The Return of Anxiety

After overcoming anxiety, it may nevertheless return unexpectedly. This article explains why, and why you needn’t panic: 790 words.

After the Christmas holidays I returned to work at  my university, taking the train as usual, then walking a short way through Sydney’s Inner West to my office. I used to walk with the majority of students and staff, only I like to walk briskly, and most people take it easy. I felt like a Formula One driver trying to work his way up from last place on the grid; so eventually I chose a different route, cutting through the engineering faculty to avoid the crowds. However, on this first day back I mysteriously reverted to my original route, and only realised what had happened as I was half way along. I chuckled a little, recognising that I had fallen victim to a significant phenomenon relevant to my clinical work, especially related to anxiety.

When we overcome anxiety, we usually learn that what we feared is unlikely to eventuate, or even if it does, it will not be as bad as we thought. An effective way to achieve this insight is to face our fears often enough that our emotional system learns the reality that perhaps our intellect knew all along. For example, the person that fears flying, despite knowing intellectually how safe this mode of transport is, will, by taking enough flights, learn emotionally that there is little to fear about flying. (This method of treating anxiety is called exposure.)

Except some people, after learning not to fear flying, will turn up to the airport one day and be overcome by fear again. Why? Well, we know from extensive research that old learning is not erased: it turns out that what is learned cannot be unlearned, so that our fear of flying, for example, never goes away. But we are able to learn something new that competes with our fear – in this case, that flying is a very safe way to travel. These two nuggets of knowledge compete for influence over our emotions and subsequent actions (whether to fly or not to fly). And a significant factor that can weaken new learning about our anxieties is a change in context compared to when we first learned these facts. This context can be the place, the people involved, or even the time – anything about the circumstances in which we learned to no longer fear something.

So we learn to not fear flying, but after a few months we might then think… “that was then, but this is now: perhaps its no longer safe to fly”. Or, “I felt safe on xyz airline, but this is abc airline – maybe it’s not safe with them”. Or, “I was okay when I flew with my friend, but now I’m alone, so perhaps its not safe after all”. None of these thoughts need be conscious, but there is nevertheless some doubt about feeling safe, so anxiety returns.

This is similar to what happened to me that first day back at work. After a couple of weeks off my brain decided to revert to an old habit-old learning if you will-which caused me to walk an old and less convenient route. When our anxiety returns we are simply walking an old route, but the good news is that the new route is still fresh in our mind, and research has shown that we can return to this route with less effort than it originally took to forge it.

A clever analogy taught to me by a former colleague (Jess), is to think of your existing fear as a wide track through a thick forest. Overcoming this fear requires you to laboriously push your way through virgin forest, making a new track, one that leads to a feeling of safety. At first this is very hard work, but over time you push back the plants and firm the ground, making it easier and easier to travel this route. And all the while the old route, which led to fear and anxiety, is becoming overgrown from lack of use. But it will never quite disappear, so it may be that some days, depending on the circumstances,  you might accidentally travel back down your old trail, ending up in a fearful place. This is perhaps inevitable, but just as certain is that our new track is still available; and we can, after realising what has happened, decide again to choose the route which leads to that sense of confidence we get from facing our fears.

So, if you find yourself beset by fear once again, remember that this is just a wrong turn. Retrace your steps, and pick up where you left off. You’ll find your sense of confidence will return more easily the second (or third, or fourth…) time around.

Types of Psychological Therapies

A brief summary of mainstream psychological therapies of the modern era.

Therapy styles discussed in this post include the insight therapiesPsychodynamic and Humanistic; and the cognitive-behavioural therapiesCBT, Third-Wave therapies, and a couple of others.

When deciding on a psychological therapy you might like to know roughly what’s in store for you. Although they all involve talking to some degree, what you’ll talk about and what exercises you’ll be asked to engage in will differ. I would say they all have one major thing in common, and that is we don’t know exactly how they work, although each has a theory behind it, and some are more scientific than others.

