REDUCING SYMPTOMS OF SOCIAL ANXIETY IN A YOUNG ADULT: A CASE STUDY ON REATTACH
Renske TER MAAT
Private practice, Nijmegen,
Online first 2-July-2018
The objective of an educational psychologist is stimulating the healthy development of young adults. This is achieved by using psychological and pedagogical interventions, for example Cognitive Behavioral Therapy (CBT), coaching of parents and ReAttach. First studies show that, within an average of five sessions, ReAttach significantly reduces problematic behaviour in children (Weerkamp-Bartholomeus, 2015-a) and psychological complaints in adults (Weerkamp-Bartholomeus, 2015-b). As ReAttach is a new intervention, the mechanisms behind the therapy are still to be researched. It is expected that the theoretical concepts of schema therapy, information processing and arousal regulation, on which ReAttach is based, explain the success of the treatment.
To gain a better understanding of theory behind the treatment outcomes in adults and the use of ReAttach in practice, this article focusses on theoretically explaining the effects of ReAttach on a young adult who experiences feelings of anxiety. In the next section, the theoretical principles of ReAttach are being outlined. Then, the use of ReAttach in practice is illustrated. Furthermore, the treatment process of Jake (alias) will be described, incorporating both ReAttach theory and practical decision making.
2. Theoretical principles
ReAttach was found to be a method of changing schemas: patterns of thoughts and behaviour that trigger maladaptive coping strategies, such as avoidance, perfectionism, and overcompensation, causing low self-esteem, negative thoughts, anxiety and stress (Weerkamp-Bartholomeus, 2015-b). ReAttach is a multimodal intervention based on the combined theoretical principles of arousal regulation, information processing and schema therapy. The next section will briefly outline these theoretical principles and its application in treatment.
By twelve months of age, infants can create schemas: representations of the self and their environment (Gelman, 2009). In literature, schemas are also called concepts, assumptions or attitudes. For consistency throughout this article, I will use the terminology of schema therapy. Schemas are important beliefs and feelings that are developed and inhibited by the individual (Young, 1999, Young, Klosko, & Weishaar, 2016). People use schemas to organize their experiences, to interpret what happens around them, to simplify the world and to adequately react to it. New information that is formed into schemas is highly influenced by our existing schemas, as schemas function as a blueprint that we use to interpret new information. Clinical anxiety could be described in terms of a biased information-processing system, in which negative schemas are over-activated, causing clients to look for more negative information (Beck et. al., 1985). Dysfunctional schemas lead to more dysfunctional thoughts and behaviour, forming the root of psychological problems (Young, 1990). Psychological disorders may come into existence due to these cognitive distortions causing maladaptive emotional regulation strategies (Leahy, 2012).
Schema therapy was developed to change old, dysfunctional thoughts and behaviour that lead to psychological complaints. The therapist works with thoughts that are important to the schema: either to prove or to disprove a schema (Young, Klosko, & Weishaar, 2016). ReAttach aims to do so by using multisensory processing techniques. Note that ReAttach is not a form of schema therapy, but that it can be described as an intervention that reduces psychological stress, based on the theoretical principles of schema therapy.
The multisensory approach is used to stimulate healthy information processing. ReAttach creates the same information processing situation as during play, in which children unconsciously process new information. This is done by tapping on the client’s hands and thereby regulating the clients’ arousal to the same level as during play: alert, but not overly aroused or frightened. As the information processing in an overly aroused person is biased by negative schemas (Beck et. Al, 1985), an overly aroused, or even anxious person, tends so see more negative information and is less able to weigh up positive information correctly. In children, over-arousal even leads to a decline in the amount and quality of play (Verhulst, 2017). The right amount of arousal creates a joint attention and a feeling of safety (Bartholomeus, 2013), thereby creating the conditions to process information through the different senses: the calming touch and verbal prompts used in ReAttach. Information processing through different senses is an essential element of the construction of healthy cognitive representations and schemas (Baum, 2015), as the brain gains more information from an event that is perceived by multiple senses, than by the sum of several senses or one sense alone (Stein, 2012).
