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.







7 responses to “Anxiety is not going down!”

  1. Kevin Avatar

    Hi Jon. Love the blog. I am waiting for my copy of Co-creating change, so this question may be addressed in your book. But I am very curious as to how the therapists countertransference and enactments are addressed within the ISTDP model. Hypothetically, if I was annoyed with a patient and it became obvious to the patient and they asked if I was annoyed, how would you work with that in this model. Thanks again for an awesome site.

    1. istdpadmin Avatar

      Annoyance in the therapist can mean many things. Thus, examining the patient, the therapist, the context, and the transference/countertransference dynamic is essential. After all, the annoyance could be just the therapist’s issue. The patient may be acting with the therapist like the patient’s parent acted with her, so the therapist’s annoyance would be information about how the patient felt toward her parent. The patient may be feeling unconscious guilt about her aggressive behavior with the therapist, and unconsciously provoking him so he will punish her for her rage. The annoyance could also be a complementary identification with the patient’s parent, if that parent was often annoyed. So, many causes, many possible paths of exploration and intervention.

    2. W. Benschop Avatar
      W. Benschop

      Hi , I hope this cliënt (not patiënt )does not read this blog . It seems like a new religion.
      I have seen them all come by the last 40 years.
      What helps people best is treating them respectfully and really listening and then a reaction of the therapist in a living human way. That is what people need . Not another interlectual theory.

  2. Jon Frederickson Avatar
    Jon Frederickson

    Hi Kevin, Fantastic question! When we are annoyed, that may mean any of a number of things. For instance, if the patient flicks cigarette ashes on your furniture, you will feel anger. That’s known as objective countertransference. Then again, a patient may trigger anger in us because the patient reminds us of someone in our past where our feelings are not worked through well. That’s a subjective countertransference, based on our own difficulties. Or a patient may trigger anger within us that communicates to us something about the patient’s own inner life. For instance, the patient may act like an abusive father, and we will feel the anger the patient felt as a child. Or the patient may act in ways that make us feel like that abusive father. Sometimes we feel a flash of anger and an urge to punish the patient because the patient is feeling guilt at that moment and wanting to be punished unconsciously to avoid the experience of guilt. As in all good dynamic therapies, we need to be as open as we can to our inner experience, then have the capacity to bear that experience long enough that insights can arise that allow us to use it as information. Then we can respond therapeutically in the service of the patient’s healing.

    1. Aleksander Avatar

      Hi! How important is the other (i.e. therapist) when it comes to anxiety regulation? I’m asking as a patient who’re having trouble self-regulating. At least theoretically you should not need another person as long as you are aware of the symptoms, no?

      1. istdpadmin Avatar

        Sometimes we can’t regulate anxiety by ourselves and we need someone to help us for a while until we can do it on our own. If the patient did not gain this capacity for self regulation early in life, sometimes it has to be learned in therapy.

      2. istdpadmin Avatar

        if you are aware of your anxiety, most of the time you will be able to regulate it. However, if you use defenses that prevent anxiety regulation, you won’t see them and that’s where a therapist can help you out a lot!

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