Communication-Focused Therapy® (CFT) for Psychosis

Haverkampf-C.-J.-2020.-Communication-Focused-Therapy®-CFT-for-Psychosis.-In-CFT-Vol-IV-pp.-240-259

Communication-Focused Therapy (CFT) for Psychosis

Dr. Christian Jonathan Haverkampf, M.D.

Communication-Focused Therapy (CFT) is a psychotherapy developed by the author, which can be applied to several mental health conditions, including psychosis. Meaningful communication is at the heart of understanding psychosis. When a patient can no longer distinguish whether the information comes from the inside or outside world, we consider it a psychotic state. ‘Information’ can include anything from new thoughts to a sensory perception or sensations from inside the body. Since information transmission happens through communication, patients’ communication patterns influence the meaningful information they are exposed to, and the level of meaning they associate with themselves and the world. Psychosis is, in this sense, a distortion in meaning-making, which can be an impairment in everyday life. However, working on communication patterns can reverse the impairment and even bring out new resources to benefit the patient.

Keywords: psychosis, communication-focused therapy, CFT, communication, psychotherapy, treatment

Table of Contents

Introduction. 4

Reality. 4

Learning through Communication. 5

Resources. 5

Psychosis. 6

Misinterpretation of Sources of Information. 7

Misinterpretation of Messages. 9

A Diversity of Symptoms. 9

Connectedness vs Psychosis. 10

Communication-Focused Therapy® (CFT) 11

Communication is Life. 11

Autoregulation. 12

Understanding Psychosis. 12

Meaningful Communication. 12

Learning about Communication. 13

Observing Communication. 14

Experimenting. 15

Reflecting. 15

The Communication Space. 15

Connectedness. 17

Experiencing the World. 17

Identifying Meaning in the World. 17

Increasing Interactions. 18

Values, Needs and Aspirations. 19

Communication Patterns. 20

Questions. 20

Confirmation. 20

Reflection. 21

Support. 21

Explaining. 21

Theory Building. 22

Experimentation. 22

‘You’ and ‘I’ 22

Time. 22

Metacommunication: Structure. 23

Testing. 23

Boundaries. 23

Communicating Internally. 24

Communication Attributes. 24

Communication Structures. 24

Communication Dynamics. 25

Meaningful Messages as the Instrument of Change. 25

Knowing Where Information Comes From.. 26

References. 28

Introduction

Psychosis means losing touch with reality in one’s perception of what is real. It is thus a failure in meaningful communication since what is meaningful ultimately becomes real. Medication is often the first-line treatment, and many schools of psychotherapy are reluctant to work with people experiencing psychotic symptoms. On the other hand, psychotherapy can be a much more delicate instrument than medication. It also needs to be remembered that both medication and psychotherapy bring about changes in the neuronal network. Psychotherapy changes the streams of information, and meaningful information brings about a change in the neuronal network because the inherent definition of meaning is that it can affect a change. (Haverkampf, 2010a, 2018a)

From a perspective of everyday functioning more specifically than medication, which can be highly specific for certain molecular pathways, but does not have the specificity for the interactions of the patient with the real world.

Underlying most psychotherapies is the belief in the effectiveness of interpersonal communication, the ‘talk therapy’ as psychoanalysis was called at the close of the nineteenth century. Since in psychosis there are patterns of communication with oneself and others that are causing symptoms and are not helpful to the individual, using therapy to change offers more than hope in the treatment and management of psychosis. Communication-Focused Therapy® was designed by the author to work on the communication patterns that play a role in the exchange of meaningful information.

Reality

When people speak of reality, they really often mean shared reality. Shared reality is the perceptions the majority of people have. It does not necessarily mean that this is the ‘true’ reality, but it is how the majority of people see the world.

The shared reality may not necessarily be the ‘best’ reality. Someone could be happy interpreting the world in a different way. Part of the shared reality is due to shared anatomy and physiology; another part is due to the exchange of information between people. Psychosis affects how information is processed. Besides medication, helping people to have a different perspective on the flows of information and process them differently is an important way to treat psychosis. Assisting patients in selecting for, exposing themselves to, and as a result, receiving more meaningful information, they can ‘build’ a reality which causes less suffering and better meets their needs and wants.

An essential feature of experiencing reality is to be able to discriminate where the information is coming from. If one hears voices, one misattributes internal thoughts as external, or if one feels pursued by a secret agent, an aggressive inner emotion gets projected into the outside world. Both these examples are a consequence of how patients work with internal and external communication. Better insight into communication and learning communication skills can help to better localize sources of messages and build a more stable view and sense of reality.

Learning through Communication

Learning to identify better the sources of information, inside one’s own body and in the outside world, can help to attach the correct meaning to a sensation or a voice one hears. This can be trained in the communication space of a psychotherapeutic setting. Practising communication and reflecting on it helps the patient to develop greater insight and sharpen his or her communication skills.

Learning about communication usually includes a theoretical psychoeducational component and a practical component. Engaging in communication can be important to increase one’s confidence and skills in the process. At the same time, better proficiency in communication also makes any other learning processes easier.

Resources

Patients who have psychosis often lose a sense of their resources because the structure of the self feels less stable and reliable. In the therapeutic interaction, through the communication process, a more stable distinction between the inside and outside worlds can be established, which strengthens the sense of self, and thus makes the own resources more accessible. The self is an experience of internal information flows (Haverkampf, 2010a, 2017b, 2017c). Therefore, it is not surprising that working on communication patterns can help arrive at a more stable sense of self.

Using communication more optimally can, for example, compensate for various cognitive impairments which are often a part of psychosis. Individual strengths can shine more if interactions with oneself and the world around improve. Resources can also be easier felt and relied upon if one communicates better with oneself. One aim of Communication-Focused Therapy® is to help the patient identify where information comes from, particularly if it represents a feeling or an emotion, what it means, and how one can react to it.

Psychosis

Psychosis is an abnormal condition of the mind that involves a loss of contact with reality. It is not a diagnosis but a bundle of symptoms. People experiencing psychosis may exhibit personality changes and thought disorder. Depending on its severity, this may be accompanied by unusual or bizarre behaviour, difficulties with social interaction, and impairments in carrying out daily life activities. Generally, psychosis involves noticeable deficits in normal behaviour and thought (negative symptoms) and often various types of hallucinations or delusional beliefs, particularly concerning the relationship between self and others as in grandiosity or paranoia (positive symptoms). Psychosis has such broad effects because it affects the flow of information, making interactions with others difficult. But it also affects the internal flows of information as discussed above, which can then lead to a misattribution of information. Internal information may then be mistaken as having an external source and vice versa. The paranoia of someone following me or a secret cabal of individuals influencing me is a projection fo the normal dynamics into the outside world. Our thoughts are questioned, obliterated, and threatened by other thoughts, as this is how normal rational thoughts processes work. The opposite happens when I am convinced that other people are influencing my thoughts directly.

Unfortunately, psychosis as a diagnostic term is often used after other reasons have been excluded. Therefore, it may be more illuminating to think of psychosis as a mental process involving changes in how information flows and how these flows are interpreted, which can occur in various psychiatric conditions.

Misinterpretation of Sources of Information

As discussed, in psychosis leads to a misattribution of information to an outside or an inside source. Patients experience their thoughts as coming from outside in the form of voices or people on the outside as part of internal mental processes. They might experience the latter as people influencing their own thoughts. From the differently perceived localization of perceptions and messages, a different reality is constructed. Since the pieces often do not integrate as well into it as in the shared reality, gaps can result, which then lead to fears, which are often of an intense and existential nature. There is evidence for an association between hallucinations and externalization errors in source monitoring. Neuroimagining results support hyperactivation of voice selective cortical regions (e.g. the superior temporal gyrus, STG) as underlying the cognitive operations shared between externalization errors in source monitoring and hallucinations. (Woodward & Menon, 2013)

From a communication perspective, an interesting question is whether the meaning that is given to the information content influences the misattribution. In one study, results suggested that external source monitoring bias may not be central to the cognitive processes underlying hallucinations early in the course of psychotic illness, and the theory linking childhood trauma and external source misattribution was not supported. (Bendall et al., 2011) Also, in dissociation, there is support for the association between errors attributing the source of self-generated items and positive psychotic symptoms and the absorption and amnesia measures of dissociation. (Chiu et al., 2016) This would also point more to an information processing problem that is relatively independent of meaning.

Another pertinent question is whether the misattribution may be due to an existing tendency to externalize, which may at least explain the inside-out misattribution or projection. Earlier findings have been that patients with hallucinations and delusions are prone to misidentifying their own verbal material as alien in a task which does not involve cognitive self-monitoring. This suggests that these symptoms are related to an externalizing bias in the processing of sensory material, and not solely a function of defective self-monitoring. (P. P. Allen et al., 2004) In a later study, Garrison and colleagues found no evidence of an impairment or externalizing bias on a reality monitoring task in hallucination-prone individuals. They also found no evidence of atypical performance on an internal source monitoring task in hallucination-prone individuals. (Garrison et al., 2017) Reality monitoring is the ability to distinguish internally generated information from information obtained from external sources.  

Impairments in self-recognition (i.e. recognition of own thoughts and actions) have been repeatedly shown in individuals with schizophrenia. Information flows in many different areas in the body, and this can also involve sensorimotor processing. Dysfunction of sensorimotor predictive processing can lead to altered self-monitoring in psychosis. (Salomon et al., 2020) In another study, individual differences in auditory hallucination-like experiences seem to be  highly related to the external misattribution of thought. (Sugimori et al., 2011) This is important because sensorimotor information also plays an important part in building the sense of self. Self-monitoring biases and overconfidence in incorrect judgments have been suggested as playing a role in schizophrenia spectrum disorders. Gaweda and colleagues found that both ultra-high risk and first-episode psychosis groups misattributed imagined actions as being performed (i.e., self-monitoring errors) significantly more often than the control group. They made their false responses with higher confidence in their judgments than the control group. There were no group differences regarding discrimination between the types of actions presented (verbal vs non-verbal). (Gawęda et al., 2018)

The misidentification of self-generated speech in patients with auditory verbal hallucinations is associated with functional abnormalities in the anterior cingulate and left temporal cortex. In a study by Allen and colleagues, individuals with hallucinations made more external misattributions and showed altered activation in the superior temporal gyrus and anterior cingulate compared with both other groups. This may be related to impairment in the explicit evaluation of ambiguous auditory verbal stimuli, according to the investigators. (P. Allen et al., 2007)

There seem to be self-recognition deficits in populations on the continuum of psychosis who are still lacking the full-blown psychotic symptoms. Lavalle and colleagues observed significantly reduced self-recognition accuracy in populations on the pyschosis-spectrum compared to controls. (Lavallé et al., 2020) Biological areas in the brain that are involved in both self-referential processing and the integration of sensory information, such as the right middle temporal gyrus (MTG) and left precuneus, may be involved. A study found that within a first-episode psychosis group, the level of activation in the right middle temporal gyrus was negatively correlated with the severity of their positive psychotic symptoms. y (Kambeitz-Ilankovic et al., 2013)

One needs to regard psychotic symptoms as being on a sliding scale, like many other mental health afflictions. For example, psychotic symptoms can occur in situations when otherwise healthy individuals are under significant psychological stress. Using a robotic device to introduce sensorimotor prediction errors (SPEs) in healthy subjects can induce a psychosis-like feeling of a presence (‘FoP’) (Blanke et al. 2014).  induction of SPE can cause self-other confusion in the auditory domain. This deficit in self-other discrimination could be correlated to specifically reduced connectivity in the fronto-parietal cortex (‘FoP network’) related to sensorimotor self-representation. (Salomon et al., 2018)

Misinterpretation of Messages

Misinterpretation of a message is different from the misattribution of the information source, but they often seem to go hand in hand in psychosis. The conviction that someone is pursued by a neighbour, who is a spy, can be a misinterpretation of a feeling towards the neighbour as a (real) outside event, while a smile from the neighbour in the hallway can be interpreted as her satisfaction about having made a plan to harm the patient, which would be a misinterpretation of her original message of saying ‘Hi’.

A misinterpretation of messages usually occurs with respect to the universe of the patient, emotionally and perceptually. When focusing on communication in therapy, it is therefore essential to first get a sense for the universe the patient finds himself or herself in, both perceptually and emotionally. This information allows the therapist to build a better rapport with the patient since the patient will interpret the therapist’s messages within the context of this universe.

A Diversity of Symptoms

A host of symptoms can follow from the underlying communication dynamics of psychosis. Psychosis is often used descriptive term for the hallucinations, delusions and impaired insight that may occur as part of a psychiatric disorder. More correct would be to use it to describe the alterations in information recognition and processing. Some symptoms can be due to a misinterpretation in the source of the information or misinterpretation of one’s own position relative to the source of information, while others are clearly due to a misinterpretation of the messages.

Connectedness vs Psychosis

Psychosis is a state in which information is no longer categorized and compartmentalized in the same way. This does not necessarily mean an increase in connectedness. Rather the opposite, as the categorization of information, such as what happens in the outside world and what happens on the inside, is important to effectively communicate with oneself and others. When it becomes distorted or breaks down, the boundaries between oneself and the other person are affected, which reduces the accuracy of encoding and decoding messages. If I cannot distinguish if a thought or emotion is mine or someone else’s, my interaction with the other person will be affected. If I am wrong, a message from the other person, or myself, will be read incorrectly, and I am more likely to respond in a way, which does not help myself or the other person. For example, if my anger about someone else is misinterpreted as anger coming from the other person, I am more likely to misinterpret their brief stare or silence. They may reflect on what I said while I could interpret their communication as aggressive.

However, connectedness can also be heightened in a psychotic episode if barriers break down, which have been impairing a free flow of meaningful communication otherwise. For example, among shamans, several may owe their visions to psychotic episodes, which brought information into conscious awareness, which may not have been as easily accessible otherwise. Several artists also had psychosis, such as Van Gogh who had schizophrenia, whose paintings with their bright colours and eerily straight forward yet fantastically distorted images remind of accounts of psychotic episodes. It does not mean that they were actually created in a psychotic episode, but a greater sensitivity and less filtering of certain types of sensory and other information in psychosis could be associated with more pronounced internal and external connectedness. How this connectedness plays out in everyday life depends on existing communication patterns, both within the person and with others. It also depends significantly on the environment, as the case of the shamans illustrated.

Communication-Focused Therapy® (CFT)

The author developed Communication-Focused Therapy® (CFT) to focus more specifically on the communication process between patient and therapist and help the patient acquire more insight and better skills. The central piece is that the sending and receiving of meaningful messages is at the heart of any process leading to changes in thoughts or external situations. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes can bring about change without focusing on them. CFT tries to be more efficient in a therapeutic sense by focusing on them more directly.

At the start, when treating psychosis, it may appear challenging to engage in a constructive communication process. However, organisms, in general, tend to react to information if it reaches them somehow. Even in states that seem very closed off, the brain still receives and processes information streaming from the external world. Persistence, and in many cases antipsychotic medication as a supportive tool, often help to get the patient to a point where they get used to the constant messages, fears decline, and it becomes easier to initiate a response. It is important to remember that it is almost impossible to interact with someone who repeatedly sends out messages under normal circumstances.

