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R W Thorburn

 

October 1996

 

 

Contents

 

Introduction                                                                                                       

Chapter 1      An Historical Perspective                                                                                                      

Chapter 2      Principles And Therapeutic Approaches                                                                                                      

Chapter 3      Cognitive Therapy With Hypnotherapy                                                                                                      

Chapter 5      Mono-Symptomatic Phobias                                                                                                      

Chapter 6      Agoraphobia                                                                                                      

Chapter 7      A Short Case History Presenting Strategies And Techniques For Cognitive Restructuring (Edinburgh, March 1996).                                                                                               

Chapter 8      Comparisons; Behaviourism And Psychoanalysis                                                                                                      

Chapter 9      Conclusion                                                                                                      

References                                                                                                          

 

 

 

 

Introduction

 

Cognitive and cognitive behavioural psychotherapies are assumptions which hold that how a person perceives and processes his experiences in life determines how he feels and behaves. The author will firstly present the history, development and principles of cognitive therapy and the contributions of influential figures such as Alfred Adler, George Kelly, Aaron Beck and Albert Ellis will be assessed. The potential of this active and time limited therapy to enable the client to become his own therapist will be explored. Generalised anxiety with or without panic disorder, mono-symptomatic phobias and agoraphobia will be defined, examined and their effects analysed.

 

The effectiveness of hypnotherapy in bringing to awareness the client’s negative automatic thoughts and visual images will be explained as will the subsequent restructuring and replacement with realistic ones. The author will provide a relevant case history to show the efficacy. A discussion will then follow leading to an evaluative comparison of Cognitive, Psychodynamic and Behavioural therapies, and their appropriate uses to differing clients.

 

The conclusion of the author is that cognitive behavioural therapy/psychotherapy is in itself a very powerful medium for helping the client to overcome his difficulties and if correctly and appropriately applied can enable the client to become his own therapist thus taking the solution with him wherever he goes.

 

Chapter 1 – An historical perspective

 

In the first and second centuries A.D. the slave Epictetus is quoted as saying “men are disturbed not by things, but by the views they take of them.” In the eighteenth century the philosopher Emmanuel Kant said that we are never able to perceive reality directly but only to see things filtered through mental categories. In the nineteenth century Alfred Adler, like Sigmund Freud, believed that a child’s formative years were extremely important in moulding the personality. Freud pursued the theory of unconscious libidinal drives while Adler asked the question [1] “What does the world seem like to a small child.” He felt that human beings began life with natural inferiority as adults were bigger than the child, and as a consequence of this perception the child would compensate. Adler asked parents to encourage the child to build confidence and self-esteem. Adler was a social psychologist who believed in social interest and that a person’s mental life is determined by his goal. Teleology. If the child’s attempts for recognition were met with persistent criticism or lack of love the perception of being inadequate would make the child behave in a manner which was incongruent and therefore detrimental to the psyche.

 

Private logic, the person’s inner belief system is based on biased-apperception rather than common sense, it is unique to the individual and it is the glue which bonds inferiority and behaviour to fantasy goals. Security without security. Utopia on tap. Realistically destructive. [2] “The meaning that is attached to events determines behaviour.” and thus Adlerian therapy involves re-educating the client towards a more satisfactory lifestyle, by changing his attitudes, his goals, his values and his behaviour.

Murray and Jacobson rightly described Adler as the forerunner of many modern cognitive therapists such as Albert Ellis, Julian Rotter, George Kelly, Eric Berne and Aaron Beck.

 

George Kelly.

In the 1950’s when behaviourism was the dominant psychology George Kelly recalls how he sat through many lectures watching Stimulus Õ Response being written on the blackboard and waited for the teacher to explain the meaning of the arrow. Influenced by Emmanuel Kant Kelly regarded man as a scientist who constructed his own interpretation of the world. Personal constructs are seen as bi-polar. [3] “We approach the Worlds not as it is but as it appears to be; we gaze at it through our construing goggles.” Kelly viewed all behaviour as if it were an experiment and then determined to validate the hypothesis. If the behaviour matches up to the pre-verbal (sub conscious) view of self then the behaviour is effective functioning, but problems will arise if the pre-verbal view of self is incongruent. At a superficial level an inability to achieve a favourable outcome is ignored [4] “problems persist until the person is able to find acceptable alternative ways of dealing with the world.”

 

 

 

Aaron Beck

Originally a psychoanalyst Beck became increasingly frustrated with its lack of efficacy. His observations in the early 1960’s with depressed patients showed a negative bias in their thought processes, rather than the Freudian concept of anger being turned inwards – reversal. Beck labelled this a cognitive triad where the client has a negative view of self, the world and the future. Beck believed that the way a client structured incoming information – schemata – led to the clients emotional disorders. Beck’s therapeutic approach was to track down and have the client test the validity of these negative automatic thoughts, and then to replace them with more effective ones. As Beck’s cognitive therapy has progressed, trials on its effectiveness have shown increasingly encouraging results [5] “The conclusion from these treatment trials is that cognitive therapy is at least as effective as anti-depressant medication in the treatment of unipolar non-psychotic major depression.”

 

Albert Ellis

Like Beck Ellis was originally a psychoanalyst but found it “inefficient.” He differed from Beck inasmuch Ellis would home in on the irrational beliefs and the emotions it brought to the client. Ellis also believed that humans have a strong tendency to think and act irrationally. He originally named his method Rational Therapy, however he later changed it to Rational Emotive Therapy as he felt there were misconceptions that Rational therapy was only concerned with thought. Ellis held that thought, emotion and behaviour were all closely linked. In 1994 he changed the name of his therapy again to Rational Emotive Behavioural Therapy. R.E.B.T. is a problem solving approach to emotional disorders. It has been described as psycho-educational, the client is encouraged to scrutinise and review his irrational beliefs such as the social phobics one of “I must come across well in front of significant others, and if not it’s awful, I’m a damnable person, I can’t stand it” (ego disturbance) and be taught that the self defeating “musterbatory” belief should be replaced with a preference thus moving anxiety to one of concern. [6] Ellis’s aim is to eventually penetrate the educational establishment with his framework of treatment. If he succeeds he may well become the new Alfred Adler.”

