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Brief Interventions for Anxiety Disorders with Children and Adults
Anxiety Disorders continuing education counselor CEUs

Manual of Articles Sections 3 - 4
Section 3
Six Stages of Anxiety... a Conflict Model of Emotions

CEU Question 3, 4, & 5 | CEU Answer Booklet | Table of Contents | Anxiety
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

Emery has developed a conflict model of emotions, in which he has attributed Six Stages or steps in the creation of anxiety.19 unknown situation Anxiety Disorders counselor CEU course
1. The sequence starts with a mismatch between your client’s perception of reality and their expectations.  This gap between perception and expectation sets the stage for emotions.
2. Your client then attempts to fill in the gap by activating memories associated with the present contextual cues.  In the case of anxiety, people activate frightening memories.
3. Using their memories as building materials, your client creates an image to fill in the gap.  He or she creates an image that is usually an exaggeration of the current situation.  This image building occurs in the right hemisphere of the brain.
4. The image is then transmitted to the left hemisphere, where it activates your client’s beliefs and thoughts in the form of an analytic code.  This “code” then reacts to the incoming images.
5. The image and thoughts clash.  This clash causes a stopping of the accepting or processing of incoming information.  This creates a psychological response that your client experiences subjectively as a feeling.
6. The feeling is a kinetic self-signal for your client to take action.  Once he or she takes this action, the self-signal stops.  Because the feeling experienced often is an unknown, this sets the stage for a spiraling of emotions. 

According to Michelson, a socially anxious client experiences these Six Stages as the following:
1. They encounter an unknown situation.  For example, they may have to go to a social gathering.
2. The situation cues in past frightening memories.  They recall past social gatherings that have negative memories.
3. They then create a frightening image, such as being awkward and looking foolish.
4. This then activates their belief and self-statements that they have to have others think well of them.
5. They stop processing current reality and focus instead on the danger; the clash creates the experience of anxiety.
6. This then becomes a self-signal to escape the social situation or to tense up.   This behavior increases the unknown aspect.  This in turn reinforces the belief that there is something to fear.  These all act to add to the memory pool of frightening events.

Because each Stage is necessary to produce and maintain the emotion, intervention at any of these six stages can disrupt the emotional chain reaction.  The rest of this section will discuss the clinical implications for each of these Six Stages.

Stage One:  Facing an Unknown
Anxiety = Unknown X Importance.  In short, this formula means the greater the unknown and the greater the importance your client attaches to it, the greater the anxiety.  As mentioned earlier, fear is the result of perceptual mismatch.  The cue to start the production of anxiety is a mismatch between your client’s expectations and his or her perceptions.  Biologically, humans appear to be wired to respond with fear when reality fails to match their expectations.  Hayward says, “The fear reaction is aroused whenever the organism has a perception which does not match its anticipation of what it should perceive in a particular situation.”  In evolutionary terms, it is more efficient to wire the nervous system to respond to the unknown than to the many possible dangers.  Because people live in a world of unknowns, they are surrounded by a circle of fear.  The fear is triggered when your client steps out, or is pushed out, of his or her familiar surroundings and confronts an unknown situation.

For this reason, anxious clients seek familiar people and places.  The familiar provides situations where they have a sense of control, approval, and competence.  The client’s domain is made up of what is known to him or her.  Behavioral intervention works because it allows your client to know what was perviously unknown.  Knowing destroys fear, whereas avoiding what one fears increases the unknown and so increases fears.


Clinical Implications
Any procedure that helps people become familiar with what they fear will be beneficial.  Self-efficacy training, for example, works by having clients approach and master what they fear.  The more one knows about something, the more confident one feels.  Similarly, choosing to experience and know one’s anxiety reduces it.

Stage Two:  Activating Emotional Memories
When clients confront novel situations, they rapidly and unconsciously search their memory for similarities from the past.  Their initial panic is due to failure to find any similarities.  The specific memories activated depend on your client’s mood and contextual features of the current situation.

Gordon Bower developed an associative network theory to show how emotional memory units are associated with current events.  Activation of this emotional memory unit aids retrieval of events associated with it.  And activation of this emotional memory unit primes emotional themes for use in fantasies and perceptual categorization.  The emotion memory is in the right hemisphere - the analogue code.  The person’s perceptions of the world are colored and twisted by past emotional experiences. 

In the case of anxiety, memories of vulnerability are activated.  These memories are the result of the person’s early learning history and center around three general concerns, such as, approval, competence, and control.  Each concern is directly related to self-esteem.  A threat to any one of the concerns is a threat to self-esteem or self-respect.

The specific memories that are activated play a significant role in which emotion is created.  Because of the power of the memories that are activated, clients appear to have multiple personalities.  For example, the client’s subpersonality when he or she is depressed is markedly different from his or her anxious subpersonality.

