Communication-Focused Therapy® (CFT) for Anxiety and Panic Attacks
Christian Jonathan Haverkampf, M.D.
Communication-Focused Therapy® (CFT) is a psychotherapy developed by the author, which can be applied to a number of mental health conditions, including anxiety disorder and panic attacks. It focuses on creating greater awareness and insight into internal and external communication patterns and making changes to them. This also helps gain insight into the basic parameters, the needs, values and aspirations which are important for motivation and the direction of changes, behaviors and interactions with oneself and others.
Keywords: anxiety, panic attacks, communication-focused therapy, CFT, communication, psychotherapy, treatment
Table of Contents
Anxiety is like any other emotion a heightened mental state with a higher probability of certain conscious processes and behaviors. In anxiety an individual dreads uncertain and often ill-defined events in the future or immediate future. It is not a fear of a specific event, but an unpleasant feeling of heightened arousal which can cause various thoughts and feelings of dread.
Anxiety and Panic Attacks are related to how people communicate with themselves and with others. They often occur when a relationship breaks apart or some other interpersonal change or issue causes. The result is often communicative patterns that are maladaptive to the individual. These changes in communication patterns are what causes then the problems to the individuals.
Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. These patterns can be analyzed and changed. Another important element is that communication can also take place on the inside of the individual. Anxiety may, for example, mean that one uses a pattern of questioning that is not directed at finding meaningful information that could lower the anxiety. If my thinking brings me back to a greater focus on the same thought, then a dynamic of change is missing, which would be important in treating anxiety. Meaningful communication brings about change in the recipients and their states, such as a lowering of anxiety. It is important to acknowledge that it is not information itself that causes anxiety, but how it is communicated and the meaning that is being attached to it. If one is stressed in the job or feels the need to accomplish something particular, it is not necessary to invent another world with a different reality, nut to see the information flows in which one is situated, and to change them through changing communication patterns with oneself and with others.
Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints, and rumination. It is the subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent death. Anxiety is not the same as fear, which is a response to a real or perceived immediate threat, whereas anxiety is the expectation of future threat. Anxiety is a feeling of uneasiness and worry, usually generalized and unfocused as an overreaction to a situation that is only subjectively seen as menacing. It is often accompanied by muscular tension, restlessness, fatigue and problems in concentration. Anxiety can be appropriate, but when experienced regularly the individual may suffer from an anxiety disorder.
People facing anxiety may withdraw from situations which have provoked anxiety in the past. There are various types of anxiety. Existential anxiety can occur when a person faces angst, an existential crisis, or nihilistic feelings. People can also face mathematical anxiety, somatic anxiety, stage fright, or test anxiety. Social anxiety and stranger anxiety are caused when people are apprehensive around strangers or other people in general. Furthermore, anxiety has been linked with physical symptoms such as IBS and can heighten other mental health illnesses such as OCD and panic disorder.
In anxiety one often finds the following four cognitions:
- intolerance of uncertainty
- positive beliefs about worry
- negative problem orientation
- cognitive avoidance
(Dugas & Koerner, 2005)
Anxiety can be either a short term “state” or a long term “trait”. Whereas trait anxiety represents worrying about future events, anxiety disorders are a group of mental disorders characterized by feelings of anxiety and fear. Anxiety disorders are partly genetic but may also be due to drug use, including alcohol, caffeine, and benzodiazepines (which are often prescribed to treat anxiety), as well as withdrawal from drugs of abuse. They often occur with other mental disorders, particularly bipolar disorder, eating disorders, major depressive disorder, or certain personality disorders.
Anxiety was defined by Freud as “something felt,” an emotional state that included feelings of apprehension, tension, nervousness, and worry accompanied by physiological arousal. Consistent with Darwin’s evolutionary perspective, Freud observed that anxiety was adaptive in motivating behavior that helped individuals cope with threatening situations and that intense anxiety was prevalent in most psychiatric disorders. In measuring anxiety, Cattell (1966) emphasized the importance of distinguishing between anxiety as an emotional state and individual differences in anxiety as a personality trait. (Spielberger, 2010)
Anxiety often occurs when the confidence to communicate one’s needs, wishes or feelings is compromised. Humans learn early on that their well-being and survival depends on communicating their needs to others, originally their parents, later their work colleagues, friends, and romantic partners. Communication makes us feel safer in the world, because it is the main tool with which we fulfil our needs, values and aspiration. (Haverkampf, 2010a) Thus, the more confidence one has in one’s communication abilities, internally and externally, the less uncertain the world seems and the safer one feels. This can also reduce anxiety in general, but probably requires a somewhat lengthy learning process.
In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst-case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.
In individuals suffering from anxiety, uncertainty is often filled with more negative imagined outcomes. In a study on four groups of students (low-anxious, repressor, high-anxious, and defensive high-anxious), evidence indicated that the high-anxious and defensive high-anxious groups were unrealistically pessimistic about some examination-related events (they possessed an interpretive bias for such events), whereas the repressor groups were unrealistically optimistic about some examination related events, showing an opposite interpretive bias. (M. W. Eysenck & Derakshan, 1997)
As uncertainty can increase the level of anxiety under certain circumstances, this may also interfere with the process that helps to reduce uncertainty and anxiety, communication. If this seems to have the trappings of a vicious cycle, this is not far from the truth. One problem with anxiety, and particularly social anxiety, is that communication, which could lower uncertainty and anxiety, is what becomes feared and reduced as a consequence. However, it is not only reduced in quantity, but also in quality, which probably related to how and which communication patterns and channels are used. According to anxiety-uncertainty management (AUM) theory, the effectiveness of communication is a function of individuals’ abilities to manage their uncertainty and anxiety. To confirm an important prediction of AUM, Gudykunst and Nishida investigated the effect of anxiety and uncertainty on perceived effectiveness of communication in two relationships, strangers and close friends, and two cultures, the United States and Japan. The results indicated that there was a moderate, negative relationship between anxiety and attributional confidence, the inverse of uncertainty, across relationships and cultures. The results also reveal that anxiety negatively predicted perceived effectiveness and attributional confidence positively predicts perceived effectiveness across relationships and cultures. (Gudykunst & Nishida, 2001)
Anxiety requires a certain amount of uncertainty. It often occurs in situations when there is uncertainty about external events or situations, often interpersonal ones, or uncertainty about one’s own feelings, mental or physical states. Without uncertainty about oneself or the world around there is no room for anxiety. However, this it is impossible to achieve a state of complete certainty, which would also make any change or progress impossible. The environment does not even have to change to make changes in the individual necessary. For example, if one develops greater insight in something in the environment or in oneself, changes in one’s thoughts, perspectives, behaviors and interactions may become necessary. Change helps people not only to survive but also to make the best out of their place int the world. The more open an individual is to change and the easier it is for one to implement the change the less reason there is for anxiety. Accepting that there is a level of uncertainty in life makes it easier to develop the tools to deal with it. This raises self-confidence, the sense of efficacy in the world, self-awareness and lowers anxiety.
