ANXIETY AND PSYCHODYNAMIC PSYCHOTHERAPY
The presence of anxiety in everyday life is a physiological fact, it becomes problematic and a source of mental discomfort when it is an affective state linked to a pathology; that is, when it is disproportionate to the triggering event, it presents itself for no apparent reason or even when it continues, as a mood, for long periods of time.
The characteristics of anxiety are linked to a very strong and pervasive psychic component that can also lead to physical symptoms. The psychic component is expressed with apprehension, restlessness, brooding, difficulty sleeping, concentration, insecurity, etc. The physical component is linked instead to tachycardia, tremors, a sense of suffocation, tinnitus, up to widespread pain in various parts of the body; in the case of panic attacks, agitation and spasms may also be present.
Freud in 1894 was the first to deal with the topic of anxiety which he defined with the term “neurosis”, characterized by a state of anguish, a sense of anxiety linked to a thought or desire removed whose dimension of care was linked to psychotherapy.
Another feature of what Freud called anguish was an overwhelming sense of panic accompanied by sweating, increased respiratory and cardiac rhythm, a sense of terror. In this case it was an accumulation of libido in relation to the absence of sexual activity.
Overcoming certain ideas and perfecting his theory, Freud described anxiety as the result of a psychic conflict between unconscious, sexual or aggressive desires and possible threats of punishment: the profound conflict that exists between Es and Super-Ego. The idea of an unconscious danger would therefore generate anxiety. At this point the ego puts in place defense mechanisms: removal, displacement, avoidance so that certain thoughts do not reach consciousness and make it feel bad. Reworking a conflict overestimated by the ego which is anxiety allows to overcome it.
Anxiety can be divided into: trait anxiety and state anxiety.
In the first case we are faced with a constantly present feature of the personality that accompanies the individual in his daily life and because of which he perceives most of the stimuli he receives as dangerous or threatening and therefore faces the time that passes with the fear that something can happen to him. State anxiety is instead considered a sort of interruption in the emotional continuum, that is, it is expressed through a subjective sensation of tension, apprehension, nervousness, restlessness. The subject who perceives this state of tension will tend to implement a series of behaviors to avoid or reduce these sensations; where these mechanisms fail, the subject experiences an increase in anxiety and therefore a psychopathological spiral.
People who have high levels of trait anxiety have reactive behaviors to a greater number of stimuli (it is part of their way of being anxiously react to situations), consequently in “Normal” circumstances or with low “anxiety potential” they will realistically react with very strong anxiety.
A psychotherapeutic path based on psychodynamic treatment is extremely indicated in trait anxiety because it allows the subject to enter into relationship with the deeper parts of his psyche.
Relate to anxiety disorders: anxiety disorder with or without agoraphobia, specific phobias and social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, due to a medical condition or substances.
The presence of anxiety disorders often does not imply a general malfunction of the individual, basically there is an ego that continues to perform its functions well allowing a good integration of the individual; although with discomfort and difficulty he manages to maintain a relationship with reality and it is thanks to good contact with reality that expressive therapy can be applied. Here the psychodynamic therapeutic approach becomes an indicated treatment modality since its purpose is to analyze the defenses so as to be able to interpret and reveal all that material that has been dynamically removed. On the other side of the expressive side, in the psychodynamic approach we find the supportive aspect of therapy which aims to resolve the unconscious conflict and strengthen the defenses.
Psychodynamic psychotherapy therefore constantly moves through the two poles: expressive and supportive. It aims to achieve insight by the patient, that is, the ability to understand the unconscious origins and meanings of his behaviors; this happens but as the resistances are dampened by the therapist with his interventions. To this must be added the objective of resolving the conflict when the nature of the defenses and of the desire which is at this point is attenuated or abandoned, making de facto defense unnecessary.
To conclude, as a third objective there is the improvement of one’s internal object relations with consequent improvement of relations with external people.
The phases that characterize psychodynamic therapy along the expressive-supportive continuum include: interpretation, that is, an intervention by the therapist that connects a feeling, a thought, a behavior or a symptom to its meaning. It helps to make what is unconscious conscious. Conversation, on the other hand, serves to put something in the patient’s presence that he does not want to accept: such as the influence of his behavior on others or repressed or denied feelings. We try to transmit to the patient in a neutral way the connection that can exist between a symptom and everything that revolves around it. Clarification is used by the therapist and the patient to have a more complete and coherent view of what the patient has communicated so that he can articulate something that is difficult for him to say. The encouragement to elaborate consists in requesting more information about a topic introduced by the patient; the aim is to focus on a theme in more depth so as to arrive at new self-disclosure. With empathic validation the therapist demonstrates his closeness to the patient’s internal state through the validation and sharing of moods and feelings. Through the use of advice and praise, the patient is helped to follow certain behaviors thanks to reinforcement. This occurs through direct suggestions on how to behave or through the praise of virtuous behavior. Finally, the last type of intervention that places psychodynamic therapy along an expressive-sports continuum is confirmation: these are reduced and impromptu comments on what the patient produces: comments, behaviors, interactions, etc. Through confirmation the therapist recognizes the patient as being through empathic acceptance.
The psychogenic reasons for the discomfort reside within the unconscious in which they are contained because the patient opposes resistance. The cure, the solution of the discomfort in psychodynamic psychotherapy is given by the integration between the awareness of these contents and the connection with current behaviors. However, due to the psychic resistances and defense mechanisms that the patient constantly implements without realizing it, it is not possible to “reach” these contents directly, here with the aid of techniques such as free associations and the interpretation of dreams it is often possible to circumvent these protective “limitations” that the patient puts in place.
Transference also plays an important role in psychodynamic therapy since it allows us to detect that direct connection between the individual’s internal world and what he expresses in his relationship with others. By reactivating the patient’s oedipal dimension of the patient, the therapist assumes the role of one or both parents so as to facilitate in him the expression of what he carries within himself from childhood, bringing it up to date in the here and now to allow him to elaborate it with the tools that he as an adult possesses.
Finally, resistances are an integral part of therapy, helping the patient to understand and elaborate them through interpretation is a fundamental point of therapeutic work; they must be accepted, evaluated, interpreted to help the patient to grasp their origin.
When dealing with anxiety disorders, psychodynamic therapy seems to be the most suitable. In fact, in the case of panic attack disorder, the transference element is very important because the figure of the therapist becomes an internal image to which to appeal when you are in the middle of a panic crisis and in some cases hear your voice. on the phone it can reduce until panic disappears. This is why the therapy to be developed with these patients must be precisely expressive-supportive, so that in the long term they develop an internal image of the therapist. Psychodynamic psychotherapy together with the drug represents the treatment of choice for panic attacks. It reduces to eliminate the resistance to the use of the drug,
The action of psychodynamic therapy is also positive and functional even in agoraphobia where the patient maintains a good examination of reality which allows him to establish a transference and work with the therapist on transference and countertransference aspects. Just as treatment in phobias in general helps to deal with resistance to traditional treatments: systematic desensitization and drugs. Finally, even in generalized anxiety disorder, the psychodynamic approach is very useful with those patients who are motivated to understand the matrix of symptoms. The patient’s fear is assessed in depth as well as the degree of anxiety it produces, but above all how it is structured in his personality organization. The main goal is to highlight and rework the terms of the conflict,
In conclusion: psychodynamic therapy is widely used in anxiety disorders even if at different levels as long as the patient is highly motivated, with a good ability to tolerate frustrations, a good capacity for insight and reflexivity. Much importance also has a therapeutic relationship that becomes the common thread along the expressive-supportive continuum.