Clinical Implications
The emotional memories that are elicited are associated with specific body reactions.  A client who acts fearful is more likely to activate fearful memories.  This is why a useful intervention is to have the client engage in a behavior associated with mastery.  The use of teaching stories and metaphors is a way to modify deep-structural memories.

By rearranging the reworking of old images, a client can recreate the past.  One effective procedure is to rework old memories into more happy and satisfying outcomes.  Similarly, mastery experiences allow clients to build up more useful memories.  A helpful strategy is to have anxious clients attend to and record their success experiences on a daily basis.

Stage Three:  Creating Images
Rather than seeing reality, people create and see their image of reality.  The unknown plus the memories set the stage for people to start “what if’ing.”...  for example, “What if I go crazy?” or “What if I die?”.  People tend to believe their self-created images.  “Availability” helps to explain this in so much as... whatever springs to mind most easily is judged to be most probable and most believable.

Because of the tendency to believe what one imagines, “what if” becomes “as if.”  Anxious clients, for example, believe and act “as if” their frightening self-created imagery is true.  They treat “what if” ideas at a high level of abstraction like “as if” ideas.  When these “what if” ideas are real and concrete they are at a low level of abstraction.  If your clients know they are pretending, they experience mild anxiety; if they forget they are pretending, they experience panic.

Fear arises when people respond to the unknown by pretending something bad will happen.  Leventhatl cites evidence confirming a common clinical observation: the anxious client functions well with real problems but becomes immobilized when confronted with unknowns.  In unknown situations, anxious people create pseudoproblems by pretending or imagining the worst.  The anxious person’s fantasy is consistently worse than reality.  One of the goals of therapy is to have the person see more and imagine less.

The Trance
A state of anxiety has a trance-like quality and has several characteristics similar to a hypnotic trance (1) construction of awareness or tunnel vision, (2) “as if” thinking or role taking, and (3) regression to an earlier state.  This trance-like state is partly due to a direct relationship between imagination and belief:  what one imagines, one believes , and what one believes, one imagines.  The person who is unable to imagine being in a car accident will believe the chances of an accident are remote and may act on this belief and reinforce it by not wearing a seatbelt.  However, the person who can imagine a car crash will believe one is likely and, in the case of a phobia, will reinforce this by avoiding driving.

Clinical Implications
The less aware your client is of their frightening images, the more effect these images have.  Teaching clients how to monitor their images and detach themselves from them is an effective intervention.  The therapist can use different techniques to help clients modify frightening images and create self-enhancing ones. 

Stage Four:  Activating Belief System
The images cross over to the left hemisphere of the brain where they activate the relevant analytic code.  The emotional memories in the analogue code have a corresponding belief in the analytic code.  This belief is developed in response to the original experience.  For example, a client who has painful memories of being abandoned as a child may have the corresponding beliefs.  These beliefs are deep-structured and deal with unacceptable life situations.  Memories of early experiences that were never fully processed or accepted remain and form your client’s belief system.

These beliefs are overcompensations for painful images.  For example, a person’s emotional memory of being inferior to others may have a corresponding belief such as “I have to be loved at all times” or “I have to be the best at whatever I do.”  Paradoxically, this overcompensating belief often creates precisely the experiences your client is trying to avoid. 

Your client’s conflict is between images of current events that are filtered and colored by past memories or analogue code.  Thus, automatic thoughts are derived from early beliefs about the world or analytic code.  The conflict is created by labeling events in: 1) an unacceptable way, “I’ll die”; 2) by exaggerating the situation, “It’s awful”; 3) by direct self-instruction,  “I have to get out”; or 4) by minimizing ability to deal with the new information, “I can’t stand it”.

Reactive Thinking
This stage consists of reactive thinking.  The person’s conscious thoughts react to incoming images, for example, “I can’t stand it” or “This is awful” or “This should not be”.  Reactive thinking, rather than stopping the intrusion of frightening images, escalates the flow of these images.  Reactive thinking is based on the premise that others are responsible for one’s thoughts, feelings, and actions and one is responsible for other’s thoughts, feelings, and actions.  The role of reactive thinking is crucial in understanding and treating anxiety.  This form of thinking is characteristic of early development, where clients cement outside events to their feelings.  They make the conceptual connection that other people or outside events are causing their feelings.  This parallels concepts derived from the physical world, where sticks and stones can actually hurt someone. Such clients project the cause of their experiences onto others and the cause of these others’ experiences onto themselves.  For example, socially anxious people believe they are responsible for what others think of them.  They also believe others are responsible for their anxiety.

