 We demystify what goes on behind the therapy room door. Join us on this voyage of discovery and co-creative conversations. This is The Therapy Show, behind closed doors podcast with Bob Cook and Jackie Jones. Welcome to the next episode of The Therapy Show with Bob Cook and myself, Jackie Jones, and we're going to be talking about working with the anxious client in this week's episode, which is something that I see an awful lot of in clients. So it's probably the main reason that people make contact with me. Oh, OK. Perhaps we can start off with you. So if you gave a picture of an anxious client, you know, give me, I'll be interested if you work mostly with a lot of anxious clients. How would they present them? Usually talking very fast and giving me lots of information, probably before we even meet each other. They need me to know their story through an email or a message or something. They're usually very good at sharing things in my experience. So they talk very fast? Usually, yeah. Would you say they're highly energetic? Yeah, nervous energy. Lots of nervous energy and their words are tumbling out to try and explain their story even before they've met you. Yes. And then there's the other extreme. What's the other extreme then? Whether or not very good at sharing anything and they're quite critical and fearful of saying too much and everything. So those people, even though. So the common theme is nervousness. Would you say high energy? Wanted to. Yeah. And that's the common theme. But then you get different categories of people who want to share a lot. But others that find it hard to actually get their anxiety out. Yeah, need a lot of permission to be able to talk about things. You see, I think that's yeah. Let's start there then. I think what you just said there is very, very important, especially with somebody who's anxious, permission by the therapist to tell their story. And more than that, to take their time to tell the story. So this is where therapists might. And if you listen to the last podcast, we're talking about how a therapist might be instrumental in the pace of the clinical work in terms of rapport. This might be where it's very important for a therapist to slow down the procedure. And to be the best way to do it is where you just started off, Jackie, in my opinion, is to give the client permission. Oh, it's OK, just take your time. Yeah, yeah, just slow down a bit. I know I can see you're very anxious about this. So we've got a whole hour. So, you know, you start wherever you want to start. So I see, I think permissions for an anxious client is really important. It's like saying to them, you know, everything's OK, you know, the world's not going to. You wouldn't say it like this, but the inference might be the world won't collapse. OK, we've got plenty of time. You just just take your time here. I hear you might be feeling apprehensive or anxious, and it's OK for us to just talk, take our time talking or however you want to do it in terms of. Yeah, yeah. So I think to give permissions to because what you're really talking about, I think, is promoting safety and security within the therapeutic room so the anxious client can feel OK to talk. Yes. Yeah, definitely. Yeah, I'm that I don't want to normalise what they're going through, but that it's OK, which might sound a bit, you know, simplistic. But, you know, often anxious clients come to me that it's am I the worst you've ever seen? You know, is this normal behavior? Should I be behaving all those questions? Oh, yeah. And I think it's really OK to just to talk like we have just said. So the child, the younger part of the anxious client feels that you understand them. Yeah. So I don't really think that is a very, you know, it may sound simple, but it's very sophisticated in other words. Yeah. If you don't do that, you can lose the client because they feel they may feel we're in the space for them to really talk about what it's all about. Yeah. And I think again, touching on what you just said then about the child part, I think it is really important and something I'm very conscious of is providing that safe space and being seen as. Strong enough to hold them in that, if that makes sense, because sometimes I think the anxious client feels like they'll overwhelm you. Yes, because they feel they're overwhelming themselves. Yeah. Yeah. Yeah, absolutely. That's why you've got permission to say it's OK. Just take your time here. We'll we'll get to what it's all about. Start wherever you want to start. Yeah. I mean, that's the bit that you're talking about. Now, it's hard to take several forms. So we have I just jotted a few down here, but let's start with them. We can have panic sorters. Yeah. For example, panic, fear and people get very anxious and they move into what might go into described as a fear or flight process. But let's stay with panic and they panic themselves and they get to a place of what I would call fear over fear. Yeah. And anxiety is very high there in that panic. And often with their panic comes palpitations. And of course, the panic is all about something. It's all really about Jackie. They're very frightened, very scared. So they panic themselves through. And the anxiety comes out in the form of panic and fear. Yeah. And palpitations, actually, is in the body. The heart races very fast. So once that's happened, it becomes super sensitive of any changes in the body. Yes, yeah, yeah. All the changes like they feel like