Information reduces uncertainty, and communication is the mechanism which provides information. Meaningful information has the potential to bring about adaptive and beneficial changes in an individual, even if it only leads to a change in perspective. The information can be about the environment or about oneself, come from the outside or the inside. Communication-focused therapy (CFT) has at its objective to improve the internal and external communication to lead to a reduction in mental health symptoms, greater satisfaction and contentment, as well as greater success in the world to get one’s needs, values and aspirations met. Especially in cases of anxiety and panic attacks, an ability to deal with and integrate uncertainty into one’ s life is very effective in reducing the symptoms.
Managing uncertainty and anxiety are according to AUM outlined above central processes that affect our communication with strangers and that the anxiety and uncertainty that we experience when we communicate with others are related to each other. In a study by Duronto and colleagues, anxiety and uncertainty were associated with avoidance in communication with strangers from both the same and different cultures. When studying communication between strangers of a different culture, anxiety and uncertainty were found to be associated with one another. Nevertheless, anxiety and uncertainty were not related to each other in communication between strangers of the same culture. These results provide partial support for AUM theory. (Duronto et al., 2005)
This study examined the relationship between public speaking anxiety and physiological stress indicators at four different milestones or stages in the delivery of a public speech. Specifically, public speakers’ gastrointestinal body sensations were compared at different times and across different levels of psychological trait anxiety. Results indicated significant differences in both the magnitude and the patterns of somatic responses between high- and low-trait-anxiety groupings. First, as the groups of speakers moved from anticipation to confrontation, their somatic responses changed in opposite directions. Subsequently, high-anxiety speakers reported a significant increase in stress symptoms immediately after the speech had ended, indicating anxious remorse or fear of negative evaluation. These findings provided important new information about speech anxiety patterns, particularly as they differ in high- and low-anxiety speakers. (Witt et al., 2006)
Individuals often are more likely to encounter anxiety when there is an underlying feeling that something or things in their life are ‘out of sync’. This can occur in many situations in professional or private realms. A patient with anxiety may not be aware of the signal directly but of the anxiety which is triggered by it. Anxiety then makes it even more difficult to connect with oneself or others to gain insight into what is causing the anxiety. Communication on the inside and on the outside suffers in states of anxiety which makes it more difficult to resolve the issues that have led to the higher anxiety states.
Aspects in life are ‘out of sync’ if they do not correlate anymore with one’s values, basic interests, aspirations, true needs, wants and desires. Through one’s behaviors and thoughts one finds out more about oneself, but one does not have to know these parameters consciously in order to have a sense for what is meaningful in one’s life, which, however, requires being connected emotionally to one oneself in a meaningful way. Individuals who are suffering from burnout, for example, often experience this disconnect.
Anxiety can be thought of as a future-oriented emotional state that is characterized by anticipatory cognitive, behavioral and affective changes in response to uncertainty about potential threat. Uncertainty about a possible future threat disrupts our ability to avoid it or to mitigate its negative impact. In a study by MacLeod and Byrne, anxious participants differed from controls only in anticipating more future negative experiences, while anxious-depressive (mixed) participants showed both greater anticipation of negative experiences and reduced anticipation of positive experiences. (MacLeod & Byrne, 1996) Miranda and Mennin in their study found that higher GAD and depression symptoms were associated with an increased anticipation of negative events, but only depression was associated with the prediction of a lack of positive outcomes. (Miranda & Mennin, 2007) In a study by Eysenck and colleagues, depression was associated more with past events than future events, whereas the opposite was the case with anxiety. In a second part, while past events were associated with more depression and less anxiety than future events whether uncertain or probable, probable future events were associated with more anxiety and depression than uncertain ones. (M. Eysenck et al., 2006)
The ability to project oneself into the future has previously been found to be related to happiness and anxiety. Quoidbach and colleagues investigated the causal effect of deliberate mental time travel (MTT) on happiness and anxiety. There was a significant increase of happiness for subjects in the positive condition after two weeks but no changes in the negative or neutral condition. (Quoidbach et al., 2009)
Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, stay unresolved. For example, if a parent feels fearful and angry with himself and this is picked up by a child, the latter may decode these messages correctly in that the parent is angry, but since the parent may not be conscious about it, the child does not pick up on the second important half of the message, that the parent has a problem with himself and his issue is unrelated to the child. Of course, one can learn to pick up on the self-blame and frustration of the parent, and therapists should become experts at reading between the lines in this fashion, but it requires experience, reflection and insight into transference and counter-transference phenomena, for example, to use the psychoanalytic terms.
Uses and gratifications is a psychological communication perspective focusing on how individual differences mediate attitudes and behavior. Incorporated in the perspective is an implicit emphasis of the interface of personal and mediated communication. As a salient psychological trait, locus of control should affect communication motivation and tendencies. Based on internal vs. external locus of control, we expected differences in communication motivation in interpersonal and mass‐media contexts, and differences in one’s communication anxiety and satisfaction. Multivariate analysis of variance supported our expectations. Externals found communication to be less rewarding and less satisfying, tended to avoid communication, and were motivated to communicate more ritualistically than internals. We discussed these findings. (Rubin, 1993)
What constitutes effective communication during conflict? Answering this question requires first, clarifying whether communication expresses opposition versus cooperation and is direct versus indirect; second, assessing the mechanisms through which communication effects relationships; and third, identifying the contextual factors that determine the impact of communication. Recent research incorporating these components illustrates that direct opposition is beneficial when serious problems need to be addressed and partners are able to change but can be harmful when partners are not confident or secure enough to be responsive. By contrast, cooperative communication involving affection and validation can be harmful when serious problems need to changed, but may be beneficial when problems are minor, cannot be changed, or involve partners whose defensiveness curtails problem solving. (Overall & McNulty, 2017)
Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run.
Since helpful communication, an open exchange of meaningful messages internally and externally, reduces anxiety, an avoidance of sources of meaningful information increases anxiety. Unfortunately, avoidance may not be self-correcting and lead into a vicious cycle in which ever greater anxiety leads to ever greater avoidance to the point where a patient can become house or even bed bound, and a normal work or private life are no longer possible.
In a study by Finn and colleagues on the extent to which the state anxiety behaviors of speakers conform to the habituation pattern, behavioral measures of public speaking state anxiety displayed a continually declining pattern associated with habituation. (Finn et al., 2003) This follows Gray’s neurological theory of anxiety (1982, 1990; Gray & McNaughton, 2000), which predicts that state anxiety will decrease with continuous exposure to a fear arousing stimulus.
From a communication perspective, however, there is a risk that habituation reduces the feelings associated with a situation not permanently, because it does not directly affect a person’s maladaptive internal and external communication patterns, which maintain the anxiety when interacting with oneself and the world. Communication-Focused Therapy® aims to create longer lasting effects by focusing directly on the internal and external communication patterns which contribute to the feelings of anxiety and panic attacks. As discussed previously, how well we feel connected with ourselves and the world has an impact on how comfortable and safe we feel in our own skin and in the world as a whole. Feeling anxious is usually a signal that something is out of sync or misaligned. It gives us less of a feeling that we can rely on ourselves and others and makes us more uncertainty averse, which then lead to anxiety and panic attacks since we live in a world that is inherently uncertain but has an enormous potential to make us feel safe and comforted if we can use the power of our internal and external communication capabilities to ask for it.
