Psychotherapy of Anxiety: Value Oriented Approach

The article outlines the principal theses of the concept of psychotherapy of anxiety disorders, based on changing the client’s perception on his problem and revising the system of values. Model of “anxietycentered” behavior is reviewed and ways of transformation of client’s self-evaluation and lifestyle that are to manage the anxiety are described. Changing the “reference system” as core element of recovery is reviewed. Material is illustrated with case studies and excerpts from therapeutic sessions. Case Report


Introduction
There are plenty of psychotherapeutic approaches to anxiety. Many of them proved their effi cacy and are being widely used. During my work with clients suffering from phobias, fear and anxiety I noted that successful recovery depends not only from client's positive goal-setting, which is well-known and widely implemented, but from, so to say, "emotional reference system" too.
I wanted to call this method "quest therapy" fi rst (in accordance with the basic techniques and metaphors), but this name has long existed for a completely different technique. So I decided to call it "value oriented approach".
A client suffering from panic attacks, anxiety, a periodic feeling of fear, helplessness, or periods of a sharp drop in mood -in general, any mental and emotional disorder characterized by periodicity -is often inclined to consider these pathological manifestations as the most signifi cant factors of his life. It is quite understandable -such affects break down the life of a person for a long time, especially if they occur unexpectedly and happen often. Moreover, unpleasant events, including physical symptoms are, in principle, remembered longer and recalled easier, than the "good" ones. After several repetitions of these episodes, which for brevity we will call "accidents", a model of behavior is being formed, in which the accident moves to the center of the perception of the world as something inevitable and so important that it is impossible to ignore it. In the future, a person begins to build his life in accordance with the primacy of an unpredictable and dangerous accident, so that, in the end, all life is made dependent it. There is a change in behavior (the desire to avoid potentially stressful situations, avoiding contacts with people, communication with which is fraught with accidents, taking preventive security measures, including taking medications on the threshold of possible accidents, etc.). Up to some limit, such a tactic can justify itself, especially in cases of specifi c anxiety episodes, that is, those that can be precisely related to a particular situation, which in principle can be changed without affecting the client's daily functioning. But the peculiarity of accidents is that, due to various reasons, their connection with external situation is not decisive, and, in any case, not the only one.
The beginning of accident is a complex process, including several factors, one of which is, so to speak, the person's inner readiness for anxiety. Let us suppose, for convenience, that the pathological manifestations which we are talking about are occurring at regular intervals. Then the life path of the client looks like that ( Figure 1).
The life period between the accidents is shown in the lower part of sinusoid. Why the accident is depicted on the crest? Because, client for the moment of visiting the doctor, it is the most signifi cant issue for a person (Otherwise he would not address to a specialist). Below, we will talk about clinically signifi cant accidents, and not about the level of problems that a person manages to cope on his own -this is a topic for another study. Let us say some words about the person's "inner readiness" for anxiety. Very often you hear from clients about "waiting for a fear". Consider, for example, an agoraphobic panic attack.
The person is going to go out on the street -to visit the doctor, for example. He often experienced panic and a fear of losing consciousness in crowded places before. Or, for instance, the panic often occurred during the descent along the escalator in the metro. He remembers this very well and, accordingly, begins to feel fear long before he fi nds himself in a situation that was the source of anxiety last time he experienced it (the client thinks so, in any way). What happens? He leaves the house being already fearful and tense, and even in the event that a panic attack did not occur, a long time is waiting for it, not believing that this time everything went well. In fact, the stress persists until he returns home. And if the panic attack really happened, then the person received additional confi rmation to his fears and became even more entrenched in his illness. Thus, our sine wave has acquired the following form (the new data is highlighted in red) ( Figure 2).
That is, the periods of well-being are getting shorter, while the problems related to accidents, on the contrary, occupy more time, strength and thought of a client, so that he practically does not have a place in his life for good health. Moreover, the life of such a client in this case is a the path from one accident to another, and the period of well-being is not only clenched in time, but also loses its signifi cance and value, which was not initially too large (in any case, from client's point of view ). Now let us analyze in more detail the proposed mechanism for the development of this system and the formation of the behavior of the person following it. P.K. Anokhin defi ned any behavioral act as an "anticipatory refl ection of reality" [1]. That is, the action is not focused on what is happening at this particular moment, it is a reaction not to the event that is happening at the given time, but to the fi nal aim, which is to be achieved in future. The indicator that the goal has been achieved is not the fulfi llment of the action itself, but the fi xation of the acquisition of emotional and physical state, indicating the satisfaction of the need for which the action was carried out. This is the result of the action. The moment of the beginning of the behavioral act is characterized by a combination of motivation, the current environment, memory of the experience of similar actions in the past and, fi nally, by the trigger that directly starts the action. On the basis of the synthesis of these factors, a person makes a decision and proceeds to execute a program that either ends when the desired result is achieved or adjusted if the original need is not satisfi ed. Now let's see what happens when the fear of accident (we emphasize -not the accident itself but the fear of it) is the main, we might say, system-forming moment of the client's life. When a client falls into a potentially stressful situation, which is signaled by the environment and the memory of the same accidents that occurred to him before, a minimal incentive is enough to trigger the entire pathological mechanism of the system. By the way, there is always the signal that triggers, say, a panic attack, though it is often diffi cult to fi nd it.
(Case: client experienced "panic attacks" in the form of unexpected fear episodes last for 30-40 minutes, accompanied by all the vegetative symptoms that occurred in very diff erent situations, having nothing common with each other, and passed independently or after taking tranquilizers. In the course of interview and exercises addressed to body awareness in the moment of panic it turned out that immediately before the accident client always experienced an unpleasant feeling in the area of the right ankle joint (due to wrong step, temporal immobilization, etc.). In the course of further work, it was revealed that at the age of two, when he was left by his parents for a long time at home (parents thought he was sleeping), he woke up, climbed on the table, fell down on his leg and spent two hours on the fl oor, waiting for the parents. After several sessions aimed on rethinking the actual meaning of body symptoms and improving client's attention to his parents, panic attacks ceased).
A person can try to avoid the situation in which the accident occurred in the past in some way, but, fi rstly, the external situation is only one of the elements of the problem, and secondly, the memory of an unpleasant event, and most importantly the realization that he is EXACTLY TRIES TO AVOID PSYCHOLOGICAL TRAUMA (the category of trauma is always present in such a system, even in the form of its negation), already fully prepare a person for the launch of the functional system and unpleasant sensations. In this case, even if the accident does not occur, it is diffi cult to fully restore the good state, and this takes more time and resources (look again at the second sinusoid). In other words, it turns out that in order to feel better, client should either feel fear so that it will end and a moment of saving relaxation came, or practically wait for next anxiety episode in the case if it did not happen this time for some reason. This is due to the fact that in both cases fear is perceived not only as something fatal, inevitable and unexpected. And even most importantly, it can sound paradoxically, but fear becomes, a necessary part of client's life -even in the form of self-absence. The evaluation of the result of the action is completely determined by the presence or absence of anxiety. All life in this case is divided into "life with anxiety" and "life without anxiety", but it is impossible to exclude this category from the client's attitude, at any rate, it is very diffi cult. It is present in the client's system of values as a principal structure -it does not matter in what form. Fear becomes dominant. It should be noted, however, that fear is not the only content of the client's life, moreover, it often, occupies a very small part of lifetime. A lot of events can occur in the life of the client, including those that are very important, pleasant and valuable for him, and even things that are not particularly positive but much more signifi cant than those Remember the "anticipatory refl ection of reality" and the second sinusoid? , and what is an indisputable fact, it is that you will reach the fi nal destination of your journey (it's also an initial one). I ask you to allow yourself, your body, and your feelings to remember and fi x this good state, described by you. Your body remembers all the good things that happened to it, all the positive feelings and physical sensations remain in the muscular and emotional memory for ever, and all that is needed to awaken them is to let them remember and manifest themselves. This simple exercise can be done by yourself every time there is a desire or need to feel better and gain strength and confi dence to achieve your pleasant, constructive goal. I ask you to please yourself before our next meeting, to make yourself something pleasant and useful, so that the light in the windows of your castle would become brighter, and so that you would better see the purpose of your journey, and would like to achieve it more strongly. Perhaps then you will fi nd an easier and more convenient way, and that pleasant feeling will be longer and stronger. On this we parted. At the next meeting, Michael said that he went home with hope and expectation of something pleasant (

