Reducing Symptoms of Social Anxiety in a Young Adult: A Case Study on ReAttach
Renske ter Maat, MSc.
ReAttach is a new, multi-modal psychological intervention based on the theoretical principles of arousal regulation, information processing and schema therapy. Practical research indicates that ReAttach significantly reduces psychological problems in both adults and children. Theories on ReAttach state that this is done by creating functional schemas, which in turn create more effective coping styles in clients and decrease psychological complaints. As many young adults face psychological complaints such as stress, insecurity and anxiety, ReAttach is an efficient intervention. This article aims to provide a better understanding of ReAttach theory, by linking theory to the treatment process of a young adult with symptoms of social anxiety. It will show that the results of ReAttach on the young adult are positive and that the theoretical principles seem applicable to the case.
Key-words: treatment, social anxiety, information processing, arousal regulation, schema therapy
In the beginning of 2013 I was introduced to ReAttach. I had just started my private practice and I was looking for a way to effectively treat adolescents with mental health problems, because I encountered a lot of young people dealing with anxiety, insecurities and stress. As a developmental psychologist, my objective is stimulating the healthy development of young adults. This is achieved by using psychological and pedagogical interventions, for example ReAttach. First studies show that, within an average of five sessions, ReAttach significantly reduces problematic behavior in children (Weerkamp-Bartholomeus, 2015-a) and psychological complaints in adults (Weerkamp-Bartholomeus, 2015-b). As ReAttach is a new intervention, the mechanisms behind the therapy are still to be researched. Expected is that the theoretical concepts of schema therapy, information processing and arousal regulation, on which ReAttach is based, explain the success of the treatment.
To gain a better understanding of theory behind the treatment outcomes in adults and the use of ReAttach in practice, this article focusses on theoretically explaining the effects of ReAttach on a young adult who experiences feelings of anxiety. To accomplish this, I will start by outlining the theoretical principles of ReAttach. I will then describe the use of ReAttach in practice. Furthermore, I will describe the treatment of Jake (alias), a 22-year old man with symptoms of anxiety, and incorporate both ReAttach theory and practical decision making.
- Theoretical principles
ReAttach was developed by Paula Weerkamp-Bartholomeus, an educational psychologist. ReAttach was found to be a method of changing schemas: patterns of thoughts and behavior that trigger maladaptive coping strategies, such as avoidance, perfectionism, and overcompensation, causing low self-esteem, negative thoughts, anxiety and stress (Weerkamp-Bartholomeus, 2015-b). ReAttach is a multimodal intervention based on the combined theoretical principles of arousal regulation, information processing and schema therapy. The next section will briefly outline these theoretical principles and its application in treatment.
By twelve months of age, infants can create schemas: representations of the self and their environment (Gelman, 2009). In literature, schemas are also called concepts, assumptions or attitudes. For consistency throughout this article, I will use terminology of schema therapy. Schemas are important beliefs and feelings that are developed and inhibited by the individual (Young, 1999, Young, Klosko, & Weishaar, 2016). People use these schemas to organize their experiences, to interpret what happens around them, to simplify the world, and to adequately react to it. Schemas function as a blueprint or a guideline which we use to interpret new information. New information that is formed into schemas is highly influenced by our existing schemas. Clinical anxiety could be described in terms of a biased information-processing system, in which negative schemas are overactivated, causing clients to look for more negative information (Beck et. al., 1985). This negative information is processed into more negative schemas. Persistent dysfunctional thinking patterns are caused by dysfunctional schemas (Young, Klosko, & Weishaar, 2016). Dysfunctional schemas lead to more dysfunctional thoughts and behavior, forming the root of psychological problems (Young, 1990). Psychological disorders may come into existence due to these cognitive distortions causing maladaptive emotional regulation strategies (Leahy, 2012).
Schema therapy was developed to change old, dysfunctional thoughts and behavior that lead to psychological complaints. The therapist works with thoughts that are important to the schema: either to prove or to disprove a schema (Young, Klosko, & Weishaar, 2016). The objective is to inhibit thoughts that prove a functional schema, and thoughts that disprove a dysfunctional schema. ReAttach aims to do so by processing information into functional schemas using multisensory processing techniques. Note that ReAttach is not a form of schema therapy, but that it can be described as an intervention that reduces psychological stress, based on the theoretical principles of schema therapy.