 

Chapter 2 – Principles and Therapeutic Approaches

 

The cornerstone of cognitive behavioural therapy is the ABC model. This is a form which the therapist may use to enable the client to accurately see how his thoughts affect his behaviour.

.         represents activating event, the location or situation where the problem arises, i.e. in the case of an agoraphobia opening the front door. A behaviourist may deem the opening of the door as the problem.

 

.         is for dysfunctional thoughts, images or beliefs, or silent assumptions, labelled so as the client is in the opening phase of therapy and will be unaware of them. They are influenced by the client’s social/cultural background. The fleeting thought from an agoraphobic may be “I will faint if I go out.”

 

.         is the direct consequences of the cognitive distortion. In the case of the agoraphobic he will stay in and as a result may feel short term relief and despair.

 

Cognitive behavioural therapy believes that emotions and behaviour are a consequence of thought and that emotional problems arise from unrealistic thinking. It would therefore follow that by monitoring and identifying activating events, dysfunctional beliefs, consequences and exposing the link to the client by means of the ABC form will give him a greater insight into the perpetuation of his difficulties. [7] “An initial goal in therapy is to help a patient restructure his thinking by first becoming more aware of his thought processes.” Then by examining the evidence and the justification of the negative automatic thoughts and beliefs this will begin to reduce the intensity by which they are held when these self defeating thoughts are challenged and disputed more realistic ones can be introduced in their place. It is important to note that C.B.T. holds that positive thinking is equally destructive as it can lead to disappointment when the goals are not met, and that rational thinking is the key to health. C.B.T. does not believe that past past traumatic events contribute towards the client’s current difficulty [8] ” A premise of cognitive therapy is that one develops anxiety not because of unconscious motivations but because one has learned inappropriate ways of handling life’s experiences.” Later we will look at cognitive psychotherapy and its relationship with hypnotherapy in identifying beliefs that may have arisen out of a traumatic event.

 

The Therapeutic Alliance

 

Goals

The therapist and client will agree on carefully formulated goals. These goals however can change as therapy progresses. The setting of an agenda at the start of each session will help clarify any pressing problems that the client may have such as disturbing symptoms or sensations from the distorted cognitions [9] “The client will have ruminated for months, perhaps years about his difficulties, and will have many ideas about the problem but still be profoundly confused, ending up in evermore vicious circle of negative thinking.”

 

Bonds

Therapy is a joint effort, with the therapist being genuine, accepting and providing accurate empathy. These three Rogerian core conditions allow an opening up of the client’s intransigent schemata as the client may perceive himself as being beyond help.  [10] ” An effective way to reduce his anxiety is to create a warm therapeutic relationship based on trust and acceptance. Without this, the techniques and procedures of cognitive therapy are unlikely to work.” Rogers believed in the unique control – growth – change potential of the organism. C.B.T. actively guides and directs the client towards his own self-actualisation by teaching the client how to overcome his problems himself. Independence and the ability to solve his own problems are the aims of this short term therapy [11] “The typical course of cognitive therapy for anxiety is from 5 to 20 sessions.” Unlike R.E.B.T. cognitive utilises a socratic approach where the client’s thoughts and beliefs are tested.

 

Tasks

An essential part of C.B.T. is homework or tasks. Graded activities must be kept to manageable boundaries and be realistically used to encourage the client towards achievement through his own way of thinking. Since, there are 168 hours in a week it is essential for the therapist to know what is happening to the client in the other 167. In between sessions, self monitoring is a highly effective way for the client to record his negative automatic thoughts so that he and the therapist may review them at a later session. [12] “Hypothesis are continually generated and put to the test.” Writing down N.A.T.’s and their consequences on a self monitoring form and equating their efficacy with more functional ones brings the client to greater awareness and in turn will begin to reduce anxiety. Common denominators relating to the client’s problems will become evident to both therapist and client [13] “With anxious patients, the activity schedule can additionally and importantly be used as a means of monitoring anxiety in relation to specific situations.” In the case of the agoraphobic graded exposure, in turn, can also begin to show the client that he can stay out even for a short period of time thus disputing his negative beliefs.

 

 

Chapter 3 – Cognitive Therapy With Hypnotherapy

 

Unlike the cognitive behavioural therapist the cognitive psychotherapist would acknowledge past traumatic events and try to change the client’s perception of them. The cognitive therapist may use hypnosis to help reinforce the client’s new thoughts and perceptions [14] “Hypnosis superficially resembles a sleep like state which is how it got its name” The first references to hypnosis can be traced back to ancient Egypt and Greece. Hypnosis is the Greek word for sleep. The father of modern hypnosis was Franz Anton Mesmer an Austrian physician who developed the theory of  “animal magnetism” – the concept being that diseases were the result of magnetic forces stuck in the body. Mesmer would sweep his arms all over his client’s body in a showman like fashion in an attempt to get him to enter “an altered state of conscious awareness.” Although the author is aware of the differing schools of thought regarding hypnosis he will hold by the National College’s dictum that once the conscious mind has been put in abeyance by the client focusing on the therapists voice and words then the unconscious mind can be directly utilised.

 

Although there has been many great pioneers of hypnosis from John Elliotson, James Braid, James Esdaile, Ambrose Liebeault, Jean-Martin Charcot, Emile Coue and Sigmund Freud, Freud’s abandonment of hypnosis, describing it as “too capricious”, held up the development of hypnotherapy. In the 1930’s an American called Clark Hull produced a book called “Hypnosis and Suggestibility”. Hull was a lecturer on hypnosis, one of his students would later become arguably the world’s foremost hypnotherapist: Milton H Erickson. Erickson viewed the unconscious mind as a source of great creativity made up of experiences, ideas and memories [15] “Deep hypnosis frees subjects from the constrictions of the conscious model of reality and places them in direct contact with their unconscious knowledge, experiential learning histories, and abilities, all of which may be vilified into new experiential understandings.” While the author acknowledges the great successes Erickson had with resistant clients and his ability to cure by surprise, confusion and metaphor, for the purposes of this dissertation he feels it appropriate to agree with Erickson’s opinion of the unconscious as a source of creativity as opposed to Freud who viewed it as a seething cauldron of sexual energy and repressions. [16] “This leaves the unconscious area of mental life to contain all the more primitive drives and impulses influence our actions without our necessarily ever becoming fully aware of them.”

