is judged by everyone there, a crowd of
evaluators who appraise his performance as clumsy or skilful. Thus whilst his actions represent a small
fraction of his interactions he fears he will be judged on these and the damage
is to the entire person.
There is the sense of a tightrope walked an error would
result in a fall from grace, watched by observers, the reaction to falling off
the rope would be shame and humiliation.
Common features of evaluative threats
The evaluative anxieties are:
1.
Social
2.
Performance
e.g. exam etc.
3.
Transactions with outside word, e.g. shopping,
buses and engaging with the functionaries
The modulators of situation are
1.
The relative status of the client and his
evaluators
2.
The clients ability to produce a front
3.
His confidence in performing adequately
4.
His appraisal of the degree of threat and the
level of its consequences
5.
The threshold of his automatic defences and how
likely they are to be activated. These automatic defences, such as speech
inhibition or shaking, suppression of spontaneity, will weaken performance
6.
The anticipated punitiveness of the evaluators
Vulnerability
A client then has a number of questions to ascertain his
level of vulnerability
1.
How much do I need to prove myself to others
2.
What is my relative status to my evaluators
3.
How important is my relative status to my
evaluators
4.
What is the attitude of my evaluators
5.
To what degree can I count on my skills
Status and ranking order
A good part of the pressure to perform is related to the
relative position on a vertical scale of power or social desirability. If a
person appears self-confident then this can induce feelings of inferiority. The
higher the status of the evaluator, the lower the status of the person, and the
more inferior they feel. Likewise the more dominant the evaluator then the more
submissive the person can respond.
Self-confidence can be knocked by valuing the evaluator and
him lower, seeing a lot being at stake on this. As self-confidence goes up
vulnerability goes down and vice versa.
Thus a person’s self-identity and value is concerned with
their performance which is gauged in accordance to others. Their
self-confidence is then affected when they are with high status people. Their
response maybe avoidance of situations where this may be encountered which then
leaves them with a feeling of low status.
Self confidence
Confidence then is related to the levels of perceived skill,
the threat of the other and the levels of danger which result in failure. There is a reciprocal relationship between
confidence and vulnerability.
Rules and formulas
As performance is key to evaluation and status then there is
a set of rules that need to be obeyed to get points. Failure to keep to these rules increases
anxiety, lowers confidence, increases vulnerability and effects performance. Feeling that rules have been broken then increases
a sense that there will be rejection.
Automatic protective reactions
Automatic Reactions
A person under threat of evaluation may evoke automatic
reactions which whilst anachronistically useful as they may protect against
attack, serve no current useful purpose, they can be to impede the flow of
speech, thinking and recall.
Anxiety
This becomes a spur to reduce the sense of danger. This
might be to escape the situation, to being inconspicuous. Again the need for
safety that anxiety can bring impacts on performance and brings a negative
spiral.
Faint
Again people fear, or have this reaction. Evolutionary this
might have been appropriate when there is the fear of imminent attack and that
playing dead may be the way to survive. But it is dysfunctional and increases
the problem
Social phobias and social anxieties
Social phobia and social anxiety clients have an exaggerated
feeling of being the focus of attention. Whilst most people have some levels of
social anxiety, the pathology is where a person’s normal activities are
restricted.
Paradoxes of Social anxiety
Social anxiety\phobia has a reality factor that agoraphobia
doesn’t, thus they may fear their mind going blank and being tongue tied and it
can happen, indeed their fears seem to increase the possibility. The person
with fear though thinks that inadequate performance will be a mortal blow to
his social aspirations.
The fear of being evaluated
Social anxiety is the fear of having ones weaknesses
exposed, being shown to be of low status. A social situation for one with
anxiety is a situation in which he is being judged and will be hypersensitive
to signs of being judged. There is also a fear of being the centre of
attention, where he fears he is being judged and scrutinized.
The agoraphobic is hypersensitive to internal signs that
there is impending disaster the social anxiety client is hypersensitive to
external signs from the other.
The primal defences
The biggest inhibitor to social anxiety is not the feeling
of anxiety per se but rather the primal responses of verbal fluency, thinking,
recall and memory. This is a freezing response that prepares the individual for
physical assault. The freeze response
gives you time to evaluate the situation and prepare your response, it also
prepares you for physical assault so you can ride the blows but it inhibits
social performance.
Differentiating Social Phobia from Agoraphobia
Situations that provoke the phobic symptoms
Symptoms more viewable in social phobia, but fainting more
common in agoraphobia. Social phobia is concerned with inter personal
situations and of being scrutinized by other people. Agoraphobia is about being vulnerable and not
being able to cope. The social phobic represents the child being scrutinized by
adults, whereas the agoraphobic is the child who has been place in a strange
place for the first time. Social phobics are a small child being judged,
agoraphobics are a small child being ignored. Agoraphobics more often have
cluster of fears around physicality. Agoraphobics tend to have collapse
response where social phobics tend to have freeze responses. Agoraphobics can
also have a fear of being alone, where the social phobic is happier in this
space. The agoraphobic has higher levels of comorbidity than the social phobic.
The common occurring problems with the agoraphobic are other sorts of phobia.
The clustering of the agoraphobic suggests the fear of being attacked i.e. they
are frightened of some physical attack or damage.
Somatic symptoms
Agoraphobics tend to have a collapse response, whereas
social anxiety people tend to have a freeze response.
The phenomena of Social Anxiety
Features of social anxiety
1.
Perceive criticism from others
2.
Expect criticism from others (anticipatory
anxiety)
3.
Feeling less capable than others, low self
esteem
4.
Have rigid rules for social behaviour and being
inflexible
5.
Negative fantasy which produces anticipatory
anxiety
6.
A sense of being watched waiting for the
judgement
7.
Hypervigilant of any sign of being judged by the
other
8.
A sense of being trapped in a situation
9.
Hypervigilant of bodily signs of social unease
10.
Fear of losing control
11.
A fear of situations where a sudden and
unexpected withdrawal would be likely to attract attention
12.
A sense of being trapped in a social situation
13.
A build up of uncomfortable feelings
14.
The unpredictability of the anxiety response,
the mood of the day and the amount of time available for negative fantasy seem
to have a determining influence on this.
Social anxiety often starts around the late teens
Shame and social image
Shame is the feared emotions in the social situation. Shame
the feeling that you are judged to be weak, inept etc. in the eyes of others,
and you don’t want to be. It’s the
feeling of having your weakness exposed and judged. What is critical is that
the other thinks their judgement of your weakness they don’t have to express
it. It is questionable whether the client believes this or not, the chances are
that they do believe it and fear the ridicule and devaluation.
A person with social anxiety, has a shame reaction, to believing
other people have thoughts of negative judgements about him. However in
private, or if he thinks he has got away with it, he is fine.
The public sanctions for lack of conformity make the social anxiety
client feel weak, inferior, depreciated and immature. They are shame, ridicule and isolation. He
believes he will be subjected to public humiliation and ridicule and he will be
powerless to defend against it. Social opinion is absolute, final and
irrevocable. The only antidote for shame is to vanish from the situation,
whereas with anxiety in general there is the desire of flight to safety.
Social group have surface and deep values, surface may be
rules of engagement, public rewards are given of admiration or punishments of
disdain, ridicule or isolation. Any person in the group is representative of
the whole group, so if you fuck up with one person, you fuck up with all.
Strangers can create more shame than can intimates. Shame is a form of social
influence where people try to control our behaviour through it.
Shame and anxiety differ in that shame lasts after the
shameful experience whereas anxiety doesn’t. Shame is a personality judgement,
anxiety is a fear response.
Intimate relationships satisfies personal needs whereas
public relationships satisfies public image. In personal relations then the
expectations are of understanding, caring and consideration and the punishments
are removal of affection or rejection. The effect of personal punishment is
sadness. Qualities valued in intimate
relations kindness, empathy and warmth are often understood as character
traits.
Things admired a group are appearance and performance. In
intimate relationships there is less concern about group norms. It seems that
strangers can produce shame reactions where intimates can’t. The stranger
becomes representative of the social group, where the isn’t.
Fear of loss or love or abandonment
In personal relationships there is more a requirement of
satisfying certain functions rather than conforming to a certain image. In the
personal relationship the requirements are understanding, caring and
consideration. The punishment for a failing in personal relationship is
rejection of the withdrawal of affection, the resulting emotion being sadness.
The functions of personal relationship, i.e. caring, warmth and empathy are
more seen as character traits, whereas in public relationships its more
concerned with performance. You can get social anxiety in the private arena
where there is the threat of the loss of love, where you need to perform to a
certain level to achieve love. The effect of this is
1.
A sense of vulnerability
2.
Feeling always judged
3.
Stilted behaviour
4.
Catastrophising about the future.
Public speaking anxiety
The anxiety here is around not being able to control oneself
which means you have no control over your mind or your body, which is a primal
survival threat. There is fear of not being able to function and fear of being
judged by the audience. Anxiety relates to threat. Anxiety is a feeling we want
to stop, anxiety might stop us in our tracks so we can judge a situation,
anxiety might make us stop so we can survive. The trouble is when the warning
system gets taken as something to be scared of, or to represent something to be
scared of. The speaker then reacts to a perceived but unreal enemy that brings
about what he most fears, not being able to perform.
The biggest fear is not being able to function and that this
will be judged by others as sign of weakness. The anxiety reaction is then
interpreted as a sign that one is not functioning well and thus you get a
negative spiral. Likewise negative response from the audience will create a
negative spiral, or non positive can do the same. The negative spiral leads to a barrage of
negative thoughts,
The cognitive set is that the audience are perceived as
threatening. There is a feeling of incompetence. He believes any deviation from
the rules will elicit a negative response. He believes he is incapable of
dealing with a negative response from the audience, and he will be open to
ridicule and criticism. The cognitive set prepares himself for danger of a foe,
the audience that is far stronger than him and is poised to attack him or
reject him. Under the influence of this fear he reacts with a primal response
of freezing and what he most wants to happen, to give a fluid presentation and
for the audience to love him becomes far harder to achieve.