Communication is Life

We continuously engage in communication. Cells in our bodies interact with each other using electrical current, molecules, vibrations or even electromagnetic waves. On a more macroscopic level, people communicate through a multitude of channels, which may depend on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission. Muscles and air stream determine the motions of the vocal chords. As a result, sound waves travel through the air, followed by various translations on the receiving end. At each end, in the sender and the receiver, there is a processing of information that relies on the nervous system’s highly complex networks. Communication, in short, happens everywhere all the time. It is an integral part of life. Specific communication patterns can, however, also contribute to experiencing anxiety and panic attacks.

Autoregulation

Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.

Understanding Psychosis

In psychosis the internal and external worlds cannot be distinguished as accurately anymore. They seem to blend into each other. This can cause various symptoms that are then summarised as ‘psychotic’. However, each symptom should make sense in the context of the patient’s communication patterns as well as the life experiences and emotions the patient faces, which influence the content of the psychosis. Having an understanding for what is happening, is important because it also helps make the patient feel more secure.

Another feature of psychosis is a more or less strong divergence from the patient’s perceived world from the shared reality, maybe one aspect which allows artists with intermittent moderate psychosis to paint stunning works of art. This divergence is largely driven by emotions or thoughts which become disassociated from the fabric of the patient’s self and personality.

Meaningful Communication

When an individual suffers from psychosis, a first important step is to help the patient see meaning in the communication process, particularly a relevance to own needs and interests. This helps to build and maintain the motivation which is necessary for a communication oriented therapeutic process. It also helps the patient build a greater sense of efficacy when interacting with his or her environment.

Since communication patterns are usually significantly affected in psychosis, a message can be given different meaning. If the information background of a message changes, the meaning attached to it changes. When information is no longer tagged correctly as to where it comes from, whether from the inside or the outside of a person, its meaning will change because it is put into a different information context. For example, ‘hearing’ a thought as if it comes from the outside world, leads the brain to create a whole setting for this ‘voice’. As the brain is constantly trying to extract simplicity from the information it has, it will offer the simplest explanation for this voice, even if it has to create a new reality where the voice fits in. The result can be a fantastic story built around the voice. Understanding these internal communication patterns, even if they cannot be seen directly, helps a patient to better live with the voice. Patients with psychosis may even understand the voice as thoughts they are having. As these may be thoughts they would not be consciously aware of otherwise, psychotherapy also needs to help the patient gain a better understanding of the content of the voice, which can be a stark distortion of the underlying thoughts.

Learning about Communication

The first step is to learn about communication, to see how it works, what its constituents are and the purposes it can serve, to talk about communication. Often it helps to go through examples that may be of special relevance to the patient. Analyzing them and looking at different options and different outcomes help to illustrate to the patient the importance of the process. Talking about communication also has the benefit that one can talk about something relevant apart from the content. Talking about communication allows to focus on something that not only underlies all the processes that produce content without talking about the latter, but also to move with the patient in a space where there are usually no discrepancies in beliefs or anything that is driven by content, which is largely superficial and dependent on the communication processes underneath it. Talking about communication also lets the therapist get a foot in the door of content. No matter how bizarre beliefs or views sound, there is some reason for the patient to have them, and to find one’s way into the deeper content is usually best via talking and learning about communication. Often, the more bizarre the belief sounds, the clearer may be the underlying thought content.

For the learning process, it is important that the therapist has a sense of the patient’s perceptual and emotional world. Understanding is here at the core, which involves the use of communication patterns that facilitate the exchange of meaningful information. Learning with the patient more about the communication patterns the patient (and the therapist) uses increases the amount of meaningful information that can be produced in the session. Insight into the patient’s communication patterns also enables the therapist to use communication styles and messages which are interpreted by the patient not as hostile, deferential or lacking in empathy. Early in the therapeutic process the interaction should help to build a strong and stable therapeutic relationship. An understanding of communication patterns is in this process more important than the content.

Observing Communication

Splitting up communication and identifying its components helps to observe the process and the variations, large and small, in it. Observing is a learning experience and helps develop an interest in communication and see the possibilities in influencing and shaping interactions with others. An interaction can exist in many shapes and forms, while the underlying communication processes adhere to common rules and laws. It helps the patient to appreciate the common underlying mechanisms, which can increase trust in the process and a sense of stability in the world, and, at the same time, to see an ecncounter as a dynamic group of interacting communication events.

Important is that the patient learns to look at the bigger picture and observe communication as it takes place, whether it involves the patient or not. This essentially requires being able to take a step out of the current interaction and to observe the dynamic without engaging in it at the same time. Over time, this becomes automatic enough that observation and engagement can alternate in one’s awareness so quickly that they seem to be simultaneous.

A patient can learn about communication if the therapist reflects and comments on what happens in the communication space the patient and therapist share. This teaches the patient patterns and skills through the expertise and experience of the therapist. However, it requires that the therapist has this expertise and experience. Especially for a psychotic patient, it is important to show this not just in theory, but also in practice through trying out new communication experiences which then translate into new perspective of the world and oneself.

Experimenting

Experimenting with communication in its different flavors can give the patient a greater sense of effectiveness with respect to the environment as well as oneself. It gives patients a greater sense of being in control, which is helpful because patients with psychosis often experience helpless and hopelessness, which can also cause some of the sudden emotional outbursts seen in severe cases of psychosis, such as schizophrenia.

A gradual increase in the scope or difficulty in the scope of experimentation probably works best. It can start with little everyday encounters and end with dating. People generally feel more vulnerable the more they feel they expose about themselves. For patients who have psychosis, this anxiety is much greater, because they sense that their perceived world and the shared reality diverge. Own emotions may also feel real, which makes their visibility to others even riskier. The fear of getting hurt at the core of one’s mental structure is universal. However, the hurt seems more devastating in a patient who has psychosis because the structure is already under considerable stress.

Reflecting

The newly gained knowledge and communication skills need to be processed, which can help increase the confidence and sense of effectiveness in the world. This should not be solely about control, but more about seeing oneself as a part of something bigger which is not something to be afraid of, but helps individuals to address and meet their needs and wants.

The Communication Space

Depending on the environment we move through different communication spaces in everyday life. The communication space is the space in which messages are being sent and received. If one is talking to someone over the phone who lives on a different continent, the communication space extends to this person, while not including the neighbor in the apartment next door, unless the walls are really thin.

To a patient suffering from psychosis the communication space can be extremely large or extremely small, but it usually diverges considerably from that of other people. Thoughts, for example, can be influenced from a large distance, or, at the other extreme, a patient could fully disconnect from the environment. To someone suffering from psychosis the internal world largely determines the communication space, while other people’s communication space is determined through an interaction with the environment.

In therapy, it is important to make the patient aware of the communication space he or she builds and what influences it. This is an important component of learning about communication and bringing about change through it. We all build our communication spaces in different ways. This does not only depend on individual communication patterns or structures, but also on other aspects of personality, individual life experiences, and more. The mental health condition, in this case the psychosis, should be viewed as something on top of it that affects the building of the communication space and the communication patterns in a fairly predictable yet somewhat crude way.

The communication space is built from communication patterns, yet it also influences communication patterns in a rather direct way. When I interact with another person, the communication patterns, and possibly also structures, I will be using, depend on the communication space I find myself in. As the communication space is subjective, it is only related to an actual physical space and situation, but it is not the same. Depending on how I feel I may perceive my external communication space as relatively large at a dinner party (good feelings, low social anxiety) or small (feeling self-conscious, distracted by internal thoughts). Although the external and internal communication space may both be large at times, they often grow at the expense of the other. When the experienced external and internal communication spaces in psychosis overlap less and less with the spaces as they appear to an observer, communication with the outside world becomes less efficient. There is more friction because the communication patterns an individual uses are adapted to the experienced communication space, which in psychosis, as also in several other mental health conditions, agrees less with the communication space another person uses to adjust their communication patterns and structures. Helping a patient identify these differences can already be very helpful. It is not necessary that people’s communication spaces agree all the time – they are not supposed to – as long as one can translate between the two and make modification. If a patient suffering from a psychosis sees her world as that of a microbe on an intergalactic sheep, it is still possible to talk about feelings thoughts and the conversation we may be having. As already discussed the content can pull the interaction, but reflecting together on the communication itself is often the technique that can lead to long-term stabilization.

Connectedness

The symptoms of psychosis can reduce the meaningful interactions a patient has with the world. The breakdown of boundaries between the outside and inside world and the changes in selecting and giving meaning to information, make communication between a patient with psychosis and someone else more difficult. These difficulties in communication can then have secondary effects, which lead to even more isolation and disconnect. The therapist can use communication patterns that lead to changes in the patient’s communication patterns, when they are combined with an overall strategy of creating more awareness and insight for the communication the patient has with the world and conducts internally.

Experiencing the World

Psychosis often leads to a vicious cycle which leads to less rather than more communication. Anxieties and a changed perception of reality can lead to a disengagement from it, which reduces the ability to distinguish internal from external reality even more. Practising and discussing new ways to communicate with the patient, including new communication patterns and better reflection on them, increases the patient’s ability to experience and bring about change in the world.

Next to improving interactions with others, better identification and understanding of meaning helps to anchor the patient better in the shared reality, making everyday life and planning for the future easier.

Identifying Meaning in the World

Fears brought about by the divergence of the perceived reality from the shared reality lead to social isolation and withdrawal, which reinforces feelings of fear and loneliness or frustrations. To break this cycle, it helps the patient find more relevance in aspects of the shared reality. This is usually not a process which happens from one day to the next, but over time leads to a closer alignment of the patient’s perceptions and intentions with the shared reality

Communication helps in identifying and finding meaning. Communicating with oneself and others raises one’s proficiency at identifying, finding and accumulating meaningful information. Organisms are already born with communication patterns they can use with themselves and the environment. These resources are encoded in the networks of cells within the organism, particularly the neuronal network. Through meaningful interactions, one accumulates more meaning, more connectedness with oneself and the world, which also provides a protective boundary against fears, guilt, self-blame and other negative emotions, depression and anxiety.

There are essentially two techniques to help the patient identify and interpret relevance and meaning in the world. One is by directly discussing the individual needs and how they can be met in the world, such as in a relationship or at the workplace. The second is by helping the patient have better internal and external interactions with the world, which make it easier to see relevance and meaning in the environment and provide the skills to attain them.

Increasing Interactions

Perceiving more meaning also makes interacting with others and oneself more meaningful. Communication patterns determine how one relates to the own environment and exchanges messages with it, which in turn affects the communication patterns. As long as this feedback loop works well, it contributes significantly to the patient’s autoregulation and a better adjustment to the environment. As the anxiety about interactions with others decreases, it should become easier to become more socially involved with others, at least to the extent that would feel comfortable to the individual.

In the beginning this often requires reducing situation- or person-dependent fears that are a consequence of the psychotic experience. Altered interpretations of information and its source lead to the perception of a less stable world, which seems to contain real threats, even if the latter is just own emotions or thoughts that have manifested as real to the patient. Meaningful interactions with the world can reduce the divergence of realities and fear because they stabilize the patient’s experience in the world. To be meaningful, the interactions should be an exchange of messages relevant to the patient’s interests, values or aspirations. This is why it is important to discuss with the patient and get a sense of the patient’s needs, wants and values. The next step is to help the patient find and make interactions that are helpful and meaningful to him or her. With the additional focus on communication, whether in a therapeutic session, internal thoughts or between the patent and others, interactions should become easier and less feared.

Values, Needs and Aspirations

Often, individuals suffering from psychosis become uncertain about what is really important to them and the fit between these values and interests and their current life situation. In all areas of life, having one’s needs, wants and values met, leads to a higher quality of life. If one values helping others in a specific way, it is important to find ways to engage in this activity, because it will result in a positive feeling. Harm to oneself and others is usually a consequence of some disconnect with one’s own feelings, needs, wants and values. Burnout or verbal abuse of another person may be examples.

The change in one’s relation with oneself and the environment, as well as the resulting change in the sense of self, make is usually harder for an individual suffering from psychosis to identify correctly the own needs, wants, values, and aspirations, partly out of fear that they could disturb a fragile feeling reality even more. In this situation, it is helpful to help the patient understand that connecting with them actually adds stability, rather than taking away from it. One way to reduce the fear of getting closer to and identifying key parameters about oneself is to help the patent emotionally reconnect. The emotions are the sum of vast amounts of information, such as a feeling of happiness as the product of perceptions of a situation and associated thoughts, and can, if they are owned by the patient, lead to a greater feeling of stability. Helping the patient to notice and identify them more accurately can lower fears and the make the inner world, and thus also the outer world in psychosis, seem more predictable. It is important to add in this context, that emotional instability is not so much due to a too much of emotions, but a consequence of impairments in a patient’s internal communication with the own emotions. The inability to read the emotions accurately leads to the sense of instability, or even the emotional and existential ‘void’ which is so prevalent in a patient with borderline personality disorder.

Communication Patterns

A more comprehensive overview of different communication patterns, elements, and structures is provided by the author elsewhere (Haverkampf, 2018b). A few will here be selected that may be particularly useful in patients with psychosis.

Questions

Questions are powerful instruments in changing communication patterns (Haverkampf, 2017a). There are many different types with vastly different effects. But what many of them have in common is that they have an influence on how information is selected and worked with. Many questions narrow the choice of communication patterns the other person can use in response. They often force the other to use a blended communication pattern and content they might otherwise not have volunteered at this point within the interaction. Questions can therefore also play a significant role to influence the timing of stages within an interaction.

Using questions in the interaction with someone experiencing psychotic symptoms should be done carefully. While it can be a challenge to preemptively analyze how a question could be interpreted by the other, it makes the interaction easier to try to stay with the patient and get a sense for how they are likely to experience the world and this interaction in particular. The advantage of using questions is that they are less overtly directive, which can help when talking with a paranoid patient. On the other hand, being more directive can help a patient who experiences a loss of structure in the world and within themselves. However, in order to provide this level of support it is important to have a proper sense of the world and the own person through the patient’s eyes. Psychotic patients are often grateful for the interaction with another human being. Important is to build enough insight that any remaining structures that provide the patient with stability are not under attack from the start.

Confirmation

Repeating the information the patient has said but with adding to it, and thus slightly altered meaning, can be helpful to strengthen the healthy resources the patient can still access in a psychotic episode. This can also be done outside the psychotic episode. Building on strengths and resources that are rooted firmly in the patient’s mental world creates greater resilience when the psychotic thought patterns try to loosen the connection with external and internal realities.

Reflection

Reflective communication patterns are mainly directed at inducing reflection in the other. This is often done by introducing something novel, such as particular observation by the therapist, which appears relevant to the patient’s basic parameters, namely the needs, values and aspirations. Reflection should help build on the healthy structures the patient uses to gain a greater sense of stability and support the grounding in reality which facilitates better communication with oneself and others.

Support

Supportive communication patterns give the patient the opportunity to narrate and explain about his or her world in a safe and non-judgmental atmosphere. At the same time, the therapist is present with a reflection on the own feelings and thoughts that are triggered by the patient’s narrative. Supportive communication uses communication patterns that make it easier for the patient to engage, while providing the openness the patient needs to do so. Statement that show genuine interest and caring can go a long way. Here it also helps if the therapist is alert to meaning within the patient’s words. As the decoding of meaning depends on the information one already has, getting meaningful information form the patient and trying to understand as much as possible about the world of the patient are important.