As to which is better, there is a school of thought that they all do roughly the same thing and it doesn’t matter much, and it does seem that a good working relationship between the therapist and client is still the most important factor behind successful therapy. However, there is evidence out there suggesting some therapies are better for treating certain disorders, so receiving a good assessment by a competent clinician will help in your choice.

Often though, you’ll go to see a clinician after a recommendation or a search on the internet, and they will already have training in certain therapies, so it would be useful at that stage to know what they are offering. Here’s a quick run-down of the major therapy styles available in the Western world at least, in roughly chronological order of their development.

Insight Therapies

Insight therapies aim to help a client by improving their awareness and understanding of relevant aspects of their psychological functioning. With this increased insight the client is able to make positive changes to their life. I’m not formally trained in these therapies, but I know enough to pass on the basics.

Psychodynamic Psychotherapy, including Psychoanalysis (345 words)

The Austrian neurologist Sigmund Freud was a pioneer in developing a formal ‘talking cure’ for mental health problems, beginning in the late nineteenth century with psychoanalysis, and his body of work has been very influential on Western culture more generally. Psychodynamic theories and therapies were once dominant, but began to wane in influence from roughly the 1970’s. They nevertheless remain a significant alternative to the cognitive-behavioural therapies I’ll discuss later.

Psychodynamic psychotherapy presumes the existence of subconscious psychological processes, (including basic drives and motivations), that are thought to significantly influence our behaviour and psychological wellbeing. By identifying damaging processes and bringing these to light, the therapist hopes to release the client from their influence.  These processes develop gradually throughout our lives, particularly in our impressionable childhood years, and are influenced heavily by interactions with our family. Consequently, there is a focus on the past, and on interpersonal relationships.

The therapist will look for subtle, often symbolic cues as to the source of distress and dysfunction, and may interpret dreams, which are a meaningful product of the unconscious mind (according to the theory).The relationship between the therapist and client is particularly important, as it represents a source of data, so-called ‘transference’, when the interpersonal patterns of the past are played out between the client and the therapist in the present.

Hence psychodynamic psychotherapists will generally take on a less active role, letting the client do most of the talking. And they are quite disciplined in their approach to therapy so that they don’t muddy the waters; for example they’ll typically maintain regular appointments at the same place and time, and will disclose relatively little about themselves in session.

The less active role of the therapist, and the rather ambitious goal of uncovering the unconscious mind means this therapy can be slow going, and that requires a substantial investment of time, and probably money. But you can expect to learn more about yourself in the process. It doesn’t have a strong scientific basis, although studies have shown it to be effective for a range of problems.

Humanistic Therapy (215 words)

Carl Rogers, who developed a humanistic ‘client-centred’ approach to therapy from the 1940’s to the 1980’s, is still thought of as one of the most influential of all clinicians. The humanistic approach was never taught to me formally in my clinical training, but his client-centred principles are infused in the way therapy is taught, and hence in the way most therapists work.

The client is presumed to have within them the ability to change for the better, and achieve personal growth. The therapist is led by the client, helping them to gain insight along the way. As in Psychodynamic Therapy, the client tends to do most of the talking; and the direction therapy takes depends on what issues or ideas the client brings to the table (…or chair, more commonly). The therapist uses active listening to reflect back the client’s own ideas in a way that promotes insight, treats the client with ‘unconditional positive regard’ to bolster their own self-regard, and shows empathy and understanding towards the client. Lovely stuff :-).

Humanistic psychology doesn’t really offer specific theories of mental disorders, and so a purely humanistic approach to therapy may not suffice for those in an acute stage of mental illness. It aims rather to promote personal growth, and to help people achieve their potential.