their stomach is knotted up or they feel like, you know, as they get like that, they come very sensitive, I think, to to any changes by rear or constipation or any of these symptoms that really come with anxiety. Yeah. Yeah. No, you talk to you about those as well. So panic is another form of anxiety. Post-traumatic stress disorder. Yeah. There's a lot of anxiety with that. And what that means is that they have been triggered by something in the presence, which reminds me of the past. So some things happen traumatic in their past, which they've repressed. But then what happens, they get triggered by something in the present, which opens that door of where they've kept those stored traumas and that they come tumbling out and that provides a very. It's all based on fear again, you see, Jack, that that provides great anxiety. Yeah. Phobias also is another form of anxiety. We're talking about people have lots of phobias and are very anxious. But again, the real bedrock of this is fear. So as a therapist, we need to provide a very safe environment and also be a safe figure for them when you think of it in terms of safety and security to help the anxious person not be so frightened. Yeah. The fear, the, you know, if you think of this, that's what's behind the anxiety, extreme fear. Then that's where you need to start to help the person have a have a safe therapy to place as an antithesis to the fear. Now, the fear is usually driven by distorted thinking. So it's so usually fine with anxious people, they overthink. Yeah. They think, think, think, think, think, think, think, think. And then they worry about their thinking and then we have an escalating process. But they if you ask any anxious person or any client and has extreme anxiety, do you overthink a lot? They would, yes, immediately. And that produces fear, that produces anxiety. And then you're in that whole hamster wheel. Yeah. I see a lot of the overthinking and the planning and the preparation and everything that goes on. It's it's it's a survival mechanism. It's needing to control the environment. So they're not going to be caught out or nothing's going to. Sideswipe them or whatever it is. Well, that you're describing a paranoid client, then, yeah. So often they may have power and a high sense of paranoia with the anxiousness. But but what is the hallmark definitely around anxious clients is overthinking. The overthinking is usually a copy mechanism to keep themselves safe. Yeah. So with anxious clients, besides having a huge emphasis on safety and security, allowing them to speak, I will want to know what drives the anxiety, what drives the fear. It's usually the distorted thinking. So you need it again to go back to the past. To see what some of these belief systems are around self and others that drives the fear. Now, some of that fear might come from some of the what I'm going to talk about is deep trauma they've had in their history. So they've made then decisions about themselves and the world, which actually feed the anxiety, feel that, you know, feed the fear anyway. So we need to go back and look at some of their belief systems about other people in the world, which might drive the anxiety and fear like, you know, I'm not a very nice person. I'm not lovable. I'm not trustworthy. Other people won't like me. And people anxious will be constantly comparing themselves. They usually have a very high negative critic, which keeps them in a place of panic and fear. They're very usually very critical themselves. Because they've externalised this high critic. Interesting. I mean, if you, you know, tend to why if you go to the doctor with anxiety, you'd probably be given the diagnosis of GAD, which is Generalised Anxiety Disorder or Traits of GAD. Traits of Generalised Anxiety Disorder. I thought I thought I knew it was this podcast. I thought I'd just look at what we could call or if you went to the doctors and gave you that type of diagnosis. So I looked at GAD and it says, right, some of these are the criteria for generalised anxiety disorder, difficulty in concentrating, difficulty in sleeping, a consistent pattern of fatigue. Having stomach problems, having over-sweating, rapid heartbeat. So, you know, it's all the picture we've just been talking about here in a way. But it's built on panic and fear. And at its base level, it's around security and safety, I think. And the third business play a lot of attention to security and safety and permissions. But they need to get to the story underneath it all, I think, because I've never seen an anxious baby. So a child, you know, usually what happens is that they make survival decisions again in response to think the environment around them. And then they have this storted way of thinking, these critical parents on their back. And then they get anxious and overthink and over all the things we just talked about. So you need to get to what the thinking feeling is and the behaviour that comes with that. And help them put more healthy coping mechanisms in place. But you need to get, I think, to the faulty decisions. Well, when I say faulty decisions, I mean, if you go right back, you know, however bizarre the content, it is logical at the time. So it's not faulty in that sense, but it doesn't help them now. Yeah, that's a very valid point that is. And I talk with clients an awful lot of other. We do the best that we can with what we've got available in that moment. So what you were saying then, it's, you