Test anxiety
Some time from the exam the student may well feel confident
and well prepared, but as the test looms, then the confidence drops as
cognitions centre around the disaster of failing and its likelihood. Once the
vulnerability set is started, then anxiety increases and self confidence
decreases and at the exam, then the primal response to danger, freezing is
evoked, and his mind goes blank. When the mind goes blank, it could be that it
feels overwhelmed so like with the electricity company shuts down the non
important, it could also be that it is a primal response to divert all energy
to the danger. Some students pass from the freeze phase to the fainting phase.
A Synthesis
To the sensitive subject being evaluated is similar to be
subjected to a painful probe. He assumes that evaluators’ jobs is to expose his
presumed weakness and his job is to conceal them. To this situation then he
stiffens becomes less spontaneous acts to some rigid rules and presumes every
slip will be pounced on and will have a long range negative effect.
As part of self protection as they feel vulnerable then they
retreat into themselves to protect their soft shell. In other words they are
inhibited.
Summary
The evaluative anxieties consist of social anxiety, test
anxiety and public speaking. Here the client sees themselves as being judged
for their performance by evaluators. The thing that they fear is the shame and
ridicule for having their weaknesses exposed. The shame that they suffer lasts
longer than anxiety which goes when the object that arouses anxiety is not
there. Feeling shame then there can be avoidance of social situations and can
leave the client feeling inferior.
If the evaluators are higher status than the client, or the
outcomes of bad performance are seen to be high, or the evaluators are seen to
be hostile then this increases the levels of vulnerability. The client sees
they have nothing that they can do to counter negative criticism or rejection. The
effect of all of this is freezing where cognitions all turn to aspects of
vulnerability. The constant streams of negative thoughts mean that the amount
of available cognitions is minimal and cognitive faculties are greatly impaired.
This can mean that the mind can go blank.
Likewise speech can be inhibited and stuttering can be seen. What is
happening here is a primal response to the feeling of danger and of
vulnerability. What the freezing looks to do is respond to a physical threat
and buys time to make the right decision and to be able to withstand blows
should an attack be occurring.
With social anxiety there is a reality that you can be
rejected, judged or make a fool of yourself. However when you make you social
identity a key aspect to your identity and that equate that with performance
then the anxiety becomes self defeating as it makes you harder to achieve your
goals, so it is something of a paradox. Again the only explanation for this can
be that a primal response that has been created to deal with a physical threat
is applied to a psychological threat.
Social anxiety is generally only found in the public arena,
in the private arena, with intimate people, family and partners then you don’t
find as much social anxiety as the nature of the relationship is more based on
functions where there is a requirement to show understanding, care and empathy.
Performance anxiety can be found in this space, when a partner has demands and
threatens the removal of love on the basis of an inadequate performance.
Chapter 10 Principles of Cognitive Therapy
There are ten prinicples of cognitive therapy
1.
Cognitive therapy is based on the cognitive
model of emotional disorder
2.
Cognitive therapy is brief
3.
A sound therapeutic relationship is needed
4.
Therapy is collaborative
5.
Between
patient and therapist
6.
Cognitive therapy primarily uses the socratic
method
7.
Cognitive therapy is structured and directive
8.
Cognitive therapy is problem oridentated
9.
Theory and technique of cognitive therapy rely
on the inductive method
10.
Homework is a central feature of cognitive
therapy
Principle 1: Cognitive therapy is based on the cognitive model of emotional disorders
a.
Dysfunctional appraisals of the situation
maintain anxiety. Anxiety can be a
result of exaggerated and automatic thinking.
b.
Sympathetic nervous system is the fight or
flight , parasympathetic is the rest and digest system
c.
Anxiety is related to prior appraisal, i.e. you
aren’t afraid of a poisonous plant until you have learnt that it is poisonous.
d.
What is feared is the feelings and the
sensations
i.
Primary fear is fear of disease, fear of going
mad
ii.
Secondary fear is the fear of the feelings of
anxiety which may indicate going mad etc.
e.
Four basic emotional states, scared, mad, sad
and glad
f.
Clients problems fall into four categories,
anger, depression, anxiety and pleasure(not getting enough I guess)
Didactic Presentation
Working with clients then anxiety can be presented as a
natural reaction to fear. Its propensity
can be created through developmental issues and its maintenance can often be
via dysfunctional thoughts. It can also be that the anxiety system can itself
be seen as something that can be seen to be dangerous and when this happens
then there is a painful and anxious cycle that is created. On the basis of anxiety there is a need to
reduce this feeling and this can happen through fight, flight, freeze or faint.
Levels of fear
In anxiety disorders there are two levels of fear. One is
fear of danger physical danger, the second is the fear of social danger, what
is really feared is the feeling of anxiety and its concomitant symptoms; the
negative thoughts, the cognitive inhibition, the physical inhibitions. So what
happens is fear of the actual danger produces anxiety then fear of anxiety
creates an anxiety spiral.
Principle 2: Cognitive therapy is Brief and time limited
Brief therapy means there is no dependency created with the
therapist, and therefore is more empowering to the client.
Brief therapy:
1.
Stays task focussed
2.
Focus on manageable problems
3.
Make treatment specific and concrete
a.
On homework
b.
On interventions
c.
With conceptualisation
d.
With language with the client
4.
Use homework
a.
This will increase the amount of result that you
can get
5.
Uses time management techniques
a.
Set agenda
b.
Give handouts
c.
Give homework
d.
Get the client to prepare what they want to talk
about
6.
Keeps it simple
a.
Complicating a problem slows down any action
taken on the basis of it
Principle 3: A sound therapeutic relationship is necessary condition for effective cognitive therapy
A sound therapeutic relationship is needed:
1.
For someone to face their fears, for someone to
deal with difficult feelings they need to be with someone who they trust and
feel safe with
a.
This can be a major part of the work, where they
can face their fears with their therapist, means that they learn to face their
fears
b.
To build trust use sincerity, empathy and non
dependent warmness
2.
Patients have style, some prefer more formality,
some more casual
3.
You can quite often map people on the autonomy,
dependence axis.
a.
Low dependency, low autonomy means capable of
managing intimacy and forming a good working relationship
b.
Highly dependent, low autonomy means a patient
is more relationship orientated. Patient can be highly sensitive to a lack of
empathy and can become dependent, so these features should make you adjust your
interventions. A therapist has to be warmer in such situations as this will
give the sense of a close relationship which will suit the client. Such a
client often wants to be the favourite client. Self-disclosure good in this
instance to increase the strength of the relationship.
c.
High autonomy and not dependent, would react
badly to how do we solve this problem as that would be patronising as he is
more than capable, self-disclosure would be bad, again let these ideas
influence your interventions. Best interventions start how are you, what are
you, stressing the independence of the client via you
d.
High autonomy and highly dependent can be really
awkward clients; someone who wants to be independent but really needs people
but conceivably fears them. Wants intimacy and has trouble tolerating it. In this instance tolerance, flexibility and
acceptance are going to be helpful.
Principle 4: Therapy is a collaborative effort between therapist and patient
Therapy is collaborative
1.
Two heads are better than one
2.
There are four selves, the thinking, emotional ,
acting and observing self
As the therapist collaborates with the client then the
collaboration needs to be with the clients adult, how are we going to solve
this problem? The therapist also collaborates with the observing self, when
there is collaboration with the clients observing self then more information
about how the problem is manifest and therefore what can be done about it is
made manifest. The greater ones awareness, the greater the choices that you can
make, the more you know yourself.
How to collaborate
1.
Have a reciporocal relationship where no one
takes a superior role
2.
Be transparent, avoid hidden agendas, so always
explain the rationale for homework, or for formulation, and indeed sometimes
even for intervention
3.
Design homework collaboratively
4.
Admit Mistakes
a.
A coping model is usually more effective than a
mastery model
Principle 5: Cognitive therapy uses primarily the Socratic Method
Socratic questions:
1.
Questions can help the patient see coping
mechanisms as these are the questions that they should be asking
Principle 6: Cognitive therapy is structured and directive
An anxious person may lack structure that therapy can give,
for their disorder you can give some order in the session. So let session
structure reflect the desires that the client has. You need to alter the level
of structure dependent on the person. A socially dependent person usually
prefers more structure
1.
How to structure
a.
Set an agenda of problems to be looked at,
client starts, usually only 2-3 issues can be dealt with effectively
b.
Choose a target problem
i.
First go for symptom relief
ii.
The teach how to recognised distorted thinking
iii.
How to respond to distorted thinking
iv.
Identify and modify underlying assumptions that
produces NATS
c.
If a client is tangential, then look for common
denominators, this simplifies the problem and gives it structure
d.
Test that you are getting there: am I on the
right track
Principle 7: Cognitive therapy is problem oriented
Its easier to change the current problems, rather than past
things that have happened, or the future, indeed you could argue that you can
only change current problems.
Problem solving Best Practice:
1.
Avoid problems that cant get closure during a
session(?)
2.
Problem solving format
i.
Conceptualise
ii.
Choose a strategy
iii.
Choose techniques and tactics
iv.
Assess
Conceptualisation
Conceptualisation is possibly the most important part of
therapy as it maps out the various aspects of the problem and what maintains
it. It also provides targets for what to do. So knowing how thoughts affect
feelings and behaviour, shows the type of interventions that can be made.
Conceptualisation shows how a problem originated and how it
is maintained. It attempts to understand what the problem means to the client
and therefore why they behave in the way that they do.
General strategies
Problem solving best practice
1.
Simplify, e.g. when anxious take constructive
action
2.
No time like the present. Things that come up in
the present have most potency, so in vivo, in session are the best.
3.
You don’t know unless you try
a.
What will you learn\get through trying, and what
will you learn get through not trying
4.
When the therapist is off track take the
opposite track
a.
So if a client is afraid of cancer, then imagine
what if you had it
b.