Panic attacks are intense phases of anxiety and can often occur ‘out’ of the blue. Still, in any case, exploring and looking into the panic attack can often unearth reasons for the panic attack. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something bad is going to happen. The maximum degree of symptoms occurs within minutes. Typically, they last for less than thirty minutes but the duration can vary from seconds to hours. There may be a fear of losing control or chest pain. Panic attacks themselves are not dangerous physically.
Lo Cascio found in their study that the indecisiveness of 13- to 16-year-old students was predicted by family communication mediated by anxiety and self-esteem. (Lo Cascio et al., 2013) In a study by Kouroshi and colleagues, family conversation orientation was a significant predictor of children anxiety and depression. Family conformity predicted children anxiety significantly but not their depression (Kouroshi Nia & Morteza, 2007)
Both CBT and short-term psychodynamic psychotherapy have shown significant, large, and stable improvements with regard to symptoms of anxiety and depression in controlled trials (F. Leichsenring et al., 2009). CBT has shown to be effective in randomized controlled trials. (Dugas & Koerner, 2005) A typical CBT treatment may have as components a presentation of the treatment rationale (learning to cope with uncertainty), worry awareness training, reevaluation of the usefulness of worrying, problem-solving training, cognitive exposure, and relapse prevention. (Dugas & Koerner, 2005)
Psychodynamic psychotherapy was shown to be as efficacious as other active treatments that have been studied for anxiety disorders. (Keefe et al., 2014) In social anxiety, CBT and psychodynamic therapy both have demonstrated their efficacy. (Falk Leichsenring et al., 2013) Both have theories about why they help. The former sees learning processes and certain thought patterns as central, the latter the processing of content at various levels of consciousness and certain processes between therapist and patient. However, they both place little emphasis the communication processes between therapist and patient and inside each that often in clinical processes are what brings about substantial change in the right direction. (Haverkampf, 2017a) Communication-Focused Therapy (CFT) in this respect may be seen as a standalone therapeutic approach or combined with one of the other two approaches.
Guided Internet-based cognitive behavior therapy (ICBT) and Internet-based psychodynamic therapy (IPDT) have been shown to be effective in the treatment of generalized anxiety disorder (Andersson et al., 2012) Interestingly, in the study by Andersson the differences between the treatment and control groups were not significant immediately after treatment, but moderate to large in the three to eighteen months follow-ups. Psychodynamic treatment approaches can be transferred to the guided self-help format and delivered via the Internet. Johansson and colleagues provided initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. (Johansson et al., 2013)
Although interpersonal psychotherapy (IPT) has demonstrated its effectiveness in depression and other psychiatric conditions, in a controlled trial, improvement with IPT was not superior to improvement with ST. However, patients in both groups experienced significant improvement from pretreatment to posttreatment. (Lipsitz et al., 2008)
Major depression and anxiety frequently co‐occur. Approximately 25% of children with attention-deficit/hyperactivity disorder (ADHD) exhibit an anxiety disorder. (Jarrett & Ollendick, 2008) Similar to adults, elderly depressives with comorbid anxiety symptoms present with more severe pathology and have a more difficult course of illness, including decreased or delayed treatment response. (Lenze et al., 2001) However, risk factors for comorbid late‐life depression and anxiety may be different from those for depression without anxiety.
Feske and colleagues examined predictors of acute response to interpersonal psychotherapy. Women who failed to remit with interpersonal psychotherapy alone experienced higher levels of somatic anxiety, were more likely to meet criteria for lifetime panic disorder, were more likely to meet criteria for nonendogenous or non-melancholic depression, and reported greater vocational impairment, higher levels of global severity, a longer duration of the index episode, and, somewhat surprisingly, lower levels of social impairment at pretreatment evaluation. Higher levels of baseline somatic anxiety and social functioning appeared to be the most consistent predictors of nonresponse. (Feske et al., 1998)
Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.
Communication takes place within complex systems in everyday life. Meaningful messages are exchanged, relayed and processed. But importantly, they bring about change in the world. As long as they are meaningful to the recipient, they can change emotional states, thoughts, perspectives, behaviors and actions. Communication in turn happens in communication patterns, which are often not conscious to the person using them. Basic ones are already built in at birth, while later and more complex ones are acquired through learning, experimentation or by necessity. How communication can affect the subjective experience of a person can be illustrated in an example involving normal everyday communication. In a study by Roach, a teaching assistant’s willingness to communicate was significantly related to perceptions of the teaching assistant’s nonverbal immediacy. Additionally, as the communication apprehension increased, student perceptions of the teaching assistant’s nonverbal immediacy and teaching assistant’s power use decreased. The teaching assistant’s anxiety was negatively correlated with student ratings of instruction, affective learning, perceptions of the teaching assistant’s nonverbal immediacy, and perceptions of the teaching assistant’s reward power, referent power use, and expert power use. (Roach, 1999) This example also shows that the actual content of what the teaching assistant was teaching was irrelevant. In other words, there were meaningful messages communicated between teacher and students that changed perceptions, experiences, thoughts and feelings, which were unrelated to the purpose of the classroom and which neither of them may have been aware of. The example also shows that certain dynamics and patterns of information sending, receiving and processing evolve, that can be quite predictable given the situation, personality and past experiences of the participants. Since communication is how individuals satisfy fulfil their needs, values and aspirations, and allows them to live psychologically and physically healthier lives in general, communication-focused therapy focuses on greater awareness for and better use of communication processes, including communication patterns and the creation and decoding of meaning.
We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal chords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life. Certain communication patterns can, however, also contribute to experiencing anxiety and panic attacks.
Communication supports autoregulatory processes by making information available which leads to better adaptation to given situations but also helps to create a better future for the individual by making greater insight into the world available. At the same, communication also takes place on the inside. Unresolved emotional memories and conflicts maintain trigger and maintain anxiety and panic attacks and lead to anxiety about the own emotional states in the sense of being anxious about becoming anxious. Better connectedness on the inside and better insight about the own emotional states and what triggers and maintains them can thus reduce anxiety and panic attacks. However, it is important that this information can lead to changes, hence be meaningful, which usually requires significant openness and flexibility on the inside, as well as in one’s communication with others. This can be developed in CFT.
As already discussed, communication also helps bring more certainty in the world. The more confidence one has in oneself to communicate effectively, the safer one feels in life and the more certain it seems. Being able to deal with a certain amount of uncertainty is important to come up with novel answers and solutions to problems or to be creative in any meaningful way.
Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.