Explaining

Explaining something to the patient may seem one-directional and untherapeutic, but it is of particular importance when working with patients suffering from psychosis. A good explanation about something the patient is struggling with or about the interaction with the therapist, for example, can be helpful in giving the patient a greater sense of stability and safety. This, of course, requires that the therapist has enough insight to be meaningful and relevant to the patient in the explanations and to be understood. Explaining can sometimes work like a question, because the additional information can lead to further information from the patient. Particularly in psychosis, a clear and mostly unambiguous communication is essential. Good communication can help the patient put more structure into the experienced real world.

Theory Building

Considering and reflecting on options demonstrates openness. Particularly in the case of psychosis, in which patients experiencing the world becoming a smaller rather than a larger place, learning that openness in terms of looking for explanations is nothing to be afraid of can be helpful in containing the destabilizing effect of psychosis.

Experimentation

Experimenting with communication patterns is one of the most important tools in therapy. When the patient experiences that the therapist experiments with new communication patterns, it also makes it easier for the patient to experiment. Adjusting existing communication patterns or synthesizing new ones so that they are more effective and adaptive is an important step for the patient. The therapist can support this by being open, reflected and playful in communicating.

‘You’ and ‘I’

Communication patterns that highlight the individual realms of patient and therapist are important to help the patient to distinguish between the own inner and the outer world and to integrate the presence of the other into these worlds. At the same time, the important of communication as a bridge between ‘you’ and ‘I’ which can make a ‘we’ in defined areas helps the patient to experience the power of communication, which can work against feelings of helplessness and control from outside.

Time

 Patients suffering from psychosis are already under tremendous pressure. It is important not to rush it and allow communication patterns that may not be directed to a specific goal and to create the space in which relaxed experimentation without fear of failure can take place. Time can take on different qualities when a patient is in a psychotic episode, which should be taken into account. As with any communication dynamic, pattern or attribute, it is important for the therapist to use a combination of picking up the patient where he is and doing something new, which can bring about a change and help the patient to move to a better state.

Metacommunication: Structure

Communication patterns have structure and the communication patterns together give rise to structures. As mentioned under support, it is usually helpful for the patient to get greater insight into how communication works. This makes it also to build on it. Raising awareness in the patient for communication structure may include some explanation, but often it may be more a combination of reflecting with the patient on past communication experiences, and how they worked, and reflecting on the communication taking place in the current setting.

Testing

Testing out communication patterns can also be important particularly for patients with psychosis. For example, to know where the information one hears in a voice is coming from, being able to test communication patterns is important. In the session this is often facilitated, when the therapist displays openness and explores with the patient helpful questions to find answers that satisfy needs and aspirations. Testing out communication patterns is frequently done by talking about situations that did nor did not work and investigating with the patients what made them work or not work. Practicing this investigative thinking can be helpful in improving everyday situations. It has also the benefit that it entrenches a way of communicating internally that can keep a greater stability in a psychotic episode.

Boundaries

It is difficult to communicate without boundaries. If there is no marked off space one can claim for oneself and outside of which there is the other person’s space, it is easy to make other people’s unhealthy thought and emotional dynamics one’s own and see own thoughts and emotions as those of others. When the distinction between the internal and external world fades in a psychotic episode, helping oneself and making decisions become impossible. If structures and categories disappear, ‘Yes’ or ‘No’ become even more of a challenge. A disconnect from vital internal information to make decisions, add to the indecisiveness.

Important communication patterns in building boundaries are those that help the patient become more aware of and identify the basic parameters, that is the own needs, values, and aspirations. As they are always present and do not change much over time, identifying them can often have a stabilizing and healing effect for the patient. But they also help establish boundaries, because they reinforce the sense of being distinct from others and unique in them. At the same time, boundaries make it easier to also explore what one has in common with others without having to be afraid to lose those attributes that are important to oneself.

Communicating Internally

Making it easier for the patient to talk about internal communication can also help in having more influence over the internal communication. One usually has more influence over communication one can communicate about. This ability to engage in meta-communication is something that is usually lost in a more severe psychotic episode in schizophrenia, for example. However, in more moderate psychotic episodes this can be possible provided one has practiced it beforehand and experienced it as useful.

Communication Attributes

Different communication patterns can have common attributes. For example, openness can be expressed through questions, statements, inviting gestures, and so forth. Particularly when working with patients suffering from psychosis, clarity is important, but so also is adjusting the amount of information that is being communicated. Providing spontaneous feedback, for example, while a generic communication pattern, can come with many different attributes. It can be information rich, have added information in the form of particular emotional undertones, invite or not invite a response, and so forth. Working communication patterns and attributes usually develop out of the interaction with the patient, which contains auto-regulatory mechanisms.

Communication Structures

More complex behaviors in life, such as socializing, doing therapy, or conducting a meeting in work, are ruled by communication structures, which specify the group of communication patterns that are most likely to be used during the event, and in what sequence and under which circumstances. More awareness of these structures can often provide additional support to patients when they feel overwhelmed and confused by the communication dynamics of the moment. It also helps the therapist to have these structures in mind when the patient discusses everyday situations that did not seem to work.

Communication Dynamics

Therapy has meaningful messages travelling in both directions most of the time. Even the most abstinent therapist can only have a positive effect on the patient because he or she communicates. When working with patients who are experiencing an episode of psychosis, the information flows have to be adjusted to the situation. Problems usually arise in any communication situation when the external and internal dynamics diverge too far from each other (Haverkampf, 2010b)

The needed communication dynamics depend on the individual and on the situation. In many mental health conditions, the self-regulation capabilities are impaired, and it is difficult for a patient to adjust the parameters of the dynamics, including intensity, directionality (for example, back-and-forth or one-way), repetitiveness, novelty, and more, to the current needs. In psychosis, the partial disconnect mentioned above makes it more difficult to perceive the own need and to communicate to others the adjustments that are needed. The therapeutic setting should be a place where this can be practiced.

Meaningful Messages as the Instrument of Change

Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist.

The main objective is that patients can make communication work for themselves on their own. Looking at communication patterns and how meaning is generated in a therapeutic session should not only help with a concrete situation or problem in the moment but provide the tools to work with a multitude of situations or problems in the future. The key to build motivation and use communication processes, is to understand that meaning, information about information which is relevant to and resonates with the recipient of the message, is very much at the heart of it. Becoming better at sending and receiving, interpreting and working with meaning can make the world for an individual suffering from psychosis more stable and broadens the scope of change that can be affected on the world and oneself. Better insight and skills around communication and meaning take some time but can have a lasting beneficial effect for and individual suffering from psychosis.

Knowing Where Information Comes From

In the end, the patent should also have a better sense of communicating and knowing where information comes from. Not only does this help this reduce the divergence between the experienced world and the shared world, but it also helps to use information and communication better. Being able to identify a source of information can make it easier to identify meaning and respond to it. This helps build a stronger sense of self, better relationships and imparts greater confidence in dealing with everyday life as well towards fulfilling own aspirations. Greater insight and skills into communication can accomplish this.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

References

Allen, P., Amaro, E., Fu, C. H. Y., Williams, S. C. R., Brammer, M. J., Johns, L. C., & McGuire, P. K. (2007). Neural correlates of the misattribution of speech in schizophrenia. British Journal of Psychiatry, 190(FEB.), 162–169. https://doi.org/10.1192/bjp.bp.106.025700

Allen, P. P., Johns, L. C., Fu, C. H. Y., Broome, M. R., Vythelingum, G. N., & McGuire, P. K. (2004). Misattribution of external speech in patients with hallucinations and delusions. Schizophrenia Research, 69(2–3), 277–287. https://doi.org/10.1016/j.schres.2003.09.008

Bendall, S., Jackson, H. J., & Hulbert, C. A. (2011). What self-generated speech is externally misattributed in psychosis? Testing three cognitive models in a first-episode sample. Schizophrenia Research, 129(1), 36–41. https://doi.org/10.1016/j.schres.2011.03.028

Chiu, C.-D., Tseng, M.-C. M., Chien, Y.-L., Liao, S.-C., Liu, C.-M., Yeh, Y.-Y., & Hwu, H.-G. (2016). Misattributing the Source of Self-Generated Representations Related to Dissociative and Psychotic Symptoms. Frontiers in Psychology, 7(APR), 541. https://doi.org/10.3389/fpsyg.2016.00541

Garrison, J. R., Moseley, P., Alderson-Day, B., Smailes, D., Fernyhough, C., & Simons, J. S. (2017). Testing continuum models of psychosis: No reduction in source monitoring ability in healthy individuals prone to auditory hallucinations. Cortex, 91, 197–207. https://doi.org/10.1016/j.cortex.2016.11.011

Gawęda, Li, E., Lavoie, S., Whitford, T. J., Moritz, S., & Nelson, B. (2018). Impaired action self-monitoring and cognitive confidence among ultra-high risk for psychosis and first-episode psychosis patients. European Psychiatry, 47, 67–75. https://doi.org/10.1016/j.eurpsy.2017.09.003

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2017a). Questions in Therapy. J Psychiatry Psychotherapy Communication, 6(1), 80–81.

Haverkampf, C. J. (2017b). Self-Discovery.

Haverkampf, C. J. (2017c). Treatment-Resistant Borderline Personality Disorder. J Psychiatry Psychotherapy Communication, 6(3), 68–89. http://borderline-treatment.com/wp-content/uploads/2019/01/Haverkampf-CJ-Treatment-Resistant-Borderline-Personality-Disorder-J-Psychiatry-Psychotherapy-Communication-2017-Sept-30-63-68-89.pdf

Haverkampf, C. J. (2018a). Building Meaning – Communication and Creativity (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018b). Communication Patterns and Structures.

Kambeitz-Ilankovic, L., Hennig-Fast, K., Benetti, S., Kambeitz, J., Pettersson-Yeo, W., O’Daly, O., McGuire, P., & Allen, P. (2013). Attentional Modulation of Source Attribution in First-Episode Psychosis: A Functional Magnetic Resonance Imaging Study. Schizophrenia Bulletin, 39(5), 1027–1036. https://doi.org/10.1093/schbul/sbs101

Lavallé, L., Dondé, C., Gawȩda, Ł., Brunelin, J., & Mondino, M. (2020). Impaired self-recognition in individuals with no full-blown psychotic symptoms represented across the continuum of psychosis: A meta-analysis. Psychological Medicine, 1–11. https://doi.org/10.1017/S003329172000152X

Salomon, R., Progin, P., Griffa, A., Rognini, G., Do, K. Q., Conus, P., Marchesotti, S., Bernasconi, F., Hagmann, P., Serino, A., & Blanke, O. (2020). Sensorimotor Induction of Auditory Misattribution in Early Psychosis. Schizophrenia Bulletin, 46(4), 947–954. https://doi.org/10.1093/schbul/sbz136

Salomon, R., Progin, P., Griffa, A., Rognini, G., Do, K. Q., Conus, P., Marchesotti, S., Hagmann, P., Serino, A., & Blanke, O. (2018). T221. Sensorimotor Induction of Auditory Misattribution in Psychosis is Linked to Neural Disconnectivity. Biological Psychiatry, 83(9), S214. https://doi.org/10.1016/j.biopsych.2018.02.558

Sugimori, E., Asai, T., & Tanno, Y. (2011). Sense of agency over thought: External misattribution of thought in a memory task and proneness to auditory hallucination. Consciousness and Cognition, 20(3), 688–695. https://doi.org/10.1016/j.concog.2010.12.014

Woodward, T. S., & Menon, M. (2013). Misattribution models (II): Source monitoring in hallucinating schizophrenia subjects. In The Neuroscience of Hallucinations (pp. 169–184). Springer New York. https://doi.org/10.1007/978-1-4614-4121-2_10

This article is solely a basis for academic discussion, and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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Communication-Focused Therapy® (CFT) for Depression

Haverkampf-C.-J.-2020.-Communication-Focused-Therapy®-CFT-for-Depression.-In-CFT-Vol-IV-pp.-320-339

Communication-Focused Therapy® (CFT) for Depression

Christian Jonathan Haverkampf, M.D.

Depression is a mental health condition that affects a large part of the population at least once over their life span, significantly reducing life quality and impairing work and relationships. Psychotherapy and medication are the main treatments for the condition. Communication-Focused Therapy® (CFT) is a therapy developed by the author, focusing on communication processes to treat depression. Improvements in internal and external communication and awareness for a patient’s needs, values and aspirations appear to be effective against several symptoms of depression and increase motivation and compliance for therapy. This article provides an overview of a conceptual framework from a communication perspective and several approaches for treating depression with psychotherapy.

Keywords: depression, communication-focused therapy, CFT, communication, psychotherapy, psychiatry, treatment

Table of Contents

Introduction. 4

Depression. 6

Flattening of Emotions. 6

Negative Interpretations. 7

Communication-Focused Therapy® (CFT®) 9

Communication Patterns. 10

Questions. 11

Timeline. 11

Getting Information. 12

Connecting. 12

Integration. 13

Analyzing Communication Patterns. 13

Emotional Signals. 14

Motivation. 15

Insight into Communication. 15

Building the Sense of Self 17

Meaning. 18

Resonance. 18

Relevance. 19

Communication Exchange. 21

Integration. 21

Values, Needs and Aspirations. 22

Internal Communication. 22

Meaningful Messages as the Instrument of Change. 23

Broader Experience. 23

References. 25

 

Introduction

Depression is a general lowering of emotional experiences, while in the lighter forms, it may just be a reduction of positive emotional experiences. A dialling down of internal and external communication, such as thoughts, feelings and activities, usually accompanies it. Loss of energy, motivation, and initiative, loss of enjoyment and interest in pleasurable activities, and loss of concentration are just some of the possible attributes of depression.

All explanations for depression seem to depend on the framework of the school of thought that produced them. An early answer from ego psychology was that depression is the emotional expression of a state of ego-helplessness and ego-powerlessness to live up to certain strongly maintained narcissistic aspirations. (Bibring, 1953) This explanation is in some ways not so far from what we can observe in depression in every clinical practice, even if we rarely use the terminology anymore. Patients who are depressed indeed mostly feel helpless and powerless, which are practically requirements of the sense of feeling depressed. When we find ourselves in a situation where there seems no escape or where we have to decide quite literally between a rock and a hard place, we are more likely to feel depressed, unless we develop a new alternative and open a door we have not seen before. Unfortunately, depression makes it seem harder to innovate and be creative. One of the techniques of Communication-Focused Therapy® (CFT) is to restore the ability to see a broad range of options and innovate in depression. The path there is through work on communication patterns, as communication is how we all get our needs, values and aspirations satisfied.

Depression usually impairs the emotional communication one has with oneself and with others. (Haverkampf, 2017e) Experimental data has been showing quite consistently that depressive subjects exhibit disrupted emotional processing.  (Delle-Vigne et al., 2014) This emotional disconnect from oneself leads to a less complete sense of self and lower confidence in oneself and the world. (Haverkampf, 2012) The disconnect then leads to significant secondary impairments in everyday life.  It affects the interaction patterns one has with other people and oneself, leading to various relationship and workplace problems, and from here to further depression and anxiety. Thus, a neverending vicious cycle can pull the individual suffering from depression ever further down. Fortunately, in most people, depressive episodes are self-limiting as self-regulatory mechanisms usually kick in once it has reached a level where the quality of life is severely compromised. What then happens is that a shift or change in the internal and external communication happens that pulls the individual out of the depression. This latter process is what Communication-Focused Therapy® aims to bring about in patients where these auto-regulatory processes are absent or maladaptive. (Haverkampf, 2010b)

The symptoms of depression are the result of maladaptive internal and external communication patterns. A disturbance in the flows of meaningful information flows within the nervous system and between the nervous system and the outside world leads to a disconnect, resulting in less perceived meaning in the world and worse decisions because there is less available information. The informational deficit about oneself and the world leads to depression and anxiety, which causes even more withdrawal in a vicious cycle.