If you can’t change a situation try accepting it
5.
Patient persistence
a.
Therapists model patience to allow the client to
do the same. So if you don’t get results first off, then stay with it
6.
Divide and conquer
a.
Focus on the part of the problem with the least
resistance to get some wins and some change. If you have a behavioural problem,
then focus on thoughts and feelings, if you have a thinking problem then focus
on behaviours and feelings
b.
Anxiety is made up of three aspects, thoughts,
feelings and behaviours, best work is to work with the aspect that is most
modifiable, so anxiety being a feeling problem then work on the thoughts and
behaviours.
7.
Do the unexpected
a.
Change requires doing something different and
surprising yourself, so if you’re stuck then do something different
8.
Go with the flow
a.
Find out the place where a client’s formulation
of anxiety is weakest and target that
b.
When the client is highly defended then use a
metaphoric approach
9.
Find the resistance and work with that, work
with how the client presents and roll with the resistance
Principle 8: Cognitive therapy is based on an educational model
Premise
that anxiety is learned behaviour and so can be unlearned. People use
repeatedly problematic solutions to problems, they give prophecies to justify
their problems and they manipulate the world to make their problems come true.
They reduce their domain to fit their image
Learning to learn
You both need to learn coping techniques and more
importantly learning to learn, as the latter makes you flexible to whatever
happens to you. The neurotic paradox is where you repeat damaging behaviours
and fail to learn
People often have some hard core beliefs and a defensive
belt around them. I guess he aim then is to loosen the defensive belt, which
would be rules, assumptions and experiences to get at the core beliefs. People often manipulate the world to confirm
their hard core beliefs. When peoples
view of themselves becomes rigid, then they fail to learn, or to adapt to an
ever changing situation.
The client has to want to learn before therapy can develop.
The therapist needs to watch out for where the client is tuning out what the therapist is saying to
justify their view of the world. With slow learners then again its learning to
learn that is the prime objective before specific lessons can be learnt.
Principle 9: The theory and techniques of cognitive therapy rely on the inductive method
If you adopt the scientific approach then beliefs are
hypothesis and should be modified according to all facts. Conceptualisation,
and treatment are all treated as experiements that are judged on the outcome.
Principle 10: Homework is a central feature of cognitive therapy
Doing homework ensures that work is done outside of the
room, which is the aim of therapy to make a difference in your life.
Summary
Ok so Cognitive therapy is based on a dysfunctional thought
maintains disorders which affects behaviour and emotion. It is time limited and
problem focussed. It is only on the basis of a good relationship that it is
enabled. Throughout the work it is a collaborative empiricist method, where you
work with your client and test conceptualisation, intervention and assignments. Homework is critical as it
extends the amount of time that you can get an impact from therapy. There
probably is more but Im tired and it was something of a summarised chapter
anyway.
Chapter 11 Strategies and Techniques for Cognitive Restructuring
Developing Self Awareness
On the assumption that thoughts and judgements are highly
influential in the impact of distress, then the initial goal in therapy is to
become aware of your thoughts.
An initial goal in therapy is to help a patient restructure his
thinking to become aware of his thought process. To be aware of your thoughts
and emotions is the first step in changing them. The depressive patient brings
depression into the room where anxious people rarely do. Patients holding back
thoughts when asked are dealing with cognitive avoidance. Writing on a board
can help put distance with thoughts and make it easier to write clients
thoughts up.
Mirrors are also useful to elicit self-judgements and can be
useful when dealing with evaluative anxieties.
When people can’t remember their thoughts then you can also
look to get them to remember situations that that situation reminds them of,
and then look for the commonality (this could be useful).
Most efficacious to get a thought whilst it’s hot, in the
room. This means if you can evoke the
feeling in the room, because of something that has happened in the room, then
you can investigate the thoughts around it, likewise if you can do an in vivo
experiment, go down the gym and see what thoughts they have.
People can use distraction whilst anxious that puts the
thoughts associated with it to one side. You can increase self-awareness
through distancing yourself, describing yourself in the third person. This
gives yourself some distance from your feeling.
Directing Patients
People aren’t aware of their thinking as either they don’t
think it important, it goes too fast, it’s so habitual that you don’t even
become aware of it, and you effectively embed your thought in action. Thoughts can be presented then as subliminal advertisements
and by learning to detect them you can be aware of their effects. Often a client will not own their emotions
but rather say someone else caused it. In this area of owning your own emotions
you can start to not ask why you are anxious but how you are making yourself
anxious.
You need to get a client to experience anxiety to know what
their thoughts are, so if they can’t remember, then get them to design a small
experiment to produce some anxiety to see what their thoughts are, so going to the
gym. This can also mean staying with the
feeling without using avoidance or any coping responses. So best to design an
experiment that only produces a small amount of anxiety. In this vain then you
need to have an inclusion strategy, to go to things you wouldn’t normally go to
with a view to finding out what it is about them makes you anxious, what
thoughts are going through your mind.
You can also manage your anxiety by referring to it from the
observing self, so give your anxiety some distance, name it, and see what is
going on for you when you have it.
Clients can also do thought records to elicit automatic
thoughts.
Ways to elicit thoughts
1.
Psychoeducate
a.
The client in terms of the importance of
thoughts that direct emotions
i.
Thinking there’s a bear in the woods
ii.
Picking a poisonous plant
b.
The nature of thoughts as automatic, subliminal
messages caused through repeated thinking
2.
Evoke the emotion deliberately to investigate
the cognitions
a.
Stay with the emotion longer by not using
avoidance or coping responses
b.
Refer to the emotion in the third person, look
rob is anxious, or look there’s anxiety again
3.
For a retold situation that are without thoughts,
then see what other situations this situation reminds the client of and what
the commonality is
4.
Write the initial thoughts up on a board, this
gives some objectivity and helps elicit more thoughts
5.
Mirrors can be useful for evaluative anxieties
Strategies and techniques
A patient needs to slow his thoughts down to correct them,
if this isn’t possible then you can simply count them. Doing this gives you
some distance from your thoughts, gives you a sense of mastery over them, sees
their automatic quality.
So to get control over NATS:
1.
Count
a.
This gives distance from the thought and
increases objectivity. Observing changes behaviour and gives more choices. It
will therefore increase the sense of mastery over them. You can also see the
relation between the number of thoughts and the feelings of anxiety. It also
helps not building on the automatic thought, it accepts it, counts it and lets
it go.
b.
You can count over a duration, or a specific
episode, or for specific time segments at random times
2.
Describe
3.
Challenge
Faulty thinking challenges:
Avoid answering questions for clients
1.
Base each question on a rationale that relates to a conceptualisation
2. Use in depth questioning...can you think of anything more..take a couple of minutes and see if we can think of anything else
Three basic approaches
1. Where's the evidence?
2. Use in depth questioning...can you think of anything more..take a couple of minutes and see if we can think of anything else
Three basic approaches
1. Where's the evidence?
2. What's another way of looking at it?
3. So what if it happens?
3 column technique...situation,thoughts, errors in thinking
To challenge the thoughts ask yourself what a good friend would say
Good homework is hypothesis testing
Anxiety has a footprint of narrow disaster laden interpretation, generating other ways of looking at something is key.
Anxiety prone clients tend to overly personalise things and see them having an excessive amount of control for negative outcomes. Reattribution is the process of diminishing agency for negative outcomes. You can do this via a responsibility pie
Decatastrophising
How probable is the prediction?
What would you do, is coping plans?
Point and counterpoint, I say the fear you say what you can do to cope...then swop
3 column technique...situation,thoughts, errors in thinking
To challenge the thoughts ask yourself what a good friend would say
Good homework is hypothesis testing
Anxiety has a footprint of narrow disaster laden interpretation, generating other ways of looking at something is key.
Anxiety prone clients tend to overly personalise things and see them having an excessive amount of control for negative outcomes. Reattribution is the process of diminishing agency for negative outcomes. You can do this via a responsibility pie
Decatastrophising
How probable is the prediction?
What would you do, is coping plans?
Point and counterpoint, I say the fear you say what you can do to cope...then swop
Counting Automatic thoughts
So to get control over NATS:
1.
Count
a.
This gives distance from the thought and
increases objectivity. Observing changes behaviour and gives more choices. It
will therefore increase the sense of mastery over them. You can also see the
relation between the number of thoughts and the feelings of anxiety. It also
helps not building on the automatic thought, it accepts it, counts it and lets
it go.
b.
You can count over a duration, or a specific
episode, or for specific time segments at random times
Questions
Questions can be helpful to challenge automatic thoughts:
1.
Where’s the evidence?
2.
Where’s is the logic
3.
Are you oversimplifying a causal relationship
a.
Does one mistake lead to a disaster, have you
seen other people making mistakes
4.
Are you confusing habit with fact
a.
Is this thought coming from reality or from my
habitual thinking
5.
Are your interpretations of the situation too
far removed from reality to be accurate?
a.
If you stick with your five senses, then you
become more attached to the situation and will be more accurate
6.
Are you thinking in black and white terms when
almost nothing is either or
7.
Are you talking in extreme words, words like to
be, always, never, forever rarely correspond with reality. Likewise the to be
verb is rarely accurate, to say I am anxious is extreme, to say I have anxiety
is more accurate
8.
Are you using cognitive defence mechanisms, i.e.
making an excuse
9.
Are you thinking in terms of certainty or probability
10.
Are your judgements based on feelings rather
than facts
a.
Some people use feelings to justify facts.
Because I feel anxious therefore there must be something to fear
Guidelines in asking questions
1.
Avoid answering the question
2.
Be specific and concrete and avoid labels
a.
This keeps the client focussed and describes in
better detail their problem
3.
Base each question on a rationale
a.
The conceptualisation
4.
Questions should be well timed and aim to
foster rapport and problem solving
5.
Avoid a series of rapid fire questions
6.
Use in depth questioning, don’t necessarily
accept, after you have listened to the first answer
Three basic approaches
Anxious clients believe something bad is going to happen and
they won’t be able to handle it. The therapist’s response is three fold
1.