Communication lowers anxiety because it makes more meaningful information available. Unfortunately, anxiety can also alter the receptiveness to and the processing of information, as it modulates the functioning of attention. Pacheco-Unguetti and colleagues studied the influence of anxiety on the efficiency of three attentional networks: orienting, alerting, and executive control. Results showed a double dissociation. Trait anxiety was related to deficiencies in the executive control network, but state anxiety was associated with an overfunctioning of the alerting and orienting networks. (Pacheco-Unguetti et al., 2010) Asymmetrical activity patterns in the frontal lobes may relate to affect regulatory processes, including contrasting opponent after-reactions to aversive stimuli (Kline et al., 2007), and it has been suggested that greater relative right anterior activity may act as a vulnerability marker for the development of depression and anxiety disorders. Blackhart and colleagues examined whether anterior and posterior EEG asymmetry patterns predicted anxiety and depressive symptoms one year later. Those with relatively greater EEG activity in the right anterior region reported greater trait anxiety one year later. (Blackhart et al., 2006)
Paulus and Stein suggested that individuals who are prone to anxiety show an altered interoceptive prediction signal, i.e., manifest augmented detection of the difference between the observed and expected body state. As a consequence, the increased prediction signal of a prospective aversive body state triggers an increase in anxious affect, worrisome thoughts and other avoidance behaviors. The anterior insula is proposed to play a key role in this process (Paulus & Stein, 2006)
Attachment plays an important role in the communication patterns with the outside world, because the ability to form and maintain deep and enduring emotional bonds that connects one person to another across time and space (Ainsworth, 1973; Bowlby, 1969) also defines the communicative future of the individual and the communication patterns that will be used. Attachment theory attempts to describe the dynamics of long-term and short-term interpersonal relationships between humans overall but puts a special emphasis on the time when attachment patterns are formed and experimented with for the first time, in young childhood. Bowlby postulated that transactional patterns between caregiver and infant become internalized by the infant as “internal working models” of self and other in relationship and that these working models then determine how the infant interprets the caregiver’s behavior and responds to it. It is believed that this also has an effect on communication patterns later in life. If, as research suggests, insecure parents’ working models of attachment relations are distorted by defensive processes, the resulting insensitive behaviors toward the child may interfere with the child’s construction of adequate working models, thus providing a potential explanation for the intergenerational transmission of insecure attachment relations in those cases where the parent has not been able to work through a rejecting or neglecting attachment relationship experienced in childhood. (Bretherton, 1990)
High social anxiety is associated with qualitative and quantitative changes in how people communicate, that result is a lowered level of participation in interactions, minimal disclosure of information about the self, cautious self-descriptions that are less positive and less likely to assert unique qualities that draw attention to the self, and a passive interaction style that avoids disagreement. (Schlenker & Leary, 1985) This is another vicious cycle in which a person suffering from anxiety is afraid to be less oneself, and show less of oneself, rather than more of oneself. One important way to overcome this is by learning more about oneself, such as the basic parameters needs, values and aspirations already mentioned above, another to get a feeling of oneself, which is a sense for the information flows within oneself. More self-knowledge, self-awareness and a greater sense of self-feeling in a helpful way can also make more confident in following one’s own path, in taking decisions and in establishing healthy boundaries. All these can be helpful in lowering overall anxiety, while also significantly reducing social anxiety.
The communication channels used by the individual has to work for the communication patterns used by that person. Different preferred channels of communication may need adjustments to or different communication patterns. Often in social anxiety, there seems to be a mismatch between a communication channel on feels a need to use and the communication patterns used. In a study on social anxiety by Pierce, analysis revealed a positive relationship between face-to-face social anxiety and (1) talking with others online and (2) talking with others via text messaging. In contrast, there was a positive relationship between the lack of social anxiety (feeling “comfortable” talking with others) and making friends online. Assessing gender differences and social anxiety revealed significant differences. Results revealed females reported more social anxiety (not comfortable talking with others in person) than did males. In addition, females, more than males, reported feeling more comfortable using SITs (text messaging and online social sites only) rather than talking with others face-to-face. Females tended to use cell phones/text messaging and online social sites more so than did males. (Pierce, 2009) Botth-Butterfield investigated the link between trait communication anxiety and communication behavior in hearing‐impaired individuals. Results indicated moderate to large effects for the trait on signing behaviors such as speed of signing, intensity, size, clarity, and overall effectiveness. Trait anxiety scores were also relatively stable over time, and average scores were lower than those of hearing communicators. (M. Booth‐Butterfield & Booth‐Butterfield, 1994) This goes to show that the use of particular communication channels, and the fit of the communication channel to the communication patterns, can affect the effectiveness of the communication, and thus also the sense of self-efficacy and as a consequence the level of experienced anxiety, whether social or more general. (Haverkampf, 2010b, 2018b)
An overview and work with communication has been described by the author elsewhere. (Haverkampf, 2019) The following discusses some communication patterns which may be particularly helpful when working with a patient suffering from anxiety. It is important to keep in mind that communication patterns take place externally and internally, and that they are tightly linked. What happens on the outside reflects what happens on the inside, and vice versa. This is also what makes psychotherapy effective in changing communication patterns globally (Haverkampf, 2010b).
While the focus in the author’s work is more on communication patterns on a smaller, more molecular level, they can also be viewed on a much larger scale. Boukhechba and colleagues, for example, used mobile sensing technology in a study on how social anxiety levels were associated with mobility and communication patterns. Their analysis based on GPS location, text messages, and call data collected indicates that social anxiety level can be predicted with an accuracy of up to 85%. (Boukhechba et al., 2017)
Anxiety can lead to communication patterns that are less effective, as it can also inhibit communication. Often, feelings and thoughts that result out of greater communication anxiety can make meaningful interactions with others even more difficult. Anxiety can, for example lead to greater loneliness, which then makes it even more difficult to get the interactional experience to reduce the anxiety. Solano and Koester demonstrated that loneliness is strongly associated with anxiety over social skills. In a second study, both factors appeared related significantly but independently to loneliness, with anxiety having a larger effect size. (Solano & Koester, 1989) Anxiety is often greater if there is a perceived disconnect with others. In other words, anxiety reflects on how one thinks and feels about communication with others, or the lack thereof. This can be changed by making communication more meaningful, which is an important aim in Communication-Focused Therapy®. One does not reduce anxiety primarily by changing the quantity of interactions with others and with oneself, but by changing the meaning that can be extracted from these communication flows. Helpful communication patterns include communicating about communication, which can happen in therapy or elsewhere, or asking the right questions, such as what may be the worst that could happen if one engages in a particular situation. It may also include such internal patterns as identifying own emotions and feelings and investigating what may be reasons for them. This may be achieved through categorizing the information contained in emotions and questioning once one has identified them. Important is to realize that all this is working with information that is being communicated internally or externally.
Anxious communication often results in communication patterns that reaffirm what is already feared. There is a certain circularity in them with trajectories that bend the line of thinking back towards the anxiety provoking information, whether thought or idea. Internal thought patterns cannot escape from the pull of the anxious thought. To break this cognitive inwards spiral requires often new meaningful information, which can pull the thoughts away. Thought patterns in therapy should thus be promoted which help the patient to perceive more meaning in the world around in themselves. The use of questions as a powerful tool in work on communication patterns has been described by the author elsewhere (Haverkampf, 2017e). They are often an effective means to help a patient to break out of a circularity, which maintains the anxiety.
Communication dynamics operate to a significant extent in feedback loops, where some information induces the processing of information and creation of another message. This can have a significant effect on the affective and emotional states of the recipient. Verheul and colleagues showed in their study that manipulations in physicians’ affect-oriented and expectancy-related communication had a large impact on patients’ affective state and outcome expectations. Only warm, empathic communication combined with positive expectations led to a significant and relevant decrease in state anxiety. (Verheul et al., 2010) However, the effect of communication is not a one-way street. If a patient with anxiety uses communication to positively influence the state of others, anxiety often also decreases. Thus, by practicing more empathy and compassion, while keeping healthy boundaries in place, anxiety can be overcome more easily. Empathy and compassion require certain external and internal communication patterns, which can be strengthened in a therapeutic setting.