The link between communication patterns and mental well-being is an essential insight for its enormous ramifications on understanding and treating depression. However, one needs to view it as a large puzzle, where the pieces all fit in in the end. These puzzle pieces can come from many areas of an individual’s everyday life. In a study on monogamous romantic relationships, for example, mutual constructive communication was associated with decreases in depressive symptoms for males. In contrast, demand-withdraw communication correlated with increases in attachment avoidance and depressive symptoms. (Givertz & Safford, 2011)

An essential step in overcoming depression is becoming curious about how one communicates with oneself and others. Using constructive inquisitive communication patterns can have a healing effect (Haverkampf, 2017i). In therapy, the therapist can encourage observing the communication patterns a client operates and the assumptions made in them about intentions, wishes and needs, values, and other factors that determine the quality, quantity and future of human interactions. Since all psychotherapies to date, use human interaction as the main instrument in the healing process, even if they do not focus on it, most therapies can have a beneficial effect. Unfortunately, the focus is often not on communication patterns, which can, at least from a theoretical perspective, render them less efficient. While it is true that learned behaviour and past experiences influence the severity of the symptoms, they do so via internal and external patterns of communication. In any instance where therapy works, it is a change in information flows and communication behaviours that brings about changes in symptoms and quality of life. (Haverkampf, 2010b, 2017a)

Depression

Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behaviour, feelings, and sense of well-being. A depressed mood can be a normal temporary reaction to life events such as loss of a loved one, a job loss, but also ‘positive’ ones, such as winning in a lottery or having sudden and spectacular success. All these events represent changes globally, requiring internal modifications to adjust internal and external communication systems to the new reality. A job that is now suddenly more practical requires a different internal dialogue, such as less analysis and more exploration. It may also require different external communication patterns with colleagues rather than work in front of a computer screen. If these changes have only occurred partially or not, the information exchange patterns do not fit the situation. This lack of fit can lead to feelings of being overwhelmed, withdrawal, emptiness and feelings of depression, or in some cases (hypo)manic states.

The sum of the basic patterns of external and internal communication, an individual’s personality, remains relatively stable over time. (Haverkampf, 2010a) This also applies if a mental health condition, such as depression, improves. In a sample of depressed outpatients receiving a 5-week trial of pharmacotherapy, changes in neuroticism and extraversion scores were modestly or not accounted for by changes in depression scores. (Santor et al., 1997) However, how individual communication elements and patterns are used in given situations can be subjected to change, leading to significant changes in personal satisfaction, contentment and happiness.

Flattening of Emotions

Depression leads to a disconnect. A patient is no longer able to access positive emotions to the same extent as before. However, at the same time he or she may also become disconnected to a varying degree from ‘negative’ emotions, such as sadness. In all cases, the individual suffers from missing out on important information about the own person. This then leads to negative feelings, possibly also fears and anxiety, because meaningful information is missing. To some degree it is possible to counteract this with activities that are meaningful to oneself. One may even say that in the best a depression weeds out thoughts and activities that are less meaningful. And in most cases short and especially the reactive depressive episodes are self-limiting. But in the more severe and longer lasting depression the disconnectedness from emotional signals accelerates the downward spiral of decreasing emotional connectedness and increasing ability to correctly send and receive meaningful messages. (Haverkampf, 2010c, 2013)

Reconnecting with emotional signals can be helpful in depression. This should not add to the pressure on the patient ‘to feel better’. In Communication-Focused Therapy®, this is usually done by using the communication patterns in the session or memories of past interactions and experiences in the world to inquire into the feelings that were associated with them. However, the main technique is concerned less with individual emotional episodes, but with enabling a patient to become more aware of and influence communication processes and information, which lead to particular emotional signals. (Haverkampf, 2017a)

Negative Interpretations

Elevated levels of repetitive negative thinking are present across a large range of Axis I disorders and appear to be causally involved in the maintenance of emotional problems. It has also been argued that repetitive negative thinking is characterized by the same process across disorders due to the inherent similarities (Ehring & Watkins, 2008). A depression leads to more negative interpretations of messages from the environment and from within oneself. As one attributes the cause of negative experiences to oneself and engages in self-blame, feelings of guilt, failure and incompetence emerge. At the same time, the own person, others and the world as a whole appear to be less meaningful and less relevant. This loss of meaning can potentially lead to dangerous situations of self-harm or even suicide. To prevent this requires an insightful and caring use of communication between therapist and patient.

It is important to realize that it can be the same information which reaches the patient, but which is associated with more negative emotions and thus more hypotheses of negative consequences. A depressed affect can so lead to an increased selection of information associated with negative emotions, which can then lead to an even more depressed affect. This vicious cycle usually does not pose a problem because positive information becomes more appealing, which pulls the individual out of the negative affective state. In a depression where emotional and other communication is inhibited already, it is more difficult for the autoregulatory mechanisms to work, making a spiralling into an increasingly depressed affect more likely.

Analytical internal communication patterns can be helpful in many areas of life. However, in depression they are often used for the wrong purpose, possibly in the attempt to extricate oneself from the symptoms of depression. In a study by Rimes and Watkins, thirty depressed participants and thirty never-depressed participants were randomly allocated to ‘analytic’ (high analysis) or ‘experiential’ (low analysis) self-focused manipulations. As predicted, in depressed participants, the analytical self-focus condition increased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the experiential self-focus condition resulted in no significant change in such judgements. (Rimes & Watkins, 2005)

Negative thinking can often be triggered by some internal or external information, frequently an intrusive, which may be easier to shrug off for a non-depressed person. In this instance, it is as if the depressed person tries to preempt any disappoints or possible negative emotions from an adverse outcome, by already realizing them intracranially and fighting them with compensating emotions. However, this only leads to further negative thoughts and downward spiraling ruminations. One solution is to identify thoughts as mere thoughts and not real, another to build a sense of oneself as being able to deal with whatever may be coming one’s way, particularly the own emotions.

Repetitive negative thinking can, on the other hand, be distinguished from other forms of recurrent cognitions, such as obsessions, intrusive memories or functional forms of repeated thinking. (Ehring & Watkins, 2008) This illustrated how certain symptoms of a mental health condition can be grouped along the internal and external communication patterns they are associated with, and that they can be categorized into a moderate number of sets.

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy® (CFT®) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy has to lead to change. This can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them. If fear inhibits the information retrieval from memory this will not fully work. CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.

Many popular forms of psychotherapy, such as Cognitive-behavioral Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, there is the concept of transference and counter-transference which focuses on the result of communication processes. CFT in contrast attempts to focus on the process itself. (Haverkampf, 2017a)

CFT attempts to analyze how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behavior of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient. Working with and analyzing patterns of internal and external communication helps to make the exchange of meaningful information work more effectively, reducing anxiety, emotional, mood, psychotic and other disorder in the long-run. (Haverkampf, 2018b) This does not mean that medication and other forms of therapy do not have their places in treatment, it does not change that at all. However, CFT provides a theoretical and empirical framework that can enrich these other therapeutic approaches, while also being used on its own.

Communication Patterns

Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. The reason why certain patterns have to be used is so that the other person can understand the message. A language can be seen as a form of communication patterns on a more complex level. We all communicate in patterns. However, unlike learning a language, people spend little time observing and reflecting on the other communication patterns they use all the time.

In biology, an emerging picture of interconnected networks has replaced the earlier view of discrete linear pathways that relate extracellular signals to specific genes, raising questions about the specificity of signal-response events (Kholodenko, 2006). In synthetic biology, researchers integrate basic elements and modules to create systems-level circuitry (Purnick & Weiss, 2009). The communication of the cells with each other and with the environment determines how effective they are in, for example, eliminating tumor cells. The important basic material is ‘information’, which is then activated and given influence over other factors through meaning, whether that is meaning in in an intracellular or an interpersonal context. Communication patterns and structures facilitate this process. (Haverkampf, 2018c)

Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the internal and external communication patterns do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. Changes in communication patterns means modifications in which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.

Questions

As has been pointed out by the author already elsewhere, questions are powerful communication patterns in effecting change in other communication patterns (Haverkampf, 2017i). In depression, they can mobilize resources and redirect thinking towards a different focus, and they can also help end ruminations and looping thoughts. Over time, the patient should become a personal expert in asking the right questions.

Questions represent a large group of communication patterns with very diverse combinations of communication elements. One needs to fine-tune questions to the present communication dynamics and the aim of the questioning. Using them is to cause a branching off in the communication dynamics, which then brings about change in everyone in the session. One should not forget that a question can also change the one asking it, even if one has used a particular type of question hundreds or thousands of times. Questions are so embedded in the social and interactional everyday life that we mostly are not aware of them more than the microtasks we carry out when driving a car. The author has written elsewhere much more in-depth about the question as a communication pattern that can be a potent therapy tool.

Timeline

Patients with depression often spend a considerable amount of time ruminating about the past. Those who also suffer from anxiety may also ruminate about the future. What frequently gets lost is thinking about the present, even though that is the point-like interval of time which is the only one that is ever real. To avoid the reality of the present can be due to various reasons. The depression can make existence so unbearable that one escapes into a different ‘time zone’, and that it is not real may even be wished for in the hope that this also makes the pain less real.

The use of observations, feedback and questions can help the patient to stay in the patient. Several other communication patterns can also achieve this goal. Whenever a communication pattern leads to greater internal and external connectedness, it helps to anchor the patient more firmly in the now. However, this does not lead to more intense suffering because it is the disconnectedness that usually causes suffering. Patients with severe depression do not feel sadder, but they often feel nothing. Truly experiencing an emotion like sadness, when one feels ready for it and while being connected with others and oneself, can be an essential step in dealing with and overcoming a loss or other saddening event. And nothing can be as connectivity promoting as communication itself.

Getting Information

Questions help the patient in changing communication patterns. Still, they can also produce information, which lowers uncertainty, brings new insight or leads to something new in the world, which is enjoyable and improves the overall mood. Often, patients with depression return to the same thoughts or situations because they do not see alternative actions or ideas, which may be enjoyable and lead to a better mood.  Ruminations result not from too much but too little useful information, yet finding the right information again depends on communication patterns.

When things look at their darkest, and everything around seems empty like a desert, it helps be aware of all the meaningful information that is already easily accessible.  Connecting within oneself and others can lead to insights that help in countering the depressed rumination. A therapist’s task is to help the patient build communication patterns that are more effective towards connecting with oneself and others. Doing so allows a patient to find more meaningful information in places such as the own life experiences, which are a treasure trove of information. If I ask what is important to me and what I value, I just have to look at situations in the past and probe how I felt, what I thought and whether my actions and interactions in these situations benefitted me. One only has to be more open to information that can be helpful, and one aim in therapy is to help patients become better at this without fear.

Connecting

Communication patterns that help the therapist and patient connect in the session can also help the patient connect with others and with themselves. As already pointed out, the internal and external communication is a reflection of the other. The ability to communicate with the outer world also increases the ability to communicate better on the inside. Communication-Focused Therapy® supports patients in becoming more aware of, reflecting on, and experimenting with communication, which leads to the flexibility and openness in communication that is very effective against many forms of depression.

Communication patterns to facilitate connecting may again include questions and other communication patterns that enable the flows of meaningful information. Patterns may be repeating a modified message, providing information about a feeling or thought triggered in response to the patient’s communication, making an observation that offers a new perspective, and so forth. It is more than small talk because the therapeutic communication patterns not only test and build relationships but should also provide greater insight. The latter also includes insight into the communication patterns themselves.

Integration

By talking about the communication between patient and therapist it is possible to help the patient see how communication can be influenced and shaped so as to lead to new insights and to make new connections between pieces of information. This integration of different strands of information flows are important in helping the patient to feel more integrated as a whole. For example, talking about communication can help the patient to associate an image with emotions, which in turn may connect with past memories. This integration, however, requires that it is first possible to talk about these thoughts and feelings, and secondly that it is possible to talk about communication in ways which helps the patient to make associations between the different flows of information.

Analyzing Communication Patterns

The first important step in therapy is to create awareness for the flows of information, and their patterns. (Haverkampf, 2018c) These dynamics happen largely outside of consciousness, but they are not random. Rather, they are a result of biology and the internal and external communication experiences of an individual over time. Complex organisms receive, combine transform and send millions of bits of information in the smallest fraction of a microsecond. To navigate within this sea of information successfully is the primary objective of every organism, humans included. Health conditions in general are a result if these processes no longer work adequately. Mental health conditions often also include a significant impairment in the external communication between a person and the environment.

The human brain is in a particularly good position to work with information, and one objective of therapy should be to help it work better with information, whether this is coming from emotional signals, sensory organs, or retrieved from within the neural network itself. Communication processes and information can be made conscious. We might not be able to identify the information stored in a neuron, which would not anyway, because that information only makes sense within the context of the neural network. However, we can become aware of information stored in the neural network, even if it is a tiny detail or something that does not seem to fit into an existing pattern.

Particularly in interactions with other humans and other living organisms, communication patterns have evolved that facilitate the exchange of meaningful information in an efficient way. They need to be largely automatic, such as a gesture in response or a change of voice, and it may be even more distracting to follow them all, but it is possible to discern and work with some universal patterns. For example, the sequence of a specific type of question and a specific type of answer can be universal, such as the nod of a waiter signaling attention, followed by a guest using the palm of her hand and finger to scribble in mid-air, which indicates that she wants the bill. A complex business negotiation, however, would also use the basic communication element of question and answer and build it into more complex patterns. Spiraling negative thoughts in depression, on the other hand, also use otherwise adaptive communication elements, however, they do so in unhelpful communication patterns. The problem is not the ability to worry and think, but how this is done, the pattern, which is not constructive and unhelpful.

Emotional Signals

The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.

The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.

The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.

Motivation

Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.

Insight into Communication

In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:

Person A

  • Selecting information for a message
  • Encoding the information in a message
  • Sending the message through a communication channel (using the speech system to say the words)

Person B

  • Receiving the message through a communication channel (using the auditory system)
  • Decoding the message into information
  • Processing the information further

One will observe quite often that a message it not received accurately. For example, one may say “the weather is nice today”, and the other person may interpret this as a signal that one wants to go on a hiking tour. The easiest way, of course, is to ask the other person again if one is in doubt. However, patients with depression or anxiety are less likely to get the full information.

The communication patterns a depressed patient uses may have served some function in the past, as they could have protected from some negative emotional consequence. However, in the present they no longer promote an optimal outcome, one that takes into account both the own needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.

Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.

Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.

Building the Sense of Self

Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.

The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.

Meaning

Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

Meaning requires that one can decode a message and extract some novel information form it which can potentially lead to change within oneself, a new thought, state or emotional signal, for example, which can then also lead to a change in the world. Helping patients to reassess and readjust communication patterns can be particularly helpful in therapy because the resulting change in perceiving and thinking usually also leads to a change in perspective (Haverkampf, 2018d), which then in turn also lead to changes in thinking, feeling, acting and interacting.

