APPLYING THE MODEL OF BRIEF SYSTEMIC-STRATEGIC THERAPY IN THE TREATMENT OF PANIC ATTACKS AND AGORAPHOBIA - A CASE STUDY

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1 APPLYING THE MODEL OF BRIEF SYSTEMIC-STRATEGIC THERAPY IN THE TREATMENT OF PANIC ATTACKS AND AGORAPHOBIA - A CASE STUDY Speranța Popescu Assist. Prof., PhD, Dimitrie Cantemir University of Tîrgu Mureș Abstract: This study constitutes the illustration, by means of a clinical situation, of a therapeutic work experience in which the brief systemic-strategic intervention model designed by Giorgio Nardone for fears, phobias and panic, was applied. The patient s suffering revolves around fear, and the changes achieved respected the intervention protocols which allow the patient to be encouraged, by way of specific tasks, to face his or her fear instead of avoiding it. The main intervention is built around symptom prescription. Keywords: phobia, reframing, symptom prescription, systemic-strategic therapy Introduction The originality of systemic-strategic intervention in brief psychotherapies The model of systemic-strategic intervention relies on the theory launched by the Palo Alto group of researchers and practitioners who emphasised observation of the problem behaviour in the subjects interactions within their life environment. This intervention model is pragmatic and can be applied through specific techniques which serve the therapist in his difficult pursuit to understand and resolve his patients psychological problems. In their work entitled The Palo Alto Clinical Intervention, J.J.Wittezaele and Thereza Garcia (2004) state the basic postulates of brief systemic-strategic therapy: (1) The continual changes in our life and the environment we live in lead us into facing various difficulties. A generally temporary difficulty might become a persistent problem if it has 268

2 been inadequately managed. The subject who is attempting to resolve it always resorts to the same solutions. (2) The problem persists to the extent to which it is maintained by the subject s behaviour or through the subject s interactions with his peers. (3) By eliminating the behaviour which feeds the problem, the problem will disappear or become a simple difficulty. The authors thus develop the paradigm of systemic-strategic therapeutic intervention. The model of brief systemic-strategic therapy is conceived as a fast intervention model; the change targets the patients perception-reaction patterns to the problems posed by reality. By changing only the patient s behaviour reactions, a level 1 change (named this way by Paul Watzlawick) is obtained. The problem may reoccur, as it has only suffered a partial alteration. Giorgio Nardone (1993) states that, in order to alter a patient s perception patterns, it is not sufficient to alter the cognitive aspects of that perception, but the emotional ones should be targeted as well. Reframing as an intervention technique implies a change to the way in which the patient perceives his or her own problem, but it can also produce an emotional change, if the patient is open to experiment the tasks suggested within the therapy. As a result of the alteration, the patient understands that he or she is now capable to do something which seemed impossible before. 1. Several considerations regarding the formation and persistence of phobic disorders, fears and panic. With regard to the formation and persistence of phobic disorders, fears and panic, the most serious aspect from the patient s point of view is related to the behaviours which he or she employs in order to avoid fear. Things get worse every time the patient attempts to avoid phobogenous circumstances; emotional and somatic reactions worsen and the symptoms become more and more uncomfortable. Almost all the patients suffering from fears, phobias and panic are generally prone to depression; this leads to disturbances in their social, family and even professional life. 269

3 The solving attempts employed in order to resolve the problem usually do no more than maintain it. The patients who are afraid to go out of their homes, fearing they might faint in the street or in a store or at their workplace begin to avoid going out and always seek assistance from other people. The patient s entourage, caught in this game, will help him or her, providing a double message: (1) I am helping and protecting you because I love you and (2) I am helping and protecting you because you are sick. Giorgio Nardone (1996) emphasises the fact that phobic disorders are the result of a complex retroactive process between the patient and reality, this process being developed by an event which is not specific to that certain disorder, but develops as a result of that event. 1.1.The persistence of the agoraphobic perception-reaction system The patients confronting such problems face a dangerous event in their lives; being exposed to it, they feel vulnerable and helpless. Consequently to being exposed to this event, the patients build two types of solutions: (1) avoidance and (2) a request for help addressed to family and friends. They begin to function in this system and become more and more helpless faced with their fear. Even if they are logically aware that these actions and perceptions are dysfunctional, they cannot behave differently. Sometimes the agoraphobic syndrome is complicated by panic attacks. Thus, an obsessional control of internal reactions is added to the previously attempted avoidance and requests for help. Giorgio Nardone (1996) suggests that intervention upon obsessional mental control and physical reactions should be the first step for subjects who have developed an agoraphobic disorder based on a panic attack syndrome. 1.2.Already attempted solutions and the persistence of phobic and hypochondriac disorders. In the case of this type of disorder, in which the patient is confronted with fear related to the seriousness of a predictable disease, there are three possible situations: (1) Following a real disease experienced by the patient. (2) Following a disease experienced by a person close to the patient 270