Emotions are often communicated within defined communication patterns. Reasons may include that these are more effective in communicating the information, that they are easier understood by the recipient due to a familiarity with socially more widely used patterns, or that they help the person communicating in doing so. The objective is again not the ‘perfect message’, but a helpful communication dynamic that meets the needs of the person communicating the message. Weijts and colleague described how patients express their anxiety during gynecological consultations and how gynecologists react to these anxiety expressions. Patients generally present their fear in very covert ways, such as by implicit allusions to the possibility of having malignancies or by pressure for more drastic medical intervention. Patients’ anxiety was identified in speech disturbances, such as unfinished sentences and hesitations. Doctors had three types of reactions to patients’ anxiety: they explored it, they started to reassure immediately or they negated the anxiety expressions of patients. Each observed consultation appeared to contain one of these three scenarios. (Weijts et al., 1991)
In different situations and personal interactions different communication patterns are used. The communication patterns one uses in turn depend on how one defines a relationship, which then also has an effect on the communication patterns the other person uses. An interpersonal relationship and the communication styles thus depend on individual choices in each person, even though that choice is often not conscious. If one is suffering is from anxiety, particularly social anxiety, it is important to reflect on how one defines relationships with other people and as one sees other people, their thoughts, intentions and their purpose for the interaction. Often individuals suffering from anxiety interpret the purpose other people have for interacting in an unhelpful way. For example, they may project their own ambivalence towards interpersonal interactions into other people, which will raise the anxiety of interacting with them even higher. In this context, it also needs to be kept in mind that all anxiety has on some level an interpersonal component, which can go back to childhood or other past experiences. But an awareness for how one defines relationships and sees others define them as well as, even more importantly as a first step, the own potential to define relationships with others is crucial in working to overcome the own feeling of anxiety.
The communication patterns used can have a real effect on the recipient’s, and one’s own cognitive and emotional states and processes. Roter and colleagues analyzed audiotapes to describe communication patterns in a primary care setting. Physician satisfaction was lowest in the narrowly biomedical pattern and highest in the consumerist pattern, while patient satisfaction was highest in the psychosocial pattern. Primary care communication patterns ranged from narrowly biomedical to consumerist patterns and parallel the ideal forms of patient-physician relationships described in the literature. (Roter et al., 1997) The patterns they identified in a cluster analysis were: “narrowly biomedical”, “expanded biomedical” with moderate levels of psychosocial discussion, “biopsychosocial,” reflecting a balance of psychosocial and biomedical topics, “psychosocial” and “consumerist” (primarily with patient questions and physician information giving). Interestingly, the biomedical communication patterns were used more frequently by younger, male physicians and in older patients. Even though the investigators were using communication patterns in a more global sense, it is not difficult to deduce that the “biomedical” communication pattern uses a certain type of information, which is only a response to a limited set of information form the patient, such as medical data, for example. Thus, what determines the effectiveness of communication patterns is not primarily the specific content, but the dynamic of back and forth flow of information or, more generally, the dynamics and directions of the communication flows. This is one reason why a conceptualization of communication as a dynamic involving individual vectors makes theoretical and empirical sense. (Haverkampf, 2018a)
Internal communication patterns are more difficult to observe, but elements can be observed in a more metaphorical way in self-talk. Communication patterns that constantly scan for certain information in estimating risks or danger, such as self-criticism or trying to ‘mind read’ others, work with the need to fill a persistent perceived information deficit, which maintains the anxiety. Shi and colleagues showed that self-critical and social-assessing self-talk were positively related to people’s anxiety scores, whereas self-reinforcing self-talk was negatively associated with their anxiety. Implications of these results for the management of public speaking anxiety are discussed. (Shi et al., 2015)
Communication patterns are not just an adaptive product of the individual, but also of groups of people and societies. If the communication patterns an individual uses does not fit the social context, the communication dynamics that develop can be maladaptive, leading to increases in anxiety, psychological stress and other phenomena. Yum has pointed to differences in communication patterns between the West and East. The five most important areas of interpersonal relationships according to the author are influenced by Confucianism are particularism, reciprocity, the in‐group/out‐group distinction, the role of intermediaries, and the overlap of personal and public relationships. Confucianism has also brought a greater focus to process orientation, differentiated linguistic codes, indirect communication emphasis, and receiver‐centered communication. In contrast, North American patterns of communication represent outcome orientation, less‐differentiated linguistic codes, direct communication emphasis, and sender‐centered communication. (Yum, 1988)
This study examined cognitive patterns involved in communication anxiety, particularly in public speaking situations. The cognitive patterns were represented by Motley’s (1990) theoretical‐clinical conceptualization of either a “performance” or a “communication” orientation to public presentations. The mediating role of public self‐consciousness in these anxious cognitive patterns was also examined. Results indicated that Motley’s measurement of performance orientation (i.e. the presentation has to be perfect and will be closely scrutinized for delivery by the audience) was not associated with communication apprehension, public speaking anxiety, nor with public self‐consciousness. Although other scales performed as expected, the Performance/Communication Orientation scale proved to be multi‐factored and internally unreliable. (M. Booth‐Butterfield & Booth‐Butterfield, 1993)
The reality a person lives in is felt, perceived and constructed substantially. Information coming in from the outside world is processed, integrated, analyzed, interpreted immediately. This process continues up to the point where one is consciously aware of it and thinks or feels about it. Anxiety, like any other feeling or thought, is a product of this process.
Exposure to an anxiety provoking stimulus can, for example, also be done via the imagination or using virtual reality, that provides users with computer simulated environments with and within which they can interact. In a virtual reality setup, input devices can sense the subject’s reactions and motions, and the computer can modify the synthetic environment, creating the illusion of interacting with, and thus being immersed within the environment. This has been shown to be a helpful in the framework of exposure therapy. (Gorini & Riva, 2008) In other words, anxiety can be influenced by information patterns and dynamics, even if they are not part of the external shared reality.
The formulation and adjustment of communication patterns takes place within a certain framework of expectations and commonly used communication patterns. In a study in a healthcare setting, Ulrey and Amazon found intercultural communication and cultural sensitivity to be related, and that healthcare care providers’ levels of intercultural anxiety were related with effective intercultural communication. (Ulrey & Amason, 2001) Anxiety can thus also be reduced by greater awareness and insight into communications patterns and communication structures within a society or culture.
Anxiety is about the future. (Haverkampf, 2017c, 2018d) If one were strictly living in the now, there would be no anxiety. Whether one boards a flight, goes to see the doctor or sits an exam, if the future does not play a role, there would be no anxiety. Now, it is quite natural to think about the future. If one walks around directionless, one might wander in circles, which may not be bad. However, for most people this is not satisfying. Even meditation is supposed to lead somewhere, even if that somewhere is nowhere. Change is a fundamental and necessary aspect of life.
Imagination itself can be used in therapy. Vincelli, for example, described imaginative techniques using virtual reality to find new ways of applications in therapy. VR produces a change with respect to the traditional relationship between client and therapist, which is now based on the awareness of being more skilled in the difficult operations of recovery of past experiences through the memory and of foreseeing future experiences through the imagination. At the same time, subjects undergoing treatment perceive the advantage of being able to recreate and use a real experiential world within the confines of their therapists’s clinical offices. (Vincelli, 1999) However, it should not be forgotten that this process depends on patterns of internal and external communication.