Cognitive & Behavioural Therapies

The psychological therapies in this category focus more on changing what you do, rather than building insight, (although increased knowledge and awareness is important still). Their development began in the 1950’s and has continued until the present day. They can be split into roughly three groups – Behaviour Therapy, Cognitive Therapy, (together, ‘Cognitive Behaviour Therapy’), and finally, the so-called ‘Third-Wave’ therapies.

Cognitive Behaviour Therapy (CBT; 530 words)

The main assumptions of CBT are that our thoughts, feelings and actions are interconnected, and hence changing one will lead to changes in the others, offering opportunities for targeted therapeutic interventions. The relationship between them is often portrayed by diagram below.

 

Whereas in psychodynamic theories the majority of important psychological processes are unavailable to our conscious awareness, CBT assumes that whilst much of our thinking may be automatic and out of awareness, with a little practice we can begin to notice our thoughts, and connect them with related feelings and actions. This allows us to consciously make beneficial changes to these processes. The therapist’s job is to help the client to develop the skills to identify and change the relevant processes, leading to improved psychological health, and providing additional coping skills for the future; when successful, the client becomes their own therapist.

Behavioural techniques were the first to be developed, and came with a fairly rigorous scientific backing (at least by psychological standards). Research has shown that certain habits of behaviour maintain psychological problems. For example, for those suffering from excess anxiety, consistently avoiding what they fear maintains this anxiety in the long run, as they never have the opportunity to disconfirm their expectations of threat. To address this, behavioural techniques for anxiety involve facing our fears (called exposure therapy). There are also behavioural techniques for depression, which aim to reverse corrosive patterns of withdrawal and social isolation. Behavioural techniques are widely used to manage behavioural problems in children, and adults in some cases, by manipulating the pattern of positive and negative consequences following targeted behaviours.

Cognitive techniques came later, and are premised on the idea that the way we feel is a direct result of our thoughts, specifically the way we appraise a situation. And although our perspective on the world is certainly influenced by our upbringing and events of the past, the focus of CBT is on the present, in that we can change how we presently think in order to improve our psychological condition. CT generally involves monitoring thoughts to identify patterns of thinking that are maintaining poor psychological health, and will then employ techniques to test the validity of these usually biased and unrealistically negative thoughts, thereby weakening their hold on our emotional health.

CBT is probably the most well researched psychological therapy, and there is a fair bit of evidence supporting its effectiveness.  It is also quite targeted and can be effective in a relatively short time, (weeks or months, sometimes even just one session for simpler problems like specific phobias eg, spiders). It requires more effort from the client though, who is generally set homework tasks, and we need to repeatedly use skills to get them to a point where they are effective. Treatments like exposure therapy are potentially very effective, but only if you can talk someone into doing them: facing our fears is not, at first, a pleasant experience (although it can be very empowering once accomplished). And the cognitive techniques use our conscious thinking to challenge ingrained ways of seeing the world, which can be quite a big ask for some people, especially those who are not psychologically minded.

Third Wave Therapies (515 words)

These therapy styles came to prominence in the 1990s (give or take), and are generally influenced by Eastern philosophies. Whereas the CT in CBT asks us to change the content of our thoughts, which leads to a change in how we feel and act, these therapies ask us to change the way we relate to our inner psychological world. Many promote acceptance of our thoughts and feelings by learning to view them as merely psychological and physical events that we can choose not to engage with, if it is unhelpful to do so. We learn not so much to change our psychology, as to live with it.

Mindfulness

Mindfulness Based Stress Reduction (MBSR) was one of the earlier therapies to adapt certain meditation techniques into a psychological therapy. This particular therapy is generally conducted in a group format, and is almost entirely based on applications of Mindfulness. Mindfulness practice is quite experiential, as you can’t really understand what it is without doing it. MBSR uses mostly meditation exercises.

All of the other third-wave therapies I mention below include some concept of Mindfulness.

