Anxiety
Neurophysiological presentation and treatment
If we consider anxiety from a neurophysiological perspective, in terms of states of vagal arousal, we can start to understand a) what is happening in the client nervous system and b) how to address it.
For clients with anxiety, the experience is very visceral. It is a felt sense that dominates the entire self.
So perhaps it is wise to first consider the ‘feeling’ aspect of anxiety so that we can really connect to the visceral experience of the client. It is my sense that understanding the felt sense AND the neurophysiological presentation of that, gives us greater insight into the complete experience… so that we can then treat it in an informed and integrated way.
So, what does anxiety feel like? While of course it is a different experience for everyone, there are common themes that arise in clinic. These may include:
Upwards movement of energy
Increased heart rate or a feeling like the heart is going to stop beating (or both)
Increase and/or decrease in body temperature
Buzzing in the head or headaches
Unpleasant tingling in limbs
Churning stomach that may present with loose stools or heaviness in pit of stomach that may present with constipation
Racing thoughts or inability to form clear thoughts/brain fog
Surges in energy interspersed with drops in energy
Poor or broken sleep
When I look at this list of symptoms, I can already connect to this sense of confusion that must be present in the body, or the nervous system. It feels to me like the system doesn’t know where to land... that it is going crazy trying to find a calm place but can’t.
The image of a blindfolded chicken running around in a frenzy comes to mind. The chicken has no idea where it is going. It wants to find its home but it can’t so it just keeps running around getting more and more agitated and confused. And if I think of that chicken, it must be absolutely terrified. I can imagine that it wants to flee flee flee - that it is in total high tone sympathetic arousal. But I can also imagine that because it can’t see and has no idea what is going on, that it wants desperately to hide, to shut down (enter high tone parasympathetic arousal) until someone takes off the blindfold (that the poor chicken probably has no idea that it is wearing in the first place).
Really, the chicken is completely confused and has no way to help itself.
Confusion is a key component to understanding anxiety.
My sense is that there is a lock in the nervous system – both a high tone sympathetic arousal (fight or flight) and a high tone parasympathetic arousal (freeze/shut down). This is a kind of neuro-physiological fight. It’s like two responses pulling at opposite ends. A tug of war. I guess in a tug of war, one side always eventually wins…
The other thing that I strongly sense, is that in cases of anxiety, it is the sympathetic fight or flight charge that lies beneath the surface and is being covered or blocked by the parasympathetic (freeze/shut down response).
It’s like the sense of danger is too great to bear, so the system is shutting down so as not to feel it. So, there is no potential for discharge or completion. The system is locked.
If this is the case, how do we help?
Let’s go back to our poor chicken…
Before we can help this chicken, before it is going to let us take off its blindfold and show us the way home, we have to gain its trust. There’s no other way to help the chicken at this time. The chicken feels so unsafe. So unsafe that it cannot even tell anyone how unsafe it feels. It is in such a frenzy it doesn’t even know how it feels. We have to help that chicken know who we are and that we are here to help. We have to gain its trust. It is only then, that we can even start to consider to attempt to take of its blindfold… and start to address how the hell that poor chicken got blinded in the first place.
Ok, enough of the chicken scenario.
What I am trying to say is, that before we can address the sympathetic arousal under the surface, we need to address the dorsal response…the shut down. And this is achieved by making the client feel safe. By achieving trust. I really believe this is the only way to work effectively with anxiety. And it takes time. It takes resonance. It takes relationship.
I sense that that shut down response, which is a strong self-protective mechanism, must be addressed first.
The clients must feel safe enough (with their therapist) to even admit to or access the fact that they feel wildly unsafe. The shut down/freeze/dorsal arousal is keeping them safe from their overwhelming sense of unsafety. And until they feel safe enough to access that sense of unsafety, there is no way to start exploring what exactly has caused this extreme level of unsafety.
So, as therapists this is the primary goal. To make the client feel safe enough to come out of high tone dorsal vagal arousal. To CONNECT with us. To make a space where it is safe enough to connect with whatever it is that is going on at a deeper level.
Anxiety is a complex neurophysiological response that, in a way, dissociates or distracts from the problem/issue/event/trauma… because it is unsafe to process. It is a survival mechanism.
As therapists, our job is to create a safe haven where processing is welcomed and safely held. Once the client feels safe in connection, the dorsal response can start to naturally switch off. Working with the mindset ‘safety first’, ‘connection first’ supports intent not to retraumatise. We are not looking to dig into the trauma or force a release. Quite the opposite, we are nurturing a dynamic within which it is safe to gently process.
So how do we do this? How do we make the client feel safe?
My belief is that relational resonance, the promotion of co-regulation, is the largest part of this process. The client needs to know ‘ I hear you. I see you. I feel you.’ And more importantly, ‘ I am here. Your trauma does not scare me.’ ‘I can hold whatever surfaces from within you.’
Because anxiety is a very visceral experience, these clients are likely going to have a visceral experience of therapy, and in response to their therapist.
As therapists, ensuring that we are grounded, that we have safely put aside our own personal process is vital. We need to be here for the client. And they need to be able to feel that.
In a somatic or body sense, a calm flow of breath and steady heart beat is also supportive. The client can unconsciously feel all these things and will respond to our body’s biological rhythms.
Working with eye contact, tone and speed of voice, language and quite moments can also be helpful in showing the client just how attuned you are to them and their process.
Mirroring is another wonderful way to show a client that you are really present – both with words and body language.
Letting a client know you notice the changes in their experience during a session may, depending on the client, help them trust you are there and that you care… however for some, this may be overwhelming.
The constant question in our minds should be: what can I do to help my client feel safe right now? And the answer may vary moment to moment.
Something that may be surprising to some therapists… if you are not sure what your client needs to feel safe… you can ask them! This doesn’t signal a lack of attunement. This signals your willingness to listen and learn and continue to attune. So ask!
Apart from our personal presence, we can also work with the physical space to create a physical safe haven that supports down-regualtion… the feeling of being supported to relax and let go. Depending on how intricate you take this idea, you can conjure everything from the comfort of the seat to the colours, the smells, the art and the lighting. The question again, is what would make my client feel safe?
If we continue to bring everything back to this question, I feel we can’t go wrong. Once the client feels safe, or just safe enough, to lift out of that dorsal response, the anxiety response, is no more. Because there is no lock or tug of war occurring. And then we can get to work on the good stuff.
When we focus on safety first, we do not need to be so concerned about retraumatising releases. We are laying the foundation of a therapeutic relationship within which it will become safe to slowly start showing parts or fragments of self that were perhaps once unsafe to show. When it is safe to show these parts, they will emerge naturally, gently and with no need to poke or dig or pull apart.
So my conclusion here, is that anxiety is this confused and contradicting response in the nervous system. A kind of shut down or dissociation because whatever the trauma or issue is, has been deemed unsafe to feel, express or process. Therefore, the first step to working with anxiety, is to build safety in connection. The safer the client feels in connection with the therapist, the safer it becomes for them to connect to what is really going on within themselves. The protective shut down mechanism is no longer valid, because it is safe to connect.
So that’s my take! I’d love to hear from you and how you are working with anxiety, your thoughts on what I’ve shared. Thanks for listening.