The basic problem is not the future, or even the past, but how we think about information and communication. Humans have the ability to imagine themselves at different moments along the time axis, in the past, in the present and in the future. This is essentially a feature of the imagination. Even when thinking of the past and when basing it on information packages retrieved from memory, the imagination fills in whatever is missing from the recollection of the experience. We are therefore at the mercy of the imagination when making sense of any point in time which is not the present one.
Communication bridges the present and the future, as well as the past and the present. It helps store information or transmit it to people somewhere else we have never met. The principle behind it is that information will be transmitted on as long as the sender feels the message is relevant to another and/or oneself. Information endures as long as it is relevant to the people who communicate it. In an emergency information can get through because it is relevant, and the sender can expect help as long as he or she believes that the own emergency situation is relevant to others. The ability to communicate by various means, spoken, gestures, email, smoke and so forth, can thus make people feel safe, if they trust in their own skills and that their message will be relevant and meaningful to another. Patients with anxiety often have lower faith in either or both, which can be a result of negative life experiences or other factors, which all have in common that they change how an individual communicates with oneself and others, the communication patterns he or she selects and how meaningful information is selected for, decoded and reacted to.
Understanding is an important objective, and also precondition to an extent, of a communication dynamic, which can change another person’s state, emotional and otherwise. However, as mentioned above, communication patterns and the communication channels used have to work together in a way to effectively communicate a meaningful message. (Haverkampf, 2010a) In a study on how the pre‐operative education process is beneficial in reducing anxiety for patients awaiting a total hip replacement, Spaulding showed that patient education can reduce anxiety by making the unknown familiar. Such familiarity was apparently achieved by providing an understanding of the experiences patients will encounter during and after surgery, giving an opportunity to meet the staff that will be caring for them, and familiarizing patients with the environments they will meet when in hospital. (Spalding, 2003)
Communication is a means which should not be the only objective in itself. A purpose can help to build, maintain and enrich the communication process. (Haverkampf, 2018b) It can even change how one thinks of time and whether one focuses on the past, present or future, and to what degree. Rappaport in a study with residents of a retirement community found that life purpose and death anxiety were found to be negatively correlated, life purpose was found to correlate positively with projection of future time, and death anxiety was positively correlated with temporal density in the present. (Rappaport et al., 1993)
Another rule is thus that the purpose of communicating information, the communication patterns and the communication channels selected need to work together to yield more effective interactions with oneself and with others. (Haverkampf, 2010a, 2018a) This is one of the underlying rules communication, whether internal or external, contains. Purpose in itself is interestingly a concept that derives from communication, as it links the reason for which something is done or created or for which something exists and a person’s sense of resolve or determination. This, however, requires the intrapersonal transfer of meaningful information or communication between memory, imagination and decision-making systems in the neuronal network. External and internal communication are therefore in some ways a reflection of each other, which also explains why communication patterns used interpersonally and intrapersonally are equally reflections of each other. (Haverkampf, 2010a, 2017b)
Trust in oneself is built through communication with oneself and others and an expectation that one can get one’s needs, wants and aspirations satisfied through these interactions. Trust is thus a two-way street as it depends on the own competency to send messages about one’s needs, wants and aspirations into the world in a way that is most likely to get a result and for the world to respond in the way expected. From a communication viewpoint many parts to have to fall in place, from the own identification of what one truly needs and values to other people’s own sense of their needs, values and aspirations. Internal and external communication facilitate the match. Practicing communication. Internally and externally, can therefore build trust.
Building trust in oneself is an important component in the treatment of anxiety. A first step usually is that the patient can identify own needs and wishes, which is an important step in reconnecting with oneself. Feeling this reconnection is ultimately what builds more trust. If one is more connected with something, it becomes more predictable and closer to oneself.
In a study by Lewinsohn and colleagues on a subset of the participants of the Oregon Adolescent Depression Project, separation anxiety disorder (SAD) was a strong (78.6%) risk factor for the development of mental disorders during young adulthood, particularly panic disorder and depression. (Lewinson et al., 2008)
Communication anxiety or communication apprehension can severely restrict the extent to which communication can have an autoregulatory effect. Results of two separate studies provide evidence suggesting that individuals with communication anxiety avoid communication if possible and report considerable anxiety when forced to communicate. (Beatty, 1987) This, however, can further reduce the competence to communicate effectively. Zakahi and Duran, for example, showed a relationship between social competence, social experience and social networks. (Zakahi & Duran, 1982)
Recent advances in neuropsychology have led scholars to investigate the relationship between biological predisposition and communication anxiety. Evidence suggests that an individual’s predisposition to experience anxiety when communicating is linked to biologically‐based personality factors (i.e., neuroticism and introversion). (Kelly & Keaten, 2000) Beatty and colleagues, among them McCroskey who redefined communication apprehension in the early 1980s, contended that communication apprehension represents individuals’ expression of inborn, biological functioning, which has been shown to be antecedent to social experience and, therefore, independent of social learning processes. (Beatty et al., 1998) Communication anxiety (CA) can be separated into state‐CA (level of fear and anxiety) and context‐CA (predisposition), which are, however, related. Two research studies using the Communication Anxiety Inventory, showed that context‐CA explains a minimum of 50% of the state‐CA variance. (S. Booth‐Butterfield & Gould, 1986)
Uncertainty is a result of a perceived deficit of information, which can also lead to anxiety. The anxiety/uncertainty management (AUM) perspective and the role of effective communication in uncertainty reduction has been developed and discussed by Gudykunst (Gudykunst, 1993) and others. AUM in turn is based on the Uncertainty Reduction Theory (URT) which was introduced by Berger and Calabrese in 1974 and asserts that, when interacting, people need information about the other party in order to reduce their uncertainty. In gaining this information people are able to predict the other’s behavior and resulting actions, all of which according to the theory is crucial in the development of any relationship. Uncertainty can be cognitive uncertainty and behavioral.
Much of everyday communication happens now online. In a study by Fuller and Vician, computer anxiety, oral communication apprehension, and CMC familiarity contributed to CMC anxiety, while written communication apprehension did not. CMC anxiety explained 34% of the variance in attitudes, while attitudes, coupled with familiarity, explained 14% of the variance in CMC use. (Association for Information Systems. et al., 2000) It is interesting to note that an apprehension of oral communication contributed more to CMC anxiety than written communication apprehension. This could also indicate that communication mediated by a computer is experienced more akin to oral communication than written communication. From a communication patterns perspective this makes sense. When using a computer, particularly nowadays where social networks support fast-paced speech like interactions, there is faster feedback than if one uses conventional written communication, and it also may feel less permanent and more easily changeable than conventional writing. Maybe it is the greater immediacy and the faster pace which contributed to the anxiety at the time Fuller and Vician carried out their study in 2000 at the dawn of widespread internet use, that could explain part of the anxiety their probands experienced when using CMC. One might speculate that over time the use of internet based social networks has to some extent replaced oral communication, however, with the distinction that it is still text based, which reduces the number of channels where information can pass through. To someone with anxiety in social situations, who feels a need to constantly scan the various channels of communication, such as the auditory and the visual, this may offer a more ‘controllable’ environment. As CMC evolves over time, channels are taken back into it, such as video calls by mobile phone or others, but still with the choice which channels to use, unless there is an increasing pressure to use as many as possible, which would then take away any potential advantages of CMC for individuals who experience social anxiety.