Lack Reversibility
People are biologically, developmentally, and socially prone to reactive thinking.  Developmentally, the brain when confronted with emotional trauma, is unable to respond differently until a child is around 11 years old.  Reactive thinking is necessary for socialization.  Helpless children need a manipulative system to get others to help them survive.  Reactive thinking helps evolution.  Cues lead to automatic feelings and responses that lead to survival.  Also by recalling bad experiences, this is more economical because fewer bad events happen to remember.  This parataxic type of thinking is in operation when children do their early learning.  Each child believes he or she is the center of the universe.  Because of the initial effect, what the person learns first is what stays.

Children lack reversibility -- the ability to uncouple events from strong feelings.  Their early-deep structure beliefs are based on a reactive premise.  The relevant beliefs in the analytic code are reactive beliefs.  Children use the physical world as a frame of reference and confuse this with the psychological world.  But the physical world is a world of change and control; the psychological world is one of selection and choice.

People and things change physically; this involves a transfer of energy.  Psychologically, however, people create different experiences by making both aware and unaware choices.  People’s efforts to change themselves usually lead to resistance and frustration.  As you know the client thinks of change and control because that is what he or she sees happening around them.  They also want to change and control things because this implies permanency and safety from anxiety.

People appear to acquire much knowledge of the world through passive association.  For example, the advertising industry is based on the power of associative learning.  Through associative or reactive learning, people weld together feelings and events.  Much of people’s thinking is unscientific.  Their thinking is based on this correlational reasoning rather than experimentation.

People maintain reactive thinking largely because they are unable to see how they create their own negative feelings.  Clients feel the following must be the cause of their problems: because people do not want them.  The client cannot see how they created the “problem.” In addition, as you know they feel they cannot get rid of the problem.  The client generally assumes that something else must be causing his or her feelings.  Projection plays a part because others seem to be creating your client’s experiences. Therefore the client feels he or she is also creating the experience for others.  Any event, internal or external, that can be coupled with a specific feeling that triggers the creation of emotion, appears to be the cause.  Because some internal or external event always precedes an emotion, that event is assumed to be the cause.  How can this basic principle be reapplied to one of your past or present sessions? Sometimes the basics are easy to overlook and may be the focus for your next session.

Reactive Thinking versus Thinking Based Upon Choice
Clients look at the most important cues and ignore the context, thereby reinforcing the idea that events are caused by feelings.  Reactive thinking is unverifiable.  The reason for this unverifiability is, when in the reactive thinking mode, your client cannot logically prove that others do not cause one’s feelings.

The brain does not give notice that there is a different way to think.  Many clients lack the learning opportunity to think in different ways.  Others have difficulty moving away from reactive thinking.  Agree?  However, after your client has practiced reactive thinking on thousands of occasions, he overlearns this way of thinking.  For example, PTSD traumatic events can lock the client into believing that the events cause feelings.  Some type of neurological pathway between stimulus and response may also develop because of overlearning.

People learn through modeling that outside events cause feelings.  Cultural distortions support reactive thinking.  Mass media, like television, music, and newspapers all reinforce the idea that others are responsible for your client’s feelings.

Reactive thinking is used for social control.  Organizations, institutions, and parents all use this system to control and manipulate those under their control.  Further, everyday language reinforces reactive thinking by encouraging people to assign psychological properties to properties that are actually one’s own... for example  “The picture is beautiful” rather than “I feel the picture is beautiful.” 

Social demand characteristics also come into play.  By this I mean that a person tends to respond as others are responding.  Sensitivity to others’ facial and other nonverbal expressions often triggers reactive thinking.  People are socialized to rank others above or below themselves directly.  They use others’ reactions as mirrors.  These mirrors reinforce reactive thinking.

Psychological defenses maintain reactive thinking.  An example of reactive thinking is a person who cannot tolerate being wrong when confronted with old stimuli. An example of an old stimuli is assessing his or her family and responding in an old conditional way.  People who have not become skilled at utilizing thinking based on choice revert to reactive thinking when under pressure.  Their insecurities lead them to hold onto old ways of thinking.  Through rationalization and selective attention, people see what they believe to be true.

Clinical Impressions
Therapists can help anxious clients deal with issues of approval, control, and competence by adopting more adaptive beliefs.  People can, for example, learn to substitute the concept of choice for that of control.  Similarly, people can learn to adopt and use more esteem-building beliefs.

Therapists can use a variety of strategies to help clients start using thinking that is based on choices, not reaction.  Most clients can learn to move into the choice system relatively easily.  However, clients can just as easily move out of it and back into the reactive system. As you know, the more your client practices, the easier and more automatic this flexibility becomes.  Clients who appear to have changed may in fact have simply reinforced a new deep-structural belief system.  A belief system that allows them to make the shift from reactive thinking to “choice mode” more easily and more often.

