Category: Anxiety

Psychotherapy 101

Many people ask, sheepishly, how psychotherapy really works.  The term “therapy” is mentioned constantly in the media as a short form of the word “psychotherapy.”  It’s natural that people are curious about something that is seemingly ubiquitous, yet apparently defies easy explanation.  There is nothing magical or new about psychotherapy.  Like most medications, however, there are aspects of its intrinsic functioning that remain a mystery.  The nebulous and fleeting words strewn about a psychotherapy session appear, mysteriously, to be less important than the conditions demanded by the therapeutic frame.  The “frame” of psychotherapy refers to all aspects of the session divorced from the actual words used within the session: for example, cost, time, place, office policies, etcetera.

Whatever the psycho-therapeutic school of thought, there are set features that are standard across most styles and techniques.  The most important element of effective psychotherapy is the promise of confidentiality.  Without a solid confidential therapeutic base, psychotherapy is nothing more than a Socratic conversation for hire.  One’s life may be blessed by many intimate trusted contacts, yet one cannot divulge literally everything to any one friend.  There are always social consequences, and consciously or unconsciously, all of us must monitor and filter the content of our conversations.  I do not believe that this encompassing social information management is strictly selfish.  As often as not, the filtering of information is used to protect the feelings of others.  Having intimate  friends is certainly important to one’s mental health, yet even the closest of relationships may be of little use when one’s situation is altered by psychological suffering.  For instance, most of my patients are very conscious of becoming a “burden” to others through ventilating their distress.  Unless the intimate attachment is based upon this sort of negative ventilation, the voicing of complaints may alter the basis of the friendship.  Existing social support may be lost.  For this reason alone, close friends are often of little help when psychological distress becomes significant.

Confidentiality is the boiler plate of psychotherapy.  Psychotherapy research of the last 50 years is convergent in revealing that the particular therapeutic technique employed is less important than confidentiality in achieving a favorable patient outcome.  Part of these findings may be explained by the decreased social risk obtained by ventilating to a professional.  Another aspect of these findings may be explained by the very nature of psychotherapy technique.  Each school of psychotherapy tends to focus on particular features of the human experience, yet similarities do exist.  Broadly, psychotherapy is dedicated to resolving problems that negatively affect one’s life.  The relative importance of thoughts versus behaviors differs, yet nearly all seek to identify “maladaptive” thoughts or behaviors that lower a person’s psychosocial functioning.  Many schools, such as Rogerian, eschew the whole notion of maladaptive, yet even the most positive and uplifting psychotherapy is seeking to alter one’s thoughts and/or behaviors.  It is unlikely that anyone would pursue psychotherapy as a treatment if they perceived their thoughts and behaviors to be wonderful.  Many schools of psychotherapy are better at appearing more positive and uplifting than others, but the mission is essentially the same.  For example, a new form of psychotherapy is termed “coaching.”  This form of psychotherapy/counseling even eschews the whole notion that it is a psychotherapy!  As in Rogerian therapy, there is a strong accent on the therapist being positive and proactive.  The word “coaching” is synonymous with “instructing.”  It appears that some people would forgo the benefits of an intimate attachment to a therapist, in order to avoid being perceived as a “psych case.”

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If I may draw on the medication analogy again, the use of different forms of psychotherapy is similar to considering side effects in proscribing a particular medication.  If we know that two medications will work equally well to cure a condition, which should be employed?  The medication with side effects better tolerated by a particular individual would be the obvious choice.  For example, the new class of antidepressants called SSRI’s are very good, yet most cause serious reversible symptoms of sexual impairment.  If the patient is very sexually active, it might be better to use an older, though less effective, antidepressant without the unwanted sexual impairment.  Similarly, group psychotherapy is the most obvious choice to reduce social anxiety, yet initially it may be the worst form of treatment.  Exposed to the stimuli they fear the most, a group of people, the patient may experience recurrent trauma as a consequence of this treatment.  For this person, it is better to lessen the initial anxiety with individual psychotherapy, and then save the finishing touches for group psychotherapy.