The disconnect with oneself and others can be reversed quite easily. The fears that are connected with it are often the hardest obstacles to overcome. Various CFT techniques are described elsewhere. (Haverkampf, 2010b, 2017b, 2017c, 2018c) Through greater awareness for the communication patterns and information flows one uses with oneself and others, the fears to experiment with them is usually reduced and meaningful change can happen. This can be achieved in a therapeutic setting through working with the external communication, which is also the only one visible to a therapist. Reflecting on the external communication is then transposed to the inside, where the same skills can be used with the internal communication. It is important to realize, however, that these observation processes have to come from the patient to be successful. This is why manualized therapies are unhelpful in this regard, because the patient has to find a style of communicating about communicating, or reflecting, which is his or her own. Thus, in a therapeutic setting the therapist should not merely supply the own style of thinking about communication, but support the patient in finding back, or forward, to his or her own style.
Memories of past experiences and the emotions associated with these past experiences can have an impact on how one feels in the present and the strategies one uses to act and interact in everyday life. Better internal communication allows to gain an understanding for any emotions that still have not found closure and other issues that have not been resolved yet. However, fears may prevent this, such as the fear to get lost in the past without resolving anything in a constructive way.
When patients learn to better connect with themselves emotionally, cognitively and in all other communicative ways, the fear usually of confronting unresolved issues usually decreases. The reason is that a better connection with oneself also makes the own resources more accessible, and hence visible, while making the sense of self feel more present and more clearly defined. These processes may not happen in complete synchrony, which can require a greater emphasis on support in therapy, whenever the pain is clearer than the positive resources. However, usually the process of connecting with oneself in itself makes the patient feel stronger an in more in charge of his or her owner inner life.
The important role the thoughts and feelings about the future play in anxiety has already been discussed. Special significance is here assumed by the imagination. Working with internal and external communication to attain more effective communication and better connectedness internally and externally are here key as well. The basic parameters, the needs, values and aspirations, mentioned above remain quite stable over time and can thus give a significant sense of stability if used in a helpful way.
The level of anxiety depends on the communication patterns a person uses, both internally and externally. The more connectedness one experiences with the world and oneself, the lower the level of anxiety will be. What increases anxiety in an interpersonal context, for example, is not a desired connectedness but a sense of partial disconnectedness. (Haverkampf, 2010c; Solano & Koester, 1989) Achieving greater connectedness begins with seeking out connections that have a higher likelihood of helping one to meet one’s needs, values and aspirations. If this need is helping another person, for example, the other person should be in a state where they can receive and accept help. One does not have to have much in common with another person to benefit from an interaction. Important is that it is meaningful to both, which depends not just on the content of the exchanged messages but also on how they are coded, decoded and communicated.
Building communication patterns for more meaningful communication, internally and externally, is the most effective way of lowering anxiety. The author has suggested several approaches elsewhere. (Haverkampf, 2017c, 2017d, 2018c) However, often the first step in the treatment is to lay the foundation that this work can become possible, which requires a therapeutic relationship marked by trust, openness interpersonally and intrapersonal, the genuine desire to help, reflection and a focus on communication as the key to overcoming the anxiety.
We were looking at different communication patterns above and at how they can make existing internal and external ways of transporting meaningful information better suited to the own person and more effective in everyday life. However, there is also a global picture that needs to be appreciated. It is probably more a painting than a mosaic, because connectedness in the world, even in spite of the little personal islands we see floating around everywhere, is much more powerful than individualized compartmentalization could ever be. The pressure and pull of meaningful information flows cannot be withstood by anything in the long run. We live in a universe that is built on information, so to have one’s little island can only be fulfilling as long as one acknowledges at the same time that the whole island is built on information and natural laws that one’s island has in common with all the other islands out there. This insight is important because it makes it much easier to build a bridge with another secluded little island, because with the knowledge decreases the fear, and increases the urge to connect. Knowing that one already shares the foundations of life with another, under the sea level in our island metaphor, makes building bridges above seal-level much easier. Since we are already heavily connected by design, not connecting is not a real option.
As already discussed, the fear of connecting with oneself and others lies below the fear and anxiety people experience in their lives. The anxiety experienced in a job, the panic attacks in a turbulent relationship or while feeling alone, the anxious pangs in social situations, the more generally the fear of life (Haverkampf, 2020), and many more are result of a disconnect. This does not necessarily mean that one does not know what meaning may lie within the kernel of those fears. There could also be a disconnect form the information about one’s strengths and resources in an area, which one feels would be needed to overcome one’s fear. It may be puzzling that after millions of years of evolution one still has little faith in relying on one’s strengths, but there is probably also an evolutionary reason why we don’t. It forces us t think about it, to develop insight, to feel, and to connect consciously. It becomes easier to end an unhelpful disconnectedness from oneself and others when we make ourselves aware of the meaning and promise of connectedness. Connecting with oneself and others has intrinsic meaning that goes beyond a better transmission of information. It transcends it because connectedness is meaningful in itself. Even if there is a moment where being in a connected state with an old friend, for example, or a lover does not contain the exchanging of information, it has meaning or the potential to bring about change.
Individuals suffering from anxiety and panic attacks often see less meaning in the things they do. In therapy an important part is to rediscover meaning and to find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires. Meaning has the potential to bring about change, and meaningful information is what the individual should learn to select for more. Anxiety often leads to a withdrawal from meaningful information in the form of social withdrawal or greater rigidity in one’s daily activities by increasingly shutting out sources of valuable information. In a therapeutic setting this should be reversed by encouraging the patient to ask questions again, by having an inquisitive mind in the world which always looks out for meaningful information. The goal is not to shut off the constructive facilities of the mind. Many forms of meditation, for example, thus not have as the objective to turn off the mind but to actually find more meaning in the world in the form of information which brings about a beneficial change. A greater openness to meaningful information can so also decrease anxiety and the feelings that can lead to a panic state in a panic attack.
Communication has to be kept going in a way that benefits the individual and the group. Non-human primates have been show to use signals decreasing uncertainty about relationship states (Flack & Waal, 2007), which also highlights the importance of relationships as fundamental building blocks of social structures. Having working relationships, however, reduces the level of uncertainty about one’s place and role in the world, which also reduces the level of anxiety, because it does not only describe the present but also reaffirms a positive expectation about the future. Communication is the instrument people use to find out what they need, value and aspire to, while also being the instrument to achieve them. Since relationships are an expectation of communication events in the future, they also give rise to an expectation of future fulfilment of one’s needs, values and aspirations, and thus a sense of contentment and satisfaction in life, a feeling of happiness.
Communication can only affect a person and lead to positive change, however, if all involved in a communication process can work with meaning. In someone suffering from anxiety this skill in working with meaning may be impeded, even if the capacity to do so is intact. Learning from communication experiences helps improve those skills, but it may be blocked in some cases. Past traumatisations and other negative experiences can cause a person to move away and become distrustful of communication, rather than to move closer towards and embrace it. This makes it more difficult to work with communication, but also with the construction, encoding and decoding of meaning. And, without access to meaning, the disconnection process often accelerates, raising the level of anxiety, particularly in interpersonal situations.