4 (3) Following news collected by the patient from the media, other people s accounts or the internet, regarding serious diseases (AIDS, cancer, cardio-vascular or mental diseases etc). Based on these three possible situations, the subject begins to check his or her own body and search for signs to prove a disease. The more the patients observe their own body, the more convinced they become that they are indeed sick. Giorgio Nardone (1996) believes that the obsessional reactional hypochondriac system is similar to a panic attack. The attributed causal connexions, the categories in which we classify events, the links connecting these pieces of information, the tendency to attribute definitive meaning to heterogeneous narrative episodes, all play an important role in organising a dangerous interpretation regarding events, an interpretation which is more or less connected to reality. (Nardone, G. 1996). In order to break this rigid dysfunctional balance of perception-reaction systems typical in the case of panic disorders, fear and phobias, Giorgio Nardone (1996) proposes a therapeutic intervention based on the following model: (1) Altering the vicious circle of homeostatic retroaction between problem persistence and already tried solutions. (2) Surpassing resistance to change, typical to all systems, without the patients being aware of it from the beginning, when the work tasks are proposed. (3) Achieving concrete change experiences with regard to the perception of and reaction to a certain fear-inducing object or reality. (4) The change must have the significance through which the patient regains self confidence. Case study: systemic-strategic intervention, brief psychotherapy in a case of agoraphobia with panic attacks Initial data The patient, aged 36, a shop assistant, married, with a 12 year old daughter, lives in the same house with her husband and mother in law and comes to the psychological consult due to a recommendation made by a neurologist who consulted her for headaches, feeling faint, palpitations and strong anxiety towards an undefined danger, especially when outside the home. 271

5 The medical examination did not reveal any specific organic disorder, and psychotherapy was recommended. The patient recounts that at the age of 22 she gave birth to a stillborn girl and she has avoided hospitals, medical investigations and doctors ever since. Intervention The therapeutic intervention took place in three stages, comprising a total of 10 sessions over a period of three months. First stage (three sessions) First session: was devoted to applying the intervention grid specific to brief strategicsystemic intervention, consisting of the following items: the problem, why it is a problem, solving attempts employed by the patient, content of solving attempts, objectives to reach and therapeutic content. The problem: For over two years, the patient has been feeling insecure when she finds herself alone at home, at work or in the street, thinking that she might feel unwell (faint) and there might be nobody around to help her. These thoughts are accompanied by an immense fear which causes several physical symptoms (palpitations, shaking, headache, and tachycardia). Why it is a problem: Due to these symptoms, the patient quit going shopping, picking her daughter up from school, or visiting her parents who live in a nearby town. Problem solving attempts: The patient consulted doctors specialised in several fields, was subject to various medical investigations, and was preoccupied with finding an organic explanation for her problem. She currently avoids leaving her home unaccompanied and asks for help whenever she is alone, being permanently assisted by her husband, mother in law or even her daughter. She feels strong guilt due to this dependence. Content of problem solving attempts: I must not be scared. Objectives to reach: No longer asking for help from her family, regaining autonomy by facing the fear. Therapy content: Accepting the fear for the time being and progressively building a series of fear confronting tasks, beginning with reflection tasks, going on to behaviour tasks and indirectly experiencing the emotional changes. Tasks: The logbook, a permanent diary in which she describes every instance in which she felt panic, mentioning the date, time, duration, place, circumstances, symptoms (behaviour task) and 272