 

In the author’s experience insight orientated therapies has been successful with only a small number of clients. On these occasions the client has been comparably young and has not built up excessive memories of suffering and despair. For the greater majority who have successfully benefited from therapy they have played an active part in their own recovery. [17] “In my opinion, too much time is spent and too much unnecessary suffering caused today by frequently searching for deep-seated causes for nervous illness, when so often none exists … it is not so often a childhood cause as many believe – present sensitisation remains. The habit of fear is the important thing now. This must be cured.” Through counselling, the constraints and limitations of the conscious mind can be addressed, by using the ABC framework and disputing methods, which will presently be shown in detail, hypnosis as an adjunct can harness the creativity and power of the unconscious mind thus putting all parts of the psyche in synchronisation [18] “An injured or inadequate conscious/unconscious relationship can produce as much pain as a dislocated elbow or severed limb. Something is out of place, out of control, or not working properly … as a result that person’s ability to cope comfortably and sufficiently is compromised, symptoms develop, and pain or suffering is experienced.” Cognitive hypnotherapy can be used to track down an isolate N.A.T.’s and images which may not be uncovered through evocative imagery and self-monitoring.

 

By inducing hypnosis and helping the client achieve a reasonable level of relaxation which will help him to be more aware and at ease to confront anxiety producing thoughts or images [19] “The use of imagery procedures is endorsed by the finding that 90% of anxious patients report visual images prior to and concurrent with anxiety…indeed, some patients describe themselves as ‘imagers’ rather than ‘thinkers’ and find it much easier to report visual fantasies than automatic thoughts.” The client may be asked to visualise a time earlier in the week when his symptoms arose and by incorporating the use of ideo-motor signalling both therapist and client can achieve insight into disturbing symptoms. If the above methods fail to achieve insight into the thoughts, suggestions (with the client’s permission) to go into an anxiety situation whilst in reality, and to be ‘more aware’ of any negative thoughts and images so that he can write them down and at a later date both therapist and client can assess. This method should also overcome the problem of “the mind going blank” which will be discussed later as a secondary disturbance. In accordance with the rational-emotive theory that humans are happiest when they set up important life goals a time projection into the future using imagery of the end result will help motivate the client towards success.

 

As therapy progresses cognitive restructuring can begin in hypnosis with the client doing imaginal rehearsal by visualising themselves in problematic situations later that week and then using the new functional thoughts that the client has created thus breaking their negative self-hypnosis. Regarding dysfunctional images the author cites a case from his own experience of a fifty year old staff nurse who had a phobia about driving test examiners. Although “sufficiently efficient” in driving skills the woman would experience extreme nervousness, dry mouth, palpitations and an inability to concentrate just on seeing him. By using imaginal rehearsal the therapist asked her to see herself calmly meeting the examiner at the outset of the test and getting into the car after following the usual test procedures. As the test commenced she was asked to imagine – when appropriate – the examiner with ‘puffy’, good bagpipe blowing cheeks, wearing a long kilt and yellow wellington boots. She was then asked to imagine him drumming on his clipboard in time to Scottish country music. As the imaginal test proceeded she was then asked to visualise the examiner asking her to pull the car the over whilst he got out of the car and started doing somersaults. The lady in question who had failed three previous tests, passed. Her perception of driving examiners would never be the same again.

 

Hypnosis may also be helpful in allowing the client a greater awareness of how his problem began (roots of self image problems) thus being able also to isolate the belief that has arisen out of it. In hypnosis, priming the client before the regression may give his unconscious mind a clearer idea of what to find. The author favours the suggestions from The Handbook of Hypnotic Suggestions and Metaphors (pp128-129) and finds them specifically helpful. The therapist initially speaks to the client about the importance of high self esteem and then about the handicap and misery caused by low self esteem. The client is then asked to take a trip through his brain where perceptions of low self esteem will reside. The therapist specifying that the client’s experiences are not a depository of what happened but what was learned from the experience. A short story about a two year old who spills a glass of milk and interprets his parent’s response of chastisement very literally ends up believing that he is a bad boy in every other way and fails to realise that his parent was merely upset about the milk being spilled.

 

The client in then asked to imagine himself sitting in a train compartment feeling very safe, calm etc, the therapist then explains that he train will go back through his life times experiences and can stop at any incident the client favours. The client is given his own control switch to stop where and when he likes: the author favours an ideo-

motor response to indicate when he has “stopped” at something of relevance. Then the train is asked to come full circle and bring the client back to the present.

 

Direct suggestions are then used so that the client does not have to accept any negative messages from the past. [20] “Hypnosis may also be used to age regress patients to an experience immediately before they begin to feel anxious. This may aid in pinpointing the situations that illicit anxiety as well as the internal dialogue and imagery that evoke problematic responses”

 

 

Chapter 4 – Anxiety

 

[21] “Fear then refers to the appraisal that there is actual or potential danger in a given situation. It is a cognitive process as opposed to an emotional reaction.”  The definition of anxiety is a “tense emotional state resulting from distorted cognitions and leading to autonomic arousal. It is the author’s experience that many clients become fearful of the state they are in. This secondary disturbance can then become an activating event, so that the client will have developed beliefs about the way that he feels. Explanation promotes insight and understanding thus reducing bewilderment and in turn reducing fear and anxiety. [22] “A third major way in which we perpetuate our psychological disturbances is explained by the fact that we often make ourselves disturbed (secondary disturbances) about our original disturbances. Thus, clients often make themselves anxious about their anxiety … Unless clients tackle their secondary problems before their primary problems, they will quite often impede themselves from overcoming these primary disturbances”

Weissman and Myers found that 80% of people with generalised anxiety will have experienced a panic attack and 39% of those with phobias will have experienced one.