An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty are quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing oneself and the feelings of a dreaded uncertainty about oneself and one’s emotional states.
This insight into the inner workings of anxiety is useful because it helps to formulate new strategies in interacting with oneself and with others. A feeling of anxiety has usually the same basic mechanisms in most people, the uncertainty about one’s inner world and affective states, the helplessness, the emotions where one has little insight, and which maintain the anxious state, as well as the at least partial disconnect which reduces the insight into the thoughts, sensations, perceptions and feelings which underlie the anxiety. But there are also the individual aspects of what triggers and maintains the anxiety, the own patterns and styles of communicating with oneself and others, which can be scrutinized and experimented with in therapy. Particularly the experimentation can be a helpful tool to create greater awareness for the communication pattern an individual engages in. In the practical context of therapy, questions about irreconcilable thought content or feelings, for example, can be helpful to get the patient to experiment with new perspectives and communication patterns. (Haverkampf, 2010b, 2013, 2017e, 2018e)
Understanding the internal and external communication patterns and styles also provides and understanding for the workings of the anxiety. The reason is that it is not particular content which necessarily leads to anxiety, but how this information is retrieved, viewed and processed. In a neural or any information network all these processes are different version of communicating information from one point to another. Manipulating information also requires communication. If different bundles of information are sent to one point they can be combined, and so on. On a larger scale, there are mechanisms which can malfunction and impede the proper workings of communication, information selection, and so on. In therapy, the focus should be on creating awareness for those points where helpful information cannot happen or can only happen partially. Important for this to work is a good therapist-patient relationship, which id itself the product of awareness for, reflection about and experimentation with communication patterns and flows.
One of the most relevant exchanges one can have is with oneself. But it cannot be separated entirely from one’s interactions with one’s environment. They both are two sides of one coin. The same rules apply to internal communication as for external communication and vice versa. It is not only necessary to develop awareness for the information coming from inside oneself but also to form patterns that are helpful in the internal communication. As we have seen, anxiety is largely due to a disconnect from oneself and the outside world, as various memories and pieces of information can no longer be seen in the context of other information for the relevance and meaning they truly have, and the lack of cognitive and emotional insight attaches uncertainty not only to them but to one’s inner world as a whole.
A therapist can help a patient reconnect with himself or herself in several ways. Using the external communication as a reflection of the internal communication, and vice versa, is a starting point. Patterns where the patient filters information in a certain way or a fear of certain messages may be obvious in patients from anxiety. Apparently high arousal levels without verbal messages that can explain the heightened arousal levels or the attempt to wrap an emotional signal in superficial rationalization of the information may be others. However, awareness of certain patterns is not necessarily a prerequisite of change. Using certain patterns to think about the patient’s communicated thoughts and experiences can alter how the patient experiences this information, if the therapist’s way is helpful to the patient. The patient integrates the meaningful information gained in a therapeutic setting with the other information contained in the various aspects of memory as well as in the neural network as a whole, which then influences the individual’s communication patterns with himself or herself and others. The most effective messages to bring about a change in these communication patterns are those which are about communication itself and which are meaningful in the sense that they can be understood and lead to change. This requires that the therapist makes sure that the information from and about the interaction is understood by the patient. At the same time, both will try to keep the information relevant and helpful. The patient learns in the process to identify what is relevant to him or her, which then has an impact on internal and external ways of communicating.
Better interactions with others, which reduces anxiety, follows from better interactions with oneself. The reason is that since one cannot know the thoughts or feelings of another person fully, one will always project an element of oneself into the other person. We assume that another person will behave either as they did in the past or in a way that seems to us reasonable, if we judge the other person as reasonable. Thus, to a degree one interacts with oneself when one interacts with another person, while being corrected by the other person about one’s assumptions as the exchange progresses. It is thus important to have a good sense of oneself to know what is a projection and what is not.
Interacting with oneself is also practicing communication, which helps in communicating with others. It is not a substitute for communicating with others but helps in experimenting with different communication patterns. Also, since there are significant similarities among people on a more basic level, one’s own reaction to a thought or feeling can be a good first indication of what another person might feel. This is how art, literature and films can excite multitudes because they touch what is shared by most people.
To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.
Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which one ways one relates to one’s environment and exchanges messages with it.
Often, individuals suffering from anxiety or burnout have become uncertain about what is really important to them and the fit between these values and interests and their current life situation. Whether in the professional or romantic realms, following one’s needs, values and aspirations has the best chance of maintaining happiness, satisfaction and contentment in the long run. If I value helping people, it is important that I do that to make me feel better in the long-run. Important is to identify those basic parameters which do not change much over time. Often people might be too focused on the short-run at the expense of a greater quality of life in the long-run and potentially higher anxiety levels. Open and rich communication with oneself and the environment can ensure that one gets the correct information about oneself and the world in this respect to make better decisions. Fears of connecting with oneself and the world may interfere with this openness, and it is important to find insight into them in the therapeutic process. Making the fears visible through greater awareness of the own communication patterns, internally and externally, leads to their resolution. This is in turn can then allow the autoregulatory mechanisms of internal and communication to lower the anxiety.
Since values and basic needs remain relatively stable over time, knowing about them can give a patient a greater sense of safety about oneself. Having knowledge of them also helps in interacting with others, partly because one feels more secure about oneself and partly because having a clearer idea about one’s needs also helps one to have a clear of others’ needs.
The process by which one identifies one’s own needs, values and aspirations is self-exploration. It means engaging in communication with oneself, being open and receptive to the information one is receiving from one’s body and mind, while also being perceptive to one’s emotions. The emotions can play an important role in gauging what is ‘good’ and what is not, because they are the end product of a large amount of information which has been integrated into them over time. So, if one truly feels contentment and satisfaction when engaged in an activity, it may be needed or of special value. Self-exploration is thus not a process of getting lost in one’s thought but an active appraisal of the various aspects and activities in life. In a therapeutic setting it helps to ask the patient about how he or she felt in various situations and activities in life. Rather than focusing on the anxiety, greater focus should be placed on the areas in life which are meaningful and valuable to the patient. When focusing on the anxiety, the main focus is on exploring potential emotional conflicts, which can also include the patient having to do something which goes against the patient’s needs, interests, values or aspirations.
Self-exploration has internal and external components, an assessment of internal basic parameters, needs, values and aspirations, as well as an assessment of activities, situations and interactions a patient may engage in. Improvements in internal and external communication can therefore lead to a shift towards following the own needs, values and aspirations, which reduces the level of anxiety.
Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process.
The therapeutic setting is a microcosm in which the internal world can be played out and the external world be experimented on. An important quality in the therapist is not to take anything that happens in this setting as personal. What happens in the therapeutic setting should be seen as relevant to that specific setting only, which can give the patient a greater sense of safety to bring the internal world out into the setting. By then experimenting and daring new patterns in the setting, the patient develops insight and builds confidence in the communication process with oneself and others. It is the task of the therapist to support the dynamics of this process through observations, reflection, feedback, and by maintaining healthy boundaries between the therapeutic setting and the outside world. At the same time, the patient will carry more of the insight and skills gained into the therapeutic process into the outside world if it appears helpful and relevant.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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