Resonance

Resonance is when synchronicity or similarity leads to a potentiation of a signal or piece of information. In a therapeutic setting, resonance can be important because it identifies information that may be important or relevant. A depressed patient who has lost a grasp of what is potentially enjoyable and meaningful can rediscover it when resonance is detected. When the therapist becomes aware of resonance in how a patient is communicating about something, it is often helpful to point that out. If there is true resonance, the patient will usually acknowledge it quite quickly. In other cases, the therapist may also identify it as a projection of something that is important to the therapist only. But if the patient sees a resonance, it can be helpful in getting more insight into the own needs, values and aspirations.

Resonance is when new piece of information becomes more meaningful because of the information that is already present (Haverkampf, 2018a). The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. In therapy, often the technique of the ‘fishhook’ (Haverkampf, 2010b) may be used. One asks the patient to describe life in general, such as the events of the weekend. The more the patient learns to work with resonance, the easier it will be for her to find insight in these everyday events by using an increasing volume of information effectively, including emotional signals, perceptions, cognitive thoughts and more.

In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is communicating, since it reflects the information the patient already has, and which represents the foundation for resonance. The question “how was life yesterday?” or “what did you do yesterday?” can be more powerful than a complex intervention, because it can serve as the starting point to greater insight if one is aware of information resonance.

Depression makes old and new information, particularly emotional information, less accessible, which lowers any potential resonance. However, in many patients suffering from mild or moderate forms of depression accessibility may not be greatly reduced. Rather, it is a question of whether a patient can still believe there is ‘something’ below the unpleasant state. Resonance can help to rebuild a connection with interests, needs, values and aspiration, whose pursuit can be enjoyable, below a surface of depressed feelings. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.

Relevance

Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.

Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout. However, the more one thinks about relevance on a smaller level, the easier it becomes to adjust larger constructs, such as ‘one’s job’. As mentioned before, it is the details which help to identify one’s needs, values and aspirations. On the smaller scale, the brain reorients focus to task-relevant stimulus information. Egner and Hirsch showed that, in response to high conflict, cognitive control mechanisms enhance performance by transiently amplifying cortical responses to task-relevant information rather than by inhibiting responses to task-irrelevant information (Egner & Hirsch, 2005). This also shows that the brain focuses on picking out potentially relevant information rather than by suppressing non-relevant one. Of course, what is relevant is subjective to the individual, but it must be based on existing information about the needs of the individual, one’s internal state and the state of the world.

From a broader and more long-term perspective, relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.

Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.

In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.

Communication Exchange

Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the center of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.

The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.

Integration

As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost form exposing oneself to the right communication environment.

Values, Needs and Aspirations

Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.

The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.

Internal Communication

Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.

Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.

Meaningful Messages as the Instrument of Change

Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017a, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017f, 2017b, 2017d, 2017c, 2017g, 2017h). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.

The actual instrument of change are the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.

Broader Experience

If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. You can reach author by email at jonathan@jonathanhaverkampf.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

 

 

References

Bibring, E. (1953). The mechanism of depression.

Delle-Vigne, D., Wang, W., Kornreich, C., Verbanck, P., & Campanella, S. (2014). Emotional facial expression processing in depression: Data from behavioral and event-related potential studies. In Neurophysiologie Clinique (Vol. 44, Issue 2, pp. 169–187). Elsevier Masson SAS. https://doi.org/10.1016/j.neucli.2014.03.003

Egner, T., & Hirsch, J. (2005). Cognitive control mechanisms resolve conflict through cortical amplification of task-relevant information. Nature Neuroscience, 8(12), 1784–1790. https://doi.org/10.1038/nn1594

Ehring, T., & Watkins, E. R. (2008). Repetitive Negative Thinking as a Transdiagnostic Process. International Journal of Cognitive Therapy, 1(3), 192–205. https://doi.org/10.1521/ijct.2008.1.3.192

Givertz, M., & Safford, S. (2011). Longitudinal Impact of Communication Patterns on Romantic Attachment and Symptoms of Depression. Current Psychology, 30(2), 148–172. https://doi.org/10.1007/s12144-011-9106-1

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010c). Depression Mania and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2012). Feel! (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2013). A Case of Depression. J Psychiatry Psychotherapy Communication, 2(3), 88–90.

Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for ADHD. J Psychiatry Psychotherapy Communication, 6(4), 110–115.

Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) for Bipolar Disorder. J Psychiatry Psychotherapy Communication, 6(4), 125–129.

Haverkampf, C. J. (2017e). Communication-Focused Therapy (CFT) for Depression. J Psychiatry Psychotherapy Communication, 6(4), 101–104.

Haverkampf, C. J. (2017f). Communication-Focused Therapy (CFT) for OCD. J Psychiatry Psychotherapy Communication, 6(4), 102–106.

Haverkampf, C. J. (2017g). Communication-Focused Therapy (CFT) for Psychosis. J Psychiatry Psychotherapy Communication, 6(4), 116–119.

Haverkampf, C. J. (2017h). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.

Haverkampf, C. J. (2017i). Questions in Therapy. J Psychiatry Psychotherapy Communication, 6(1), 80–81.

Haverkampf, C. J. (2018a). A Primer on Communication Theory. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2018b). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2018c). Communication Patterns and Structures.

Haverkampf, C. J. (2018d). Fear, Social Anxiety and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Kholodenko, B. N. (2006). Cell-signalling dynamics in time and space. Nature Reviews Molecular Cell Biology, 7(3), 165–176. https://doi.org/10.1038/nrm1838

Purnick, P. E. M., & Weiss, R. (2009). The second wave of synthetic biology: from modules to systems. Nature Reviews Molecular Cell Biology, 10(6), 410–422. https://doi.org/10.1038/nrm2698

Rimes, K. A., & Watkins, E. (2005). The effects of self-focused rumination on global negative self-judgements in depression. Behaviour Research and Therapy, 43(12), 1673–1681. https://doi.org/10.1016/J.BRAT.2004.12.002

Santor, D. A., Bagby, R. M., & Joffe, R. T. (1997). Evaluating stability and change in personality and depression. Journal of Personality and Social Psychology, 73(6), 1354–1362. https://doi.org/10.1037/0022-3514.73.6.1354

This article is solely a basis for academic discussion, and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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Therapy of Social Anxiety Disorder (5)

Therapy-of-Social-Anxiety-Disorder-5-Christian-Jonathan-Haverkampf-psychotherapy-series

Therapy of Social Anxiety Disorder

Christian Jonathan Haverkampf, M.D.

Social anxiety disorder can significantly reduce an individual’s choices in life and the quality of life overall. Since communication is the process by which humans fulfil their needs, values and aspirations, its effectiveness is important for satisfaction, contentment and happiness in life. It is the main autoregulatory instruments, also in the psychotherapeutic process, to promote mental health. If interpersonal communication is interfered with by anxiety, these processes can no longer work effectively. As the individual withdraws further, the capabilities for needs fulfilment and autoregulation decline further.

Focusing on interpersonal and intrapersonal communication patterns can help to reverse the vicious cycle of social anxiety. Communication-Focused Therapy® (CFT®) provides a toolset, methodological and theoretical framework to facilitate the awareness for individual communication patterns and the interventions to improve them in line with the patient’s needs, values and aspirations.

Keywords: social anxiety, communication-focused therapy, CFT, CBT, psychodynamic psychotherapy, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Self-Image. 4

External Image. 5

Focus. 5

Experiencing the Interaction. 6

Transparency. 6

Habituation. 7

Social Network. 7

Social Exclusion. 7

Hierarchies. 8

Technology. 8

Symptoms. 9

Measurement 9

Neurobiology. 9

The Amygdala. 9

Identity. 10

‘Lost Opportunities’ 11

Judgment 11

Location. 11

Treatment 12

Cognitive-Behavioral Therapy (CBT) 12

Psychodynamic Psychotherapy. 13

Mindfulness-based stress reduction (MBSR) 13

D-Cycloserine. 13

Communication-Focused Therapy® (CFT®) 13

Introduction. 14

Communication as Autoregulation. 14

Communication Patterns. 14

Attention. 15

Communication to Participate in Life. 15

Understanding Social Anxiety and Shyness. 15

Internal Communication. 16

Uncertainty. 16

Communication Deficits. 16

Avoidance. 17

Meaning. 17

Awareness of Thought Patterns. 17

Flow of Information. 18

Emotional Reconnection. 18

Experiencing the World. 18

Communication Techniques. 19

Breaking the Cycle of Anxiety. 19

The Reward of Seeing More. 20

Values, Needs and Aspirations. 20

The Need for Communication. 20

Meaningful Messages as the Instrument of Change. 21

Embracing Change. 22

Living. 23

References. 24

Introduction

A person suffering from social anxiety disorder feels unwell in social situations and begins to avoid them, which can not infrequently lead to significant problems in daily life. Social anxiety is more than just shyness. According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. (World Health Organization, 1992) The prevalence of 12-month and lifetime prevalence of social anxiety disorder is around 3% and 5%, respectively. (Grant et al., 2005) It is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. (Stein & Stein, 2008) In a study by La Greca and Lopez on adolescents, girls reported more social anxiety than boys, and social anxiety was more strongly linked to girls’ social functioning than to that of boys. Girls with higher levels of social anxiety reported fewer friendships, and less intimacy, companionship, and support in their close friendships. (La Greca & Lopez, 1998)   Social anxiety disorder is also sometimes referred to as social phobia.

Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (e.g., personality trait neuroticism) core phenotypes to identify risk loci. (Stein & Stein, 2008) There are several psychological and psychopharmacological treatments (Haverkampf, 2017h) available. Communication-Focused Therapy® (CFT®) as developed by the author is an approach that targets the processes and patterns which are underlying interpersonal interactions. (Haverkampf, 2013, 2017a, 2018f)

Self-Image

The sense of a stable self-image plays an important role in lowering social anxiety. The more confident one is oneself, and thus the more one is connected with oneself in a meaningful way, the lower the anxiety will be in interpersonal or social situations. Having a good and stable self-image requires connection with oneself, the ability to be open and receptive to information that originates within oneself, other than the information that is received from the external world through the sense, for example. Even though the distinction between the internal and the external maybe somewhat artificial, it is important to acknowledge that there are sources of information which are not in the external world. In some psychiatric conditions, such as in psychosis, this distinction between the external and the internal can get lost with potentially severe consequences.

How the internal self-image can affect the communication with others has been demonstrated by Hirsch and colleagues. One group was asked to hold in mind a negative self‐image, while the other held in mind a less negative (control) self‐image. When holding the negative image, the socially anxious volunteers felt more anxious, reported using more safety behaviors, believed that they performed more poorly, and showed greater overestimation of how poorly they came across (relative to ratings by the conversational partner). Conversational partners rated the socially anxious volunteers’ performance as poorer in the negative image condition. Furthermore, both groups of participants rated its quality as poorer in the negative image condition. (Hirsch et al., 2004)

External Image

Social anxiety arises when individuals are motivated to make a preferred impression on real or imagined audiences, such as when one tries to portray an image to others one believes others want to see, or where a person believes there is an external benefit to making oneself appear with certain characteristics. This is inextricably linked to the fear that just being oneself is not good enough, that one will be judged in unpredictable and possibly harsh ways by everyone or a defined group of others.

The cognitive state of the individual can mediate both affective arousal and behavior. (Schlenker & Leary, 1982) At the same time, external factors within the environment can have an effect on how an individual thinks and feels in a given situation, which is also influenced by individual predispositions and traits. In clinical experience, the more an individual tries to adhere to portraying an external image that is believed to be required by external factors and other people, but which does not match with the individual’s communication styles and personality traits, needs, values and aspirations, the less stable the interaction will become, leading to more anxiety and a mutually less satisfying experience. (Haverkampf, 2010a, 2013)

Focus

When it comes to the important role of information dynamics in the epigenesis of social anxiety, focus is an important mediator because it selects the information that becomes available in an interaction. Since all forms of anxiety arise from a deficit of meaningful information or unhelpful ways of processing it, social anxiety can be improved by helping a patient to learn more helpful ways in selecting and focusing on particular types of information.

Socially anxious individuals are excessively concerned about negative evaluation by others. And they often focus more on threat cues or imagined threat cues. In a study by Mansell and colleagues, high socially anxious individuals when compared to low socially anxious individuals showed an attentional bias away from emotional (positive and negative) faces when under conditions of social-evaluative threat. (Mansell et al., 1999) As discussed above, this leads to a situation where less information is available to the socially anxious person, which does not help mitigate the social anxiety.

Socially-anxious individuals also have an increased number of negative cognitions and fewer positive cognitions, while situational factors appear to mediate the absolute level of reactivity. (Beidel et al., 1985) This probably turns the focus even more away from sources of information which could lead to a reduction in the anxiety, resulting in a vicious cycle in which social withdrawal and more negative interpretation of interpersonal interactions and the environment overall leads to even more social withdrawal. In Communication-Focused Therapy® this cycle can be broken by working on the communication patterns the individual uses, which are the structural entities that facilitate the information flow to him or her.

Experiencing the Interaction

Many people who are suffering from social anxiety are familiar with the feeling of continuously asking themselves what other people are thinking about them. In one study, anxious subjects were more likely to attribute more meaning to others’ thoughts. (Hezel & McNally, 2014) The same study interestingly also found that socially anxious individuals performed worse on theory of mind tasks. Theory of mind is the ability to attribute mental states — beliefs, intents, desires, emotions, knowledge, etc. — to oneself and to others. It is necessary to understand that others have beliefs, desires, intentions, and perspectives that are different from one’s own. In other words, to fully appreciate the separate mind of another person with its unique content and information processing requires a theory of mind, which seems impaired in individuals with social anxiety. However, to fully reflect on the information dynamics and communication patterns within an interaction it is important to have a basic working concept of an “I” and a “You”. Communication-Focused Therapy® also includes techniques aimed at strengthening this distinctions. (Haverkampf, 2017a, 2017e)

A person suffering from social anxiety takes great pains to not only try to follow the dynamics of an interaction but at the same time to interpret what the partners to an interaction are thinking and feeling about them. While individuals with social anxiety are often quite perceptive and sensitive to various channels of information, this can lead to an information overload, which as a result makes them turn away from the interaction, which increases the anxiety even to a higher level. Communication-Focused Therapy® attempts to reverse this vicious cycle by developing awareness for communication patterns and information flows and practicing communication in a way that leads to fulfilment of own needs, values and aspirations, which also lowers the anxiety.

Transparency

Being able to give oneself permission to practice greater openness in communicating with others is an important step towards overcoming social anxiety. The feedback and information from others help to lower the anxiety as others’ dreaded thoughts turn out to be untrue. However, many people suffering from social anxiety already believe that they are overly transparent to others, that others can see what they are thinking and feeling, such as the anxiety or negative feelings, such as anger or frustration, which could interfere with the social bond from the interaction. As the distinction between the inside and outside worlds of the mind are weaker, the socially anxious person tries even harder to control themselves. Individuals with social anxiety are often quite sensitive, but their interpretation of information is often more on the negative side. Depression with anxiety can mask as the ‘pure’ social anxiety disorder.