know, often anxious clients will say to me, it's really stupid. You know, I don't know why I do this. It's so stupid. Why can I not go out unless I've got X, Y and Z in my bag? And it's like, well, it's not stupid because it makes it made sense at the time. You know, they can be really critical of themselves and the things, the processes that they need to go through. You know, if they've got social anxiety or if they get anxious when they're going out or whatever it is, they have lots of crutches that they need to take with them. And they often say it's ridiculous. It's stupid. Well, let's start off with a philosophical you know, process where I just talked about. However bizarre the behavior, if you trace it back to where it was made, it's going to make logical sense in that context. Yeah. And this is what I'm talking about. If you trace the fear back, if you trace the social anxiety back, yeah, to where it began, it will be make total sense in that context. Yeah. And that's when the problem is they carry on as if it's the same. It's like a habit. They just carry on as if it's the same context when it usually tend to one, isn't? Yeah. And I think our brain, you know, is is really good at certain things and pretty rubbish at others. And it it gathers lots of information and connects the dots that then becomes all around the anxiety in certain situations. You know, there's a thing it fascinated me. I was reading a book on it called Apophenia, where our brain needs to connect the dots so it can hold onto it as a memory only connect random dots around fear and anxiety. Well, in transaction, I say they have a concept called script theory. Yeah, means an unconscious life plan which is formed in childhood and you play it out throughout life. And I think that's what we do. We make decisions to become part of a life plan and then we're carried out even when we don't even in the most unhealthy of situations. So a therapist needs to help the person, I think, change those decisions which are causing the fear and the anxiety and implement healthy ones and healthy. Coping mechanisms as well. Yeah, the first step, though, is right at the beginning is to help the person through permissions, have the space to talk. Have the space to slow down. Yeah, because though it may not feel frightening for the therapist in the room, the client, the anxious client is probably or might be petrified. Yeah, not necessarily. Of what's happening in the room. I think it's a really important point that you say to clients, especially anxious clients anyway, I know you feel anxious. However, that might be coming from a different time zone. So it's not that you discount their things in the present, but actually it might be coming from, it's a bit like Doctor Who. It might be coming from a different place, even though you feel it in the present. So in other words, you're helping them look for triggers. Yeah, and that's a really nice way of putting it. You know, it's not discounting the the feelings that they're, you know, having in that moment, but it's coming from a different time zone. Yeah, I like that. I should do write an article with Doctor Who phenomena. Yeah, it's it's like it's a very important that. You know, clients, especially from this framework, could start understanding that what they feel and think in the present isn't necessarily. Doesn't necessarily have a have its origin there. Comes a different time zone, and that's where we need to go to. Yeah. And if we change in that different time zone, then what's happening in the present will change. Yeah. So you have to connect those dots you're talking about. Yeah. And it's like the butterfly effect, you know, going backwards and in the present and backwards and in the present and just seeing and exploring. Our past without judgment, being curious about things without being critical. That's what I love in the therapy room. Let's just have a look and see what we come up with. That's right. What you're going to come up with with somebody who presents in an anxious way is that their narrative inside their head will be very critical. Yeah. Now, again, if you can get to a place where they start really take on board, it isn't themselves being critical about themselves, it's that they've taken on board. Somebody else is critical. South, you're halfway there. And for those people listening and, you know, one of the things that I love about transactional analysis is the parent, adult and child and the, you know, the pack. And from a very, very young age, we just absorb things from our parents and our surroundings without life experience to filter what's useful and what's not. Do I want that or do I not want it? We just absorb it all. And, you know, for me personally, my critical parent when she's in full force is amazing. There's a there's a television program, which is I just started to watch. So there's only six episodes. It's called Professor T. Oh, yeah, I started to watch that night. And he's a very disturbed professor, actually. And he helps the detectives. He's I think he's a professor of criminology, but he's very disturbed and he has internalized a very critical mother. And he can see he's a critical mother in quite a lot of things. And it's not surprising, you know, that people get very frightened when they are, you know, responding to that critical narrative in their head, just as they did in that original childhood situation. And the other thing about people are anxious, they often