In psychiatry, just as in any other branch of medicine, the real cause of a symptom may be hidden from the patient, the doctor or both. In psychiatry, the root causes of disorders are often unintentional hidden because of internal conflicts that are submerged below one’s consciousness. We all have experienced worrying about one thing only to eventually discover that the real issue is something quite different.
1. Anxiety may be caused by a taboo subject we simply cannot or do not wish to face.For example, a young woman married to an abusive man may not consider divorce an option, will not even see it as a possibility. Sometimes that is because there are children involved, sometimes it is because of financial circumstances or religious teachings. Such a person coming to a therapist for help presenting a variety of anxieties and depressive symptoms may never mention the domestic violence – even though it is the core issue. It behooves the therapist to exercise their sensitive radar to clue in because direct questioning will often elicit a simple negative answer resulting in everyone involved heading down the garden path of deception.
2. Anxiety often creates other symptoms in order to create a distraction that can lead both the patient and therapist on a wild-goose chase. For example, a sore back, a stiff neck or a splitting headache or compulsively cleaning at a specific time late each evening may be the complaint. Focusing on the distractions soon turn the distraction into a real problem that even more strongly leads away from the root issues.
3. Anxiety is characterized by a state of helplessness, of complete loss of self-control. Typical examples include, ” I cannot breathe” in a panic attack as well as “I can’t sleep” in insomnia. Normally breathing and sleeping are part of the effortless behavior pattern of a living being. The anxiety is interrupting the basic human operating systems.
4. Anxiety leads to cognitive distortions. Even doctors have anxiety/depression. I know of a doctor, a specialist, who in the depth of his depression, without any reason, worried that no one would come to see him in his practice when in reality, the usual waiting time to see him was 6 months.
Key Remedies to Consider:
1. Come back to the present.
For runaway anxiety such as panic attacks, the first thing to do is to bring oneself back to the present moment. That is empowerment. In other words, don’t fight the panic in your mind: Reassert control over your physiological response to the thoughts. How to do this? Well, the most common complaint in anxiety attacks is ” I cannot breathe.” Under the circumstances, until the patient is able to do this alone, the therapist will have to strongly take over and direct the patient to breathe SLOWLY. I would reassure my patients that it is safe to regain the control by holding the breath for ten seconds. I would tell them that even at my age, I could still hold my breath for one minute without causing any harm to my body. That usually caught their attention. By seeing that it was harmless for me to hold my breath for 1 minute, they were reassured that holding their breath for 10 seconds would not hurt them. Once they had intentionally slowed down their breathing, they generally felt re-empowered, back in control of their most basic body function. This was simple, immediate, effective and within their capacity. The fact that I was willing to throw myself into their fearful experience reassured them that I was taking their concern seriously, not casually dismissing their complaints as trivial.
2. Learn how to worry constructively
Some worries are necessary while others are not. Let us call one group “constructive” and the other “destructive.” First, we need to learn to distinguish between the two. The reason we usually cannot separate one from the other, leading to the paralysis of anxiety disorder, is that we are too emotionally involved with the subject of our worry. Effectively, we are talking about correcting cognitive distortion.
Destructive worrying is worry that entraps one onto a vicious self-perpetuating cycle. The resultant worry feeds into whatever is causing the worrying making it worse, creating a sense of loss of control or “dis-empowerment.” There are usually two internally opposing voices at work. One tells you that your worrying is justified. The other says that you are just worrying too much, that you should not be worrying. Constructive worrying enables you to consider the issues without entrapping yourself in a vicious self-perpetuating cycle.
How can we determine whether or not our worry is constructive? A patient came to see me once for anxiety issues. I applied the paradoxical intention concept from Victor Frankl’s Logotherapy approach. I asked my patient to sit still for a few minutes to prepare himself, organize his thoughts and review what was bothering him, before telling me all the things that were bothering him. In other words, I was asking him to worry without trying to fight it.
As a result of my request, he gave himself permission to worry. He sat down and focused on the internal turmoil without worrying about his worrying. When he was sitting and reviewing what he was supposed to be worrying about without that self-criticism, he was able to process his situation without further outside input. After a few minutes, to my surprise, he opened his eyes and said that what he was worrying turned out to be of no real significance. He did not even need to tell me! His body language confirmed it.
Be very clear about your non-verbal language as a therapist because it carries a lot of weight – often more weight than the spoken word. It was clear to my patient both verbally and non-verbally that I took his complaint seriously and respectfully, rather than being dismissive of his worries.
