Monthly Archives: January 2017

Anxiety is not going down!

“Hi Jon!  I have a relatively new therapy client who reports in session all the signs of parasympathetic dominance: light headedness, migraines, dizziness, nausea, blurry vision, ringing of the ears, etc. Aren’t blurry vision/ringing of the ears signs of cognitive perceptual disruption? Is there a difference between the early signs of vagal syncope and parasympathetic dominance (or are they the same thing)?

I’ve pointed out to her that when she has a feeling, that she becomes anxious very quickly (high rise, slow drop=fragile, I believe).  She is very concerned that I will leave her, as many other male figures have done in the past (father, step-father, her last therapist-a woman- who preemptively terminated). I’m “working the triangle” and pointing out causality. What might be helpful for this client?”

Thanks so much for this question! This is clearly a fragile patient because her anxiety goes into cognitive/perceptual disruption: light headedness, blurry vision, ringing of the ears. Her anxiety also goes into the smooth muscles: nausea and migraines.

The therapist did two really important things: 1) help the patient see signs of anxiety in the body; and 2) help the patient see causality. These are the essential early interventions: identify anxiety, and cognitively recap the process that just occurred. And the therapist did them. Good.

But the interventions did not work. Why? The patient is probably using some defenses that prevent anxiety from becoming regulated. Without seeing the video we can only speculate. Sometimes the patient does not pay attention to the anxiety, so it can’t come down. Often, the patient is projecting upon the therapist. The resulting projective anxiety prevents any anxiety regulation from occurring. Sometimes the patient has some delusion that is preventing anxiety from coming down. So what to do?


Th: I notice when I bring up your anxiety that you shift to other topics. When you ignore your anxiety this way, it keeps us from paying attention to it so we could bring it down. Would you be willing to pay attention to this anxiety so we could help you with it? [Ignoring anxiety as a defense that prevents anxiety regulation]

Th: You are really anxious as you are telling me about your problems here in therapy. I wonder what thoughts you might be having about the therapy that could be making you anxious. [Inquiry to find out what projections she might be putting on the therapy and the therapist.] [Projection as a defense that prevents anxiety regulation]

Th: Since this anxiety is still not coming down, I wonder how you might be perceiving me? [Inquire to find out what she might be projecting onto the therapist.] [Projection as a defense that prevents anxiety regulation]

Th: You seem really anxious about telling me about your problems. Before you say anything more about yourself, l wonder: was it your will to come here today? [Inquire into her will to see if her anxiety is due to projection of will.] [Projection of will prevents anxiety regulation]

Th: [If the patient’s anxiety is in the striated muscles at the beginning of the session] We notice that in coming here to talk to me, that you become quite anxious. Do you notice that too? I wonder what feelings might be coming up here toward me that are making you anxious? [Inquire into feelings that could be triggering the anxiety.] [Feelings rising toward the therapist trigger anxiety that continues to rise because the patient is unaware that the anxiety is actually triggered by his internal feelings.]

In my book, Co-Creating Change, the last third of the chapter on anxiety addresses lots of problems that prevent anxiety regulation. If you review that section, you will find additional strategies to find out what is preventing anxiety regulation.

Basic rule of thumb: if you can’t regulate the patient’s anxiety within five minutes, start assessing what defenses prevent anxiety regulation.