Month: October 2023

One of the maintenance factors for anxiety is when an individual does not fully go through the anxiety cycle and where their safety behaviour patterns kick in, such as avoidance behaviours, the suppression of thoughts and other safety seeking behaviours. We all know that avoidance, the suppression of thoughts and safety seeking behaviours just strengthen and maintain anxiety over the long-term and make real internal and life-changing behavioural changes much more harder over time.

So what do I mean by the anxiety cycle? Well in a nutshell, this includes the ‘build-up’ to an event that an individual focusses on and which is causing a sharp rise in anxiety related behaviours. This event itself may include specific actions such as taking a flight, travelling on the underground or sitting in an enclosed space that feels claustrophobic.

Part of the anxiety cycle will also include the event itself, though the degree to which an individual places themselves into that event will determine if their anxiety or their phobias related to their anxiety strengthen themselves and are sustained, or weaken over time through continued exposure.

This obviously depends on how long someone can feel comfortable, for example, by travelling on a plane or sitting in tunnels and carriages on the London Underground. The quicker they get off these modes of transport as a form of avoidance to their sharply rising anxiety, the more their anxiety and the phobic/intrusive thoughts will remain a driving force for their safety seeking behaviours. ‘Cutting out’ early or as fast as possible to anxiety causing situations simply re-enforces and embeds in the anxiety cycle to a much deeper level. This is key to understand and comprehend and it is ego-dystonic.

Research work has shown that such individuals should stay in their anxiety causing situation until the intensity of their anxiety drops below 50% from the start. This can be measured in the form of their pulse or their heart rate and provides somewhat of a measure as to how long the person should stay in that situation, and through which there will be some form of therapeutic gain as the body re-learns that the situation is not catastrophic.

So, anxiety sufferers should repeatedly place themselves into specific situations that are anxiety producing, and stay in those situations until their heart rates fall to below 50% of the frequency of their pulse before they started the activity. Consistency is key, as is repeating these exercises on a weekly basis.

The greater the frequency of these exposures and the smaller the time difference between these exposure events, the greater the chance of real long-lasting change in response to anxiety. Furthermore, the greater the chances the individual will have to be able to overcome any anxiety inducing events in a much shorter period of time. The positive knock-on benefits to this also include a higher level of self-confidence and self-esteem in individuals, which act as a counter-loop to the anxiety cycle.

So going through the anxiety cycle is one of the most essential of activities that anxiety sufferers can undertake. With that in mind, therapists need to be aware that sufferers will more than likely have a ‘fear of fear’. Being curious with the client at the start of the counselling journey can ascertain this, before any exposure related behaviours can form part of any therapeutic planning process.

‘The fear of fear’ is what one individual said to me.

“All I do now is to fear the fear of panic and that is adding a whole load of anxiety to me, that I just don’t need”.

For those who experience panic attacks, there is a real desire for many not to think about the ‘fear of fear’. Yet, this is what their ruminations and thoughts latch onto. Which is why exploring how individuals have coped with previous anxiety producing situations is key, so that they start to reflect on their resilience and their ability to cope with panic in the future. Yet, the word ‘coping’ does not fully describe the reality, that those who have panic disorder, should be supported in working through the panic events so that they can see that the anxiety process reduces over a short period of time, that they have got through it and that previous coping mechanisms that they have employed do not have to re-engaged with.

Previous coping strategies may in  fact be perpetuating the fear and thereby the panic and anxiety itself.

So talking through how anxiety is not harmful is important as part of the psycho-education process. As is the need to normalise anxiety – that it is a natural body reaction used to defend us and that those who have anxiety and panic attacks, have an over-sensitive and over-reactive sympathetic nervous system. Reducing the ‘fear of fear’ is therefore important which has a knock on effect of reducing thoughts and feelings that the individual is somehow ‘faulty’ or ‘significantly different’ than the general population.

Another way of anchoring clients who ruminate and who reflect on the past, is to help them to catch themselves and be mindful when they start to go into the ruminatory cognitive process. Staying in the present and the ‘here and now’ and noticing 5 things around them, is a useful way of anchoring them in the present moment, helping them to engage with the world around them and with nature itself. It is anxiety reducing and helps to make people feel that they are part of something larger and wider than them. This process is one of a number of tools to help sufferers of panic attacks to slowly build a mindset that accepts and lives with mental flexibility, rather than the inflexibility of mindset that anxiety creates.

