From a nervous disposition to phobias to a full-blown anxiety attack, how do we understand and work with anxiety? Of necessity, people do need a certain degree of vigilance for their own protection. How then do we assess what is rational in relation to potential threats and what may seem to be disproportionate? When does a healthy degree of anxiety become pathological? What if someone is just born and brought up in an atmosphere where anxiety, with forethought, can potentially be a life-saving safeguard? In the 1980’s when New York was the murder capital of the world, the comedian Anita Weiss famously said of living in that city “I’m paranoid, and it was the only place where my fears were justified.”
So many questions and thoughts were discussed last night at the monthly clinical meeting. There are many stories, variations of aetiology – physical and emotional, of how anxiety manifests; from unstable early attachments, neglect, abandonments, fear of death and dying, lack of important communications, more vulnerable sensitivities and sensibilities, low to high impact traumas, losses, identity issues, self-esteem and more.
Some anxiety is obvious – it can be seen, noticed, as well as expressed in words by the client. Other anxiety is felt, palpably by others. It may be denied and therefore not owned by the client who may express it via physical signs and symptoms such as distractedness, shortness of breath, clenching and twiddling, interrupting, being unsettled, and more. The client may not even be aware as to how anxious s/he is.
After considering how anxiety manifests in the mind and body, we discussed habituation and reinforcement of an anxiety identity; acute anxiety being activated when perhaps moderate anxiety would be more ‘proportionate to the situation’; how anxiety can escalate out of control and how it can be tolerated and accommodated. What is the difference between neurotic anxiety and psychotic anxiety? How is this managed psychotherapeutically and pharmacologically? We also looked relationally at how anxiety can become an armour to keep people at a distance, or even weaponised to control (and sometimes manipulate) others.
Art therapy interventions offer space for the expression of anxiety in different ways. From coming to the session late, to facing the blank page, to choosing the art materials, to staying with the unknown, the context offers a space to hold and explore the anxiety. The art therapy room can become the safe container for the anxiety and the consistent space allows for exploration, discharge and expression. In the artmaking process we may observe deliberations, tentativeness, perfectionism, repetition compulsion, or perhaps something counter-phobic – an expressive bravado that is not shown in relationship with the outside world.
We may also hear stories of fears and concerns. They are mostly about the future. When the world is under threat of ecological destruction or terrorism or health pandemics, the fears are somewhat rational although may well be a foil for other more immediate personal worries. Thus anxiety gets projected and sublimated into other world issues – as well as being important anxiety-provoking issues in their own right. When we have something to fear we are likely to be less loving and trusting – and this too impacts negatively on society.
Unlike anger which needs an object (or person) for its trajectory, anxiety is usually formless. Like a gas, it cannot be captured and can be challenging to manage or control. A cognitive approach is often useful here. It can be helpful to encourage the client to name his or her specific anxieties so they can be ring-fenced. For example, anxiety about not sleeping (which can lead to a whole series of issues), can partially be abated by discussing with the client how long these periods of not sleeping last for. If the client reflects and notices the non-sleeping periods usually last 2-3 days, for example, then they may be easier to tolerate. If we can anchor each of these concerns, not with solutions (which may be spurned and anyway we are not offering solution-based therapy) their hold over the client can be reduced or disempowered.
Sometimes talking about anxiety is tricky in itself: At the start of a session a client said even talking about the anxiety made her anxious, but by the end of the session acknowledged that talking about it helped her distance herself from it. By talking about the anxiety rather than being overcome by the anxiety, or acting it out, the client has the possibility of developing some mastery over it. It can change from something gaseous to something that is confined and limited.
Humour, using the proper therapeutic protocols and intentions, can also be helpful to diffuse anxiety. One of the team mentioned working with a young teenage boy who yawned. The art therapist said, “I noticed you yawned”, the young person said “That’s very insightful of you”, the art therapist said “Thank you!”. They both laughed and connected and this took the edge off the situation and enhanced rapport. Another therapist described saying to a family member, “You’re loading up the cannon with anxiety and about to light the fuse!” Again, this funny comment, delivered with the requisite love and a twinkle in the eye, helped diminish the intensity of anxiety that was affecting everyone negatively.
Finally we considered the transference neurosis and how our own anxieties may affect the work and how to manage them. When we understand our own anxieties and how they operate, then we are less likely to project our anxieties into our clients and be more attuned to the projected anxiety which may take many forms. On top of this we have the real shared anxiety of life outside the therapy room and we need to acknowledge the psycho-social reality and how it can wobble therapists as well.
Hephzibah Kaplan | Feb 2020