While tapping on the hands of the client, the therapist gives verbal prompts to steer the process of changing schemas. To change schemas, the client needs explicit or implicit cues from language (Gelman et al., 2008). The verbal prompts used in ReAttach help reprocessing existing negative thinking patterns into more functional schemas (Bartholomeus, 2013). By adding new information, a negative schema can be disproved and positive schemas can be created (Young, Klosko, & Weishaar, 2016). Adjusting and reprocessing negative thoughts into more realistic schemas creates more compassionate coping styles, which in turn decreases psychological problems (Leahy, 2012, Weerkamp-Bartholomeus, 2015-b).
3. ReAttach in practice
This section will expand on the use of ReAttach in young adults who feel stressed and insecure. Although a slight increase of insecurity accompanies this age (Feldman, 2016), a fair amount of mental health problems can be reduced by ReAttach (Weerkamp-Bartholomeus, 2015-b). As ReAttach could be used as a form of secondary prevention of psychological problems: the objective is to reduce light to medium psychological complaints and enhance mental functioning in clients. ReAttach requires five therapy sessions on average (Bartholomeus, 2013), thereby presenting a solution in the search for shorter and more cost-efficient treatment.
ReAttach sessions follow a protocol, but also leave room for coaching and the use of additional treatment methods such as cognitive behavioural therapy, to assist the client in making a more conscious transfer to situations they encounter in daily life. ReAttach can be valuable in therapy for clients who are unable to tell their story. The exact contents of the schemas are not important to the therapist to give helpful language cues (Bartholomeus, 2013). Not having to talk about problems while still processing the information leaves room to focus on strengths, which is one of the principles of an empowering and motivational therapist attitude (Miller & Rollnick, 2002). ReAttach also leaves room for motivational interviewing during coaching, in which clients talk about changes they envision and look for ways to incorporate the new schemas into their daily lives, instead of talking about problems and negative schemas (Miller & Rollnick, 2002). The more clients hear and talk about the new schemas, the better these are embedded in the long-term memory and the better the treatment outcomes (Miller & Rollnick, 2002).
4. Empirical case-study: the treatment of Jake.
To illustrate the use of ReAttach in practice, this chapter focusses on the case of Jake, a 22-year old man with anxiety and negative thoughts. Background information will be provided; then the treatment will be described and likened to the theoretical principles and clinical decision making.
4.1. Background information and description of the problem
Jake, a 22-year old man, sent an email in which he explained the problems he faced on a daily base: anxiety, insecurity and negative thoughts. Jake did not feel comfortable going outside anymore, because he thought that other people watched him and talked about him behind his back. He gave the example that, while travelling by train, he was aware of all the people looking at him, making him anxious and overly alert. He used to put on music to focus on something else, but still needed to check every five minutes whether people were talking about him: turning the volume down to listen to the contents of the conversations around him. Jake did not feel comfortable walking in the city, past terraces and at university. He kept thinking that everyone was staring at him, judging him and talking about him, leaving him anxious and insecure. Jake could not explain these thoughts and decided that he needed help.
4.2. Intervention analysis
During the intake, Jake appeared to be a modern man that took good care of himself. He openly explained the problems he experienced. He added that he was in his last year of university: Jake was studying to become a geography teacher. He doubted that this was the right profession for him, for teaching children did not make him happy, but he did not know what else to do. He was given an assignment to do research on education, but he did not like it much. Jake also explained that the relationship with his boyfriend was ambivalent. He used marihuana on a regular basis, usually at night, to relax and fall asleep. Jake obsessed about the relationships with his friends: he felt that he did not belong in their group of friends. He also felt that his friends talked about him behind his back, even though he rationally knew this was not true. Jake felt anxious when he thought about how these problems had got worse over the last year. He had heard of ReAttach when his aunt had treatment with ReAttach and experienced positive outcomes, so his outcome expectancy was high. Jake was using marihuana, so it was explained to him how quitting the use of marihuana could be beneficial for the treatment. As THC in marihuana impairs episodic memory and learning (Curran et al., 2002) and creates differences in information processing (Kempel et al., 2013), not using drugs is a condition for ReAttach to have better effects.