have a part of themselves that needs to be perfect. If they're not getting it perfect, then something awful will happen. So they'll always be comparing themselves to other people and things like that, because they have to get things right. Yeah. So non-judgmental attitudes really important for a therapist. Yeah. I I I like that. It's not so not so easy to do, by the way, because what you may think or what I might think as a non-judgmental transaction is often or can be perceived in a different way than you actually clinically mean it, and you'll never know. So the best we can do is come from, I think, as much as we can, a non-judgmental, judgmental attitude. Yeah. Yeah, and in the therapy room, I'd like to say that I don't think we can be 100% neutral in all our thoughts. But I would like to say that most of the time I'm in it, I'm okay, you're okay situation. Yeah, you might be. Yeah. Great, by the way. But the problem I think is, is that your clients won't always see you that way. No, but then that's something that we are that way. Yeah. Yeah. If you know about it, if they tell you, and if someone has had a very frightening parents, for example, then what you may think, do and feel is so opposite to their way of thinking, feeling and experience that you're in another ballgame. Yeah. You know, in psychotherapy terms, we then talk about transfers and things like that. Yeah. But I think that's why I love transactional analysis, because there's lots of diagrams and things that you can share in the session to explore and explain all of this stuff. Then it's not coincidence that these things happen. It's not a fluke that we shift from I'm okay to I'm not okay. And these things, if somebody's got that understanding, then I think in the therapy room, we can switch it on and switch it off. You know, if I'm talking about live scripts or the okay, Parallel or all this stuff, they get, they get what I'm talking about. Yes. I mean, I would call that agix to therapy. And I think it's a, you know, big space for educative therapy. So we're thinking, so on the last bit of this, I can leave the people who's listening to this with a picture. What is the most important thing for me anyway, in the treatment of somebody who presents anxiously, is to give them space to talk and to have a concentration on safety and security, so they will feel safe to be able to talk. And that will mean the therapist, I think, leaving their ego out of the room to enable the, to enable the space to occur so the other person can feel safe to be able to talk. And most importantly, feel understood. Yeah. Now, half the battle is, if they feel understood, they'll become less anxious. Secondly, is to help them put past to present. So it's the same with the depressive client in a way, if you can help them understand what drives the anxiety, how come they're so scared in the first place, then you're halfway there. Yeah, don't get fine for no reason. So the child of them has become frightened because of reasons. This isn't to do with them. No, no, and like you say, it makes sense. If you're trying to protect yourself from something that's big and scary, it all makes perfect sense. Yeah. So how then as the client become safe and secure with the therapist. So I think it's going to take time. They've got the space to talk. They're going to feel understood is the most important things because you're right. Usually they come from a place of they might well overwhelm the therapist because they've got so many needs and over needy or whatever they're saying in their head. So what you said, right at the beginning of the podcast, I really liked, which is about giving permissions for safety and security for exploration between the two of you. Yeah, yeah, I think that's really important. And being curious and not critical, you know, judgments, I know, I know there probably will be a lot of judgments, but, you know, that it's understandable why they do what they do. If you're looking through their eyes, it all makes perfect sense. Yeah, as they start making new decisions on an emotional and thinking level, behavior will change. Yeah, there's something that always kind of, I don't know, it gets to me is when you see these online courses or certain therapists and I want them who they are, say that they can cure people of their anxiety and fear. What are your thoughts on that? What do you mean by gets to you? That, you know, anxiety is part of a human response to something that we think we need to be protected against. And if somebody says that you can be anxiety free for the rest of your life, I'm not sure whether that's a promise that we should be making. I certainly don't do it. It's part of the flight and it will always be parts of us as human beings. Yeah, I think there's a level of action that is existential part of the human condition. So, you know, without getting into the world of ethics here, which is not a podcast on ethics, but I think it would be unethical for somebody to claim that. Yeah. And alongside that, I think most people that come through, probably you can tell me you might disagree with me here, but certainly my practice. Anyway, I'm not practicing anymore. Most people who came through the door would project a father Christmas transfers on to me. In other words, that I can cure everything, take everything away and everything will be all right. And most clients that come in the door to see therapists will want to quick fix and want to want the pain