A multisensory approach is used to stimulate healthy information processing. ReAttach creates the same information processing situation as during play, in which children unconsciously process new information into schemas (Bartholomeus, 2013). This is done by tapping on the client’s hands and thereby regulating the clients’ arousal to the same level as during play: alert, but not overly aroused or frightened. As the information processing in an overly aroused person is biased by negative schemas (Beck et. Al, 1985), an overly aroused -or even anxious- person tends so see more negative information and is less able to weigh positive information correctly. In children, over-arousal even leads to a decline in the amount and quality of play, during which children process information and learn to cope with anxiety, frustration and conflicts (Verhulst, 2017). The right amount of arousal creates a joint attention and a feeling of safety (Bartholomeus, 2013), thereby creating the conditions to process information through the different senses: the calming touch and verbal prompts used in ReAttach. Information processing through different senses is an essential element of the construction of healthy cognitive representations and schemas (Baum, 2015). This is because the brain gains more information from an event that is perceived by multiple senses, than by the sum of several senses or one sense alone (Stein, 2012).
While tapping on the hands of the client, the therapist gives verbal prompts to steer the process of changing schemas. To change schemas, the client needs explicit or implicit cues from language (Gelman et al., 2008). Inhibiting new and more positive information creates new positive schemas (Young, Klosko, & Weishaar, 2016). The verbal prompts used in ReAttach help reprocessing existing negative thinking patterns into more functional schemas (Bartholomeus, 2013). By adding new information, a negative schema can be disproved and positive schemas can be created (Young, Klosko, & Weishaar, 2016). Adjusting and reprocessing negative thoughts into more realistic schemas creates more compassionate coping styles. This leads to a decline in dysfunctional schemas and cognitive distortions, which in turn decreases psychological problems (Leahy, 2012, Weerkamp-Bartholomeus, 2015-b).
- ReAttach in practice
This section will expand on the use of ReAttach in practice. As the objective of my private practice is to have all young adults stress-free, empowered and mentally healthy, I regularly meet young adults who feel stressed and insecure. Although a slight increase of insecurity accompanies this age (Feldman, 2016), a fair amount of mental health problems can be reduced by ReAttach (Weerkamp-Bartholomeus, 2015-b). As ReAttach is an accessible intervention, I use ReAttach as a form of secondary prevention of psychological problems: the objective is to reduce light to medium psychological complaints and enhance mental functioning in clients. This means that, within a few sessions, diagnosis and further mental health care may even become unnecessary. ReAttach requires five therapy sessions on average (Bartholomeus, 2013), thereby presenting a solution in the search for shorter and more cost-efficient treatment.
ReAttach sessions follow a protocol, but also leave room for coaching and the use of additional treatment methods. For example, I use ReAttach combined with coaching based on cognitive behavioral therapy, to assist the client in making a more conscious transfer to situations they encounter in daily life. I like to add a dose of humor and I create a connection with the client to create a therapeutic alliance. Shared goals are important for successful outcome of the therapy. However, a good relationship between therapist and client is just as important as a factor (Goldsmith e.a., 2015, Horvarth et.al., 2011).
ReAttach can be valuable in therapy for clients who are unable to tell their story. The exact contents of the schemas are not important to the therapist to give helpful language cues (Bartholomeus, 2013). Not having to talk about problems while still processing the information leaves room for the client to focus on strengths on developing new and healthy schemas. The focus on strengths is one of the principles of an empowering and motivational therapist attitude (Miller & Rollnick, 2002), ReAttach fits this empowerment-based coaching style. ReAttach also leaves room for motivational interviewing during coaching, in which clients talk about changes they envision and look for ways to incorporate the new schemas into their daily lives, instead of talking about problems and negative schemas (Miller & Rollnick, 2002). The more clients hear and talk about the new schemas, the better these are embedded in the long-term memory, and the better the treatment outcomes (Miller & Rollnick, 2002). This is important as it incorporates tools to make a transition to daily life.
- Empirical case-study: the treatment of Jake.
To illustrate the use of ReAttach in practice, I will describe the case of Jake, a 22-year old man with anxiety and negative thoughts. First, I will describe background information, the treatment, and the theoretical principles and decisions that played a role during treatment. I will then analyze the outcomes of the treatment.
4.1. Background information and description of the problem
Jake, a 22-year old man, sent an email in which he explained the problems he faced on a daily base: anxiety, insecurity and negative thoughts. Jake did not feel comfortable going outside anymore, because he thought that other people watched him and talked about him behind his back. He gave the example that, while travelling by train, he was aware of all the people looking at him, making him anxious and overly alert. He used to put on music to focus on something else, but still needed to check every five minutes whether people were talking about him: turning the volume down to listen to the contents of the conversations around him. Jake did not feel comfortable walking in the city, past terraces and at school. He kept thinking that everyone was staring at him, judging him and talking about him, leaving him anxious and insecure. Jake could not explain these thoughts and decided that he needed help.