When under excessive stress, strong emotions such as fear begin to arouse the autonomic nervous system. After experiencing a number of panic attacks it could be argued that the fight or flight response becomes well oiled. Our nervous system has two divisions. Voluntary nerves are under our direct control. Involuntary nerves control our organs; heart, bowels, lungs etc, they respond to our moods, thoughts and images. If we think frightening thoughts our face may become pale, blood pressure rise and heart race. These autonomic nerves consist of two branches – sympathetic and parasympathetic, when relaxed both compliment each other. When angry, afraid, excited, the sympathetic branch usually dominates the parasympathetic and the fight or flight response occurs, along with the aforementioned symptoms. It is the author’s experience that a client suffering from prolonged anxiety attacks should be given the immediate explanation of what is happening to him as too often the consequences of the dysfunctional thought / image spill into the activating event. Thus the agoraphobic will complain “just opening the door was enough to give me a turn.” these symptoms become so distressing and bewildering that the client can become more afraid of them than the original cause of his illness. [23] “However, once the anxiety problem is established, the person is often more concerned with the consequences of the anxiety…” The sufferer is usually in a vicious circle of:-

 

first fear:       flashing thought image – adrenalin / stress hormone.

 

Second fear:  “what was that”, “what if this happens”, “what if I faint”, “what if I die” = more stress. more adrenalin, more arousal = more bewilderment = more fear = more stress hormone = depletion = worry, mental fatigue, depression / despair. and so the cycle turns.

 

In the initial phases of therapy it is important to reiterate the message to the client, that the client’s body is functioning “normally” under the circumstances of arousal and that it is only following recognised laws of science. This explanation will hopefully begin to reduce the client’s bewilderment and adrenalin output, so that gradually the body can begin to recover itself. The immediate course of action the author favours is by replacing the second fear with acceptance and allowing the body to do what it wants to, as arousal is such it will do it anyway. By doing a hand levitation experiment, in hypnosis with the client’s eyes open, will show him the futility of fighting his body particularly if the therapist asks the client to consciously put his hand down, but the harder he pushes down the higher it will lift.

 

In her book Cognitive Therapy for depression and Anxiety the author Ivy Blackburn explains a useful method to redefine these distressing symptoms and to give respiratory control to the client. She asks the client to over breathe by filling and emptying his lungs as much as possible. One breath every two seconds for two minutes. As over breathing reduces the amount of carbon dioxide in the system, physical feelings of panic, dizziness, chest pain and nausea will appear. Once the symptoms have been induced, they can be dissipated by asking the client to breathe into a paper bag or by cupping his hands over his mouth, thus increasing the amount of carbon dioxide into the system and relieving the symptoms. [24] “Respiratory control has been found to be effective in the treatment of panic attacks and somatic anxiety symptoms”

Beck et al defined anxiety disorders and phobias in two ways. It would appear that there is two types of cognitive content in generalised anxiety: the first involving physical threat or injury, or threat to an interpersonal relationship, the second form involves an extension and aggravation of fears a person has experienced during his early development. The person who has experienced so much fear and anxiety will be in a constant worry mode as his body has done so many alarming things, he will be constantly on the alert, watching, waiting for the slightest disturbance. As a result of this, mental fatigue will surely follow. This is one of the most frightening symptoms of mental illness. The person has become such a student of himself in a relentless struggle to find a solution to his problems, and thus making his symptoms even worse. This may lead the suffer to believe he is going crazy. This making explanation all the more important as this will hopefully free up a tired mind which is susceptible to obsession and lack of confidence [25] “Beck, Laude and Bohnert found that their patients with GAD showed ideation (images and automatic thoughts) revolving around at least one of the following general fears; physical injury, illness, or death; mental illness; psychological impairment or loss of control; failure and inability to cope; and rejection, depreciation, domination…Patients without panic attacks focussed on psychosocial rather than physical fears.”

 

 

Chapter 5 – Mono-symptomatic Phobias

 

A phobia can be classified as a persistent irrational fear of a specific situation, animal or object. Laughlin (1967) identified at least 76 different phobias and reported that patients with phobias or anxiety disorders should not automatically receive the same treatment.

Cats = Ailurophobia

Dirt = Mysophobia

Height = Acrophobia

Sleep = Hypnophobia

Trees = Dendrophobia

Vomit = Emetophobia

Blood = Hematophobia

Enclosed spaces = Claustrophobia

 

Phobia is derived from the Greek word phobos which means flight. This means that the client has to escape a situation or experience. Some clients are afraid of more than one experience; they are labelled multiple phobics. The therapist must be careful not to classify them as suffering from G.A.D. A behaviourist would view a person’s fear as being not of the object itself but due to conditioning and the fear associated with the object. The favoured approach would be a gradual exposure to the feared stimulus paired with relaxation – systematic de-sensitisation. A psychoanalyst would view the person’s fear as being transposed onto something more socially acceptable – sublimation. He would then search for a deep unconscious cause in the hope that exposing it would lead to cure. The cognitive therapist however takes the view that he beliefs, thought/images lead to the consequences i.e. the phobic’s reaction. These being dizziness, nausea, fainting, dry mouth, racing heart. A client will seek help if they become aware that other people are able to manage a situation better than him. The irrationalities of a phobic appear limitless. The author has dealt with one case where a 12 year old boy was fearful of spiders but kept a snake as a pet! In support of the behaviourists’s view of classical conditioning, it later transpired that his mother shared the same fear [26] “First, our predisposition to experience fear/anxiety in specific ways and to react to these with predictable patters of behaviour are partly determined by inherited biological factors…Evolutionary factors may be invoked to explain the limited range of phobias that commonly arise in people.”