Interesting is that studies suggest that socially anxious individuals remember more negative memories than those less distressed. This may either have a biological explanation or be a learned phenomenon. However, since social anxieties do seem to run in families at least partially, there may be a biological explanation to it.  A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

Habituation

Habituation is the process by which through a ‘getting used’ to an anxiety or fear inducing stimulus the psychological and physical reaction to it decreases. One becomes less anxious or fearful in the face of information that otherwise induced anxiety or fear, such as the visual input that one is looking out high up on a tall building, if one exposes oneself repeatedly to the information. Social anxiety involves social cues that can induce anxiety. The latency at which habituation occurs, however, seems to be different in individuals that are suffering from social anxiety. (Beidel et al., 1985)

From the perspective of Communication-Focused Therapy® (CFT), any information that is repetitive and has lost its characteristics of novelty will lead to a lesser response, whether in terms of feelings, emotions, thoughts or otherwise. Thus, the internal and external context matters whether habituation will take place. One may reach habituation in one type of situation and when experiencing a particular family of thoughts and perceptions, but conventional behavioural and cognitive methods in the form of CBT, for example, often lead to improvements that are limited in time and circumstance. However, changing one’s exposure to meaningful information, that is information which brings about a change in the recipient, through changes in communication patterns, can be highly effective. Changes in communication patterns also have a longer-lasting effect because the flow of information is permanently altered. CFT works to adjust the communication patterns in the session through awareness, reflection, experimentation and change. It is not primarily the change in perspective or learning new thought patterns that bring about change but changes in communication patterns that determine them through the information they make available, and how information is processed. (Haverkampf, 2010b, 2017a) Practising new communication patterns in the therapeutic session usually shows a significant over time with respect to anxiety, but also anxiety in general.

Social Network

Various aspects of social relations uniquely contribute to feelings of internal distress. In a study by La Greca and Harrison with adolescents, crowd affiliations (high and low status), positive qualities in best friendships, and the presence of a dating relationship protected adolescents against feelings of social anxiety, whereas relational victimization and negative interactions in best friendships predicted high social anxiety. In contrast, affiliation with a high-status peer crowd afforded some protection against depressive affect; however, relational victimization and negative qualities of best friendships and romantic relationships predicted depressive symptoms. (La Greca & Harrison, 2005)

Social Exclusion

Baumeister and Tice’s social exclusion theory of anxiety proposes that a primary source of anxiety is perceived exclusion from important social groups. The relationship between perceived social exclusion and social anxiety, jealousy, loneliness, and depression. Self-esteem can moderate reactions to perceived exclusion. (Leary, 1990) Relationships are expectations of future communication (Haverkampf, 2018c), and not being part of a web of communication increases anxiety. One of the reasons is that living organisms fulfil their needs, and in the case of humans also their values and aspirations, through communication, the exchange of meaningful information with others (Haverkampf, 2010a). Not just the shared reality, but even only the imagined reality can lead to significant anxiety.

Hierarchies

Social rank theory (Price and Sloman, 1987; Gilbert, 1989, 1992) argues that emotions and moods are significantly influenced by the perceptions of one’s social status or rank; that is the degree to which one feels inferior to others and looked down on. A common outcome of such perceptions is submissive behavior. Gilbert showed in a study that shame, social anxiety and depression (but not guilt) are highly related to feeling inferior and to submissive behavior. (Gilbert, 2000) Since these feelings develop from the workings of communication patterns as they determine the information that will ultimately reach various centers of the brain (Haverkampf, 2018c), an adjustment to these communication patterns changes feelings that can be associated with social anxiety. Especially with feelings that have a strong social context, such as shame, changes in communication patterns with the help of a therapeutic seeting can be very helpful. Shame is a result of internal and external communication patterns that are being used, while communication patterns can be influenced by a feeling of shame. Important is to remember that work with any communication pattern can be used to change the whole vicious cycle. (Haverkampf, 2017d, 2017a)

Technology

Increasing the number of available communication channels, such as adding communication via the Internet, can in theory help reduce the sense of isolation rather than increasing it. However, this has been hotly discussed. A study by Caplan supports the hypothesis that the relationship between loneliness and preference for online social interaction is spurious, and that social anxiety is the confounding variable. (Caplan, 2007) Communication means offered by the Internet are tools to interact with humans or human-designed programs in a meaningful way. It depends on what the individual makes out of them. How much one can use a technology to one’s advantage depends on the use of the right communication patterns and an insight into the own basic parameters, including one’s needs, values and aspirations. (Haverkampf, 2017f)

A ‘reduced channel’ communication offered, for example, by online chats or social networks may make it easier for a person suffering from social anxiety to connect with others, but to do in a less anxiety provoking and non-threatening way. As long as it is seen as steps on the way towards overcoming the social anxiety and adding more channels of communication, according to the individual needs, preferences and aspirations, it can be even helpful. For many people suffering from social anxiety the step from no communication to full interpersonal interaction in subjectively experienced high stakes settings can be too high. Online dating platforms, for example, can make it possible for people to go on dates who would otherwise never been able to do so.

Symptoms

Social anxiety often leads to physical symptoms that can worsen the vicious cycle of trying not to appear nervous and anxious, but by ‘fighting’ to do so the nervousness and anxiety just keep on getting worse. In adults, feelings of social anxiety may be associated with tears, blushing, excessive sweating, nausea, difficulty breathing, shaking, and palpitations. They are somatic manifestations, though often experienced much more intensely subjectively than observed objectively, of the fight-or-flight-response, which is largely hardwired into our brains. Since as we have discussed previously, social success is as much a matter of survival as finding food or warding off an attacker, anything that seems to interfere with it can lead to negative emotional states, such as anxiety.

Research suggests that socially anxious individuals interpret ambiguous social information in a more threatening manner compared to non-anxious individuals. It has even been shown that experimentally modifying interpretation in non-anxious individuals affected their anxiety. (Beard & Amir, 2008) Since how information is interpreted depends on external communication channels and on how the information is communicated internally, the techniques of Communication-Focused Therapy work with communication patterns to affect a change. As external and internal communication patterns reflect each other (Haverkampf, 2010a, 2010b, 2017a), the work on communication patterns in therapy has a direct effect on the internal information processing that leads to and maintains social anxiety.

Measurement

The clinically most commonly used questionnaire to assess social anxiety is the Liebowitz Social Anxiety Scale (LSAS). The LSAS has been empirically shown to be a reliable, valid and treatment sensitive measure of social phobia. (Heimberg et al., 1999) It lists a variety of different situations and asks to rate for anxiety and avoidance. This practical orientation is very helpful because it leads to greater insight into the underlying motives of the anxiety. For example, if the contexts of the anxiety provoking situations have in common that they are more of an interpersonal nature with people that are familiar (or strangers), awareness of it can lead to greater understanding of possible underlying causes. People adapt particular communication patterns as a reaction to the perceived need to manage interpersonal dynamics.

Neurobiology

The Amygdala

The amygdala is often implicated in social anxiety and the processing of social threats. In a quantitative meta-analysis, Etkin and Wager compared functional magnetic resonance imaging and positron emission tomography studies of posttraumatic stress disorder (PTSD), social anxiety disorder, specific phobia, and fear conditioning in healthy individuals. Patients with any of the three disorders consistently showed greater activity than matched comparison subjects in the amygdala and insula, structures linked to negative emotional responses. Hyperactivation in the amygdala and insula were, of interest, more frequently observed in social anxiety disorder and specific phobia than in PTSD. Only patients with PTSD, on the other hand, showed hypoactivation in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex—structures linked to the experience and regulation of emotion. (Etkin & Wager, 2007)

Amygdala activation to interpersonal threat has been linked to the severity of social anxiety symptoms. Phan and colleagues examined in a study the association between response to emotionally harsh faces in the amygdala and severity of social anxiety symptoms in patients with generalized social phobia. Relative to happy faces, activation of the amygdala in response to harsh (angry, disgusted, fearful) faces was greater in the patients than in controls, and the extent of amygdala activation was positively correlated with severity of social anxiety symptoms, but not general state or trait anxiety levels. (Phan et al., 2006)

However, it needs to be remembered in this context that information is stored in many areas of the brain which all contribute to the signals that then flow through and are integrated, compared, subtracted and processed in specific areas like the amygdala. (Haverkampf, 2018g) Thus, to understand the complexity, and at the same time simplicity of social anxiety one also needs to look at the actual communication patterns an individual uses, externally and internally, and how information is received, selected for, transported and stored. Meaning

Identity

An important question is why I as a socially anxious person feel as the center of attention if it is not what I want, or is it? Many people with social anxieties actually want to have good relationships and are often fond of people. The problem is how they see themselves or that in many cases they cannot really see who they are. Sometimes there may also be an ambivalence in one’s relationship with people, which might be a result of personal life experiences or some unresolved conflicts from another source.

The search for identity lies at the heart of any form of social anxieties. Often, if some fundamental questions about oneself can be answered the social anxiety decreases. Basic parameters are:

  • Needs
  • Values
  • Aspirations

(Haverkampf, 2018h)

An important method in therapy to have the client imagine a situation and run through it. This helps break down the distinction between reality and the imagined world. Many people suffering from social anxieties are very sensitive, which also contributes to the symptoms. Physical symptoms often include excessive blushing, excess sweating, trembling, palpitations, and nausea. There may even be stammering and rapid speech. Panic attacks can also occur under intense fear and discomfort.

Many people with social anxieties have difficulties imagining the future because it is too painful. Here it helps to identify emotions and feeling that underlie the negative thoughts. Often the tensions and anxieties have underlying processes that need to be identified.

People with social anxiety often set high standards for themselves for social situations. Since they believe they cannot reach these standards they have a lot of negative thoughts about how they do in those situations and the outcomes. The sense of failure can be reinforced in the situation by very minor mishaps, such as a stutter or notices sweating. This leads to even greater self-consciousness and the likelihood actually of sweating or stuttering increases. Anxiety can increase to panic attacks.

‘Lost Opportunities’

It is also important to deal with the losses patients subjectively think they have incurred as a result of their social anxiety. People avoid situations where the social anxieties cause the symptoms. In more severe cases this can mean that the individual has no romantic relationships and does not take up jobs that could be interesting and enjoyable. Here the first step it to acknowledge the problem and realize that while one may not have done the preferred choice in the moment, social anxiety is often a problem of not knowing what one really wants. Finding this out can be a tremendous chance.

Judgment

The sense of being judged is quite common in social anxiety disorder. The judgment by others gets a relatively high significance. People with social anxieties can be very competitive in professional or academic situations. It seems easier to believe the judgment of others. The combination of a greater focus on oneself, being more alert to anything other people may see or perceive, and reduced trust in oneself and others frequently gives rise to the fear of being judged. If there is a greater disconnect from oneself and others, this can cause additional problems and potentially more anxiety.

There is a perceived need for a more complete control of one’s external communication, out of fear that the connection with the world could be lost, but this sought-after control by necessity also has to extend then to the internal communication, which destabilizes further can causes additional anxiety. The ultimate fear in social anxiety is not of social situations per se, but that connections and relationships could be lost forever. Fears of loss of relationships and loss of control is often at the heart of social anxiety. Helping people with social anxiety means exploring new ways of communicating, so that they learn that communication and relationships are in their essence quite predictable and stable.

Location

The setting can also play a problem and may be worthwhile to thematize. Instead of making a new friend at a bar, a person with social anxiety might find this task easier to accomplish via an online friendship or dating site. As patients develop a greater understanding of their wants, needs and aspirations, they also develop a better understanding of how they interact and communicate with their environment in ways that are more helpful, more efficient and better suited to their own needs and personality.

Treatment

he most well-researched psychosocial treatments for social anxiety disorder are cognitive-behavioral therapies (CBTs). However, there are several other therapeutic approaches which have shown promising in the treatment of social anxiety disorder. There are also various psychopharmacological approaches which demonstrate effectiveness.

Medication can help. From clinical experience the selective serotonin reuptake inhibitors (SSRIs), such as be helpful, particularly in the form of selective serotonin reuptake inhibitors (SSRIs) or sometimes serotonin norepinephrine reuptake inhibitors (SNRIs) if needed over a longer interval. Selective Serotonin Inhibitors (SSRIs) are often used in generalized social anxiety disorders, if psychotherapy does not help fast enough or as a support. Historically, paroxetine and fluoxetine have often been used, but newer SSRIs, such as escitalopram, seem also to work. In clinical experience, some people benefit significantly from SSRIs, while others do not. One explanation is that it depends on the presence of other symptoms and psychiatric disorders, as well as how generalized the symptoms are, or how specific they apply to certain situations. Overall, there can be many different reasons, especially psychodynamic ones, that make up this diverse diagnosis, and they need to be carefully explored to increase the chances of therapeutic success.

Cognitive-Behavioral Therapy (CBT)

Meta-analyses indicate that all forms of CBT appear likely to provide some benefit for adults. (Rodebaugh et al., 2004) On the behavioral side, exposure therapy, for example, involves exposing the patient to anxiety invoking interpersonal situations in a gradual fashion, beginning with less anxiety provoking scenarios, and moving up to the ones to which a greater level of potential anxiety is attached. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. (Craske et al., 2014) Exposure optimization strategies include the following:

  1. expectancy violation
  2. deepened extinction
  3. occasional reinforced extinction
  4. removal of safety signals
  5. variability
  6. retrieval cues
  7. multiple contexts
  8. affect labeling.

(Craske et al., 2014)

On the cognitive side, other techniques commonly used in CBT are to reflect on the negative thoughts and ruminations in interpersonal situations, identify unhelpful beliefs and biases, make more realistic probability estimates and use other more or less structured thought processes. The cognitive approach focuses mainly on intrapersonal rather than interpersonal processes. (Stangier et al., 2011)

Psychodynamic Psychotherapy

In a large multicenter study Leichsenring and colleagues used a manual-guided form of psychodynamic therapy that was specifically developed for their trial. (Leichsenring et al., 2013) It was based on Luborsky’s model of psychodynamic therapy, including supportive and expressive interventions. A secure helping alliance is an important element of the model. Expressive interventions relate the symptoms of social anxiety disorder to the patient’s underlying core conflictual relationship theme, such as a wish, an anticipated response and a response from the self, in order to reduce the symptoms of social anxiety disorder. (Leichsenring et al., 2013) The response from the self represents the symptoms of social anxiety disorder. The core conflictual relationship theme is worked through in present and past relationships as well as in the relationship to the therapist. (Leichsenring et al., 2013)

Mindfulness-based stress reduction (MBSR)

Mindfulness-based stress reduction (MBSR) has shown in several studies to reduce symptoms of stress, anxiety, and depression. MBSR is believed to alter emotional responding by modifying cognitive–affective processes. Since social anxiety disorder is characterized by emotional and attentional biases as well as distorted negative self-beliefs, this can be a helpful approach. MBSR training in patients with social anxiety disorder may reduce emotional reactivity while enhancing emotion regulation.

Goldin and Gross examined MBSR-related changes in the brain–behavior indices of emotional reactivity and regulation of negative self-beliefs in patients with social anxiety disorder. Compared with baseline, MBSR completers showed improvement in anxiety and depression symptoms and self-esteem. During the breath-focused attention task, they also showed decreased negative emotion experience, reduced amygdala activity, and increased activity in brain regions implicated in attentional deployment. (Goldin & Gross, 2010)

D-Cycloserine

Clinical data with specific phobias has suggested that the treatment effects of exposure therapy for SAD may be enhanced with D-cycloserine, an agonist at the glutamatergic NMDA receptor, and its use has been suggested for social anxiety disorder. In a study by Hofmann and colleagues, patients receiving D-cycloserine in addition to exposure therapy reported significantly less social anxiety compared with patients receiving exposure therapy plus placebo. Controlled effect sizes were in the medium to large range. (Hofmann et al., 2006)

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.