Dialectical Behaviour Therapy (DBT)

This therapy was developed in response to the specific needs of a particular clinical group, but is now used more widely. It combines pretty pragmatic behavioural techniques with Mindfulness and other skills-based practices. DBT therapists are often more forthcoming in style, may disclose more about themselves, and will sometimes be available to consult with their clients out of session (often to coach people through crises).  Some therapists use DBT techniques to supplement their main therapy modality, but this won’t be the full DBT experience.

Acceptance and Commitment Therapy (ACT)

As the name suggests, ACT promotes acceptance of our psychological experience, and asks the client to commit to living life according to what they most value. In ACT, the therapist will help the client to see that the way they have struggled to manage their symptoms so far has not helped, and may even be making things worse. They then make use of a range of analogies and other techniques, such as Mindfulness, to help the client accept their negative thoughts and feelings, and re-focus on living a meaningful life, taking some of their symptoms along for the ride! Although symptom reduction is not the aim of ACT, the paradox of acceptance is that by not trying to reduce symptoms we no longer fuel them, and they may subside as a result.

Metacognitive Therapy (MCT)

This therapy focusses not on managing symptoms directly, but on managing what we think about our symptoms, and how we respond to those symptoms. It has elements in common with ACT, although acceptance itself is not a central theme. Many of the techniques are designed to change the processes of thinking without necessarily changing the content of thinking. It nevertheless aims to challenge unhelpful thoughts about our own symptoms, such as worrying about how we worry too much, which only adds to the worry (and don’t I know it!). It also uses analogies, visualisation techniques, attention training, and a more specific concept of Mindfulness (without the meditation practice).

A Couple of Others (130 words)

Schema Therapy

Still quite new, Schema Therapy combines the focus on thinking from Cognitive Therapy, with the past focus and longer term approach of Psychodynamic Therapy. The CT part of CBT focusses (at least initially) on individual thoughts identified by the client, but recognises that these thoughts come from ‘core beliefs’ that we hold about the world. Schemas are collections of core beliefs on related topics, and so represent maps or blueprints of our life. Schema Therapy aims to improve our psychological health by re-programming these schemas, re-drawing the maps in our mind in a sense. It can be quite experiential, dealing with significant memories and themes from a client’s life.

Interpersonal Psychotherapy (IPT)

This cognitive-behavioural therapy is an evidence-based treatment for depression, and focusses on the interpersonal aspects of this disorder.

The Complex Symptoms of Trauma

A brief look at common responses to trauma, addressing some of the complexity in these responses, and the relationship between associated disorders: 640 words.

The symptoms of Post Traumatic Stress Disorder (PTSD) are a common response to a traumatic event. They include vividly re-experiencing the event and associated anxious arousal, but also growing avoidance of anything related to the trauma, and an increasingly negative view of the world. For the majority of people such symptoms will subside over time, particularly if they are well supported in the period after the trauma. But for a significant minority the symptoms will persist.

Not all responses to trauma fit this picture however. The situation is often complicated when we are exposed to more than one traumatic event, when we experience trauma as a child, or when our trauma has an interpersonal element, as in abuse. Feedback loops that develop after trauma can set in motion processes associated with other disorders, such as anxiety and depression. And many people will become addicted to alcohol or other drugs in an unhelpful attempt to manage these complex and self-reinforcing symptoms, and addictions cause a whole set of problems by themselves.

It may be helpful to think of each person’s trauma response as a point floating somewhere in the Venn Diagram below, often falling within the PTSD oval, but just as often encompassing greater complexity. And so to make sense of these complexities it is useful to consider other diagnoses and their relationship with PTSD.