Where’s the evidence
2.
What’s another way of looking at it
3.
So what if it does happen
Where’s the evidence
If there’s a specific fear then you can ask where’s the
evidence that this is going to happen. If there is no specific fear then you
need to find one. With a specific fear
you can use a three column approach. What the situation is, what the
interpretation is, and what thinking errors are there. If you can’t use
thinking errors then you can ask what would an objective observer say, or a
trusted friend. You can also use hypothesis testing, so write down the feared
consequence then see what happens. So if
someone thinks I’m too anxious to do x, then break x down into small pieces and
see what they can do. When no evidence is found of the feared event then
anxiety will be lowered.
What’s another way of looking at it
Generating alternative interpretations. If there is a dire
prediction are there any alternative interpretations that can be created. This
can be done in a two model form, one with the dire interpretation and the other
column the alternative interpretations. By considering other interpretations
the anxiety can be lowered.
DTRs can also be used to generate alternative ways of
looking at something.
Decentring is the process of getting some perspective on
yourself and also seeing that you are not the centre of attention. To do this
you can establish some concrete criteria to establish if people are paying
attention to you. To do this you need to
watch other people and see how they are responding, the effect of this is to
take the focus of yourself and onto others. This works very well with social
anxiety as the self has become the focus for attention and creates the anxiety
and when you are looking at other people then you lost the impact of this self-focus.
Get better instead of feeling better is a useful mantra.
You can also look to enlarge perspective so if you feel
anxious about x, find out all the good things about x.
Reattribution: in anxiety you can attribute a lot of
negative outcomes to be your fault. To reattribute is to say are they really
your fault are there other factors involved, do a responsibility pie.
So what if it happens
Decatastrophising
So if it does happen so what? Play the scenario through, I
may go mad, what would happen, how would you cope
Coping Plans
Look to provide coping plans for if the worst does happen
Point\Counterpoint
Client gives fearful idea, you say why it’s not so fearful,
using either coping plans or decatastrophising. Four ideas are covered in this:
1.
Probability of the feared event
2.
Its degree of awfulness
3.
Client ability to cope with it
4.
Clients ability to accept it and deal with the
worst possible outcome
Summary
Thinking is the key in cognitive therapy so this really is
the centre piece. I guess the stages to get to here are firstly the client
needs to buy into the relation between thinking and anxiety. Anxiety is fear of
something, then there is the anxiety response which can be fight, flight,
freeze or faint. The anxieties that we
have around dark spaces, being away from a caregiver, being afraid of bears are
all learnt behaviour and are the basis of judgement. So let’s find out what
that judgement is. The other issue with anxiety disorders is where the warning
systems within the fight, flight, freeze and faint responses and anxiety itself
are seen to be something to be afraid of, this creates a vicious cycle.
So the first thing we need to do is to find out what you are
afraid of, and what the judgement is about this.
So when a client feels anxious then we need to find the
thought behind this. To find thoughts then what you need to do is:
1.
Ask client for thought
a.
Probe deeper to find out if this is the main
concern
2.
If no thought comes then
a.
Ask the client to think of similar situations
and see what is in common with this one
b.
Write base thought up on board to give client
some distance from it
c.
Recreate the feeling of anxiety in the room, or
in vivo and get the client to see what their thoughts are
d.
Get the client to stay with their emotion
without using avoidance or coping responses
e.
Get the client to give some distance from their
anxiety by referring to it in the third person
3.
Once you have elicited the fear then you need to
get control over it
a.
Count the thoughts, this gives distance a sense
of mastery and will change behaviour by observing it, so you will act out less
on it
b.
Question the thought
i.
Where’s the evidence
1.
Do experiments, predict and see the results
2.
Get the client to write down the evidence
3.
Three column technique
a.
What happened
b.
Interpretation
c.
Where the thinking errors are
ii.
So what if it happens
1.
Could you cope, how would you do it? The aim here
is to show that you would actually cope, so it produces coping plans
2.
Point\Counter point. This works between client
giving fear and therapist giving counterpoint to it
a.
Counter points are probability of it happening,
coping response, how bad it really is, ability to accept it
iii.
What’s another way of looking at it
1.
Thought records
2.
Two column technique, what’s the feared outcome
and what are the alternatives
For people with social anxiety, then a decentring technique
can be useful, so focus on other people to observe and look for concrete
criteria of disapproval.
Reattribution: here
if there is personalisation at stake then do a responsibility pie.
Chapter 12 Modifying Imagery
Most
anxious clients have an image before and during their anxiety. Images can produce
the same reactions as if something is actually happening. If you hold the truth
of an image despite contradictory information then its an hallucination but if
when you find contradictory evidence you don’t, then it’s imagination.
Induced Images
It has been shown that using relaxation then imagery can
help prepare sports men for sport and can reduce anxiety, and help with
childbirth
Delineating maladaptive patterns
For
clients who are having difficulty remembring then get then to imagine and make
an image. Likewise if you have an emotion about a situation but you don't know
why then use an image.
Pinpointing cognitive distortions
If thought work doesn’t get anywhere look to use images. Get
the client to imagine a picture of their feared situation. Once the image has been brought out then it
can be reality tested. Likewise brining up an image of a feared situation can
put reality into a situation that pure thought lacks.
Modification of induced images
If you repeat the feared image, then a modification should
happen. What can happen is the first image relates to primal fears, the second
image to more current concerns. So a childhood fear to a an adult competence.
Techniques for modifying images
Turn off technique
You
can turn off an unpleasant image by using sensory input, e.g. clap, blow a
whistle... Or concentrate on immediate environment then replace with
positive fantasy.
Repetition
When clients repeat their images then they change just
slightly in content, this will be followed by a persistent change in attitude.
With deliberate repetitions then you tend to get closer to reality at each
pass. Anxiety generally drops with each deliberate repetition. If repetition
happens naturally then you get no reduction in affect, but if you consciously,
deliberately repeat then you do.
Time projection
If you are upset about a particular situation project
yourself in to the future to gain perspective on your current trouble. I think
the situation needs to be distinct, e.g. worry about x, rather than I am depressed
at the moment as otherwise the future will be grim as well. Good example
worried about husband being unfaithful, what would it be like after a week, 6
weeks, 6 months,.
Symbolic images
Use a symbolic image to address the problem and the
solution, so if a person has writers block imagine an old rusty pump that takes
a bit of time to get going then flows water.
Decatastrophising the image
So what would happen if your worst fears came true, you actually
probably could cope. If you focus on the feared outcome, prepare for that,
anything else will be a bonus, you are in the shit, things can only get better.
Sometimes clients prematurely close down images, and shut it down with childish
words like this is silly, stupid etc. Then the image comes back stronger, you
can then use the so what if technique, which says so what if your worst fears
came true, and the underlying thought is that you could cope, so you need to
make sure that there is enough time in session to enable this. People discount
the amount of rescue factor, for every danger there is some rescue around for
it.
What happens is that the image stops at the feared event,
then there is a dreadful feeling of not being able to cope with it. If you roll
the image forward to what happens next you would find out that you can cope. It’s
almost like a downward arrow technique with coping attached to it.
You can only use the what if technique after you have a good
relationship, as it needs trust to be effective, as you need to take a person
through their worst fears. The so what if technique is a cognitive flooding
technique. So again you need time in the session to let the anxiety reduce.
Anxiety can reduce by realising it’s a low probability, realising for every
danger, there is a rescue factor
Images and thoughts
Undesirable images often have accompanying thoughts alongside
the image, what if that happened to me. These thoughts then can increase the extent
of the anxiety, so you get image one, then cognition 1 which can lead to image
two and cognition two, and you get an anxiety spiral.
Facilitating change in induced images
What you can do is from a negative image, then little bit by
little bit, change the image to become a positive one. Imagine the image is
like a movie and you are the director and you change one bit at a time.
Substituting positive imagery
Develop an independent positive image that can be used as a
diversionary tactic after a stop; can also be used to get to sleep.
Substituting contrasting imagery
If the fear is of disaster then create an alternative image
of success and substitute the former with the latter.
Exaggeration
Here you can exaggerate your worst fears to hyperbole, which
then puts your current fears in perspective. You need to emphasise that
thoughts don’t lead to action. This
seems like a scary technique if violence is used.
Coping models
Imagine someone you know coping with the feared situation or
imagine yourself to be a certain person, George Clooney if you have social
anxiety.
Imagery to reduce Threat
Intimidated by someone, imagine them in shorts or on the throne, interviewed by a panel,
imagine them as lambs and yourself as a
lion. You can also do imagined walk throughs of feared situations.
Escaping a worse alternative
Imagine something really terrible, chased by a gang and you
manage to duck into a room and perform your feared action, e.g. a recital.
Mixed Strategy
Literally mix and match the above techniques
Future therapy
Patients often have a grim imagined future. So create a
better imagined future. Wait until anxiety is at a low point, get patient to
imagine a date in a few months then ask what they would have liked to have
happened by then. The therapist then interviews the person as if they are at
that date, asking about his new attitudes and behaviours. He notes what areas
give him trouble and what don’t. To get the movement between now and then, rate
yourself on a scale now and then, then imagine the movement between the two.
The patient needs to choose goals that are under his control otherwise he is
setting himself up to fail. After you have developed your three month goal,
imagine what it’s like on that day being successful, feel the feelings, see what
you see etc., then imagine what it’s like on the day being successful, then
work out what you are going to do to get there. One of the key ingredients in
creating the future is repetition. You can see how repetition works by the use
of advertising. So imagine the future goal as often as possible. Feel the
feelings associated with the goal
Goal rehearsal
Imagine your goal and how you will get there. This will mean
that you practice the various steps in imagination and then be prepared for
their eventuality. This increases coping strategies.
You can use future autobiography, so interview you in the
future after you’ve overcome your goals to know how you overcome your obstacles
to your goals.