 

The author finds that by using systematic desensitisation to treat phobias it is interesting to note that the person’s fear is less at a distance but increases the closer the client comes to the object. This the author believes is due to cognitive distortions. [27] “The increasing ‘danger value’ he imputes to the feared object or situation increases until the idea of threat completely dominates his appraisal of the situation. By that time, cognitive distortions, visual imagery, and somatic imagery combine to magnify the actual danger. His belief  switches from the concept ‘ it is harmless’ to ‘it is dangerous.'”  It would then appear that a ‘dual belief’ system is present. On the one hand, the person is far removed from the danger and is able to assess that there is no real danger in the situation he fears, but as he approaches the feared situation the cognitive appraisal of danger leads to ‘it may, it could. it’s very likely, it will’ (second fear): flight becomes overwhelming. Memory of past unsuccessful attempts can so often be ready to lead the client to despair and apprehension, thus alerting the client to dangers in the future situation [28] “Without memories it would be impossible to take any precautions for the future.” Again hypnotherapy can be most useful in targeting memories, thoughts, images and beliefs for change, i.e. asking the client to imagine a spider with a red nose and yellow wellington boots should hopefully provide a light hearted response to the feared stimulus.

 

To conclude, it may appear that when under sudden frightening circumstances a reactivation of childhood fears and beliefs come to the fore and become associated with the situation or object and the resulting absolutistic or dichotomous thinking dominates. [29] “The rules are overly absolute and overly conclusive but serve a general protective function until the child is mature enough to operate to a less absolute system.”

 

 

Chapter 6 – Agoraphobia

 

The word agora derives from the Greek word meaning a place of assembly. It was first used by C. Westphal in 1871. A principle symptom in agoraphobia is the panic attack. the word ‘panic’ derives from Greek deity panikos. agoraphobia is commonly referred to as a fear of open spaces. It may be more accurately defined as an incapacitating fear experienced away from the safety of home. According to Beck et al, anxiety disorders and phobias are experienced in crowds, such as a busy street, crowded stores or being in tunnels, on bridges, elevators or public transport. Often these people insist that a family member or friend accompany them when they leave home, the predominant theme in agoraphobia being a reliance or dependency on others, and a fear of losing control. These needs and fears are similar to childrens. [30] “many of these persons have a history of separation anxiety dating back to early childhood. thus, a prolonged stay away from home (e.g. attending a distant college) could remove this prop and make one subject to agoraphobia.” This seems to be in sharp contrast to a survey done in 1970 by Dr Claire Weekes who found that out of 528 agoraphobic men and women, 91% were females (presumably their lifestyle at that time was more conducive to the illness) some 75% said their childhood was either very happy, happy or passably happy, with only 25% saying they were unhappy.

 

In following the theory of separation anxiety, if the person is compensating for a perceived loss he will be placing restrictions on self not to lose again, a demand for perfectionism and approval will follow whenever life‘s situations or events make demands on that person to become more independent and ‘stand on his own two feet’ the incapacitating feelings of panic will surface especially when the person’s resources of independence are absent. [31] “In the pathological forms of fear, the same goal of power and superiority may be seen.” In dealing with the symptoms themselves the arousal of the autonomic nervous system has triggered the secondary feelings of panic. These are never far from the client’s find waking, sleeping or eating. The body has become so aroused that the ringing of the telephone may trigger a panic attack. As previously mentioned it is the author’s experience and opinion that these symptoms must be addressed and explained to the client. Emphasis should also be placed regarding the fact that panic symptoms may return months even years after recovery. In fact panic should be encouraged as a chance to get better correctly. Windy Dryden in his book Rational Emotive Counselling in Action asks his clients whether they could have a panic attack if their parents had been captured by the Shi’ite Muslims and that they will only release his parents if they agree to having ten panic attacks. The client invariably says “Yes,” Dryden then says “but I thought you couldn’t stand the experience of panic.” The client usually replies, “Well, but I would do in order to save my parents.” To this Dryden replies “Yes, but will you do it for your own mental health?”

 

With this approach beliefs that have moved to the activating event column of the ABC model will have been by now hopefully disputed. Therapy can then progress to the beliefs column, home of dysfunctional beliefs, negative automatic thoughts and images. One of the major problems a cognitive therapist has to contend with when attempting to dispute and reconstruct thoughts and images is the client’s difficulty with thinking (mind going blank). In the author’s practice this phenomenon can be explained with this analogy “Supposing a fellow came in and asked my telephone number I could easily recall it, but if the fellow came in with a gun and said in an aggressive voice “What’s your telephone number,’ I would stammer and my mind would go blank.” It is excessive fear which causes the mind to freeze. Panic is akin to excitement; the client is asked how he would feel if he won one million pounds when specifically asking what sensations he would feel he invariably replies “breathless”, “tingly”, and “faint.” The author reminds the client that this is the same physiological response as panic. Cue cards, used to remind sufferers of their more effective thoughts, are helpful, but frightening visual images must not be neglected. It was usual for one client the author dealt with to see himself being carried out of a supermarket on a stretcher and being taken to hospital, but with reconstruction in hypnosis of a more realistic visual image, i.e. walking into the supermarket with strong legs, strengthened with an associative post hypnotic suggestion (finger and thumb) to remind him of his new image. [32] “Evidence from a recent study suggests that imagery plays a role in the psychopathology of agoraphobia.”

 

Systematic desensitisation or graded exposure is the main behavioural treatment for agoraphobia. The author has found this helpful, but in severe cases of panic the client should be helped to accept the symptoms, not just get used to the place, or the symptoms will return somewhere else [33] “The surest way to permanent recovery is to know how to face and cope with panic and not placate it with subterfuge.”

 

Chapter 7 – A Short Case History Presenting Strategies and Techniques for Cognitive Restructuring (Edinburgh, March 1996).