The goals of the treatment were:
- Jake to feel less anxious in social situations and in public life
- Jake to experience less negative thoughts in social situations and in public life
- Jake’s feelings of self-worth to increase
ReAttach protocol was used to activate information processing. The first session focused on processing the thoughts that Jake experienced while walking on the street and sitting in the train, to make these thoughts less present and decrease the anxiety. Regulating the overall arousal was important here, because the processing of information only happens when people are not anxious (Weerkamp-Bartholomeus, 2015-c). The first session focused on creating positive schemas to improve self-esteem and reduce insecurity. These schemes were composed of the positive things in life, such as positive traits and everything Jake was proud of. Afterwards, Jake was given the task of talking to his friends and find out what they thought about him. He was also asked to fill in a symptom questionnaire as a pre-test.
By session two, a few weeks later, Jake had talked to his friends and found out that they appreciated him. He had also stopped using marihuana and had been clean for a week. His boyfriend helped him to stay clean by staying over and supporting Jake during the evening. Jake elaborately spoke about his doubts about university, not belonging with his friends and his jobs. For example, Jake worked both in a clothing and plants store and in a cloakroom: at the store, he felt safe and accepted; in the cloakroom he had had a few negative comments about his looks. This second session of ReAttach focused on processing negative thoughts about friends and strangers talking behind his back, on further establishing the positive schema of the self and on creating a schema with information regarding everything that would keep Jake able to stay clean.
Before session three, Jake had filled in the questionnaire. All clients are asked to fill in the CSE-R questionnaire, so that the therapist can monitor the treatment process and results. The CSE-R questionnaire measures psychological distress and consists of symptoms of mental health problems (Weerkamp-Bartholomeus, 2018), for example symptoms of anxiety, depression and ADHD. The CSE-R is currently being validated, but first research indicates that a change of 10 points is a significant change. Jake found filling in the questionnaire confronting as he recognized most symptoms. He discussed the score and the questionnaire confirmed the symptoms Jake already described. His overall score indicated serious problems. His score was particularly high on the items that indicated anxiety, specifically insecurity. Both the pre-test and the post-test scores are presented in table 1.
Scores on the CSE-R
During coaching in session 3, Jake admitted that he had been to university that day and that he wanted to change his major subject, but that he did not know if he could do the course he wanted to do. Furthermore, Jake found that his research assignment took too long, blaming himself for taking the time he needed. He was afraid of failure and felt insecure. Jake still had not used any drugs, making him more restless, but also a little proud. To help Jake in changing his view on people talking behind his back, the chance that people talked about him while he was walking in the city was being discussed: Jake estimated that this chance would be around 20 percent. After drawing a pie chart and talking for a while, Jake concluded that the actual chance was likely around 5 percent. During the session, this topic was briefly touched upon, as these thoughts were already activated while talking. Instead, the third session focused on processing general thoughts of insecurity to reduce anxiety in its broadness, as the need to be perfect – resulting in anxiety and negative thoughts – seemed to be the root of the problem. To reduce maladaptive emotional regulation strategies (Leahy, 2012) and to establish an adaptive coping strategy, creating a schema of self-love was stimulated.
About three weeks later, during the fourth session, Jake stated that whilst commuting, he had experienced less negative thoughts and anxiety. He wondered whether this could have been the effect of our previous sessions. Jake also broke up with his boyfriend. His feelings about this were both relief and sadness, as the relationship had been ambivalent and he had seen the break-up coming. Whilst discussing this timing, Jake concluded that he had never felt secure enough to break up before. This was a positive improvement, as Jake faced a lot of insecurity. To reduce his symptoms more effectively, Jake agreed to focus even more on the underlying problem of insecurity and coping. He talked about his personal history, in which Jake had struggled with his identity and had been trying to learn to accept himself as he was. The fourth session aimed to establish the positive schema of the self and visualizing throwing away the judgments of others. Jake was given tools on handling negative comments he would encounter in the future. Visualization is another successful tool to form schemas (Pham & Taylor, 1999), enhancing the link between thought and action. Combining multiple tools, such as language cues and visualisation, leads to better treatment outcomes.
Session five started on a very positive note: Jake had met a new guy and whilst this guy was double his age and Jake felt insecure about the age difference, he had told his friends. It did not occur to him that his friends might have had thoughts or judgments about the age difference. This was another positive improvement, as during our first session Jake explained that he suffered from negative thoughts about not belonging in his group of friends. The negative schema appeared to be less present. This fifth session focused on processing general information and on establishing positive thoughts in the schema of the self, creating a positive image of the self. Jake also worked on the schema of being good enough, even though nobody is perfect. Afterwards, Jake was given the task of writing down everything he wanted to remember from our ReAttach sessions.