Also look at the common strategies you use to stop you
getting goals.
Summary
Images and imagination is an important area. If cognitive
approaches don’t work directly then imagery work can pay dividends as a client
may hold more of their cognitions visually.
It is seen that most anxious clients have an image before they feel
anxious. If this image can be brought
out then the cognitions that are attached to it can be brought out. When they
have been brought out then they can be challenged, via where’s the evidence, so
what if (decatastrophising), what’s another way of looking at it.
If cognitively getting involved with the image doesn’t work
then you can try manipulating the image directly of which the following
techniques are available
1.
Repetition
a.
Repeating the image will make it become more
realistic
2.
Time projection
a.
Imagine a time 3 weeks hence, 6 weeks hence
which can show you how you cope with it
3.
Exaggeration
a.
Exaggerate the image to put your current fears
into perspective
4.
Modifying
a.
Modify the image, sharpen, blot out, until you
change it to a more acceptable image
5.
Replace
a.
Get a more pleasant image to replace it with,
use the stop technique to move between one and the other
6.
Comedy
a.
If threatened then imagine your persecutors as
cartoon characters
7.
Symbolism
a.
Imagine a symbolic representation of you
overcoming the feared image
8.
Escape a worse alternative
a.
Imagine a terrible alternative and you
9.
Turn off technique
a.
Here you can either use a noise or concentrating
on the current situation to stop the image
10.
Decatastrophising
a.
Here imagine yourself coping, list all the
coping response that you could do and imagine yourself doing them
11.
Role model
a.
Imagine a role model in that situation, then
imagine yourself as that role model
Chapter 13 Modifying the Affective Component
Modifying the affective component means (AWARE). Accept the
anxiety, watch the anxiety, act with the anxiety, repeat, emotional review and
owning one’s own emotions. The below are strategies to achieve this
1.
Accepting the feeling
a.
Once anxiety is at a certain level then you can’t
control it, but paradoxically through accepting it, you will control and reduce
it. When you are afraid of anxiety, you are afraid of your feelings of anxiety
not anything else and by accepting these feelings you can lessen them. Acceptance is acknowledging the existence of
an event without placing a judgement on it. Value judgements on the anxiety
only deepen the anxiety and should be avoided.
b.
Patient may fear bad things will happen because
of his anxiety, i.e. social disapproval, going mad, loss of control. Anxiety
about anxiety is about these secondary problems. Anxiety comes in waves has a
beginning , a peak and an end, even though it might reoccur there is a still
period between instances.
Accepting the feelings
Clients want to fight the anxiety, but once it reaches a
certain level then you can’t control it and you must accept it. What you fear
is fear and anxiety and the feelings associated with it. This may not entirely
be the case with social anxiety where you fear not being invited to the party,
but let’s face it there are many parties. People fear going mad, but this is cognition
about what anxiety means.
Reducing anxiety about anxiety
Anxiety can be seen as that which makes you go mad or suffer
permanent psychological damage. How bad does your anxiety feel, if you had to rate it against the worst
possible pain and the mildest pain, where would it be? Anxiety doesn’t go on
for ever it starts, reaches a peak then subsides. It comes in waves and can
return but it doesn’t deviate from this pattern.
Anxiety myths
1.
I can’t function, many people can even when they
have anxiety, its only when you don’t believe you can that you stop trying
2.
I will lose control, this isn’t the case a person may become rigid trying to hold
themselves, but not lose control
3.
I may go crazy: there has been no incidents of
anxiety causing madness
4.
Anxiety means feeling shameful: it’s a childhood
notion to think that you will be judged as weak, foolish or inferior for
exhibiting anxiety
5.
I will go mad, you may feel you have lost
control, but its only because you stop trying, even if you have stopped trying
anxiety will go away and control will return.
Reducing shame about showing anxiety
If a patient adopts an anti-shame philosophy towards his
anxiety then he can avoid much pain and discomfort. If he adopts an open door
policy and tells other people that he felt anxious then he can reduce his
feelings of suffering
Common beliefs about anxiety
1.
Feelings of shame having anxiety as others think
I’m a fool
a.
What do you think of other people having anxiety?
If it is low, it may explain your feeling of what others think, but usually
they don’t have a negative opinion
b.
Ask others what they actually think
2.
It shows I’m weak
a.
But what would a person with no anxiety be like,
the macho happy warrior stereotype from society
b.
From a physical point of view it is irrelevant
3.
I’m neurotic
a.
This is a label with no specific validity.
Anxiety is merely a specific symptom that arises in a specific situation
4.
Others can tell I’m anxious and are put off by
me
a.
Probably an exaggerated view that others can see
this. There’s no necessity people are put off by it, if people do have a
negative reaction then they are not necessarily correct. He can check if people
can see he is anxious by asking them
5.
No-one else gets as anxious as I do
a.
As much as peoples empathy might get discounted
so can other peoples experience of anxiety, most people get anxious at one time
or another
6.
They will reject me
a.
Rarely is a person rejected just because they
are anxious rather people see it as a transitory situation like having a cold.
People can reject people for a myriad of minor reasons
7.
I look ridiculous
a.
Other people may label you as that, but to label
yourself is unhelpful and unproductive
8.
Since I have appeared anxious nobody will want
to be my fired
a.
Where’s the evidence. Have you appeared anxious
to friend before and lost them
You are not your anxiety, it is a feeling that you have. If
people downgrade you because of this, there is no point in buying into their
adolescent attitudes. Albert Ellis has done a tape how to stubbornly refuse to
be ashamed of anything.
Normalising anxiety
One way to reduce anxiety is to help the patient become less
self-absorbed and to act in spite of what’s going on.
There are the symptoms of anxiety, then a thought that these
are dangerous somehow, or say something bad about you. This creates more
anxiety. The more anxious you become the worse it becomes and you have a
vicious cycle. When you become hyper vigilant on your symptoms then they become
stronger.
Strong emotions are signals that you need to correct the way
you are engaging with the world. Anxiety
is a call to you that you need to act or think differently. Anxiety says either you are in danger or you
think you are and need to think more realistically. By acknowledging painful
emotions then you send the signal to the brain that you are responding to this
and the feelings subside.
Anxiety can give you an edge in performance.
Active Acceptance
Choosing to accept, welcome say hello to anxiety takes some
control over it. Sometimes telling people you are anxious can help, e.g. in a
presentation. Acceptance is an active
not a passive thing.
Identifying Emotions
Mad, sad, glad and scared are the four basic emotions and
all other emotions are a mix of this, for instance hurt is sad and mad. Most
anxious patients have had the glad\scared mix, e.g. on a roller coaster and one
of the most common mixes for anxiety is scared\mad. There are many secondary feelings about
anxiety, sad, shame etc. that can get in the way of dealing with the feeling.
Action strategies
Getting a client to act as normal as possible lessens
symptoms, if you run from a situation your anxiety will decrease but your fear
will increase, but if you stay both will reduce.
Activity schedules
Planning a schedule provides the patient with a sense of
direction and control and is an antidote to feeling overwhelmed, it can also
provide a distraction from anxiety. Finish one task and do something pleasurable
as a reward. The goal is to engage in activities not do them perfectly.
Activities that absorb concentration are best.
Increasing tolerance for anxiety
Increased tolerance decrease the amount of anxiety about
anxiety. With practice people can learn to increase their tolerance for all
sorts of discomfort.
To increase tolerance, then you need to decrease escape
behaviour and diversions or increase the level of time before reaching for
these. Doing this tests the thought I can’t cope with anxiety. If there’s the
thought of I can’t cope with this pain, then construct a pain hierarchy. You
can break anxiety by having a cold shower or going for a run
Alcohol, stimulants, diet, stress
Patients with anxiety are urged to avoid high levels of
stimulants, or indeed sometimes any as the effect may be misconstrued to be
anxiety. Also avoiding being too low on blood sugar, so eat regularly is
recommended. If low blood sugar is
suspected then eating protein is recommended. Stress, fatigue or lack of sleep
can increase predisposition to anxiety. Likewise avoid anything that can subdue the
effects of anxiety but that don’t help to manage it.
Maladaptive coping behaviour
Secondary behaviours that originated as a coping behaviour
for anxiety, e.g. alcohol or eating become embedded and autonomous.
Interventions included graded task assignment, pleasure and mastery schedules.
With these behaviours that become automatic coping response, then breaking the
chain can be useful, this prevents the behaviour from being automatic and
running away. Again to increase the amount of time before the coping behaviour
is adopted will always be an improvement!!
Self-Observation
The observing self is non-judgemental and won’t get caught
up in the subjective drama of anxiety. The observing self just describes the
situation.
To observe yourself without judgement gains perspective and
embeds the person in a wider context. The awareness brings the person back to
the present and out of the anxiety whole. Anxiety is the outcome of projecting
oneself into a dangerous situation in the future, by remaining in the present
then this can reduce this happening. Rather than thinking I am anxious, think I
have anxiety.
Why questions in self-observations can promote more anxiety,
however how and what questions provide a greater description and more.
Homework that is more in the line of putting the person as
investigator\explorer in more likely to have a better outcome than just giving
someone an activity to do. The reason for this is that they become more of an
observer if they investigate and explore.
To get good observation then you need to detach yourself
from core schema or these cloud your observations. You can get more observation
when you watch yourself watching, depersonalise, you do this automatically in
anxiety but doing this deliberately can reduce anxiety.
Positive Self instruction
Instead of telling yourself not to be anxious, tell yourself
things that you can do, such as observe yourself, it will go, be alert, this
will decrease the feeling of helplessness. If you tell yourself something you
can’t do you are setting yourself up to fail, if you tell yourself things you
can do this increases your sense of mastery. So instead of saying don’t spill
the coffee, which will increase the chances of spilling it, say be careful
carrying the coffee. Also there’s the sense of detaching feelings and thoughts
from self. I am not my body, I have a body. I am not my thoughts, I have
thoughts. I am not my emotions I have emotions. All this does is increase the
awareness you have of your situation and decrease your identity with the
problem, it gives you a sense of control and mastery
Graphs and diaries
Recording the situation and intensity of anxiety, via Suds
show the client that anxiety is time limited and generally related to external
situations. This counters the client feelings that their anxiety will never end
Concentration (or distraction) exercises
Get the client in the room to get anxious, then focus on an
item in the room and describe it in detail and watch how the anxiety goes down.
