Tales from the Therapist's Couch: The two faces of anxiety

A woman arrives late for a session due to a security alert on the Tube. She was stuck in a tunnel for some time during the rush hour, in an airless carriage. As she recalls the event, she is visibly anxious. During the stoppage she had a mild panic attack that she just about managed to control with deep breathing. She is not someone who usually worries about travelling on the tube, yet due to the current political climate, her anxiety levels are high.

A woman arrives late for a session due to a security alert on the Tube. She was stuck in a tunnel for some time during the rush hour, in an airless carriage. As she recalls the event, she is visibly anxious. During the stoppage she had a mild panic attack that she just about managed to control with deep breathing. She is not someone who usually worries about travelling on the tube, yet due to the current political climate, her anxiety levels are high.

A woman who has been coming to therapy for several years enters the room with a look of relief on her face. For a long time her life has been sapped by an obsessive-compulsive disorder. At its worst, she used to check her house doors literally hundreds of times in one day to make sure they were locked. But she has fought back hard, determined to reclaim her life, and today she looks surprisingly untroubled and relaxed. In a tone of triumph she tells me that she hasn't needed to check a single door, even once, during the last few days.

Psychotherapeutic theory is in general agreement over the Janus-headed nature of anxiety. At best, it is a vital part of everyday life, and provides the alertness and adrenalin needed to drive us forward. At worst, it spills uncontrollably into every nook and cranny of someone's being, making them a prisoner of continual angst. So what makes it destructive, not constructive? And what can we do to control its ebb and flow?

Freud's method of enquiry was to always dig deep for the cause before applying the treatment. He classified many different types of anxiety (free-floating, hysterical, obsessive, phobic) yet bracketed all of them under one main cause: namely a damming up of libido, which could be released through regular sexual activity. Post Freud, there has been a continual reviewing of this theory. Some therapists argue that it is the trauma of birth itself that is the root cause of all anxiety, others highlight the painful and more gradual process of separation anxiety. Klein believed its origins lay with our early fantasies of aggression experienced towards the mother's breast, and resulting anxiety that this will somehow boomerang back on us in a retaliatory fashion.

Whatever the cause being argued for, most psychoanalytic theories largely focus on an individual's personal and long-since-past history to unravel the causes of anxiety. Increasingly, I wonder how helpful this really is. Like a child on the beach trying to dig through to Australia, there is rarely time to get to the bottom of it all before the tide comes in. And how can we be sure that we're backing the right theory?

Set against these theoretical conjectures is the very real and noticeable increase in anxiety levels in the consulting room these days, which has little to do with patients' early experiences and much to do with today's political climate.

There is, however, a very similar therapeutic approach for all symptoms of anxiety, whether they be pathological or mildly neurotic, habits of a lifetime or recent emotions. The best tool of all when learning how to control anxiety rather than be controlled by it is to challenge one's experience of powerlessness. The woman in the tube did this by instinctively practising deep breathing. The door-checking woman sensed that there was a life elsewhere that her anxiety was cutting her off from, a life she wanted more than the safety the obsession superficially provided. So, at the end of the day, the psychological rule of thumb is that, when faced with terror, fight not flight is always the better option.

elizabeth.meakins@blueyonder.co.uk

Elizabeth Meakins is a psychoanalytic psychotherapist in private practice. None of the clinical material above refers to specific individual cases