6 a reflection task: to think that every time she asks for help from her peers, her problem worsens, but she should not hesitate to do it when necessary. Second session After a week, the patient returns with the diary in which she has noted details of the first days, after which she notices there were no more panic episodes. Third session: After another week, the patient returns with the logbook in which she has few notes, explaining she had short moments of fear. The task given: for 30 minutes every day, at the same time, the patient is to evoke an imaginary scenario in which in a certain context the fear would escalate to panic. She will attempt to relive the same uncomfortable sensations she had in past experiences. In order to respect the established time, she is to use an alarm clock. Second stage (three sessions) First session: The patient returns after two weeks and claims that in the first week she felt very uncomfortable while evoking a day at the beginning of a school year, in which she had to take her daughter to school. In the next week, she attempted to imagine other panic-laden scenarios, but the uncomfortable sensations did not return. Second session: The patient returns after ten days with a new scenario she imagined, having an uncomfortable content which she experienced a year before, when, willing to pay a visit to a friend, she got lost in a neighbourhood and was frightened for a few moments. The images and emotions returned strongly, the 30 minutes barely passed, but in the following days she had no more panic attacks, even though on one of the days she was forced to remain alone at her workplace, as her colleague was ill. Third session: The patient returns after another two weeks in which the imaginary scenario is a bus trip to her parents. Despite the fact that throughout the 30 minutes she expected to feel uncomfortable emotions, this did not occur. The therapist s remark: As you have noticed, the more able you 273

7 are to provoke your own fears, the more able you become to control them during the day, even in real situations. Throughout this stage, the patient was praised for her imaginative abilities and for the conscientiousness with which she performed the given tasks. Third stage (three sessions): During this stage, behaviour tasks were proposed. Through them, the patient had the opportunity to expose herself directly and progressively to anxiogenic situations. A paradoxical task was given, in which the patient was requested to prepare a trip to her parents one weekend, packing her bags and going to the bus stop, but being forbidden to get on the bus and travel to her home town. The patient returned, excitedly recounting that the moment she found herself at the bus stop, she was unable to refrain from getting on and, although she felt a range of emotions during the trip, everything went better than expected and she was able to see her parents. In another session, the patient returns describing an episode in which she went to the school by herself to take a notebook her daughter had forgotten home, and managed to do so without requesting help from anybody. Fourth stage (last session) The benefits of the therapy are assessed, the changes are restrained and the risk of relapse is discussed. The patient assesses the changes by reaching her objective to gain autonomy and by improving the quality of her family relationships. After 6 months, the situation was constant and the patient able to come to the practice unaccompanied, to look after her daughter, do shopping and see her parents, plan holidays and allow her daughter to go to camp with her class, reflecting upon the risk of passing on a dependence model created by her previous problem. Observations on the case In the case of the patient with panic attacks and agoraphobia, changes were made by using reflection tasks, direct and indirect (paradoxical) behaviour tasks associated with constant analysis of emotional changes. The tasks were built conjunctly with the patient and served the objectives set for the therapy. 274

8 Conclusions Applying the systemic-strategic intervention model in brief therapies regarding fears, phobias and panic involves the application of the assessment and intervention grid in which great stress is put on identifying all the terms: who is the therapy client, what is the problem, why it constitutes a problem for the patient, what are the problem solving attempts, what is the content of these attempts, what are the objectives to reach and what the content of the therapy will be. Applying the intervention grid in brief systemic-strategic therapy contributes, even beginning with the first session, to the creation of a context in which paradoxical interventions play the role of a catalyst for change. Every time, with every clinical situation, a reality is built in which the patient expresses his or her own life history and vision of the world. Therapist and patient share the recounted life difficulties in order to be able to understand the solutions built. BIBLIOGRAPHY: 1. Nardone G., Watzalawick, (1993), L art du changement, L esprit du Temps. 2. Nardone G., (1996), Peur, Paniques, Phobies, L esprit du Temps. 3. Wittezaele, J.J., Garcia, T., (2004), L approche clinique De Palo Alto, IGB. 275