If the client isn’t anxious then get them to imagine an anxiety making
situation, then if that doesn’t work, use hyperventilation. The technique here
is that by focussing on an external event then you don’t focus on an internal
event, and focussing on anxiety holds it up.
Relaxation methods
Relaxation methods reduce symptoms and are a means to an
end.
Letting go, means that you are more in control!!
1.
Tense muscles, hold breathe, release, purse lips
and slowly release and notice the difference and the sense of relaxation.
2.
Take long breaths and let them about slowly
3.
Stretching time, count every second, then every
30 seconds, imagine the past is way in the past, and the future is way in the
future
Emotional Review
Go over a feared situation in the office, and tell the
client that the pain is like a lump of pain that can be smoothed out. So repeat
the description of the feared event several times and you start taking a
different perspective on it. This also decreases the sense of avoidance
tendencies. This increases observation, by more identifying with the observing
self rather than the anxious self then anxiety decreases.
Over time worries are replaced by other worries, repeated
review merely speeds this process. This is very similar to a flooding process,
and enables a client to work through the feared event, to prepare an emotional
response. One of the main gains from this is also to counteract the avoidance
tendency. It also provides some distance from the situation. Repeated reviews
also enable underlying fears to be made apparent. Through the repetitions
through the cycle a client can often access more of their coping responses,
more reality and allay their fears.
Imagery methods
Imagine in detail the feared situation in detail pre talking
about it. This can help for people who can’t talk about it, so you can do an
emotional review using images, then get the client to describe it.
Metaphors
When talking about it, or imagery hasn’t been successful,
then metaphors can be used. So look for the clients’ interests, or assets, and
use a metaphor in that vain to explain the situation. This can increase a
feeling of strength in the situation as you are appealing to a person’s
stronger side.
Repeated review outside the office
If a client has trouble reviewing outside of the office then
here are some guidelines
1.
Give yourself plenty of time
2.
Repeat until the anxiety diminishes
3.
If there are a stack of problems do one at a
time
4.
Review the problem in slow motion
5.
Describe the problem rather than judge
Owning ones emotions
Most anxious people believe that the thing they are anxious
about is causing their anxiety not themselves. So if an event precedes the
anxiety then the event causes the anxiety. Anxiety is in some ways a primitive
response and can cause other aspects of primitive thinking
Sequential reasoning
When you ask a girl out or go for a test you get anxious
then this is about your opinion and belief nothing intrinsic about asking the
girl out. For instance if you ask a girl
out you like and a girl you don’t like then you have different emotional
responses, so there is a belief in there that explains your emotion. Therefore
you create your emotions.
Correlational reasoning
Something may appear with something else but not cause it.
Analogical reasoning
You may feel like you are going crazy when you have anxiety
but this is a feeling not a fact. Physical pain can be caused by others, but
emotional pain is caused by yourself.
Emotional reasoning
Because someone feels that others cause you anxiety doesn’t
mean that is the case
The Payoff
There is sometimes a secondary gain from anxiety, so ask
what would you have to give up if you let go of your anxiety. Emotions may draw
attention to you. The payoff may not be
the motivation for anxiety but can make it harder to shift. Emotions can act like adverts they grab our
attention, they hold our interest and then motivate us to take action. The
secondary gain then can be the emotional equivalent of the payoff in adverts.
Special treatment
Anxious people have fewer demands put on them
Help
People help, pay attention to, stroke an anxious person.
This can be an obstacle to getting better as it asks the other to take charge
of you, where you could do that for yourself.
Lack of risk
With anxiety you don’t have to take risks and you avoid the
chance of failure
If only
Can maintain the idea that the person is superior if only
they didn’t have anxiety
Justification
Can justify secondary activities, e.g. smoking drinking etc.
Special privileges
If having an anxiety attack so I must be by myself
Role of victim
The only way to get love is to see myself as not ok
You can deal with secondary gains by looking at other more
direct ways of getting them, stressing that indirect is less effective as you
have to get more dramatic and effective to get the pay off.
Summary
Ok to modify the feelings of anxiety the following is an
approach
1.
Accept the feelings
a.
Dispel the
myths: ask the client what they believe about anxiety and challenge the
dysfunctional attitudes which may include
i.
I’m weak
ii.
I’m going mad
iii.
Others will reject me
iv.
I’ve got something wrong with me
v.
I can’t do anything when I have anxiety
vi.
I will lose control
b.
Normalise
i.
Everyone gets anxiety
c.
Active acceptance
i.
Name the anxiety as part of you, refer to it in
the 3rd person
d.
Rate the feeling
i.
Compare how bad it feels in comparison to other
imagined pain
e.
Reduce the shame
of anxiety
i.
Operate an open door policy and tell other
people about your anxiety
2.
Take action
a.
Activity schedules
i.
If you plan your day then it can give structure
where when you anxiety you can lack it
b.
Increase tolerance for anxiety
i.
Reduce time to go to escape behaviours, show
that you can tolerate the levels of discomfort
ii.
Use the distraction technique, focus on some
external object to reduce internal focus
c.
Substances
i.
Avoid substances and behaviours that make you
more vulnerable to anxiety, and cut out those that avoid it
d.
Maladaptive coping behaviours
i.
Avoid alcohol and escape behaviours as whilst it
makes you feel better it doesn’t make you get better
3.
Self-observation
a.
When you observe you take a distance from
yourself and give yourself more options. When you observe ask yourself how and what questions be an
investigator and explorer, describe your circumstances, your thoughts and your
feelings
b.
Give yourself positive self-instructions, say
carry the coffee carefully, don’t say don’t drop the coffee
c.
Graphs and diaries can help to show that anxiety
comes and goes
d.
Use concentration on external objects to stop the
internal focus which maintains the anxiety
e.
Use relaxation to reduce anxiety
i.
Slow breaths
ii.
Progressive muscle relaxation
4.
Emotional Review
a.
Doing an emotional review is a flooding
technique. You repeat the story over and over, during each iteration then you
will find it changes, you will find your anxiety reduces. If you find it hard
to talk about it then you can use images. Again look to describe rather than
label. You will get closer and closer to reality through each iteration.
5.
Own ones emotions
a.
First of all use logic to show how emotions are
created
i.
Asking two different types of girls out and how
your emotions differ, so it’s your beliefs about these two girls that create
your emotions
ii.
Show how emotions and physical sensations differ
and that we use the physical explanation to
b.
Show how secondary pay offs can maintain the
emotions
i.
Special privileges
ii.
Getting help
iii.
Getting attention
iv.
If only, justifying high status
v.
Justifying secondary acts like drinking
Chapter 14 Modifying the behavioural component
To deal with anxiety you need to get the patient to face
anxiety provoking situations and to practice specific coping techniques. This
can be done in the room by imagination or in vivo. Here they can look at their
thoughts and beliefs with a view to modifying them.
Identifying Protective mechanisms
You need to find out what techniques the client uses to
decrease their feelings of anxiety. There are two main mechanisms,
flight/avoidance and reassurance.
Often flight, or
avoidance is used to diminish anxiety.
You will also see attempts by the client to reassure themselves, either
through checking with the other or by continually appraising the feared
situation. The client may also respond to the situation by freezing, tightening
muscles, in which case the therapist needs to get the client to let go, relax.
In summary then a client will avoid, seek reassurance and
freeze. So the work is to stand in the face of the feared situation, relax and
not seek reassurance.
Motivation
Explaining the therapeutic approach to the patient
The context when you learn is the context when you can
recall. So learning something whilst drunk will mean you can only recall when
drunk. Likewise learning how to manage anxiety must be done when anxious. There is a gradient here, learn in a safe
environment, then learn in a more challenging one.
Blocks to learning
When difficult material is brought up the client may yawn,
say he’s tired, become irritable, angry or bored. It can be useful to look at
the beliefs that prevent a client from learning, i.e. I’d be inferior to the
person who teaches me, I’d be a phoney, I can’t trust myself etc.
Likewise a client might verbally agree, but then do nothing
about it. To get a change you need to
have a connection between thoughts, actions and feelings. Actions speak louder
than words. Learning is a combination of intellectual learning and experiential
learning.
You need to address and deal with these blocks to learning
before learning takes place, however you would only address them if they came
up in the room and not force the issue.
Learning can be agreeing with a proposition but not
incorporating it into beliefs. Incorporating it into beliefs but not acting on
it. To get full learning then proposition, belief, emotions and actions all
need to be related.
Educational devices
The following educational devices can prove handy
1.
White board
a.
This can provide objectification of ideas, gives
clients some distance from them and allow them to observe them and therefore
think about them.
2.
Audio tapes
a.
Clients may dislike listening to themselves but
repeating this leads to greater self-acceptance
b.
Often anxious patients have difficulty
remembering the session and this can help
3.
Video tapes
a.
This can show that anxiety isn’t as publicly
obvious as is thought
4.
Hand-outs
a.
This enables repeated review, to establish
learning and recollection
Futility of self-protection
Need to psychoeducate to see how avoidance and protective
measure strengthen the unrealistic, unhelpful thoughts. The more you protect
yourself from bad feelings, the more ominous they become. You need to face your
fears to overcome them. Each action strengthens the ideas underpinning that
action, so if you avoid something because it is fearful, then it strengthens
the idea of it being fearful.
Experiments
Approach any homework, or activity as an experiment to see
what can be learnt. So it’s all very
well logically disputing an idea in a session but to do an experiment and put
it into action will reinforce the position.