The basics of psychotherapy are centered about confidentiality, a solid frame, and the identification of unwanted thoughts and/or behaviors.  The choice of which psychological technique to employ is similar to choosing amongst equally effective medications.  The choice of interventions should be based upon the comfort level of the particular patient, in light of their unique situation and lifestyle.

Anxiety of Life

Many people have a goal of reducing or eliminating anxiety in their lives.  Through groundbreaking research in the 1950’s, the average person is aware that chronic stress may lead to unpleasant health effects.  Heart disease to hair loss is ascribed to chronic stress.  It begs the question as to how stress differs from anxiety, or does it?  Perhaps it is best to begin with a definition of terms.

Chronic anticipation of the future is considered anxiety, and if one views this future as negative and unavoidable, then it is more apt to receive the label of stress.  Anxiety is often viewed as a symptom of the mind, and stress is perceived as affecting both the mind and body in a negative fashion.  Anxiety may have positive connotations; such as anticipation of a wedding or performing in front of an audience.  The original conception of stress segregated it into the two poles entitled distress and eustress.  Distress is obvious, but eustress is a term not likely to be encountered since it was first coined.  Eustress refers to the type of anxiety experienced as relatively pleasant and stimulating.  Rushing home from work to usher a child to band practice may have multiple interpretations.  It may be experienced as an opportunity for personal time with the child.  Band practice is an enriching and stimulating activity.  The situation may also be perceived as a helpless madcap dash that always seems to end with a tardy and upset child.  Stress research strongly emphasizes the role of a person’s evaluation of their situation.  If someone feels caught and helpless in a situation, even if they have real control, they will experience the bodily effects of chronic stress.

There does not appear to be much difference between eustress and optimistic nervous anticipation.  Perhaps anxiety commonly denotes short-term nervous anticipation and eustress tends to favor a longer experience of the pleasant anxiety.  Unpleasant anxiety is experienced as stressful if the person becomes convinced that they are unable to help themselves or others in a meaningful way.  A perceived lack of power to effect the unpleasant situation is the most direct route to physical decline.  When rodents are punished in an arbitrary fashion, shocked on a random basis, they will uniformly give up and sit shaking in a corner.  A reduced appetite, weight loss and a diminished lifespan result if this torture is continued.  Sexual activity in the rodent disappears, and subsequent socialization is minimal and not helpful to their survival.  The key cognitive factor initiating distress appears to be helplessness-a profound lack of control.
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Unfortunately, there is no research to support that a greater level of real control results in a less anxious person.  If a person believes they have control over their environment,  then they typically report less symptoms of anxiety than most people.  Many of my patients over the years report chronic anxiety over the welfare of children and other close others.  Most of these people do not classify themselves as anxious, nor do they meet the criteria of an anxiety disorder.  Many of my patients worry about their jobs on a chronic basis, their health and the fidelity of their partners.  Few of these patients meet the criteria of an anxiety disorder, nor are they experiencing stress-related illnesses.  On the other hand, many people believe they are in control of their life, but they cannot consciously admit certain fears that conflict with their confident self-image.  For example, a wealthy business owner came to be evaluated for his emotions and cognition, secondary to several stress-related symptoms.  He was happy at work, which he controlled, but felt foolish and incompetent at home, which he did not control.  This person did not meet the criteria for depressive or anxiety disorders, rather the chronic stress he experienced at home made him avoidant of his family.  He doctor shopped to explain the hair loss, stomach troubles and irritable sadness he experienced in the presence of his family.

Perhaps the only way to avoid anxiety is to avoid living.  Less anxiety is also equatable with less joy, less expectation and a diminished sense of being fully alive.  The avoidance of stressful anxiety appears to balance on a person’s perception of control.  The strange truth is that an easy-going homeless pauper may experience less stressful anxiety than the King of Araby!  Maximizing the anxiety that enlivens and minimizing the stress that kills is a key challenge to constructing an ideal life.  Please leave comments regarding this article in the space provided below.