taken away and hope that you'll do it. Yeah. Now, of course, we all know that's not true. But who are we to take that belief away? The problem is, is the people that in print say that or the people that actually I think we are on to the edge of an ethical process is then because, of course, it's impossible. However, I do think most clients are coming with that view. Or that desire, that unconscious process, even though actually they might understand that you can't fix everything and they they need to be part of that process as well. I think the child in that might have that desire. Yeah, 100 percent. If you're suffering from anxiety, the desire is so you don't want to feel that ever again. Yeah, I can understand that and that you can fix it. Yeah. And here I'm paying all this money to you and you should try to fix it quickly. Yeah. Yeah. So, you know, I think it's unethical to actually advertise that way because you're advertising something you can't possibly do. And in fact, it's, you know, it's like saying you're some sort of superhuman being even cure X, X, X, X. And we know that not not to it because the other person in the process, I the client has to take some responsibility in this because they made the decisions in the first place. Yeah. And that is a very important thing, I think. Which they have a choice. They made a decision at some point in their past and they can make a new decision. Absolutely. How it works a lot of the time in my therapy room when they have that realisation. Yes, I don't disagree with you. And it's how you get there. Yes. Yeah. Because you might have to go to the child, which is so broken to the place they didn't actually have a decision because they they were around the significant power for other people which were violating them, invading them, traumatising them or whatever words you want to use. They didn't actually have a choice. So they might actually fear in the regression, they might actually feel they haven't got a choice. Yeah. So we need to get to the place of healing so they can actually you know, differentiate out between what was and what is now so that they can start to do things differently. Yeah. Yeah. Yeah, because ultimately as human beings, I were I was aim is for survival and we do that to the best of our ability in that moment. Yeah. And yeah, you're right. I'm really giving a plea for the therapist to go to these places of regression, these younger parts of the self and the client to give them space for some healing before they can move to a place or they've got to make some decision of choice. Yeah. We have to go to the healing places to enable the person to get to a place where they believe they can make a choice. Yeah. I am all for autonomy and I'm all for somebody taking charge and all the things you're just talking about. But I'm also believe that we need to get to that place in the younger self of healing before the therapist can actually believe they can make those decisions until the client actually can get to a place where the broken parts have been healed enough for them to believe they may just be powerful enough to make a decision. But if you do it for them, they'll never get there. No. If the therapist does it for them or if the timings and it's so easy to do, by the way, if the timing slightly off then, you know, the therapy can go wrong. So it's a very delicate, very, very delicate process. What you're talking about in terms of dealing with people being highly traumatised and how they get to a place where they can believe that they can take back some of the power which was taken from them. Yeah. And it can be a very slow process. It has to be a slow process. And that's OK. Yeah. It's we're all unique and some people don't need that long and other people do and that's OK. And with the answers, Clyde, the more you give permissions in the beginning, I think the more they will calm down. Yeah, to go to these places we're talking about. Yeah. Yeah, without adding more fear on the fear, because often that with anxious clients, that can be how it feels. It's the fear of the fear and it's layer upon layer. It's, you know, yeah. So permissions, permissions, permissions. Order of the day. So they feel so cool. Until the next time, Bob. Yeah, till the next next time. And what is the next where we move into? We have a list. I don't know where we're moving to next time, because sometimes we keep changing. Yeah, I thought maybe we had on the list, we were thinking of things like how to deal with the traumatised clients, you know, we've got eating disorder, you've got many other things. But attachment, we had quite a few things in the mix. Yeah. So we could start with trauma. OK. How to work with trauma in therapy. Yeah. Could be. And that might go to one and two, but how to work with trauma is, I think, a really important part. And we need to we need to talk about that. And of course, another podcast, which I think is one and two, I don't think we can do it in one. But anyway, it's how to work with the sexually abused or clients. You know, I mean, trauma is part of sexual abuse. I know, but we can split the two out. OK. Those will be the next two or four dependents on how it goes. That's it. OK, Dopey. Thanks a lot. Better get off. See you next time. Bye bye. You've been listening to The Therapy Show behind closed doors podcast. We hope you enjoyed the show. Don't forget to subscribe and leave us a review. We'll be back next week with another episode.