 

Angus was a sixteen year old joiner referred to me via his doctor. He had been complaining of dizziness and the GP had diagnosed anxiety. At the consultation he told me that he had left school and thought that he would never get a job. He had felt depressed and worried. He lived at home with his parents and older brother, with whom he had a good relationship. It was subsequently revealed that his parents had been putting pressure on him to find work. This he had successfully done. The dizziness problem would improve when he was in the house. He himself was convinced that the cause of this was a brain tumour. He stated that he used to feel good with himself, but now felt everyone else to be more important. Angus had enjoyed school, and since leaving had an active social life. His early goal in life was to be a footballer. He confided in me that his main worry was people looking at him. My diagnosis was generalised anxiety without panic disorder, with social phobia. I viewed Angus to be a good candidate for cognitive behavioural therapy as suitable explanation of the cognitive approach and an initial ABC form seemed to give Angus sufficient insight into how his symptoms were perpetuated. I estimated a minimum of eight sessions.

 

At the outset of therapy an agenda was set and I explained that we would continue with the ABC model to find and isolate his negative automatic thoughts, and that we would use hypnotherapy to see if there was anything contributing to his problem from the past and also to bolster the work we would do in the counselling session (i.e. visualising himself in problem situations and being more aware of negative thoughts and images so that he could write them down on the self monitoring sheet provided). I then asked if there was any pressing concerns that he had. He explained that he was still convinced that he had a brain tumour. I explained to Angus that nervous giddiness is tension which interferes with the balancing mechanism in the semi-circular canals of the ear. This mechanism is responsible for receiving the correct messages from eye, neck and body muscles. His initial response was “It seems I have nothing to worry about.” He was capable of querying his own interpretations and was very keen to play his own part in his recovery. His goals were to be less anxious and more carefree. The common theme that arose by means of the ABC model was a lack of self esteem in work situations and in night clubs, common examples of his negative automatic thoughts: at work ‘if someone says I’m useless’ (selective abstraction; the client reaching a conclusion without sufficient evidence); in night clubs: ‘people are looking at me.’ Angus hesitated at times when trying to express the emotions that he had felt in those situations. When this happened I encouraged him to take a wild guess. The emotions that Angus felt in these situations were foolishness and nervousness. I then asked Angus if we could check these thoughts to see if he had evidence for thinking them. This was done by asking him who he loved and respected. Angus replied his mother. I then asked him if his mother thought he was a porcupine, would that make him one. He replied ‘No’, thus giving Angus sufficient insight that he was hooking his self esteem on what his colleague at work had said; so it does not necessarily follow that he was useless. In disputing his thoughts that he was being watched I decided to use humour. I asked Angus if he thought all those people in the night club, got up at eight in the morning, looked in their diaries and thought ‘tonight we are going to look at Angus,’ they then phoned each other, synchronised watches and said ‘at 10:30 pm tonight we will all turn around and look at Angus. In fact,’ I continued, ‘I heard Trevor McDonald at News At Ten reminding everyone to do this.’ Angus exploded in laughter. He eventually said ‘No’ I became more animated and said ‘Well you think all these people are looking at you.” Angus replied ‘Of course not.’ He then said ‘I’m fearful of making a fool of myself.’ This confirmed my hypothesis and also let me know at an early stage of therapy before using hypnosis that Angus did not require a psychiatric referral. In fact he later said it was good as I was not as formal as he thought I would have been. For my part I was also aware of being careful not to present an authoritative image as I suspected his dysfunctional core belief was one of approval. Angus was then asked to come up with more realistic thoughts for those situations. These we marked down in the ‘new thoughts’ column of the ABC model. I then focussed on showing Angus how thoughts could affect his feelings by asking him to visualise himself in the problem situations thinking his old thoughts, and feeling the consequences. At the end of this exercise Angus was asked how he felt. He remarked ‘Pretty down.’ He was then asked to visualise himself in the same situations, but thinking the new thoughts, after which he said he felt good. For his homework assignment he was given a behavioural exercise to go into these situations and to start to think the new thoughts.

In hypnosis a progressive relaxation induction was used and his ideo-motor response indicated his problem was purely a ‘habit.’ A time projection of him achieving his goals in the near future was used, visualisation of him implementing his new thoughts in the problem situations closed the hypnotherapy session. Before Angus left he was asked what had been beneficial, and what had not. He replied that the explanation regarding the dizziness had been extremely helpful, and the exercise we had used to show how his thoughts affected his emotions.

 

On seeing Angus at sessions 2 and 3 his self monitoring sheets were immediately checked. Subsequent ABC forms showed that Angus had been introverting and watching himself. Again it had transpired that he was very fearful of making a fool of himself and worried that people would laugh at him. He had become self conscious as the dizziness had given him a fright. We followed a similar approach to session 1 with Angus finding more realistic thoughts which were again reinforced with the use of hypnosis, suggestions for interpersonal effectiveness were used.

 

Session 4 proved to be a turning point for Angus. He report having a good week and his self monitoring showed a good array of rational thoughts. At this juncture I decided to home in on the irrational belief which by now the thoughts were clearly showing that a need for approval was evident. We did this by going through all the ABC and self monitoring forms to date and asked Angus if he could find a common denominator. He felt that the recurring theme was how he came across in front of people, namely his boss, women, peers and class tutor. Explanation of the dysfunctional core belief and its musterbatory demands for approval from significant others was akin to demanding a million pounds and, on inevitably failing to get it, becoming a terrible person. Angus agreed with this wholeheartedly. We further showed the irrational demands and consequences of them on his health by evaluating the pros and cons of them.

 

At session 5 it transpired that tension was a problem in Angus’ day release class. It was found that a triggering factor of this was Angus’ distorted visual images. He visualised himself being carried out on a stretcher into an ambulance and to the intensive care department of a hospital. These had resulted from his fear that he would get questions wrong if asked by his class tutor – again the need for approval was causing the tension. In hypnosis comedy was used with Angus visualising the tutor (who had a long moustache) behaving like a seal while balancing a beach ball. Follow up sessions showed that this problem had been resolved. The session was closed again by disputing the dysfunctional core belief, and ‘musts’ being replaced with preferences.