Graded steps or a gradual approximation
Clients have often faced the feared situation but done so in
an all or nothing approach, taking smaller steps can make this easier, as it
builds up learning, strengthening of will and self esteem
Hierarchy
Create feared hierarchy, stay in each step until the anxiety
develops and you can move onto the next step. If the step is too great, go to
the previous one. This also helps as a
global problem can be broken down into a series of steps.
Aids to exposure
Initiation technique
1.
Tell a friend, make a public commitment
a.
However just state this as a serious intention
as if it does go wrong you don’t want the client to be depressed
2.
Homework (a private commitment)
a.
Doing any sort of homework, gets a foot in the
door to getting homework done, but you need to get some sort of result out of
doing it, so you need to review in the office.
b.
Use reinforcement strategies, what are the
rewards that you can give yourself for doing homework?
c.
Stress the value of homework, that it increases
the amount of therapy that you are getting
d.
Practice homework in the office
e.
Develop collaboratively
f.
Explain the rationale
g.
Treat each piece of homework as an experiment
h.
Ask about any obstacles that there could be to
completing homework
i.
You could also do a future biography
Self-instruction
You can use self-instruction to help you enter the anxiety
making situation, so there can be some motivational phrases that you use.
Use coping statements, e.g. anxiety isn’t dangerous, it will
subside. These are the self-same techniques that advertisers use. Repeat these
phrases in a self-confident and self-assured manner.
You can also use a role model, how would they act, or maybe
a symbolic object, a stone to represent being strong.
You can also invert statements, so when you say I hate
filing, say I love filing and shout it from the roof tops.
Behavioural rehearsal
In this role play then the therapist can model the worst
possible fears the client has. Of course you need to build up quite a level of
trust to do this.
The use of significant others
Significant others can help the client stay in the anxiety
longer, they can
1.
Reinforce small steps
2.
Encourage don’t pressure
3.
Make the process a collaborative effort
4.
Let the client take the lead
Notice the difference between feeling better and getting
better, one strategy changes the feelings temporarily the other takes them
away.
Technical aids
Cognitive avoidance
A client may enter a feared situation but avoid thinking
about it, then they must be reminded to keep their thoughts, emotions and behaviours
all pointing the same way to get the most benefit out of facing their fears.
The critical-decision technique
In an anxiety making situation there are a chain of
behaviour up until the critical decision to avoid. This chain of decisions will somewhere
include within it a decision and a self-instruction. When this position comes
then you need to take the opposite form of action, instead of avoiding then
being with, engaging with or acknowledging your fears, so if you are social
anxious instead of leaving go and talk to someone.
There’s a paradox with anxiety that when it’s applied to
psychological aspects it’s better to face your fears than run away, to protect
yourself makes you more vulnerable. Anxiety is a very primal system that helped
us with physical threats many years ago, and now it’s better to face our fears.
What then, if your fears are realised, you have anxiety about dark alleys,
walking down dark alleys would not be sensible, so how do you tell if your
anxiety is sensible or not. Does the anxiety stop you doing something you want
to do? Is the anxiety a psychological issue? Is it a reasonable level of
anxiety for the situation?
So when the anxiety isn’t justified, then do the opposite of
your instinct. So if you want to leave a party as you are feeling anxious then
stay. People say this feels phony when you do, but any new behaviour feels
uncomfortable when you try it.
Surprise
Why don’t you surprise yourself and see what happens
Choice
People who have lost trust over themselves and their
situations seek to get unreasonable levels of control, they mentally rehearse
to ensure control over a situation. However the concept of control is an
illusion as you really don’t have control over what you’re going to think or
feel and none over the environment. So
instead of thinking in terms of control think in terms of increasing or
decreasing levels of choice.
Task orientation Tic\toc technique. Task interfering
cognitions, task orientated cognitions. Tic=I’ve got to get out of here, Toc=what can
I do to get what I want out of this situation. Toc think of your purposes(s)
and the means to achieve this, recognise thoughts that get in the way and
replace them with more helpful thoughts.
Behavioural thought
Given an anxiety what can you do to alleviate. Afraid of
breaking down in the car, join the AA
The As if technique
If you are anxious about not having confidence, try acting
as if you had confidence and shortly you will find that acting in the way that
you want to will eventually bed in. You can do this via imagery and imagination
and also role play.
Shame and other feared experiences
Most anxious patients are afraid of feeling shame, therapy
provides the opportunity where you can deliberately experience shame. To
desensitize yourself to shame you have to give yourself shame. So that what you can do is find out what is
most feared, being not nice, taking criticism, being rejected. Then you can
rate behaviour that would encounter that and give yourself points for each time
you experience it.
Developing self confidence
Increasing self-confidence can decrease anxiety. So afraid
of being by yourself, do more activities by yourself. Anything that enables you
to manage your fears increases confidence. In a social encounter there are
generally four options say nothing, agree, disagree, change the topic. People
are fascinated by silence and what lies beneath the mystery. Self-confidence
increases with knowing you can handle risky situations, so take a risk just for
the sake of it.
Agreeing
Sometimes anxious people can fend off both criticism and
compliment, which provokes more attention that they don’t want. So to reduce
this then with criticism you can say thank you for bringing this to my
attention, and with compliments you can say thank you I like it myself.
Disagreeing
Try disagreeing twice and that’s it, its ok to disagree and
still remain friends.
Doing the unexpected
In sales whoever answers the question first loses..If you
don’t want to answer a questions answer with a question.
Making a mistake part of the show
Make any mistakes you make part of the show. Like they say
in jazz, if you make a mistake, play it again.
Summary
Ok, so behavioural work to deal with anxiety. There are 4 aspects of dealing with anxiety,
you first of all need to know what the usual responses to anxiety are, flight,
avoidance, coping responses and are they functional. Once these have been
highlighted then you know what exposure means, i.e. doing something without
resorting to these dysfunctional coping mechanisms. To motivate a client to expose themselves to
anxiety, then find out:
1.
What are the blocks to learning
2.
Self-protection with anxiety is futile as it
doesn’t go away, the only way to get it to go away is to face your fears
3.
Create a graded task hierarchy
The four aspects of dealing with anxiety
1.
Exposure
a.
To aid exposure then
i.
Tell a friend
ii.
Rehearse
iii.
Use Self-coping statements
2.
Acting as if
a.
Establish your fears and invert them and act as
if they are true, use a role model from TV to help
3.
Shame
a.
Fearing shame can make you anxious so treat
experience as an anti-shame technique and see how much you can cope with, the
more you cope with the less anxiety you will feel
4.
Developing self-confidence
a.
Establish your fears and create an anti-shame
policy and put yourself in a situation to get this feeling
b.
Do the unexpected
c.
Expose yourself to risks
d.
Practice being silent, or disagreeing only twice
then leaving it
e.
If you don’t accept compliments or criticism
then you draw more attention to yourself so learn how to accept both
5.
Critical decisions
a.
There is always a self-statement and a decision
before flight or avoidance, do the opposite of your instinct
b.
Surprise yourself
c.
Look for anything pragmatic you can do to make
things easier
d.
Look instead of using control to giving yourself
choices in a situation as you can’t really get control anyway it’s a myth
Chapter 15 Restructuring a patients assumptions and major issues
Anxious maladaptation’s are centred around acceptance,
competence and control and are associated with particular domains, autonomous,
sociotrpic, public or private
Identifying Assumptions
To establish what the root issues with anxiety are then you
need to start with feelings and behaviours and then move to NATs and beliefs.
To get underlying beliefs, get the patient who has a troubling situation, to
think of the earliest time he has had a similar situation, get the image in his
head, and say what belief he was operating from at the time. Anxiety will be
created when a situation provokes one of their major concerns, vulnerability,
acceptance or control, so whilst you can remove symptoms with graded task
assignments, you need to work on the core schema to fully address this.
With any of the assumptions around
1.
Acceptance
2.
Control
3.
Competence
Then there is a feeling that there is a need around these
assumptions and something bad will happen if they aren’t fulfilled, I must be
successful, I must be loved etc.
Major issues
Identifying Major Issues
The major issues around anxiety are acceptance (other),
competence (self), control (vulnerability). The major issues have been thought,
felt and acted on thousands of time, are therefore fixed and habitualised. This
means that the behaviour gains a life of its own, an alcoholic drinks because
their team wins, draws, loses or doesn’t play. When they started it was
probably only because they won. They then develop a lifestyle around this
habit, his major concern.
Positive and negative reinforcers
If you fear incompetence then a positive reinforcer would be
your career success that you use to prove you are not incompetent. There are
negative reinforcers that you get when your fear isn’t realised then you are
relieved. There can also be some social reinforcement where you join a group on
the basis of your major concern, e.g. Mensa, the gym.
A persons responses to their major concern also feeds it. So
a person with control issues, tenses up when meeting a person in authority
which provides them evidence that they can’t control situations with authority
Psychological double
Likewise people will seek partners on the basis of their
major concern, so issue with control, then you find someone who is
dominant. The patients major concerns
quite often generates two images, one is the one lacking the major concern the
other is the overcompensation one. Thus there is fear that the feared image may
come true, and the loved image may not be met
Development of major concerns
Feelings of lack of control often generates through a
dominant parent. Major concerns develop in a spiral there is the initial
concern that via a group of rules and assumptions generates its anti-thesis as
a way of coping, but what happens is the original position isn’t challenged.
You often create self-fulfilling prophecies \situations to justify your major
concerns. Selective abstraction also
seeks to justify and embed major concerns.
Magical thinking, I had an image of the plane crashing so I
cancelled my trip. Holding onto rigid beliefs, stops learning and excludes a
whole bunch of reality that doesn’t fit with the rigid belief. Sometimes
virtues stop you learning, so rename the virtue to a vice.
Shame is the biggest block to learning, pride is the next.
You can be proud in your success area, and have no capacity in your problem
area because your pride says I must be good, I’m not good in this area so don’t
engage with it. The person who does not
learn from his mistakes will repeat them.