Introduction

We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal cords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life.

Communication as Autoregulation

Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.

If one suffers from social anxiety, this autoregulation seems to fail. One reason why it fails is because communication is such an important and basic process that there is nothing that could hierarchically control it and put a problem in it right. Only changes in communication can put a communication failure right. This is why a therapy that focuses on communication by identifying communication patterns and reflecting on them is in a good position to treat social anxiety.

Communication Patterns

Communication patterns are sequences in which meaningful information flows between individuals who are interacting with each other. A question in one person leading to an answer in another person is an example, which also illustrates how one communication pattern gives rise to another one. Communication patterns exist as templates in a social or cultural setting. They are activated and modified by the person using them. In a therapeutic setting one may, for example, look with patients at which communication patterns they use and how. Since meaningful information can only flow if it is transmitted within the dynamics of communication patterns, no matter how simple and rudimentary they may be, improving one’s selection and use of communication patterns also leads to a more efficient transmission of meaningful information. This is particularly useful in anxiety conditions, which are characterized by a subjective lack of meaningful information. Since a socially anxious person may actually be very sensitive and perceptive, and thus have more information about interactional clues and the other person available, the focus in Communication-Focused Therapy®, for example, is not necessarily the quantity of information, but how the patient finds, absorbs and processes the information which is most helpful to further the own needs, values and aspirations. In clinical experience, the more competent a patient feels in this regard, the lower the anxiety usually is. This applies particularly to social anxiety, where the anxiety revolves around external communication.

Attention

Attention is the ability to notice new information within a defined space, but also the capability to attach relevance to it.  Both attention and focus are important in the acquisition of meaningful and relevant information form the environment. If they are interfered with or misdirected, there is less relevant information available, which can increase the experienced anxiety. The attention of highly anxious individuals is more automatically captured by sub-threshold cues.  (Mogg & Bradley, 2002) Attentional bias toward negative social cues is thought to serve an etiological and/or maintaining role in social anxiety disorder. As discussed above, anxiety in general is a result of the subjective perception of missing relevant information. (Haverkampf, 2010a, 2018f)

Schmidt and colleagues tested in their study whether training patients to disengage from negative social cues may ameliorate social anxiety in patients with a primary diagnosis of generalized social anxiety disorder. Patients who underwent attention training exhibited significantly greater reductions in social anxiety and trait anxiety, compared with patients in the control condition. At termination, 72% of patients in the active treatment condition, relative to 11% of patients in the control condition, no longer met the DSM-IV criteria for social anxiety disorder. At 4-month follow-up, patients in the attention training condition continued to maintain their clinical improvement. (Schmidt et al., 2009)

Communication to Participate in Life

Communication is important to be connected into the web of life. The exchange of meaningful messages helps one to get what one needs, wants and aspires to. This applies to communication with oneself and others. Finding out what one needs, wants and aspires to happens through communication with oneself. It requires openness and insight.

The feeling of being a part of ‘the whole thing’ is important to an individual, not jut because the individual is part of a chain of generations. When one exchanges meaningful messages with others, oneself and the world around become meaningful to oneself. Losing a part of oneself or a loss of meaning, however, represents an existential threat, which can induce anxiety. This is how social anxiety and a loss in meaningful connectedness with others can lead to more anxiety. To an extent, this can be compensated for with meaningful communication with oneself, but for most this is not enough.

Understanding Social Anxiety and Shyness

Social anxiety is often present from childhood. The fears already interfere with one’s development early on. Since some of the most experiences in a human life are the interpersonal ones, this can interfere with one’s personal development. As already mentioned, shyness is not a disorder, and a person may be happy about it. However, the potential loss to quality of life of social anxiety and shyness can be similar. Shy people often develop adaptive communication pathways, such as relying more heavily on the Internet and may be content with it. However, interpersonal communication is an important piece of change and of bringing about in the world, and without it some of this dynamic may be missed out on. Given the many possible channels of communicating with the world, it does not matter so much which one is used. The important factor is that it allows the exchange of meaningful messages, which aid the individual in becoming better connected with oneself and the world.

Internal Communication

Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. These patterns can be analyzed and changed. Another important element is that communication can also take place on the inside of the individual. Individuals with social anxiety are often very critical of themselves, and this is what is then projected into others, who then appear critical of oneself. An important, and often helpful, step is to become aware of this.

The internal and external communication go hand in hand. Thought patterns that are used in one’s communication with oneself are usually also used in the communication with others. If there are doubts and fears in the communication with oneself, they often will also be present in one’s communication with others.

Uncertainty

In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst-case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.

Studies have shown that the intolerance of uncertainty explains a significant amount of variance in social anxiety severity when controlling for several cognitive correlates of social anxiety, such as the fear of negative evaluation, and for neuroticism. Intolerance of uncertainty also seems to be related with symptom levels of GAD, OCD, and social anxiety, but not depression. (Boelen & Reijntjes, 2009) It seems to play a significant role in performance and interaction social anxiety, but probably a slightly greater role in the former. (Whiting et al., 2014) Intolerance of uncertainty also appears significantly associated with symptom levels of separation anxiety disorder. (Boelen et al., 2014)

Communication Deficits

Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, stay unresolved. For example, if a parent feels fearful and angry with himself and this is picked up by a child, the latter may decode these messages correctly in that the parent is angry, but since the parent may not be conscious about it, the child does not pick up on the second important half of the message, that the parent has a problem with himself and his issue is unrelated to the child. Of course, one can learn to pick up on the self-blame and frustration of the parent, and therapists should become experts at reading between the lines in this fashion, but it requires experience, reflection and insight into transference and counter-transference phenomena, for example, to use the psychoanalytic terms.

In one study, hildren with social anxiety disorder scored significantly higher than anxious children without on the Social Communication Questionnaire (SCQ), reciprocal social interaction, communication and repetitive, restrictive and stereotyped behaviors subscales. They were also three times more likely to score above clinical cut-offs overall. (Halls et al., 2015) This shows that these children have difficulties with certain communication patterns. However, this may not be due to a social skills defict, but they may believe that they appear nervous during social encounters. (Cartwright-Hatton et al., 2005) It would further support the view that it is the flow of information, internally and externally, which is really at the base of social anxiety disorder and many other mental health conditions (Haverkampf, 2018b). These can, on the other hand, be influenced and changed through work on the communication petterns and individual uses.

Avoidance

Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run. While smaller skillsets seem to pla role, it is also important to keep in mind that the avoidance of internal and external flows in itself lowers the available quantity of meaningful information, which plays a significant role in increasing uncertainty about the world and oneself (Haverkampf, 2010a) and thus the levels of anxiety, while holding the tolerance for uncertainty constant.

Meaning

Individuals suffering from social anxiety do not see less relevance in social interactions, but often even more. It is not necessarily seeing more meaning, though, but a different kind. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

However, someone with social anxiety may see the meaning in things differently from someone what does not suffer from it. Approaching someone of the opposite sex may be seen differently because of life experiences. Also, if different meaning is seen in it, the expectations can be different. Expectations that are so high that they are self-defeating can be a problem. However, to set expectations that are not too high and not too low mean having a view of reality that works for oneself.

Awareness of Thought Patterns

An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty is quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing psychologically and the feelings of a dreaded uncertainty about oneself and one’s emotional states.

Awareness means observing the own thought patterns and gaining insight into them. This requires being receptive to this information from oneself and the ability to reflect on it. Important is being able to perceive the flow of information between the parts of oneself, and the ability to let the information flow freely.

Flow of Information

A free flow of information within oneself and with the environment is important to reduce the anxiety and physical symptoms associated with social anxiety. Often, such an openness has become difficult for people because of inadequate interaction patterns and a fear to change anything. In a therapeutic session, this can be changed in two ways. Interaction patterns can be experimented with in a therapeutic session and reflected upon. One objective should be to help the patient develop greater efficacy and confidence in his or her interactions with the environment.

Emotional Reconnection

If there have been adverse life experiences as a significant factor in the social anxiety, there can still be unresolved emotions underlying the anxiety. To resolve them means answering the hypothetical question, what one may have felt in the difficult situation, but then also seeing the strength that allowed one to pull through, which only becomes visible now. The goal is not necessarily to reconnect with only negative emotions form the past, but also the good ones, and emotions as a whole today.

If there is a disconnect, and emotional reconnection would be helpful, one should approach one’s feelings gradually. Especially in cases of social anxiety, it could be problematic trying this too fast. In any case, as internal and external communication go hand in hand, so do internal and external emotional connection. Someone who is disconnected from oneself will have a more difficult time to emotionally communicate with others or stay reflected and calm in situations where there is a potential for greater emotional communication, such as in romantic situations.

Experiencing the World

Social anxiety means potentially experiencing less of the world, although the higher sensitivity can at the same time let someone experience more. It is important again to note that many patients suffering from social anxiety disorder put themselves under an enormous pressure. Their more frequent feeling that they need to interact with others and live their lives in certain can add to the anxiety, rather than diminishing it. The more permanent solutions to this dilemma are, as outlined above, a greater connectedness with oneself and better insight into the own needs, values and aspirations. Work with the communication patterns a patient uses, as well as reflection on how she felt when engaged in activities and with other people in the past, sheds light on the ‘truer’ needs, values and aspirations. The focus is here completely on the patient and her experiences, not on the expectations of others. This focus establishes more meaning in the life of the patient and helps is the acquisition of more helpful communication patterns.

Communication Techniques

Various communication techniques can be helpful, not as an end in themselves, but to help the person have more confidence in oneself and to see communication not as something dangerous one needs to be guarded against, but as something that can help one meet one’s needs, wishes and expectations. Thus, the reason for communication techniques should be not an end in itself, but to increase one’s repertoire, ease and confidence in communicating with oneself and others.

Openness to others, a positive and welcoming attitude towards the messages of others and engaging in reflection on the interaction are some helpful approaches towards communication, but there are many others as well. Important is not to be deterred from the interaction when something unsuspected or disappointing happens, but to reflect on what it could mean, whether it is a message from outside or inside oneself. Genuinely new information is never meaningless and reflecting on it helps to gain more insight into the world. Social anxiety, on the other hand, is often a result of engaging with messages only superficially, rather than letting them resonate with oneself and determining what they might mean.

Technology can also play a useful role in gradually exposing oneself to potentially more anxiety provoking situations. For example, beginning with interactions with fewer communication channels, such as an online dating site, can make it easier to then move on to an in-person date. More information could already be screened in a less communication intensive setting before exposing oneself to the many communication channels of an actual physical date. Pierce demonstrated in a study a positive relationship between social anxiety (not comfortable talking with others face-to-face) and (1) talking with others online and (2) talking with others via text messaging. In contrast, there was a positive relationship between the lack of social anxiety (feeling “comfortable” talking with others) and making friends online. (Pierce, 2009) Gender differences were also pointed out in the study.

Breaking the Cycle of Anxiety

To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.

Insight and connectedness reduce anxiety. Openness and receptiveness to information and messages can lead there. This can be practiced in therapy and brought from there into everyday life. The sense of competence helps build confidence in dealing with oneself and the environment. Important is to connect with oneself to a level that there is greater insight into what is truly important to oneself.

The Reward of Seeing More

Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which ways one relates to one’s environment and exchanges messages with it. People with social anxiety often see less in an interaction, although they often have a greater sensitivity and perceptiveness to see more. This has to do with a different focus on where to find a relevant and meaningful message in the interaction. For example, in an interaction with a romantic love interest, the socially anxious person may be too focused on signals and own thoughts about a possible rejection rather than on information from the other person that could help in getting to know that person.

An important step is therefore to become aware that what may be behind some of the social anxiety, or much of it, is actually something quite positive, something that can be used to one’s advantage. Central is merely how to use a heightened percetiveness and sensitivity to certain information signals for one’s benefit rather than to one’s detriment. In Communication-Focused Therapy, through work on communication patterns, within and without oneself, the selection and steering of information flows can be changed, which also directly impacts the information and meaning a person is exposed to. Since anxiety is tightly linked with the flow of information and the available information, changing internal and external communication patterns can lower anxiety quite substantially (Haverkampf, 2013, 2017i, 2017b).

Values, Needs and Aspirations

Beyond food, drink, a roof over one’s head and basic safety, humans have values, needs and aspirations that drive much of what they are doing throughout their lives. None of us is born to live the life of a Robinson Crusoe, and just like the fictional character, interpersonal interactions with others, as well as the intrapersonal communication that is tightly lined with it, are the main instruments to get these needs, values and aspirations met. The exchange of meaningful information is what brings about positive and lasting change in oneself and in the environment (Haverkampf, 2010b). The author has referred to the own needs, values and aspirations before as basic parameters because they can determine whether some information that has become available in a person is meaningful or not (Haverkampf, 2018h).

One of the most painful elements of social anxiety is that a person finds it more difficult to find the own needs met. It interferes with dating, in workplace situations or in academia. People suffering from this condition, do so in silence, which tends to make it even worse. To escape this vicious cycle, a new orientation towards the own values, needs and aspirations is needed (Haverkampf, 2013, 2017e). What helps to achieve this is through a better connectedness with oneself and others. The work on communication patterns in Communication-Focused Therapy can here be very helpful (Haverkampf, 2017e).

The Need for Communication

Living organisms constantly need to communicate within themselves and with others, and humans are not an exception. Close relationships in humans, for example, have been linked to a wide variety of psychological and other processes, including physical and mental health (Jones et al., 1990). Communication with others is needed to grow, innovate and propagate. Most of the human accomplishments in the arts, sciences and professions are based on the exchange of meaningful messages, communication. But communication is also to have one’s needs met and to survive in general. Even a hermit in the mountains needs to interact with his or her living mountain environment. People who enjoy nature usually do not want to shun communication but focus on an exchange with a nonhuman environment. Communication is fundamental to life itself.

Suffering from social anxiety does not mean a disinterest in people or an objection to being with them, rather the opposite. An indifference ot something does not lead to anxiety or the feelings that are commonly experienced by indidividuals with social anxiety. The latter are testamount to the importance a person with social anxiety attaches to interpersonal connections and the social realm. People with social anxiety may even be more sensitive and perceptive to social signals, though they may be minterpreted, and to the importance of social interactions. In one study, perceived closeness was greatest when the most socially anxious individuals interacted with each other (Kashdan & Wenzel, 2005). At the same time, in another study, when asked how an investigator viewed them based on that person’s facial expressions, socially anxious subjects made ratings that were consistently less favorable than the ratings made by subjects lower in social anxiety (Pozo et al., 1991). In other words, we have the semmingly paradoxical findings that people with social anxiety may experience social connections even mor eintensely, while possibly doubting them more in other situations. One explanation would be the fear of losing something very important. The more important social connections are to a person, the higher may also be the apprehensiveness about doing something wrong and losing it. Adding in higher anxiety levels to begin with, might give us a fairly adequate representation of the underlying dynamic in social anxiety.