 

At session 6 after reviewing self monitoring Angus had shown significant improvement. In hypnosis a Barnets yes-set ego strengthening technique was used, this involved ideo-motor signalling to check that there was no detrimental events or emotions affecting Angus’ health. The technique then focuses towards asking the unconscious mind to make a commitment towards respecting and looking after Angus.’ This was a major turning point as Angus thought he could never be ‘friends’ with himself.

 

On sessions 7 and 8 Angus reported that he genuinely did not mind what people’s perceptions of him were. The only problem had been a continuation of his tense shoulders. Again a behavioural task of Angus being more aware of the tension and releasing his shoulders to a more relaxed position was set. At session 8 his self monitoring showed a recurrence of his need for approval as he had been overly keen to prove to his boss how well he was working. Angus smiled and laughed and said ‘I know where I went wrong.’

Session 9 was a cursory session with Angus telling me that he was thinking about working in an office. In hypnosis more suggestions to specifically boost his new core belief were used. Afterwards Angus told me that explanation and initial acceptance of the dizziness had helped 80%, knowing that the problem was not serious 100%, learning to relax and changing attitude 100%, hypnosis, especially ‘yes-set’ 90%. A future appointment was arranged but Angus phoned up to cancel saying that he did not need it and thanked me very much.

 

Chapter 8 – Comparisons; Behaviourism and Psychoanalysis

 

The principle theory of the behaviourist’s approach to psychotherapy is that all behaviour is learned and that these laws apply to animals as well as human beings. All individuals respond and behave naturally in accordance with the environment. [34] “Behaviourism claims that consciousness is neither a definite nor useable concept. The behaviourist, who has been trained always as an experimentalist, holds, further, that belief in the existence of consciousness goes back to the ancient days of superstition and magic.” The father of modern behaviourism John Broadus Watson believed neurotic disorders were caused by learned behaviour and that the behaviour could be unlearned. In trying to prove this in 1930 he conditioned an 11 month old boy named Albert to be fearful of white rats. Watson, and his colleague Raynor, hammered on a steel bar whenever Albert was shown a white rat, thereby scaring him. This process was repeated whenever Albert tried to touch the rat, needles to say the very sight of the rat would cause him to cry. Generalisation occurred when he became fearful of dogs, fur coats and Santa Claus masks.

 

B F Skinner used pigeons and rats placed in a “skinner box.” When they pressed a bar food, the primary enforcer, was released from a dish thus establishing their primary behaviour. Skinner did not like theorising about the internal workings if the organism and called this “spurious physiologizing.” His approach was known as “Black Box Psychology” which looked at stimulus and response. Years later in 1985 he would accuse cognitive scientists of [35] “…speculating about internal process with respect to which they have no appropriate means of observation. He called for behaviourism to be brought back from Devil’s Island to which it was transported for a crime it never committed, and let psychology become once again a behavioural science.”

 

Albert Bandura showed that by children modelling an adult’s aggressive behaviour it was possible to understand the theory of stimulus response from a cognitive viewpoint. The author would like to demonstrate that thought processes are extremely important and to do this would ask the reader to imagine a client with an obsessive compulsive disorder regarding handwashing. The author believes it is neither the hands nor the sink which is responsible for the behaviour, but the intensity of the emotion created by the fear of the sufferer in intensifying the very thought itself, after all it is only a thought, but a thought which is being perpetuated by the fear of engaging in the behaviour. By understanding and accepting the thought the fear attached to the thought will be significantly reduced, thus dissipating the behaviour instead of trying to stop it which would merely underline it in red. It is evident to the author that the behaviourist harnesses the client’s thoughts through the behavioural treatments. Unless carefully and judiciously applied they run the risk of instigating a change which is beneficial to the therapist but not to the client. [36] “…and by making behaviour into an idol, it turns the human subject into an object of manipulation while correspondingly inflating the behavioural standards of the given social order.”

 

 

 

Psychoanalysis

Sigmund Freud developed the psychoanalitic theory of personality. He and fellow physician Josef Breuer found that hysterical symptoms could be replicated with the use of hypnosis. (This he later abandoned describing it as “too capricious.”) This was an extremely important breakthrough as hysteria had been viewed as organic in origin. This emotionally charged material was never remembered by the patient or recalled by him through introspection. Freud believed that the real force in people’s behaviour was submerged in the unconscious. By reliving, recalling and releasing the original stuck emotions from the unconscious mind to the conscious mind abreaction was achieved.

 

The consistent theme in the case studies was repressed sexuality. These conclusions sparked violent hostility in the medical profession. Freud believed that there was a connection between neurosis and early traumatic events in children. Breuer’s break from Freud was exasperated by the sexual attachment which one of the female patients – Anna O – had for him. From this Freud developed his theory of transference in which he stated that the concepts of unconscious mental activity, repression, resistance and transference were the fundamental pillars of psychoanalysis. Transference is a strange mixture of hostility, suspicion and jealousy between an analyst and client. Freud used free association when the client would lie in a couch with the therapist sitting behind him – to allow unconscious expression – the client was encouraged to let himself go in what he said, as you would do in a conversation in which you were rambling on quite disconnectedly and at random.

Psychoanalysis is a long term therapy with very little guarantee of success. It may provide insight into how the symptoms arose but unlike cognitive therapy does not directly tackle the perception and the thoughts which perpetuate the symptoms [37] “The work of Adolph Grunbaum has explicitly and meticulously demonstrated just how weak the scientific claims of psychoanalysis are, and has inspired numerous analysts to rethink their position.”

 

 

Chapter 9 – Conclusion

 

The writer is of the belief that a great many behavioural therapies have their place and can be successfully and easily used. However to use behavioural therapies alone would be futile. There would be very little point in using systematic desensitisation for someone suffering from recurring dreams and apiphobia if the underlying cause was sexual abuse, and the phobia was a displacement for his anxieties. The author does feel however that it would be effectual after release of the repression. However, in a case history presented in “Individual Therapy” by Geraldine O’Sullivan (pp270 – 271) a client being helped with panic attacks using self-exposure “She experienced some discomfort in certain situations but was able to endure this…At six months there had been some deterioration arising from a holiday abroad with her husband when anxiety and panic attacks recurred.” It is the author’s opinion that memory and sight, sound and smell were recalled. It seems she had been helped how to deal with the places but not with the thoughts or the panic. Cognitive therapy, as has been shown, enable the client to become his own therapist and overcome his difficulties.