A person’s response to trauma may fall somewhere within this Venn diagram. PTSD symptoms are common, but so is a mixture of symptoms from related mental health disorders, as are addiction and relationship problems (not represented here).
Anxiety

Anxiety symptoms are often prominent after trauma. We commonly react to anxiety by avoiding the things that make us anxious, but avoidance undermines our confidence and leads to further anxiety and avoidance in a vicious cycle. The traumatised person may avoid doing things and going places that remind them of the trauma, and may avoid even talking or thinking about the trauma. As their cycle of avoidance widens, they may begin to experience difficulty just leaving the house, or carrying out everyday tasks. I’ve worked with highly trained and very competent members of the military who were reduced to staying at home all day, reluctantly going out only with their partner, or who found it difficult to answer the phone and check their emails in case it meant doing something they felt unable to handle. In this way anxiety becomes its own problem as it spreads and leads to conditions like agoraphobia (roughly defined as a fear of public places), social anxiety, severe worry and stress.

Depression

Negative thinking and mood states are now formally part of a PTSD diagnosis, and the effects of trauma are so debilitating that people may understandably respond with the feelings of hopelessness and helplessness closely associated with depression. When you feel nothing can be done to help, you may give up and withdraw from life, and if you think nobody understands you, or that you are a burden on others, you may isolate yourself socially. Severe and chronic depression works against people seeking help and engaging in treatment, so when depression is bad enough clinicians may opt to treat this before addressing trauma symptoms, even if they think the trauma symptoms came first.

Borderline Personality Disorder (BPD)

This diagnosis represents long standing problems with strong and chaotic negative emotions, interpersonal insecurity, confusion with one’s own identity, and frequent self-harming behaviours, including suicide attempts. There are many variations of symptoms that can earn this label, so BPD can be experienced quite differently by different people. It may well develop from early experiences of repeated abuse, including sexual abuse, hence the relationship with trauma. The methods used to treat PTSD can be quite different from those appropriate for someone with BPD symptoms, so differentiating between them is important.

Conclusion

Perhaps it is to now state the obvious that determining how someone has been impacted by trauma is critical for planning their recovery, so I recommend an assessment by a qualified clinician as a good first step.

Finance Analogies: Mental Accounting and the Positive Events Diary

I make a case for paying extra attention to the positive events in our lives, and offer one way of doing this: 460 words.

As a former accounting and finance professional I like to find some common ground between my two careers. Here’s my fourth attempt…

In life we can expect some events to add value, and some to reduce value. For example, when we receive a compliment this adds value, and when someone insults us this diminishes value, if we take it seriously anyway. As an accountant, I would record transactions that increased and decreased the value of an organisation, namely income (credits), and expenses (debits). Of course, many expenses are necessary, as we can’t expect to achieve anything without incurring cost. But on the whole we hope to make a net profit (more income than expenses).

Sometimes, though, our mental version of accounting goes a bit haywire. We start recording only the negatives, and fail to notice the positives. This is very common in depression, when we become biased towards noticing failure and setbacks. The reality for the depressed person may well be okay, but their disorder stops them from seeing this.

In accounting we record financial transactions in a ledger. If we are keeping a kind of depressive ledger, recording just the expenses in our life, then we will soon start to question whether it’s worth doing anything at all; we become hopeless. To counter this, we can start to keep a second set of books, in which we will record only mental ‘income’.

Clinicians call this a positive events diary. At the end of the day we can take a simple note of the good things that have happened during that day, whether little or big, and by doing this we begin to build a more accurate picture of our lives. It’s an unashamedly biased exercise, because depression is biased too. Think of it as affirmative action for your positive thoughts.

Each time you do something that your depression would have prevented you from doing, record this as a positive event. It’s an achievement for many depressed people just to get out of bed in the morning. All the usual good things can go in there, and don’t take things for granted. If you make someone laugh, enjoy your morning coffee, or get a question right at college, or in a work meeting, all these are positives and deserve to be recorded. Social media can be used in this way. If we take Facebook as an example, spend less time examining others’ highly curated lives, and record your own ‘best of’; you don’t even need to share these publicly, but going to the trouble of recording these events will remind you of them, and you can look back over them in the low times.

However you do it, keeping a positive events’ diary is a relatively simple way of balancing your mental books. And although you don’t need to be an accountant to do it, you might find consulting with a therapist will help you keep track of all those mental credits.