Lastly, breathing techniques, and learning to let thoughts ‘come and go’ – much like leaves on a stream, are other useful tools that people with anxiety and panic attacks can use. These are all mechanisms that I use within my therapy sessions with clients.

Social anxiety affects many people and is very treatable through counselling and hypnotherapy.

Allied with social anxiety are behaviours that include avoidance, stress that is sometimes felt in the shoulders, arms and back muscles and sensations such as blushing. Cognitive thoughts could include, “am I able to cope”, “this will be embarrassing” or “I cannot look at people that I am presenting to”. Underlying these thoughts are core beliefs that I work with the client to uncover as a starting process to look at what is ‘underneath the bonnet’, driving such thoughts.

For some clients, core beliefs may include “I am not able to cope”, or “I am weak” and it is important for the client to be aware of these and to go through the psycho-educational process of understanding that they exist and that they can change their responses and the internal dialogue that they are having with themselves. It is at moments of stress, such as when they are giving a speech or a presentation, when the core beliefs can affect and develop thoughts that are anxiety inducing and affect the confidence of individuals.

Role plays and working through the internal dialogue that clients have, so that they can take a more compassionate approach to internal narratives, can help them to train, manage and weaken the core beliefs. It also gives them the space for them to reflect on language that can build and support their resilience and which can be embraced by them as the scaffolding to overcome their social anxiety.

Repeating this process of reappraising their core beliefs, deconstructing them and reflecting with clients as to whether they have any actual substance or not, are an essential part of the re-appraisal process. Furthermore, gently placing the client into those moments, (such as getting them to visualise that they are going to give a speech), and using breathing and muscle tension and relaxation exercises, provide additional tools that clients can use, whilst chipping away at any cumulative anxiety that may be building up if they are going to give a speech in the future.

Social anxiety is therefore one of the spectra of anxiety conditions where we as therapists can make a real difference  to the client’s resilience. In today’s world, where there are more work pressures and where greater duties at work are expected from staff, reducing social anxiety makes significant gains for clients emotionally, mentally and economically. It also raises their sense of self-achievement and more importantly, their sense ‘that they can cope’.

Social anxiety is therefore based on an internal defensive reaction and it is not the anxiety that is at the root of the issue. Whilst client’s will feel discomfort and focus on the anxiety symptoms around societal engagement, at the root of this is what the client believes about themselves and what a specific social engagement will do to them. These are the driving forces which are at the root of social anxiety. Focussing on these, whilst providing anxiety reducing tools, are a roadmap for a future where client’s can widen the scope of life experiences and with it, a greater joy in life.

Specialising in anxiety conditions such as generalised, social anxiety and obsessive-compulsive disorder has demonstrated to me how deep and ingrained cognitive distortions are in people who have suffered long-term anxiety. This is also a problem with people who may have had anxiety-related cognitions for less than five years and this depends on the strength of belief in the distorted cognitions that individuals have.

I stress this again and it is not necessarily the length of time that someone has suffered from anxiety conditions, it is the strength of believability in the cognitive distortions that pulls in people and which then hyper-fuels and stimulates a sensitised limbic system and the amygdala.

What has also been missing in many therapeutic interventions is around curiously working with clients around understanding how cognitive distortions affect many of the sensory functions of sufferers. Smell, sight (shades of colour), touch and even taste become fused in certain circumstances with distorted thoughts and these fusions are often missed in work that is done in therapy.

Therapists need to take a much wider view of the variety of sensory systems that are affected by cognitive distortions, as well as how believable the thoughts are for clients. In not addressing these sensory and cognitive fusions, therapists may miss out on how sensory stimulations and reactions keep cognitive distortions alive.

The fact is that short-term work on getting clients to understand and work on accepting alternatives to their cognitive distortions is important. Yet, many therapists do not ensure that the work is central to their therapy and many move into the framework of getting the client to understand their triggers and their family history or traumas. All of this is essential work in giving clients a wider understanding of how they have reached this point, but the point that I am trying to make is that the cognitive distortions still remain as deeply ingrained in many and continue to cause real problems for people.

Allied to this, very subtle behaviours that go with the cognitive distortions as a means of coping with them further fuel and enhance their relevance to anxiety sufferers and many of these subtle actions will not be noticeable to therapists.

Approaches in therapy that seek to let clients find alternative thinking patterns to their cognitive distortions are essential. It allows them to take ownership of alternative ways of thinking that can resonate with them. However, it is important that therapists use their natural sense of curiosity in getting clients to think as widely as possible so that they are armed with a range of alternatives that they can turn to.

Therapists should also provide psycho-education to clients to ensure that they do not use alternative interpretations of their cognitive distortions as a crutch which they automatically return to when they are anxious. This may keep the anxious thoughts alive and alternative narratives to their cognitive distortions are simply to be used as a means of getting them to think about alternatives that may ‘stick’ with relevance. This is subtle work, yet important.

Finally, this is subtle and nuanced work. Many of us are willing to tick a box to say that we can work on anxiety conditions; the truth is, are we really able to work with the complexities and range of anxiety conditions there are?

There seems to be a pattern to intrusive thoughts and the corresponding anxiety that lead to the brain mis-interpreting the danger of the thought and placing more weight and credibility around it, when it comes into the mind of an OCD and anxiety sufferer.

Intrusive thoughts have a link to the values, moral codes and experiential fears of individuals. Intrusive thoughts don’t just have a theme that is ‘plucked’ out of the air and they are based on cognitions that play on the values, moral codes and fears of people that I listed earlier. So, for example, someone who grows up hearing that his/her mother had incontinent problems after the birth of her children, may well have intrusive thoughts about losing control of their bladder. Or someone who works with children and who finds significant personal value in working with children and who passionately cares about their safety, may get intrusive thoughts that they could be a risk to children. The intrusive thought flips their moral code on its head in this instance, eliciting a sharp anxiety reaction in an individual.

So, when an intrusive thought enters into the mind of an individual who is prone to OCD and anxiety, the thought is so polar to their values and belief system that it leads to a rise in anxiety that the brain interprets as a threat. That is the way that the brain has evolved, so any detrimental changes in the body are picked up as a threat and if this is caused by a thought, then that thought becomes cognitively and automatically marked as ‘dangerous’.

This pattern is followed in the same way as someone who has obsessive fears about their bladder or about ‘wetting themselves’. The thought enters their mind and any previous incidents about their mother losing  control of her bladder, subconsciously add weight to the thought and the brain marks the thought as dangerous and problematic.

There are however, additional safety behaviours and sensory perceptions in the body that further add to the layer of mis-interpretation by the brain around such thoughts. Keeping with the bladder experience, as the anxiety rises around the initial intrusive thought, the brain obviously interprets the thought as a threat and nerve impulses automatically sense the ‘state of the bladder’. These nerve impulses that test or check the state of the bladder add further weight to the cognition and inner feelings that there is a problem and something bad is going to happen. This loop further re-enforces perceptions that the thought has real meaning to it and something catastrophic is going to happen.

It is also interesting to note that someone with OCD may then ruminate on the thought in an attempt to ‘fix it’ or come to a conclusion, and we all know that there is no conclusion since this very action re-strengthens the weight of it and the fears around it.

It is not just bodily sensations that are associated with the initial intrusive thought. Imagery that comes to mind with the corresponding intrusive thought all add to it, where the initial intrusive thought is based on the exact opposite of the values and moral framework of the individual.

It is therefore the alarming nature of the intrusive thought, and the corresponding bodily responses and ‘internal scanning process’ in the body that all add to the cycle and the strength of such thoughts.

The process lays out areas where CBT and other specialists can work with the client on. Breaking the consolidation of the intrusive thought and removing the initial anxiety ‘whoosh’ of the thought can make a real difference to this process, short-circuiting it so that the individual does not end up in a regular ruminative process.

Understanding this process is a liberating to many clients and allows them to understand the process which has historically sucked them into consistent ruminations and confusion.