 

The length of time needed for a “successful” analysis is in itself a major drawback, with less guarantee of cure than other therapies. The longer analysis continues the greater chance of a client making things up to bring therapy to a conclusion. This is dangerous. At face value psychoanalysis offers a realistic answer to a lot of problems but it is extremely doubtful whether it cures more clients than not. [38] “The limitations of the Freudian approach are manifold.” Freud himself that neurotic misery could only be replaced with ordinary unhappiness.

 

Cognitive therapy accurately address the very core of the client’s problems: his thoughts and beliefs. It is scientific and above all else allows the client to become independent from his therapist. The main drawback of the approach may be with the client who expects to be prescribed a cure and who is unwilling to engage in self monitoring. [39] “The emphasis placed on homework and self-help can be a limitation for some clients.” Cognitive behavioural therapy runs the risk of rationalising client’s behaviour, cognitive psychotherapy, however, considers events from the past that are having a detrimental effect [40] “There are times, however, when a phobic response or generalised anxiety is caused by more than simply conditioning or irrational cognitions. In these cases unconscious exploration, has successfully identified conflicts, functions, purposes or past experiences that are beyond conscious awareness…”

 

[41] “Moreover, unlike behaviourism, cognitive therapy is explicitly human both in its origins and its applications. It is primarily concerned with ideas rather than behaviours and its rational is based on reasoned arguments and the persuasive powers of evidence. The thinking man’s psychotherapy, if you like.”

 

 

In a recent report [42] on chronic fatigue syndrome the working party, consisting of sixteen physicians, psychiatrists and general practitioners, produced evidence that up to three-quarters of CFS sufferers had some kind of psychiatric disorder including depression and anxiety and concluded that the best approach appeared to be a combination of behavioural techniques and helping the patients to re-evaluate their understanding of the illness, combat depression and anxiety and look for underlying thoughts or assumptions that might contribute to their disability. They felt that the patient’s knowledge of the condition had a bearing on recovery.

 

Examples of Information Processing Errors

 

Selective Abstraction:       Client picks one detail and perceives the whole situation

Arbitrary Inference: Client perceives situation without sufficient evidence.

Overgeneralisation: Client draws conclusion from one situation, or a few, and applies it to all.

Magnification and minimisation:  Client makes small negative aspect outweigh larger positive one.

Personalisation:       Client identifies with erroneous situations.

 

Three dysfunctional Core Beliefs:

“I must do well and be approved by significant others, if not I can’t stand it and I am a terrible person when I am not loved and do not do well.” This belief often leads to anxiety, depression, shame, and guilt.

“You must treat me well and if you don’t I can’t stand it and you are terrible person and should be punished.” This belief is associated with feelings of anger, passive aggressiveness, and acts of violence.

“Life conditions under which I live must be the way I want them to be, if not I can’t stand it; poor me.” This belief is associated with feelings of hurt, procrastination and addictive behaviour.

 

 

References

  1. Understanding Human Nature (p.10);  Alfred Adler;  Oneworld Publications 1994
  2. Cognitive Therapy For Depression & Anxiety (p.17);  Ivy-Marie Blackburn & Kate Davidson;  Blackwell Science 1996
  3. Individual Therapy (129);  Windy Dryden (Editor);  Open University Press 1995
  4. as for 3. (p.132)
  5. as for 2.  (p.32)
  6. A Complete Guide to Therapy (p.275);  Joel Kovel;  Penguin 1991
  7. Anxiety Disorders & Phobias (p.190);  Aaron T. Beck & Gary Emery;  Harper Collins 1985
  8. as for 7. (p.186)
  9. Cognitive-Behavioural Counselling in Action (p.13); Peter Trower, Andrew Casey & Windy Dryden;  Sage Publications 1995
  10. as for 7. (p.173)
  11. as for 7. (p.171)
  12. as for 3. (p.242)
  13. as for 2. (p.64)
  14. The Dictionary Of Psychology (p.334); Arthur S. Reber; Penguin 1985
  15. The Wisdom of Milton H. Erickson (p.34);  Ronald A. Havens;  Irvington 1985
  16. What Freud Really Said (p.114);  David Stafford-Clark;  Penguin 1973
  17. Peace From Nervous Suffering (p.8);  Dr Claire Weekes;  Harper Collins 1992
  18. Hypnotherapy Scripts – A Neo-Ericksonian Approach to persuasive Healing (p.12);  Havens & Walters;  Brunner Mazel 1989
  19. Cognitive-Behavioural Approached to Psychotherapy (p.79);  Beck, Laude, Bohnart; 1974
  20. Handbook of Hypnotic Suggestions and Metaphors (p.154); D. Corydon Hammond; N N Norton 1990
  21. as for 7. (p.8)
  22. Rational-Emotive Counselling in Action (p.13);  Windy Dryden;  Sage Publications 1994
  23. as for 9. (p.114)
  24. as for 2. (p.66)
  25. as for 7. (p.95)
  26. as for 3. (p.257)
  27. as for 7. (p.128)
  28. as for 1. (p.50)
  29. as for 7. (p130)
  30. as for 7. (p.134)
  31. as for 1. (p.191)
  32. as for 7. (p.137)
  33. Simple Effective Treatment of Agoraphobia (p.38); Dr Claire Weekes;  Harper Collins 1995
  34. Behaviourism (p.11);  Peter Morris;  Open University Press 1975
  35. The British Journal of Psychology (p.300);  D. E. Blackman (Editor);  British Psychological Society 1985
  36. as for 6. (p.82)
  37. as for 3. (p.34)
  38. as for 3. (p.33)
  39. as for 3. (p.244)
  40. as for 20 (p.154)
  41. as for 2 (p.vii)
  42. John Von Radowitz, Scotsman Publications 3 October 1996

 

 

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