Finance Analogies: Spread Your Risk

A short analogy reminding the reader that we should apply prudent investment strategies to our lives more generally: 300 words.

Here’s my third attempt to find crossover between my former career in finance and my new career as a psychologist…

The idea of not putting all your eggs in one basket is fairly well accepted. You spread your risk, putting a few eggs in a few baskets. You might drop one or two baskets but probably not the lot, thereby averting disaster. Following this principle, financial advisers will suggest that their clients invest in a portfolio of investments, rather than betting their life savings on just one or two.

We don’t always apply this principle more generally across our life though. We invest time, effort and emotions in all aspects of our lives, and to spread our risk in life makes sense as an investment strategy. How many people dedicate themselves wholly to their careers, see only their immediate family, or perhaps spend all of their spare time at the gym. These situations are great so long as nothing goes wrong. But consider the career oriented person who’s made redundant, or the person who unexpectedly gets divorced and realises they don’t have friends anymore, or the gym junky who develops a chronic injury, and can no longer get their fix of exercise. Each of these people will lose a significant source of self-esteem, comfort and coping overnight, and will have little else to turn to.

We can be dedicated to our spouse and family, but also spare some time for friends. We can be ambitious in our career whilst remembering that it’s not the only thing that makes us valuable. And we can benefit from a regular exercise routine without obsessing over it.

So, try taking an inventory of the investments in your life, and see whether you could benefit from diversifying a little. It will take more effort, but even if all of your existing investments continue to pay a return, you just never know how rewarding other opportunities might be.

Finance Analogies: Don’t Over-insure Yourself

A finance metaphor illustrating the cost of trying to eliminate all risk from our lives, and presenting an alternative to this: 480 words.

Here’s another go at finding commonality between my former career in finance and my work as a psychologist.

When we purchase insurance we incur a small cost upfront to eliminate the risk of greater losses later on. That all sounds lovely, only insurance companies earn a profit margin on these transactions, ensuring that in the long run they will earn more in insurance premiums than they will pay out to cover people’s losses. In fact, over a lifetime a large majority of us will claim less in insurance than we will pay out in premiums. So why take out insurance at all? Well, one reason would be if there is a plausible risk of a major loss that you could not expect to cover, such as your house burning down. But aside from these situations, the benefits from insurance are mostly psychological – specifically, we gain peace of mind.

But another way to achieve peace of mind in these circumstances is to take a long term view of risk. If we can accept that over a lifetime there is only a very small chance of ever claiming enough on our insurance to justify it, then we could do away with insurance on all but those big ticket items like a house. Sure, we will have a few occasions when we do have to replace an item that we didn’t insure, but the money we save will most probably more than offset this. But many of us struggle to take this long term view. Our emotions are built to focus on more immediate concerns, and if I’m concerned about my new refrigerator breaking down unexpectedly then I’ll buy that extended insurance to allay my concerns. Consequently many of us over-insure our lives.

But this tendency to over-insure doesn’t only apply to financial transactions. We do the same thing if we always carry an umbrella as insurance against it raining, or when we put in unpaid overtime to prepare for almost every possible question at the next work meeting, or when we take a swath of vitamins each day just in case we pick up a particularly virulent flu virus. The cost of carrying that umbrella may be small, but add that up over a lifetime and then compare it to the odd occasion when we’ll get wet, and it’s likely that we could benefit in the long run from leaving the brolly at home.

My examples may seem trivial, but the risk-averse people amongst us insure almost every aspect of their lives, and in doing so, weigh themselves down with the burden of all that insurance. If that is you, then try and take a long term view of the risks in your life, learning to accept the smaller risks that you can deal with should they eventuate, (and you can cope with a lot more than you think). Allow yourself a wry smile when you get caught in the odd rainstorm, but remember that you travel lighter nowadays.