In this trio of blogs, three of our therapists – a psychologist and two psychotherapists – of differing modalities will be sharing their views on how to work with a fictitious client. The “client” James, is a high achieving barrister in his mid-thirties presents with severe anxiety. He has recently started a new relationship and they are thinking of moving in together.
James comes from an upper-middle class background where there was a family culture of not talking about feelings and difficulties. He was sent to boarding school ages 6 – 13. He is eldest of 3 children and his parents divorced when he was 13. There’s has been other traumatic childhood incidents that he is yet to disclose.
He presents well dressed, competent, practical and wants quick solutions. He is very busy and wants to know what therapy can do for him and how long it will take.
An integrative approach [i]
The way therapy might begin is for me to invite James to collaborate in formulating a clear description of his presenting issues of anxiety broken down into these three key areas:
- Predisposing factors – historical events that may have contributed to his symptoms of anxiety
- Precipitating factors – more recent events that may have triggered his anxiety
- Perpetuating factors – factors that maintain his anxiety
In addition, it would be useful to identify existing Protective factors in James’ life that might help him overcome his symptoms.
Finally, an understanding of James’ goals and a plan of how these might be achieved needs to be included.[ii]
Importantly, for effective collaboration on the formulation and to undertake subsequent work, James needs to feel that the therapeutic space is safe; that he is in a containing, non-judgemental and accepting environment.
What follows is obviously speculative, it is undertaken to give the reader an idea of what James’ formulation and treatment plan might look like.
This relates to the ways events in James’ life may have contributed to his problems. Of note here is being sent away to boarding school from the age of six, potentially exposing him to traumatic events, including abuse. Nowadays, it is accepted that such environments can be toxic; described as ‘Boarding School Syndrome.’
In addition, the culture in his family of origin was one of emotional repression. James may have learnt from a very young age that he must manage difficult feelings without emotional nurturance from grown-ups. He may have managed his feelings by employing such strategies as denial and repression; painful issues are kept out of awareness.[iii]
These strategies will be more effective if James keeps people at a distance, leading to a core belief that ‘people can be dangerous and I must not let them get too close.’ Being sent away as a small child could have led to additional core beliefs around James believing that he is not loveable, and that he must try much harder than others in order to feel worthwhile. In all likelihood, his parent’s divorce would have compounded many of the above issues.
This part of the formulation considers more recent events in James’ life that may have contributed to him seeking help; why now? Of likely relevance is the fact that James and his new partner are thinking of living together. This constitutes a dangerous step toward intimacy; his partner will expect not just physical, but also emotional closeness.
James’ previous strategy of keeping his distance could cause conflict. How will he cope? Unable to recognize his dilemma, James begins to experience an increase in symptoms of anxiety. But he does not know why.[iv]
What he is aware of is that these symptoms are very unpleasant and he wants them to go away. For James, this inner conflict takes place in the context of a demanding, stressful busy career. He is known as competent and practical. His high-profile role needs him to be in control.
Presenting Problem (as described by James)
This relates to the factors that maintain James’ symptoms. James’ anxiety is described as severe. This implies that his symptoms developed over time – without being treated – and presently have a firm grip on his life. Because he has not been receiving any treatment, James may have developed unhelpful behavioural coping strategies such as avoidance of anxiety provoking situations, and unhelpful cognitive strategies that reinforce beliefs about genuinely being in danger.
Unaddressed, these factors alone could maintain and/or increase James’ symptoms. He is attempting to cope without a real understanding of how the mechanisms of anxiety operate.
James’ is obviously capable and bright, qualities that may help him overcome his problems. The fact he continues to work indicates that he remains able to function at a reasonable level and is not completely incapacitated by anxiety.
James is seeking treatment, implying he is able to reach out for help and understands he does not have do this on his own. He is in a relationship and probably has a partner who will support him while he undertakes therapy. He may have other good relationships, for example with his siblings, who could also offer support.
All of these factors will contribute to the likelihood that James will make progress in therapy. When undertaking the actual formulation, James will be encouraged to add to this list of protective factors.
James’ own treatment agenda is to reduce his symptoms of anxiety. This involves an explanation of the anxiety/panic model (e.g. fight, flight, freeze), to help him develop an understanding that though he is in no physical danger, his body will react physiologically as if a threat is imminent, and that is why anxiety is so ‘convincing.’ He will learn that all he has to fear, is fear itself. This process is not complicated, but it often it takes time to absorb.
In addition, James will be encouraged to engage in simple relaxation training, and to challenge fearful cognitions around being in danger. Development of such skills will allow James to remain in a feared situation and not reinforce his fears by – for example – avoidance.
Short-term medication may also be useful to help James reach his initial goal. As James’ own agenda is addressed and he experiences a reduction in anxiety symptoms, he may be willing to look at other, earlier issues in his life.
Having collaborated in his own formulation, he is already aware that the roots of his anxiety may be more complicated than he originally thought. Longer term treatment would include exploring his earlier experiences in some depth. The rationale for this would be that unless underlying issues are explored, and new ways of relating to others are established, James’ symptoms of anxiety are likely to return.
[i]This Integrative approach is primarily based on Cognitive Behavioural Therapy (CBT) and Psychodynamic Therapy. In addition to the above, subsequent work with James may also include Systemic Therapy.
[ii]In Cognitive Behavioural Therapy, this approach is known as the five P’s formulation. I often add a sixth P, which allows for the treatment Plan to be included.
[iii]These are concepts used in psychodynamic approaches, usually referred to as unconscious processes.
[iv]Again, this refers to psychodynamic concepts such as defence mechanisms and repression.