Spirituality in the treatment of a man with anxiety and depression.

Anxiety, like spirituality, involves a person's beliefs, experiences, feelings about the self, and important relationships. The following case illustrates the use of spiritual resources in the psychotherapy of a middle-aged, Roman Catholic man with anxiety and depression.

Mr. R. was a 52-year-old, married, high-tech professional who had stopped working several years earlier in the context of worsening depression and downsizing within his industry. When referred by his psychopharmacologist for therapy, he was living with his wife and several children, trying to establish himself as a high-tech consultant. A daily communicant at Mass, he was very involved in several of his parish church's activities. Mr. R. expressed concern that his therapist be a Catholic who could understand and support his beliefs.

Mr. R. found that if he became stuck while working on a project, he immediately became anxious, and was flooded by his anxiety to the point where he could not stop, or change the flow of his work. This led to increasing frustration. Distractions coming from family members increased his anxiety and guilty rumination. His psychopharmacologist had diagnosed generalized anxiety with depression, and prescribed Zoloft 100 mg a day, BuSpar 20 mg three times a day, and trazodone 50 mg at bedtime for sleep. We agreed to a trial of psychotherapy aimed at helping him improve his anxiety and mood so that he could function.

I began by explaining Cognitive Behavioral Therapy (CBT) and its underlying premise that the way we think affects the way we feel. As I often do, I suggested that he consider using The Feeling Good Handbook by David Burns, MD as a resource. (1) I further explained that individuals with anxiety and depression often react to their relationships and their life situations in maladaptive or unhelpful ways because of automatic thoughts, (1,2) which in clusters form more pervasive ways of experiencing the world called core beliefs or schemas. (2) I let him know that an important goal of therapy would be to identify these maladaptive thought patterns, to test them out, and to find more reasonable alternatives. For example, whenever a request was made of him, the automatic thought that "It's too much, it will overwhelm me" occurred. Tracking and monitoring such thoughts was comfortable to him, and he understood it as an adaptation of the Catholic Examination of Conscience, which is a daily review of one's thoughts and feelings to notice where one has gone astray because maladaptive thoughts have crept in. When such thoughts were brought to light, we focused on examining the actual request, what about it felt overwhelming, and whether there was a more adaptive way of dealing with the situation, such as finding the positive, or cognitively reframing it. For example, by thinking "what's being asked of me is inconvenient, and a pain, but doable" he could acknowledge the stress and his hesitancy engendered by a request, while also seeing it was feasible.

Insight into the origins of his automatic thoughts and schemas also helped him find some distance from them. He had grown up in a family where overwhelmed parents modeled poor flexibility, and, by communicating their anxiety to him as a child, had made him feel less competent.

A second goal of our work was for him to identify strategies for managing stress and for reducing the physical symptoms of anxiety. Cognitive Behavioral Therapy encourages the scheduling of pleasurably activities as a way of changing how one is feeling. (2) Mr. R. had found that regular exercise and stretching were helpful to him, but he often sabotaged these efforts because of the pressure he placed on himself to carry out the very activities that were to be stress reducing. For example, when he would miss his scheduled exercise time, he would then become angry at his inconsistency. This anger would lead to automatic thoughts about his inadequacy, which would in turn fuel further anxiety. His "all or nothing" thinking created further unease and stress: in this common pattern, an individual feels that he is either a success or a failure, and, therefore, if he is not a success then he is surely a failure. When Mr. R. did not exercise at the "appropriate" time, he would automatically feel like a failure, increasing his anxiety and distracting him from as much as a whole day's work.

As a result, our initial intervention was to help him set a flexible schedule for himself: he could either exercise at the end of the morning or at the end of that day, four out of seven days a week, so that a missed exercise session would not lead to automatic failure and a lost day. Over time, this strategy led to a more flexible style of coping not only with this issue but also with other issues that required greater flexibility on his part.

Another early intervention was to help him learn a way to relax physically. As he had little prior experience with meditation or stress reduction, we discussed several possible strategies, including the basics of a breathing-related relaxation exercise that I explained could be used as prayer as well. We chose the Jesus prayer, a form of meditation in the Christian tradition which dates from the time of the desert fathers and the early Eastern Orthodox Church, and which involves the rhythmic repetition of a repeated phrase timed with the inhalation and exhalation of one's breath. I invited Mr. R. to select a scriptural or personal phrase to repeat, explaining that individuals frequently choose the name of God or Jesus; longer phrases, such as the prayer of the publican: "Lord Jesus Christ, Son of the Living God, have mercy on me a sinner," are frequently employed, as are nonreligious phrases such as "peace," "calm," or "all is well." (3) We set the goal of trying to do this once or twice daily for ten to fifteen minutes each time. I let him know that this skill needed to be developed through practice, and that he would benefit only with time and repetition.

As treatment progressed, we focused on how well and how frequently he was able to use these self-care skills, and with what response. If he was unsuccessful, we examined what interfered and how to work around that problem. Although not a direct focus of the work, another important aspect was modeling flexible thinking and adaptive responses to common, regularly occurring events, particularly ones which might interfere with "the perfect schedule". Looking together at what happened when Mr. R. was successful in keeping up with these self-care practices, and what happened when he did not, helped to make his gains self-reinforcing.

Over time, Mr. R's difficulty in dealing with authority became a problem that interfered with his treatment. One reason he had left his high-tech job was his difficulty in dealing with authority figures: he felt that they were always looking over his shoulder, ready to attack him if he "screwed up." This pattern emerged several times in the transference during therapy, as he would comment about expecting me to be upset with him when he was unable to keep up with a strategy, or had an episodic worsening of his anxiety. When this occurred, I discussed with him what transference is, how everyone brings unconscious road maps to life situations and how difficult it must be for him to engage in work, always expecting that his boss will be angry with him. I also used these occasions to ask how this difficulty with authority might be influencing his relationship with his God, since it must be very difficult for him to be expecting someone who can see everything to step out and "catch him" doing something wrong.

Over the course of a year-and-a-half, usually at two week intervals, Mr. R. improved enough to taper the frequency of his sessions. We had used a combination of cognitive behavioral skills linked to his Catholic tradition to help him track and reframe maladaptive ways of thinking, self-care practices, including religiously-based meditative practice, and insight into the origins and transferential effects of his feelings, including toward God. Another important element of working with a therapist he trusted as a fellow Catholic was being able to incorporate a more accepting, nonpunitive attitude toward his failings and to experience his encouragement. In summary, my therapeutic incorporation of Mr. R's faith helped him learn to modify his thoughts, to monitor himself, and to relate better to authorities whose expectations had always made him anxious.

References

1. Burns D. The Feeling Good Handbook. New York, Plume Penguin, 1990.

2. Wright JH. Cognitive behavior therapy: basic principles and recent advances. Focus 2006;4:173-178.

3. Pennington BM. Centering Prayer: Renewing an Ancient Christian Prayer Form. New York, Image Books Doubleday, 1980, p 65.

Dr. Ronald Hamdy and the editorial staff of the SMJ would like to thank our guest editor, Dr. John Peteet, and his team of authors, for their assistance with this issue of the Spirituality/Medicine Interface Project.

Bernardino Vaccaro, MD

From Brigham and Women's Hospital--Medical Psychiatry Service, Boston, MA.

Reprint requests to Bernardino Vaccaro, MD, Brigham and Women's Hospital--Medical Psychiatry Service, 75 Francis Street PBB-Mid-Campus GR, Boston, MA 02115. Email: [e-mail]