Stage Five:  Blocking of Acceptance... Creating Subjective Feelings
The clash between your client’s images and their reactive thinking stops them from processing information and creates instead the experience of the feeling.   An example is the shudder response.  The client has a frightening image and then makes an evaluation of it, for example, “It’s terrible”.   The resulting clash creates a sudden vibration through the body known as the shudder response.  But when your client skips the “shudder” response, he or she imagines something bad happening but accepts this image without fighting it and there is no corresponding emotion.

The above model suggests that people process or take in information about the world through their acceptors.  The concept of “acceptors” is a hypothetical construct.  People assimilate an uninterrupted stream of consciousness about internal and external events.  They absorb or remember useful information and eliminate the rest.

In summary, salient information about an event is first filtered through a person’s emotional memory system or analogue code in the right hemisphere of the brain.  This is out of the client’s awareness.  Past anxious memories color the event and help create the images.  The information in the form of rapid images then goes to the left hemisphere of the brain. This is where conscious awareness is checked against the belief system or analytic code.

Normally, the information is then processed from the left hemisphere of the brain back to the long-term memory in the right hemisphere.  In the right hemisphere, the client assimilates or remembers useful information and eliminates or ignores the rest.

Clinical Implications
Because anxiety is caused by a self-conflict, as you know, your client needs to learn how to let go or accept current reality.  He or she also, however, needs to know the difference between surrendering internally and giving up to external events.  Many people confuse accepting the reality of the moment with resigning themselves to circumstances.  Acceptance is decreasing the emotional “charge” around the event.

Many different acceptance strategies can be used.  One strategy involves working the information through the acceptor by simply reviewing it systematically.  These range from the analytic working-through process to behavioral flooding procedures.  A straightforward method would be to have the client repeatedly review emotionally painful material.  This can be seen as a deliberate way of getting and processing the information to result in acceptance.  Clients suffering from emotional disorders appear to be trying to do this involuntarily.  Your client may, for example, have a great amount of motivation to discuss the material or have painful intruding daydreams or recurrent nightmares.  One client repeatedly told herself, “My father is dead” until she accepted this fact.  Showing anxious clients how to take a more reflective and balanced view of the situation by answering their automatic thoughts stops the conflict and the manufacture of anxiety.

AWARE Technique
One of the first clinical steps involves helping people stop the spiraling effects of anxiety.  One such acceptance strategy is the five-step AWARE strategy, developed by Emery.  The goal of the AWARE program is to help your client to accept and know his or her anxiety by remaining present in context of the situation. Duplicate the following, sketch it on a pad in a session for a client or on chalkboard or flip chart.  The AWARE strategy:
1. Anxiety is welcomed; deciding to be with the experience.
2. Watching anxiety as an observer, separate from the experience.
3. Acting as if one is not anxious.
4. Repeating acceptance create affirmation: “I can handle this.”  “I am okay.”
5. Expecting the best and accepting future anxiety by giving up the hope that the anxiety will never recur and connecting that with trust in one’s ability to handle anxiety.

Short-circuit Technique
Another strategy to short-circuit anxiety is to have your client experience or receive the brain’s self-signal.  Your client feels the anxiety for 45 to 60 seconds.  However, during this time they do not try to fight or change it and without feeding the anxiety any frightening thoughts or images.

Stage Six:  Motivation
Your client’s subjective feelings motivate them to take some action; for example, with anger, to attack; with depression, to shut down; with happiness, to approach; and with anxiety, to flee or protect themselves.  Once a person takes this action, the motivating emotion starts to disappear.  However, the beliefs that help create the emotions are strengthened.  Avoidance, for example, decreases anxiety and fear.  Anxious clients often reinforce the motivating powers of anxiety by using it as self-motivation or self-manipulation.  They unwittingly use anxiety to motivate themselves to take some action.  A person, for example, may imagine failing a class and ending up as a homeless person if he or she does not finish a project.  This scenario creates anxiety, which motivates the person to take action.

Clinical Implications
Clients can be taught to switch from a motivation based on feelings to one based on choices.  They can use the ACT formula (Emery) to do this:  Accept current reality, Choose what you want, and Take action to get it.  This permits clients to move out of the reactive system into the choice system.  A client accepts the situation as it is.  The client then chooses the experience he or she wants to have, and acts as if he or she  is having this experience.  For example, socially anxious people can accept their feelings and lack of social skills.  The client then has a feeling of confidence for upcoming event, and acts as if he or she is confident when they are in the social situation.  Your client learns that instead of using anxiety as motivation, they can do the task directly.  (The preceding was adapted from Beck.)
The article above contains foundational information. Articles below contain optional updates.

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What sets the stage for anxious emotions?

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What happens when your client confronts novel situations?

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What are the five steps in the AWARE technique? To select and enter your answer go to CEU Answer Booklet.

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Table of Contents

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