4.2. Intervention analysis
During the intake, Jake appeared to be a modern man that took good care of himself. He he openly explained the problems he experienced. He added that he was in his last year of university college: Jake was studying to become a geography teacher. He doubted that this was the right profession for him, for teaching children did not make him happy, but he did not know what else to do. He was given the assignment to do research on education, but he did not like it much. Jake also explained that the relationship with his boyfriend was ambivalent. He used marihuana on a regular base, usually at night, to relax and fall asleep. Jake obsessed about the relationships with his friends: he felt that he did not belong in their group of friends. He also felt that his friends talked about him behind his back, even though he rationally knew this was not true. Jake felt anxious when he thought about how these problems had gotten worse over the last year. He had heard of ReAttach when his aunt had treatment with ReAttach and experienced positive outcomes, so his outcome expectancy was high. We discussed how, in addition to the treatment, quitting the use of marihuana could be beneficial for Jake. As THC in marihuana impairs episodic memory and learning (Curran et al., 2002) and creates differences in information processing (Kempel et al., 2013), not using drugs is a condition for ReAttach to have better effects. We decided that the goals of the treatment were:
– Jake feels less anxious in social situations and in public life
– Jake experiences less negative thoughts in social situations and in public life
– Jake’s self-worth is increased
We started with the first session of ReAttach protocol to activate information processing. We focused on processing the thoughts that Jake experienced while walking on the street and sitting in the train, to make these thoughts less present and decrease the anxiety. Regulating the overall arousal was important here, because the processing of information only happens when people are not anxious (Weerkamp-Bartholomeus, 2015-c). We created new schemas to improve self-esteem and reduce insecurity. These schemes were composed of the positive things in life, such as positive traits and everything Jake was proud of. Afterwards, Jake was given the assignment to talk to his friends and find out what they thought about him. He was also asked to fill in a symptom questionnaire as pre-test.
By session two, a few weeks later, Jake had talked to his friends and found out that they appreciated him. He had also stopped using marihuana and had been clean for a week. His boyfriend helped him to stay clean by staying over and supporting Jake during the evening. Jake elaborately spoke about his doubts about school, not belonging with his friends, and his job. For example, Jake worked both in a clothing and plants store and in a cloakroom: at the store, he felt safe and accepted, in the cloakroom he had had a few negative comments on his looks. During ReAttach we focused on processing negative thoughts about friends and strangers talking behind his back, on further establishing the positive schema of the self, and on creating a schema with information regarding everything that would keep Jake able to stay clean.
Before session three, Jake had filled in the questionnaire. All clients are asked to fill in the CSE-R questionnaire, so that the therapist can monitor the treatment process and results. The CSE-R questionnaire measures psychological distress and consists of symptoms of mental health problems, for example symptoms of anxiety, depression and ADHD. The CSE-R is currently being validated, but first research indicates that a change of 10 points is a significant change. Jake found filling in the questionnaire confronting as he recognized most symptoms. We discussed the score, and the questionnaire confirmed the symptoms Jake already described. His overall score indicated serious problems. His score was particularly high on the items that indicated anxiety, specifically insecurity. Both the pre-test and the post-test scores are presented in table 1.
Scores on the CSE-R
|Psychological distress||32 (serious problems)||12 (no problems)|
During coaching in session 3, Jake told me that he had been to college that day and that he wanted to make a switch in his major, but that he did not know if he could do the track he wanted to do. Furthermore, Jake found that his research assignment took too long, blaming himself for taking the time he needed. He was afraid of failure and felt insecure. Jake still had not used any drugs, making him more restless, but also a little proud. To help Jake in changing his view on people talking behind his back, we discussed the chance that people talked about him while he was walking in the city: Jake estimated that this chance would be around 20 percent. After drawing a pie chart and talking for a while, Jake concluded that the actual chance was likely around 5 percent. During the session, we briefly touched this topic, but we did not focus on it because these thoughts were already activated while talking. Instead, we focused on processing general thoughts of insecurity to reduce anxiety in its broadness, as the need to be perfect -resulting in anxiety and negative thoughts- seemed to be the root of the problem. To reduce maladaptive emotional regulation strategies (Leahy, 2012) and to establish an adaptive coping strategy, we started creating a schema of self-love.
About three weeks later, during the fourth session, Jake stated that while commuting, he had experienced less negative thoughts and anxiety. He wondered whether this could have been the effect of our previous sessions. Jake also broke up with his boyfriend. His feelings about this were both relief and sadness, as the relationship had been ambivalent and he had seen the break-up coming. While discussing this timing, Jake concluded that he never felt secure enough to break up before. This was a positive improvement, as Jake faced a lot of insecurity. To reduce his symptoms more effectively, Jake agreed to focusing even more on the underlying problem of insecurity and coping. We talked about his personal history, in which Jake had struggled with his identity, and had been trying to learn to accept himself as he was. During the session Reattach we focused on establishing the positive schema of the self and we visualized throwing away the judgements of others. We also discussed how Jake could react on negative comments he would encounter in the future. Visualization is another successful tool to form schemas (Pham & Taylor, 1999), enhancing the link between thought and action. Combining multiple tools, such as language cues and visualisation, leads to better treatment outcomes.
We started session five on a very positive note: Jake met a new guy and, while this guy was double his age and Jake felt insecure about the age difference, he had told his friends. It did not occur to him that his friends might have had thoughts or judgements about the age difference. This was another positive improvement, as during our first session Jake explained that he suffered from negative thoughts about not belonging in his group of friends. The negative schema appeared to be less present. During ReAttach we focused on the processing of general information and on establishing positive thoughts in the schema of the self, creating a positive image of the self. We also worked on the schema of being good enough, even though nobody is perfect. Afterwards, Jake was given the assignment to write down everything he wanted to remember from our ReAttach sessions.
Two weeks later, after 5 sessions, Jake had filled in the questionnaire and it came out symptom-free (Table 1). He stated that filling in the questionnaire felt very different than the first time: he had experienced more positive thoughts about himself. We agreed on finishing the therapy and on keeping in touch if necessary.
Three months later, Jake told me that he felt good, but that he still had not finished his research. Although Jake made a negative comment on his functioning in school, the results of the therapy remained positive. Jake was asked to fill in the questionnaire as a follow-up, but he did not fill in the questionnaire as he did not feel the need to.
In the case of Jake, ReAttach treatment has been successful. The treatment reduced feelings of anxiety and the presence of negative thoughts. Is also established a more positive and realistic self-image, increasing feelings of self-worth in Jake. Treatment goals have therefore been accomplished.
Because Jake was anxious and in an overly aroused state, regulating the arousal was an important component of the treatment. When Jake would have been aroused during the sessions, a negative schemas bias, as described by Beck et. Al. (1985), could be present. The regulating of his arousal by tapping on his hands may have facilitated a balanced information processing situation in Jake.
The processing of negative information and dysfunctional thoughts had led to the presence of less dysfunctional schemas, which may be the cause of the decline of symptoms. Information that is less present, leads to less cognitive distortions and emotions (Bartholomeus, 2013). Jake also reported more feelings of security and happiness, indicating the presence of more functional schemas. The verbal prompts focusing on establishing a good and positive image of the self, might have increased a positive thought pattern in Jake regarding his identity. Jakes new and different view on social situations and on expectations of others towards Jake diminished his anxiety and created a more functional coping style with social situations.
In conclusion, ReAttach treatment decision making followed the principles of schema therapy, information processing and arousal regulation. These theories seem applicable to the case of Jake. ReAttach may have helped Jake developing healthy schemas, which may have led to a decline in his symptoms of anxiety. Further mental health treatment seemed unnecessary, as five sessions of ReAttach in secondary prevention was enough to enhance the psychological functioning in Jake.
Although Jake experienced positive treatment outcomes while following ReAttach theory, different explanations and further recommendations can be considered. In this section, I will briefly touch other possible explanations that might have caused a decrease in the symptoms of anxiety in Jake. Then, I will add recommendations on the questionnaire and research.
ReAttach might not be the only possible explanation for the results that have been found in the case of Jake. Therefore, it may be useful to consider other possible explanations. For example, since Jake had a high outcome expectancy, the success of the treatment may have been the effect of a self-fulfilling prophecy. When outcome-expectancies are high, clients tend to report better outcomes than clients who have a lower outcome-expectancy, accounting for a substantial part of variance in treatment results (Joyce & Piper, 1988). Jake might have reported better outcomes on the questionnaire due to the successful treatment of his aunt and his fear of failure.
Also, the coaching techniques based on cognitive behavioral therapy might have caused a decrease in symptoms of anxiety. Although cognitive behavioral techniques usually need more than five sessions to be effective, these techniques help clients to change their view on situations and are known to significantly decrease the symptoms of anxiety (Korrelboom & ten Broeke, 2004). Research on the amount of variance caused by ReAttach and the amount of variance caused by cognitive behavioral therapy could be considered when ReAttach is used combined with coaching.
For a ReAttach therapist it is not necessary to know the contents of the maladaptive schemas and the CSE-R has given enough insight in Jake’s problems to intervene. However, schema questionnaires – for example the Young Schema Questionnaire (YSQ) – could give a better and more evidence based insight in the contents of the schemas, forming a more accurate indication for the therapist in deciding on treatment goals and intervention strategies. It also creates the opportunity to describe treatment goals in schema therapy terminology, embedding schema theory further into practice.
Although short and cost-efficient solutions to psychological complaints are very useful, research on ReAttach is practice-based. Further research on ReAttach is currently being done to build a stronger theoretical framework, and to find more evidence for the working of ReAttach. I support the search for stronger evidence on the elements that explain the working of ReAttach.
I would like to thank Jake, who was willing to let me write down his story.
Renske ter Maat, MSc.
Bartholomeus (2013). Als praten niet helpt….
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