Experimentation with adjustments to existing communication patterns and the development of new ones is the road that leads to less social anxiety (Haverkampf, 2017e, 2018d). The first steps can often be quite small for good reasons. It often helps people with social anxiety and shyness to connect with and appreciate their need and joy in communicating. Once communication is seen as a potential source of pleasure rather than a necessary task, it can become much easier, as ‘I want’ replaces ‘I should’. It often helps to take on a more investigatory perspective, donning a lab coat so to speak, and having fun observing the communication dynamics as they unfold in an interaction. The benefit is often twofold. Once one takes on an observer role it is easier to extricate oneself from the emotional vortex of being caught up insight a problematic interaction, while being able to better reflect and understand the dynamics. The greater awareness and space to experiment with new communication elements and patterns either in the current or a future situation can lead to a massive change in how effectively and satisfyingly one interacts with oneself and the world and thereby fulfils the own needs, values and aspirations.

Meaningful Messages as the Instrument of Change

Communication is the vehicle of change, and meaning drives it. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings about change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist. Over time, changes and sjudtments to in internal and external communication patterns facilitate a greater awareness for and processing of meaning (Haverkampf, 2010a, 2017c, 2018i).

Information underlies practically everything from physical quantum states and classical processes to psychological ones (Haverkampf, 2018g). Information Perceived emotions are also communicated information (Haverkampf, 2012b). In an interpersonal conext, meaning is generated from the information carried by signs.  Creation of meaning events in-therapy, for example, are change episodes that occur when a patient seeks to understand the meaning of an emotional experience (Clarke, 1996). Meaningful information is information which can bring about a change in the recipient of the information (Haverkampf, 2010a, 2018a). It has also been argued that information is objective, but inaccessible to humans, who exist exclusively in a world of meaning, while meaning is intersubjective, or based on shared agreement and understanding, rather than purely subjective (Mingers, 1995). However, the description of meaning as information that carries the potential to effect change may allow for a broader and more generally applicable delineation of the term. In Communication-Focused Therapy it is an important means of change dependent on the effective communication of the information that codes for it. Social anxiety illustrates quite brightly what happens when the process at one or more points affected by other factors, either within or outside the person. Social anxiety is primarily a communication problem, often alongside or based on generally higher levels of anxiety.

Embracing Change

In the case of social anxiety, embracing change can be associated with anxiety, while it can also be liberating because it means that there are no rigid rules one needs to adhere to other than those linked to the communication process itself, which has clear laws. Understanding these laws of communication, on the other hand, which humans subconsciously operate on and use as they accumulate experience in their interactions with others is essential to gain greater confidence in tolerating and working towards change. Basic communication concepts, such as what constitutes communication, how meaning is created, how information flows, and how communication processes are influenced, is usually not conscious. Reflecting on it and beginning to use it, however, can be especially helpful to sensitive people, who quite frequently have experienced social at some point in their lives. One might say that only those who do not care about people and themselves are entirely free from social anxiety, but this tantamount to the description of a sociopathic personality disorder.

Change should thus not be understood as changing oneself or one’s ability to perceive and be sensitive to the nuances of daily interactions, but to develop new communication patterns. Some of the techniques used in Communictaion-Focused Therapy have been described elwhere (Haverkampf, 2017a, 2017e, 2017i, 2018e). Important is the concept that external and internal communication patterns are closely related to each other, and that work on communication in therapy leads to change on both sides. Several of the techniques involve the use of certain communication elements and structures, such as a variety of the question (Haverkampf, 2017g) and other functional concepts.

Living

It is not the number of social contacts which is relevant. Having a few good friends is often worth more than thousands of contacts in an online social network. However, this does not mean friends have to be always physically present. Meeting friends online also allows for communication, while close physical contact in an intimate relationship is to most people important on a regular basis.

Important is that the communication patterns, the frequency and the interaction style fit the needs, values and aspirations of the individual. People who are shy can be quite happy with the intensity and frequency of their interactions, those with social anxiety are usually not. It is thus important to help individuals with social anxiety discover what is important to them and how they want to live their lives. Communication patterns change more easily when the change creates more meaning in the world of the patient (Haverkampf, 2012a). Communication-Focused Therapy thus aims first at creating greater awareness for the basic parameters of needs, values and aspirations to support the process of change in communication patterns (Haverkampf, 2010b, 2017a).

In the end, communication is an activity. One ultimately needs to do it. However, when one has worked on the own communication, developed awareness for them, gained insight into them and made it a habbit to experiment with them, communication becomes something to look forward to rather than something that causes apprehensiveness and anxiety.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

References

Beard, C., & Amir, N. (2008). A multi-session interpretation modification program: Changes in interpretation and social anxiety symptoms. Behaviour Research and Therapy, 46(10), 1135–1141. https://doi.org/10.1016/j.brat.2008.05.012

Beidel, D. C., Turner, S. M., & Dancu, C. V. (1985). Physiological, cognitive and behavioral aspects of social anxiety. Behaviour Research and Therapy, 23(2), 109–117. https://doi.org/10.1016/0005-7967(85)90019-1

Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and social anxiety. Journal of Anxiety Disorders, 23(1), 130–135. https://doi.org/10.1016/j.janxdis.2008.04.007

Boelen, P. A., Reijntjes, A., & Carleton, R. N. (2014). Intolerance of Uncertainty and Adult Separation Anxiety. Cognitive Behaviour Therapy, 43(2), 133–144. https://doi.org/10.1080/16506073.2014.888755

Caplan, S. E. (2007). Relations Among Loneliness, Social Anxiety, and Problematic Internet Use. CyberPsychology & Behavior, 10(2), 234–242. https://doi.org/10.1089/cpb.2006.9963

Cartwright-Hatton, S., Tschernitz, N., & Gomersall, H. (2005). Social anxiety in children: Social skills deficit, or cognitive distortion? Behaviour Research and Therapy, 43(1), 131–141. https://doi.org/10.1016/j.brat.2003.12.003

Clarke, K. M. (1996). Change processes in a creation of meaning event. Journal of Consulting and Clinical Psychology, 64(3), 465–470. https://doi.org/10.1037/0022-006X.64.3.465

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/J.BRAT.2014.04.006

Etkin, A., & Wager, T. D. (2007). Functional Neuroimaging of Anxiety: A Meta-Analysis of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia. American Journal of Psychiatry, 164(10), 1476–1488. https://doi.org/10.1176/appi.ajp.2007.07030504

Gilbert, P. (2000). The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clinical Psychology & Psychotherapy, 7(3), 174–189. https://doi.org/10.1002/1099-0879(200007)7:3<174::AID-CPP236>3.0.CO;2-U

Goldin, P. R., & Gross, J. J. (2010). Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion, 10(1), 83–91. https://doi.org/10.1037/a0018441

Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou, S. P., Goldstein, R. B., Dawson, D. A., Smith, S., Saha, T. D., & Huang, B. (2005). The Epidemiology of Social Anxiety Disorder in the United States. The Journal of Clinical Psychiatry, 66(11), 1351–1361. https://doi.org/10.4088/JCP.v66n1102

Halls, G., Cooper, P. J., & Creswell, C. (2015). Social communication deficits: Specific associations with Social Anxiety Disorder. Journal of Affective Disorders, 172, 38–42. https://doi.org/10.1016/j.jad.2014.09.040

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. http://www.jonathanhaverkampf.com

Haverkampf, C. J. (2012a). A Case of Severe Anxiety. J Psychiatry Psychotherapy Communication, 1(2), 35–40.

Haverkampf, C. J. (2012b). Feel! (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2013). A Case of Social Anxiety. J Psychiatry Psychotherapy Communication, 2(1), 14–20.

Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. http://www.jonathanhaverkampf.in/wp-content/uploads/2018/06/Communication-Focused-Therapy-CFT-for-Anxiety-and-Panic-Attacks-2-Christian-Jonathan-Haverkampf.pdf

Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) for OCD. J Psychiatry Psychotherapy Communication, 6(4), 102–106.

Haverkampf, C. J. (2017e). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.

Haverkampf, C. J. (2017f). Finding Your Dreams.

Haverkampf, C. J. (2017g). Questions in Therapy. J Psychiatry Psychotherapy Communication, 6(1), 80–81.

Haverkampf, C. J. (2017h). Social Anxiety and Medication (2). http://www.jonathanhaverkampf.com/

Haverkampf, C. J. (2017i). Treatment-Resistant Anxiety. J Psychiatry Psychotherapy Communication, 6(3), 61–67.

Haverkampf, C. J. (2018a). A Primer on Communication Theory.

Haverkampf, C. J. (2018b). Atypical Deprerssion. J Psychiatry Psychotherapy Communication, 9(4), 91–97.

Haverkampf, C. J. (2018c). Beginning to Communicate (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018d). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018e). Communication Patterns and Structures.

Haverkampf, C. J. (2018f). Fear, Social Anxiety and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018g). Information.

Haverkampf, C. J. (2018h). The Basic Parameters (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018i). The Power of Meaning (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Heimberg, R. G., Horner, K. J., Juster, H. R., Safren, S. A., Brown, E. J., Schneier, F. R., & Liebowitz, M. R. (1999). Psychometric properties of the Liebowitz social anxiety scale. Psychological Medicine, 29(1), 199–212.

Hezel, D. M., & McNally, R. J. (2014). Theory of mind impairments in social anxiety disorder. Behavior Therapy, 45(4), 530–540. https://doi.org/10.1016/j.beth.2014.02.010

Hirsch, C., Meynen, T., & Clark, D. (2004). Negative self‐imagery in social anxiety contaminates social interactions. Memory, 12(4), 496–506. https://doi.org/10.1080/09658210444000106

Hofmann, S. G., Meuret, A. E., Smits, J. A. J., Simon, N. M., Pollack, M. H., Eisenmenger, K., Shiekh, M., & Otto, M. W. (2006). Augmentation of Exposure Therapy With D-Cycloserine for Social Anxiety Disorder. Archives of General Psychiatry, 63(3), 298. https://doi.org/10.1001/archpsyc.63.3.298

Jones, W. H., Rose, J., & Russell, D. (1990). Loneliness and Social Anxiety. In Handbook of Social and Evaluation Anxiety (pp. 247–266). Springer US. https://doi.org/10.1007/978-1-4899-2504-6_9

Kashdan, T. B., & Wenzel, A. (2005). A transactional approach to social anxiety and the genesis of interpersonal closeness: Self, partner, and social context. Behavior Therapy, 36(4), 335–346. https://doi.org/10.1016/S0005-7894(05)80115-7

La Greca, A. M., & Harrison, H. M. (2005). Adolescent Peer Relations, Friendships, and Romantic Relationships: Do They Predict Social Anxiety and Depression? Journal of Clinical Child & Adolescent Psychology, 34(1), 49–61. https://doi.org/10.1207/s15374424jccp3401_5

La Greca, A. M., & Lopez, N. (1998). Social Anxiety Among Adolescents: Linkages with Peer Relations and Friendships. Journal of Abnormal Child Psychology, 26(2), 83–94. https://doi.org/10.1023/A:1022684520514

Leary, M. R. (1990). Responses to Social Exclusion: Social Anxiety, Jealousy, Loneliness, Depression, and Low Self-Esteem. Journal of Social and Clinical Psychology, 9(2), 221–229. https://doi.org/10.1521/jscp.1990.9.2.221

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., Huesing, J., Joraschky, P., Nolting, B., Poehlmann, K., Ritter, V., Stangier, U., Strauss, B., Stuhldreher, N., Tefikow, S., Teismann, T., Willutzki, U., Wiltink, J., & Leibing, E. (2013). Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial. American Journal of Psychiatry, 170(7), 759–767. https://doi.org/10.1176/appi.ajp.2013.12081125

Mansell, W., Clark, D. M., Ehlers, A., & Chen, Y.-P. (1999). Social Anxiety and Attention away from Emotional Faces. Cognition & Emotion, 13(6), 673–690. https://doi.org/10.1080/026999399379032

Mingers, J. C. (1995). Information and meaning: foundations for an intersubjective account. Information Systems Journal, 5(4), 285–306. https://doi.org/10.1111/j.1365-2575.1995.tb00100.x

Mogg, K., & Bradley, B. P. (2002). Selective orienting of attention to masked threat faces in social anxiety. Behaviour Research and Therapy, 40(12), 1403–1414. https://doi.org/10.1016/S0005-7967(02)00017-7

Phan, K. L., Fitzgerald, D. A., Nathan, P. J., & Tancer, M. E. (2006). Association between Amygdala Hyperactivity to Harsh Faces and Severity of Social Anxiety in Generalized Social Phobia. Biological Psychiatry, 59(5), 424–429. https://doi.org/10.1016/J.BIOPSYCH.2005.08.012

Pierce, T. (2009). Social anxiety and technology: Face-to-face communication versus technological communication among teens. Computers in Human Behavior, 25(6), 1367–1372. https://doi.org/10.1016/J.CHB.2009.06.003

Pozo, C., Carver, C. S., Weflens, A. R., & Scheier, M. F. (1991). Social Anxiety and Social Perception: Construing Others’ Reactions to the Self. Personality and Social Psychology Bulletin, 17(4), 355–362. https://doi.org/10.1177/0146167291174001

Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social anxiety disorder. Clinical Psychology Review, 24(7), 883–908. https://doi.org/10.1016/J.CPR.2004.07.007

Schlenker, B. R., & Leary, M. R. (1982). Social anxiety and self-presentation: A conceptualization model. Psychological Bulletin, 92(3), 641–669. https://doi.org/10.1037/0033-2909.92.3.641

Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118(1), 5.

Stangier, U., Schramm, E., Heidenreich, T., Berger, M., & Clark, D. M. (2011). Cognitive Therapy vs Interpersonal Psychotherapy in Social Anxiety Disorder. Archives of General Psychiatry, 68(7), 692. https://doi.org/10.1001/archgenpsychiatry.2011.67

Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115–1125. https://doi.org/10.1016/S0140-6736(08)60488-2

Whiting, S. E., Jenkins, W. S., May, A. C., Rudy, B. M., Davis, T. E., & Reuther, E. T. (2014). The Role of Intolerance of Uncertainty in Social Anxiety Subtypes. Journal of Clinical Psychology, 70(3), 260–272. https://doi.org/10.1002/jclp.22024

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

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Communication-Focused Therapy (CFT) for Autism and Asperger Syndrome (2)

Communication-Focused-Therapy-CFT-for-Autism-and-Asperger-Syndrome-2-Christian-Jonathan-Haverkampf

Treatment of Psychosis and Schizophrenia (1)

Psychosis, and particularly in the form of schizophrenia, is often seen as a serious life altering condition. However, in clinical practice many patients can attain remission or at least substantial remission, which enables them to lead the personal and professional lives they want. While medication plays a significant role, particularly in the acute stages and their aftermath, psychotherapy and social support gain additional prominence in relapse prevention over the long-term. They are also indicated in patients who may not have had a full psychotic episode yet but are at greater risk for one. Work on internal and external communication patterns has shown in individual cases to be very helpful as a psychotherapeutic approach to support the patient in fulfilling own needs and aspirations, while increasing treatment compliance and the overall quality of life. Communication-Focused Therapy®, as developed by the author, offers a theoretical framework and an extensive toolset for this approach to treatment.

Keywords: psychosis, schizophrenia, psychotherapy, Communication-Focused Therapy®, CFT®, medication, psychiatry

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