Two weeks later, after 5 sessions, Jake filled in the questionnaire and it came out symptom-free (Table 1). He stated that filling in the questionnaire felt very different than the first time: he
had experienced more positive thoughts about himself. He agreed to finish the therapy and to keeping in touch if necessary.
Three months later, Jake told me that he felt good, but that he still had not finished his research project. Although Jake made a negative comment about his functioning at university, the results of the therapy remained positive. Jake was asked to fill in the questionnaire as a follow-up, but he did not fill in the questionnaire as he did not feel the need to.
Although Jake experienced positive treatment outcomes while following ReAttach theory, different explanations and further recommendations can be considered. This section briefly touches other possible explanations that might have caused a decrease in the symptoms of anxiety in Jake. Then, I will add recommendations for the questionnaire and research.
ReAttach might not be the only possible explanation for the results that have been found in the case of Jake. Therefore, it may be useful to consider other possible explanations. For example, since Jake had a high outcome expectancy, the success of the treatment may have been the effect of a self-fulfilling prophecy. When outcome expectancies are high, clients tend to report better outcomes than clients who have lower outcome expectancies, accounting for a substantial part of variance in treatment results (Joyce & Piper, 1988). Jake might have reported better outcomes on the questionnaire due to the successful treatment of his aunt and his fear of failure.
Also, the coaching techniques based on cognitive behavioural therapy might have caused a decrease in symptoms of anxiety. Although cognitive behavioural techniques usually need more than five sessions to be effective, these techniques help clients to change their view on situations and are known to significantly decrease the symptoms of anxiety (Korrelboom & ten Broeke, 2004). Research on the amount of variance caused by ReAttach and the amount of variance caused by cognitive behavioural therapy could be considered when ReAttach is used combined with coaching.
For a ReAttach therapist it is not necessary to know the contents of the maladaptive schemas and the CSE-R has given enough insight in Jake’s problems to intervene. However, schema questionnaires – for example the Young Schema Questionnaire (YSQ) – could give a better and more evidence-based insight in the contents of the schemas, forming a more accurate indication for the therapist in deciding on treatment goals and intervention strategies. It also creates the opportunity to describe treatment goals in schema therapy terminology, embedding schema theory further into practice.
Although short and cost-efficient solutions to psychological complaints are very useful, research on ReAttach is practice-based. Further research on ReAttach is currently being done to build a stronger theoretical framework and to find more evidence for the working of ReAttach. I support the search for stronger evidence on the elements that explain the working of ReAttach.
In the case of Jake, ReAttach treatment has been successful. The treatment reduced feelings of anxiety and the presence of negative thoughts. Is also established a more positive and realistic self-image, increasing feelings of self-worth in Jake. Treatment goals have therefore been accomplished.
Because Jake was anxious and in an overly aroused state, regulating the arousal was an important component of the treatment. When Jake would have been aroused during the sessions, a negative schemas bias, as described by Beck et. Al. (1985), could be present. The regulating of his arousal by tapping on his hands may have facilitated a balanced information processing situation in Jake.
The processing of negative information and dysfunctional thoughts had led to the presence of less dysfunctional schemas, which may be the cause of the decline of symptoms. Information that is less present, leads to less cognitive distortions and emotions (Bartholomeus, 2013). Jake also reported more feelings of security and happiness, indicating the presence of more functional schemas. The verbal prompts focusing on establishing a good and positive image of the self, might have increased a positive thought pattern in Jake regarding his identity. Jake’s new and different view on social situations and on expectations of others towards Jake diminished his anxiety and created a more functional coping style with social situations.
In conclusion, ReAttach treatment decision making followed the principles of schema therapy, information processing and arousal regulation. These theories seem applicable to the case of Jake. ReAttach may have helped Jake developing healthy schemas, which may have led to a decline in his symptoms of anxiety. Further mental health treatment seemed unnecessary, as five sessions of ReAttach in secondary prevention was enough to enhance the psychological functioning in Jake.
I would like to thank Jake, who was willing to let me write down his story.
Conflicts of interests
The author declares no conflict of interests.
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