So the model is there is an ultimate concern then an
opposite behaviour that compensates for it, both are held simultaneously. The
opposite behaviour reduces anxiety about the ultimate concern but never
addresses it. The client can shape their world to ensure that their ultimate
concern remains true, so one therapeutic approach is to show a client how they
shape their world to reinforce the belief they have, how they make the world
fit their beliefs, how they narrow the world to achieve this.
Major concerns get fixed by developing your lifestyle around
them, choosing partners, careers to support, using modes of thinking that keep
them in place.
Acceptance
A core belief is that the client is flawed and will not be
accepted by others. The development of this may have come from a lack of
acceptance by a parent. Clients
overgeneralise and homogenise seeking everyone’s acceptance equally. Clients
also see acceptance or rejection is
absolute. Other peoples acceptance affects his self-esteem, if he gets it he
becomes more self-confident and contrariwise, thus his self-esteem is built on
sand. He believes mass acceptance is
critical for his self-esteem. It is a difficult lesson in growing up to see
that there is a world outside that has nothing to do with you. It is like
wanting to be treated as the favourite child. If he hasn’t been given special
treatment then he feels rejected. If I am to get anywhere I must be accepted by
others, maybe even all others. He believes others are better judges of what is
good for himself than he is. Therefore he must always be kind, generous and
show empathy, this excessive concern shows that others know best, that others
are critical to his self-esteem.
Within issues of acceptance there are issues of
personalisation and narcissism. At one extreme I must be accepted by everyone
to get self-esteem, as my fear is I won’t be accepted, things that happen
outside of my influence can be seen as
related to me and signs of non-acceptance. I am the centre of the world and
everything must connect and agree with me.
Competence
The core belief here is that he is inferior. He may well
have been raised in an environment that supported this view, either family or
society. He may be fearful of finishing projects, enlist other people to help
and procrastinate. Sometimes are drawn to strong people who they see as
superior to both draw from their strength but also to confirm them in their
inferiority, The feedback as to whether one is competent is usually derived
from the other.
People with issues of competence are especially sensitive to
people in authority, who can judge their inferiority. Competence is about
evaluation and comparison.
Control
The fears of the person concerned with control centre on
being dominated by the other or by events. Another pattern is where a child has
had to live with ambivalent parents, not being able to get a consistent answer
then they seek to overcompensate by seeking control over their lives. The loss of control may be about a fear of
going crazy and a panic attack. There is a belief in a dominance hierarchy
where one is either a master or a slave. In some ways it’s not what control
gives you the outcome, but it is rather the sense of being in control, thus the
other has to give into my requests to ensure that I feel in control
Motivation and Major Concerns
Often a client wants to get rid of their anxiety but not
their major concerns. You can loosen major concerns so move from I must be
accepted to I’d like to be accepted, it would be nice to be accepted but it’s
not disaster if I’m not.
Each major concern leads to a behaviour that reaffirms it
Summary
Underlying anxiety and other forms of symptoms of distress
is the root cause. These are major concerns and in anxiety centre around issues
of
1.
Control
2.
Competence
3.
Acceptance
What happens is that the anxiety around not being accepted,
being in control or being competent can generate the opposite action where
people attempt to be competent, in control and accepted at any cost. If the
opposite isn’t achieved then depression can follow.
People’s major concerns can be embedded by lifestyle, so the
jobs that people choose, their partners, their cognitive set and way of looking
at the world.
The therapeutic aim here I guess is to loosen the original
belief. The original belief needs to be pulled up and out and into
awareness. If the feeling is I’m
inferior then I guess the work isn’t to dispute that as that is what the client
tries to do with their inversion but rather to say ask is your identity purely
tied up with your performance. Could you be loveable without having to
perform. In the case of acceptance then
again it’s difficult as you need to say that you can be ok, without everyone
accepting you. With control, you can be ok, without being in control. You can
go back to look for the original time when this was created, the child who felt
horribly out of control, if you can repeat this time so that the adult to come
to terms with this that might help.
Part of what they want, acceptance, control and competence
is needed, but the absolute sense of I’m nothing without it needs to be
challenged. I suppose you can also challenge it directly where the original
fear gets buried, I’m incompetent, there can be evidence of both where you are
competent, and also evidence of where making mistakes is useful or ok. Likewise
with acceptance, then there can be both evidence where you are accepted and
also where you aren’t and that’s ok. Same thing goes for control .
Book Summary
Anxiety is a feeling we want to get away from, it demands
our attention, it speeds us up as it is insistent that it is paid attention to.
Anxiety seems to be part of a system that enabled us to deal with physical
danger. Anxiety is the affective
component with fear, fear being an evaluation that there is danger around.
Often with anxiety the object of fear is not known but rather a situation or
time provokes anxiety. In these times it could be because we have forgotten the
object of fear, but have been frightened so often in these situations that the
appraisal has been lost in the association of affect with situation. Possibly
there has been stimulus generalisation, so the new object of fear is a
generalisation from the original source and we are not aware of the
relation. It is also possible that we
are afraid of the thought that provokes anxiety itself so we push it out of our
awareness. Finally there is the possibility that an accumulation of aspects
collectively result in a feeling of anxiety, so all of its constituent parts
need to be isolated.
Anxiety seems paradoxical often as it decreases our ability
to cope and therefore increases the danger.
The reason for this is that anxiety seems to have originated in response
to physical danger. When anxiety strikes all we can think of is feared and
dangerous situations, we can see ourselves not coping, our breathing,
perception and cognitive faculties are all impaired. This can be useful in
terms of physical danger. Anxiety can stop us performing a reckless act. It can
make us freeze to give us more time to think and to be able to absorb blows if
we are under current attack. Likewise fainting
can be useful to play dead, so as the enemy avoids you, or again to staunch
any blood flow. When it is used with
psychological danger then it seems to make the danger worse, the person with
social anxiety finds it hard to speak, the person taking the exam finds it hard
to think, the person who fears loss of control becomes more out of control.
With anxiety disorders there are a couple of things that
happen. Firstly there is a very high level of anxiety response where the danger
is magnified and the ability to cope is minimised.
The first point that needs to be made with client is that
the target for work with anxiety is not the feeling of anxiety itself but
rather its causes.
Before you start on treatment its worth thinking about what
the client thinks about anxiety to see if there are any meta feelings and
thoughts that can contribute to feeling bad about having anxiety, these need to
be dispelled before starting.
So with clients then first of all what needs to be
established is what are they frightened of and why. If a client has anxiety
without knowing why in a situation then you can look for other situations where
they have similar feelings then find out what is in common between these. The
other thing is to ask them for any thoughts that happen before the situation.
Alternitavely then ask if they have any images that come to mind. If none of
this works then look to get anxiety within the room then find out what they are
thinking.
There are 3 main aspects of anxiety
1.
Competence
a.
This is where performance anxiety comes in. The
base schema is that to be loved then I must be competent, therefore performance
becomes a significant aspect to a persons identity.
2.
Control
a.
This is where fear of going mad comes in, being
in control is central to a persons personality and anxiety is provoked where
they feel out of control
3.
Acceptance
a.
This is where social anxiety can come in, where
being part of the gang, accepted by the other is crucial to identity. Social
anxiety can also tie up with competence, where there are a defined set of rules
that must be adhered to to ensure social success, any deviation from these,
provokes a feeling of shame, guilt and then anxiety
The response to anxiety are fight, flight, freeze of faint.
If the danger is seen to be less than the clients resources then the fight
response can be offered, if not then flight, freeze of faint is taken. The way
anxiety comes is firstly there is the primary perception of finding something
of interest to me which can either increase my values or decrease, fear is the
reaction to the threat of something valuable being taken away
Once what the feared object\situation is then you need to
use the downward arrow technique to find out what the base fear is. Given this
being establish then you need to look at the coping mechanisms used, be it
avoidance, or looking for someone externally to reduce the threat, or a magic
ritual.
With the coping mechanism isolated then you need to do an
ABC analysis to see what effect the coping mechanism has and what its effects
are. Chances are it reduces anxiety, chances are that there are secondary gains
that keep it in place. So isolate the reinforcers. This being done then work
with the client to see how their coping mechanisms don’t challenge the
underlying thought or schema of vulnerability and how the fear can be
maintained by the reinforcers.
The other part of analysis of the feared situation is to do
though records to see what the catastrophising thought is and how it can be
challenged This will increase their coping resources. Likewise asking wheres
the evidence can increase their coping resources as it will show them how they
can reduce the perceived level of danger by their cognitions.
The next step is to get the client to have more control over
the situation. To do this then they need to count the number of times that they
are anxious. Doing this will firstly find out more about their anxiety what its
scope and frequency are. Secondly in counting they will take some distance from
it and therefore become an observer which will change the anxious reaction, it
will also give them a greater feeling of control as they can at least count.
When counting has been performed then you can get to increase their control
over their anxiety by naming it, maybe even give it a character and refer to it
in the third person. Having done this then you can increase their frustration
tolerance by getting them to wait longer before resorting to their coping
mechanisms.
Once the increase of mastery has happened then look to
increase coping resources. You can do this by decatastrophising a situation,
look to see if their worst fears took place
how would they cope
Now strengthening has happened, then you can start to think
about exposure. Get them to created a graded hierarchy of feared situations.
Teach them relaxation through breathing, meditation and progressive muscle
relaxation. Get them to get into a state of relaxation and imagine themselves
performing one of the items on the hierarchy. When they can do this
successfully without excessive anxiety, then look to get them tpo think of a
reinforcer to be conditional on success of each task. Then get them to perform
each task in turn to increase their feelings of mastery. For each task then see
it as an exercise
Techniques
1.
Images
a.
Repetition (flooding)
b.
Modifying image
c.
Replacing image
d.
Cartoonifying image
2.
Cognitions
a.
Thought records
b.
Acting as a role model
c.
Decatastrophising
3.
Actions
a.
Distraction
b.
Focussing on the other
c.
Graded task hierarchy, exposure
d.
Acting as if
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