and it really happened). He experienced several panic attacks after that, but gradually he managed to signifi cantly weaken their intensity and duration, evoking a pleasant image of the house in his memory.
What is essentially important in this work: all the feelings and events discussed with the client are absolutely real, taking place in reality, moreover, in fact, quite every day. From the point of view of simple logic, a person does not go out of the house to ride a vehicle (with or without adventures), and even, ultimately, not to make any planned action, but in order to, having accomplished this action, calmly return to a comfortable home environment or an equally comfortable destination.
During the following sessions, Michael began to note such an interesting moment for him that did not happen before (in any case, he did not fi x it): the panic sensations happened twice unexpectedly, BUT: the fi rst thought that he had with it was I did not expect it" (did not expect the onset of fear, did not prepare the ground for it), and paradoxically, precisely because he was not already internally predisposed to the onset of total horror, as before, the attack was less intense and passed faster.
What happened? Absolutely important thing happened, on which this concept of therapy is based. Michael, speaking in physical language, changed the frame of reference. The starting point and the end point for him was not fear, as before, but a period of well-being. That is, he just turned the sinusoid upside down, putting a positive on the basis of his life, and not a disease (Figure 3).
Over time, the values on the second sinusoid also changed places.
That is, the perception of the system of values had been This is by no means a rescue therapy. That is, fear is not ignored, it is not avoided (avoiding an anxious episode by changing the situation from traumatizing to another, usually does not work, anxiety arises on another occasion), but it is given a new meaning, its place and function in the client's values system is reviewed. I propose the term "devaluation" (it has nothing to do with the type of resistance in Gestalt therapy of the same name), that is, a decrease in the signifi cance of the actual symptom by changing the attitude towards it in comparison with other, positive components of client's system of values. In the concept of "anticipatory refl ection of reality", fear ceases to be such a reality, something positive that every client owns takes the place of fear in this scheme.
So, the main stages of the therapeutic process are: 1. Analysis and crystallization of symptoms.  and, accordingly, cannot use them in full volume, because they are perceived as something regular and neutral. In order to help client to reap the benefi ts from his positive essence, which is to help to manage with accidents and possible bad state, the "Positive diary" is used, in which positive events are being noted, as well as people and events clients is grateful for them. Diary sheet is enclosed. In general, the combination of the proposed method with pharmacotherapy and work at different stages of medical treatment is a topic for a separate article, but the basic principles remain unchanged. Equally, practice shows that this technique brings results with different genesis of anxiety states -both as an independent phenomenon, and as a symptom of other pathologies, which is also supposed to be described separately.

Conclusion
I want to conclude with one more phrase from a conversation with one of the clients: