Anxiety Disorders

People in our modern societies are increasingly becoming anxious, even though prosperity continues to grow and people appear more self-confident on the outside. Twenge (quoted from Wilkinson & Picket, 2010, p. 48 ff.) determines in a summary of 269 studies: “Whether the interviewees were students or children, the result was always the same. At the end of the survey, a student had 85% more anxiety than the population average at the beginning. And the fears in children were higher in the late 1980s than in psychiatric patients in the 1950s. […] A similar trend is also found in related areas, such as depression. […] In Great Britain […], people born in 1970 are twice as likely to experience depression in their mid-twenties compared to an earlier survey of people in this age group born in 1958. […] In young people, this phenomenon is accompanied by increasing behavioral disturbances such as criminal offenses and alcohol and drug abuse. It affects both young men and women.” The youth, however, hide their increasing anxieties by portraying a self-confident compensatory attitude on the outside. This is supported by the fact that “in the 1950s, 12% of teenagers agreed with the statement: ‘I am an important person’. At the end of the 1980s, 80% answered in the affirmative” (Wilkinson & Picket, 2010, p. 51 f.). “This kind of self-confidence was (and is) fragile and rejects any criticism–like whistling in the dark. […] These characteristics are also summed up in terms such as ‘pathological egoism’, ‘insecure self-confidence’, or ‘narcissism’. […] In 2006, two-thirds of American college students were reported to have scored above the 1982 average on the narcissism index.”

Central idea

Wilkinson and Picket determined that increasing income inequality in society reinforces the trend toward more anxiety (Wilkinson & Picket, 2010, p. 50). They attribute this to the fact that psychosocial stress factors are more significant in societies with high-income disparities.

People worry about their social status. The number of social relationships is considerably less. Children are more likely to experience stress in early childhood. “The key realization is that mortality and health in society depend a lot less on its overall wealth than on the distribution of wealth. The more evenly the wealth is distributed, the better the public health” (Wilkinson & Picket, 2010, p. 101). A decrease in income inequality is directly reflected in better public health. This is apparent in the example of Great Britain in both the world wars (Wilkinson & Picket, 2010, p. 104) and in the example of Japan after the Second World War (Wilkinson & Picket, 2010, p. 107). It is noteworthy that if income inequality increases in wealthy industrialized countries, the health risks increase even among rich people, decreasing their life expectancy (Wilkinson & Picket, 2010, p. 95). For example, “in the USA, where the social gap between the rich and the poor is huge, the incidence of serious mental disorders across all income groups is five times higher […] than in the Scandinavian countries […]. […] The allegedly comfortable existence of a millionaire does not protect one against one’s anxieties. […] The rich wall themselves, which perhaps creates an illusion of security. But people don't notice that their social environment is no longer functioning. The stress comes back in through the back door, so to speak. It’s the fear of losing something. […] The USA, Singapore, Portugal, and Great Britain are at the bottom of the rank order. In these states, the top 20% earn seven, eight, or even nine times the income available to the 20% at the bottom. […] In Japan and Sweden, […] those at the top earn only up to two to three times the average earnings of their poor fellow citizens. […] These countries occupy the top position in terms of life expectancy and general health” (Süddeutsche Zeitung from November 2nd, 2009). In line with these findings, “the risk of anxiety disorders in cities is 21% […] higher than in rural areas” (Christian Weber, SZ, a report from June 24, 2011, on a study by the Mannheim Central Institute for Mental Health by Florian Lederbogen and Andreas Meyer-Lindenberg).

Other threats also further the general fearfulness of people: Countries are falling apart. The number of refugees is increasing worldwide. Terrorism and its defense have reached industrialized countries. Climate change is progressing rapidly without adequate countermeasures from the international community. The indebtedness of the industrialized countries is increasing steadily and reaching astronomical heights. The governments of the industrialized countries, responsible for balancing the tensions between the rich and the poor, have primarily surrendered politically to the financial markets. They have handed over the responsibility of finding solutions to existing problems to future generations. At the same time, the psychologically stabilizing factors in societies are also weakening: The relationships between people and the relationship with nature are strained due to increasing urbanization and cyber technologies. Religious values and norms are increasingly being replaced by the values of the capitalist market economy.

The term ‘anxiety’ is used in common parlance to refer to different types of fear. Not everyone who feels afraid has an anxiety disorder. In the ICD-10, anxiety disorders are listed under F40 and F41. Nevertheless, fear is a common emotion in people with anxiety disorders. It is essential to differentiate between real justified and pathological fears in a practical therapy approach (see Fig. 6.1).

Central idea

The respective psychodynamic cause of fear determines the disorder-specific therapeutic approach. Therefore, I differentiate diagnostically between real justified fears, exaggerated fears, object-related fears, self-referential panic attacks, and the secondary fear of panic attacks (see Fig. 6.1).

The diagnostic differentiation of anxiety

Full size image

1. 1.

   A real justified fear is a signal and warns of real danger in an actual conflict (see Fig. 6.1). It occurs, for example, in the event of an impending job loss, an examination, cancer, the corona pandemic, or a real threat of loss of a loved one. In such a case, the patient doesn’t express fear. Instead, he talks about a current external conflict that frightens him. The therapist then diagnoses acute stress reaction (F43.0) but not an anxiety disorder (F40). An acute stress reaction is a potentially traumatizing situation. For example, in the case of cancer, the patient thinks as a healthy adult in the as-if mode: “I have cancer, I am afraid. But if I get adequate treatment, I will probably survive the disease.” However, she thinks in the equivalence mode when in panic: “I have cancer. So I'm dying.”

In the case of real anxiety, the therapist orients herself through the following procedure (Krüger 2020):

1. i.

   He represents the patient's panicked self, her ‘fearful ego’, with a second empty chair next to the chair on which she is sitting: “This is your fearful ego, your stressed self. You are currently sitting in the chair of the coping ego. However, you keep slipping into thinking and feeling as your frightened ego again and again, especially at night when you cannot sleep.”

2. ii.

   The therapist asks the patient to name all of their different fears. He then uses various building blocks to symbolize each of the patient’s fears on the chair of her ‘frightened ego’, for example, the fear of dying, the fear of losing control of one’s own life, the fear of financial hardship, and/or the fear of becoming needy and dependent. The therapist accompanies the patient as she grasps her various fears as a doppelganger.

3. iii.

   He asks her to rate the extent of each of her fears on a scale of 0–10.

4. iv.

   He replaces the symbol for her strongest individual fear with a large object, for example, a waste paper basket. In doing so, he appreciates the magnitude of this particular fear.

5. v.

   The therapist lets the patient switch to the chair of her fearful ego and asks her: “Please allow yourself to get in touch with your worst fear. What do you feel and think?” As a doppelganger, he paradoxically sharpens her fearful thinking a little. The patient talks to herself in this role and differentiates her fear in the as-if mode of play. In doing so, she completes the psychosomatic resonance in her worst fear of missing parts to a holistic psychosomatic resonance pattern. This neuronally connects the five memory centers of her sensorimotor interaction patterns, physical sensations, affect, linguistic concepts, and thoughts (see Sect. 2.7).

6. vi.

   The therapist lets the patient switch back to the chair of her healthy adult thinking and asks about actions that help the patient to deal with her fear: “How do you cope when you feel your worst fear? What is good for you? How do you manage to reduce your anxiety?” The therapist names these actions as ‘self-stabilization techniques’. These can be, for example, (1) Becoming aware of the specific kind of threat, (2) Physical movement, (3) Writing a letter to trustworthy people, (4) Pursuing a creative hobby, or (5) Talking to someone else.

7. vii.

   The patient writes the discovered self-stabilization techniques on a piece of paper and places this paper on the table in front of her.

   Central idea

   The therapist verbally appreciates every self-stabilization technique the patient has already discovered. This is especially indicated if the patient is in a very stressful situation because it has an ego-strengthening effect.

8. viii.

   If necessary, the therapist teaches the patient additional self-stabilization techniques (see Sect. 5.9).

9. ix.

   The therapist and the patient get an overview of the extent of the real threat to the patient in their current conflict.

10. x.

    They process potential relationship conflicts with a significant person or an employer using the seven steps of the psychodramatic dialogue (see Sect. 8.4.2).

11. xi.

    If necessary, the therapist and the patient work together in a future play to grasp the consequences that would occur if the patient did nothing about her fear and just waited.

The ego confusion between the patient’s fearful and coping ego is resolved by externally representing the fear with a second chair in the therapy room next to the patient. This is because the patient internally delegates the various psychosomatic resonance patterns (see Sect. 2.7) of current anxiety-provoking situations externally to the second chair. In doing so, she psychosomatically frees the development of her inner self-image in the current therapeutic relationship from their fears. The therapist sees the patient’s two contrary self-images separately as chairs in front of him. This helps him develop compassion not only for the patient’s coping ego but also for her frightened ego.

Exercise 16

You can not understand the two-chair technique just by reading it. You have to try acting psychosomatically. Talk to a friend for five minutes and tell them about your fears concerning the corona pandemic. Then start the conversation all over again and put a second chair next to you for your fearful self. Use this second chair to place symbols for your various individual fears. What is the difference in your experience with and without the second chair? You will notice that if you place the chair for the frightened ego next to you, you will distance yourself from your fears internally because they're next to you on the other chair. Regardless, you justify your various fears internally.

Central idea

Real justified fears diminish if the patient informs herself well about the real impending threat. This is because the patient must know the reality of the threat to be able to act appropriately. Even small, appropriate actions can diminish the real fear of the real threat.

Important definition

Fears are pathological if they are inappropriately intense or cannot be justified in a given situation.

1. 1.

   Exaggerated fears arise when an external actual conflict further triggers self-referential anxiety in the patient because of fixation in a defense system (see Fig. 6.1 above). As a result, the patient cannot adequately cope with the real threat due to self-esteem problems, self-injurious thinking, or dependent thinking. Patients with exaggerated fears often experience a dependent personality disorder (F60.7), fear of failure (F41.2), or depression (see Sect. 8.2). In such a case, the therapist first treats the patient's real, justified fear (see above). If the exaggerated fears persist, he continues to treat the patient like he would a patient with a personality disorder (see Sects. 4.7 and 4.8).

2. 2.

   Object-related fears in isolated phobias (F40.2) are an expression of a neurotic conflict. The patient unconsciously suppresses a relationship conflict that has generated fear in the past. He shifts the emotion of fear, however, to another relatively insignificant external object (Mentzos, 2011, p. 110), for example, the fear of the choleric father to the dogs that bark. The result is a dog phobia. In such a case, the therapist offers the following steps of therapy: (1) He lets the patient engage in a psychodramatic dialogue in the relationship conflict with the dog using role reversal, (2) And then switch to the analogous conflict in childhood through an external change of scene, and enact the conflict. Thus, the patient integrates her fear into the childhood conflict. In doing so, the patient converts her fear into anger. (3) She integrates this new feeling into her inner relationship image with her father using psychodramatic dialogue with role reversal (see Sect. 6.8.2). Sometimes, an object-related fear is part of a flashback in trauma disorder. For example, a 65-year-old man suffered from a phobia of men wearing white coats, resulting from a hospital admission when he was 4 years old (see case example 32 in Sects.5.1, 5.5 and 5.9).

3. 3.

   Self-referential anxiety in panic attacks.

Important definition

Panic attacks are a symptom of self-referential anxieties. They are a reaction to an old defense. The defense can be a relational neurotic defense (see Sect. 8.4.2) or an entire defense system in the case of a structural disorder. Patients with a neurotic disorder defend through denial because of their fixation on perfectionism and adaption. Patients with structural disorder panic because they lose control of themselves due to a destabilized defense system. “It’s about the unconscious, intrapsychic threat” caused by the impending collapse of the patient’s old, rigid defense system (Mentzos, 2011, p.117) (see Sect. 6.3).

Central idea

The dominant defense pattern of people with panic attacks is defense through denial: “And so he concluded in a razor-sharp manner that what cannot be cannot be.” The therapist represents this defense with a chair next to the patient and names it as her ‘self-protection behavior’. Together with the patient, he searches for a personally suitable name for the patient’s unique way of self-protection. In doing this, he works explicitly metacognitively (see Sect. 2.14).

According to the ICD-10, panic attacks are severe anxiety states “that are not limited to a specific situation [...] and are therefore not predictable”. They are accompanied by “sudden palpitations, chest pain, feelings of suffocation, dizziness, and alienation. [...] The fear of dying, losing control, or going insane often arises secondarily”. For patients with panic attacks, there is an intrapsychic need to blindly maintain their old defense against negative emotions and their perfect goals (Schacht, 2009, p. 92 ff.) even in the face of real latent threats (see case examples 52 and 53 in Sect. 6.3, 54 in Sect.6.4 and 55 in Sect.6.6). They often experience the impending collapse of their psychological defense system physically in the form of reactions from their parasympathetic system. They then look for a rational explanation for their psychosomatic complaints. In the case of cardiophobia, for example, the diffuse fear is psychosomatically accompanied by tachycardia and shortness of breath. The patient rationalizes her psychosomatic symptoms as a result of an incipient heart attack. The healing principle of ‘anger instead of fear’ applies to anxious patients with panic attacks because of neurotic disorders. In patients with a structural disorder, the defense through perfectionism or grandiosity is additionally secured by masochistic self-censorship provoked by a self-destructive superego. Enhanced self-actualization in external conflicts updates the self-destructive superego. According to Mentzos (2011, p. 117), these patients are not afraid of the actual physical death, “but rather of the psychological death, [...] fear of losing self or, in other cases, fear of losing control over their impulses”. Panic disorder (F41.0) can present as a comorbid condition with trauma-related disorder (see Sect. 5.2), or with personality disorder as borderline personality disorder (see Sect. 4.3).

1. 4.

   The secondary fear of panic attacks. In response to the feeling of existential threat from panic attacks, patients mainly develop a secondary fear of panic attacks. As a result, they often try to avoid the situations that trigger their panic attacks.

Central idea

The diagnosis of anxiety affect provides information on the disorder-specific therapeutic approach. The various anxiety disorders listed in the ICD only describe symptom complexes. They do not give any indication of the indicated approach.

1. 1.

   According to the ICD-10, people with agoraphobia (F40.0) are “afraid of leaving the house, entering shops, being in crowds and public places, traveling alone by train, bus or plane”. They often experience panic disorder and depressive or obsessive–compulsive symptoms.

2. 2.

   Patients with social phobia (F40.1) are “afraid of being examined and observed by other people. This leads to the avoidance of social situations”, low self-esteem, and fear of criticism. “Some common symptoms include blushing, hand tremors, nausea, or the urge to urinate.”

3. 3.

   In people with isolated phobias (F40.2), the phobia “is limited to narrowly defined situations such as proximity to certain animals, heights, darkness, flying, closed rooms, urinating […] in public toilets, […] or the sight of blood […]”.

4. 4.

   Panic disorders (F41.0) are characterized by “recurring, severe anxiety attacks […] that are not limited to a specific situation”.

5. 5.

   In the case of a generalized anxiety disorder (F41.1), the fear is “persistent and not limited to certain environmental conditions, […] it is rather ‘free floating’. The […] symptoms are variable, […] such as constant nervousness, tremors, muscle tension, sweating, drowsiness, palpitations, dizziness, or upper abdominal discomfort”. A patient may also be afraid of themselves falling sick or “[…] that a relative might soon fall ill or have an accident”.

“Around 25% of all people develop an anxiety disorder in the course of their lives: 6% suffer from agoraphobia, 3% from panic disorder, 5% from generalized anxiety disorder, 11% from a specific phobia, and 13% from a social phobia” (Morschitzky, 1998, p. 130).

In patients with panic attacks self-protection through denial blocks access to the psychodynamic conflicts. Thus, they defend negative feelings.

Case example 51

During the intake interview, a 32-year-old patient said his panic attacks (F40.0) started at the age of 23. That was when he decided to live by the motto: “There is no such thing as impossible!” The panic attacks occurred in situations in which he would have to be kind to himself despite his mistakes.

Case example 52

An engineer, Mr. C., sought psychotherapy because of massive panic attacks (ICD F41.0). The therapist and the patient together searched for genuine reasons for his fears. It turned out that the patient had just opened the fourth store in a nearby town and wished to open six more. He wanted to ‘get rich’. Together the therapist and the patient realized: Mr. C. had always taken loans to open a store. In doing so, he had mortgaged the existing stores. If even one of the stores failed, the others would also become insolvent. The patient realized that his very existence was in real financial danger. He decided not to rent another shop for the time being. However, his panic attacks continued to occur. Two years later, Mr. C. came into the therapist’s practice and reported that his panic attacks had disappeared. He was unemployed and divorced. Despite his engineering degree, he now worked as an unskilled worker for 5 euros an hour and was 35,000 euros in debt. Instead of panic attacks, he now had a real existential fear.

What had happened? Mr. C. had appointed his wife as the manager of all his stores. But, since they got married, he had noticed that his wife would secretly stash away thousands of euros every now and then. His panic attacks, therefore, had a justified reason. His stores went bankrupt. He had to pay off his debt. He changed employers because he was getting 1,000 euros more monthly in the new company. He took his customer base with him to the new company. However, he was let go from there after six months. He was now in real financial danger. The fear had become a reality. Mr. C. did everything he could to counter this real justified threat; he worked for wages as an unskilled worker. That's why he didn't have panic attacks anymore. After the reunification of Germany, he built a new professional life for himself in the new federal states.

Case example 53

A 35-year-old businessman had agoraphobia (ICD F40.0) and panic attacks for three years. These typically occurred on the bus, on the train, at the hairdresser's, or in the car on the highway. These different situations had one thing in common: the patient had to adapt to the current situation and pretend it was nothing. He could not leave the situation without others wondering about him and perhaps laughing at him. After a year of group therapy, the therapist and the patient realized that a latent real justified fear had initially triggered his anxiety states. He and his wife had consulted an orthopedic surgeon. In his presence, the doctor said to his wife: “If you do nothing about your back pain, you will be in a wheelchair in ten years!” This real threat had retraumatized the patient. He had had a difficult childhood and an even more difficult youth. His parents divorced when he was thirteen years old. He had slept with his suicidal father for years and was constantly on guard. It was only through his marriage and two children that he led a free and happier life. He could catch up on all he had missed as a child with his supportive, warm-hearted wife. But when his wife became chronically ill, his self-protection through adaptation was at risk of breaking down, and he reacted with panic attacks.

“The probability of developing an […] anxiety disorder is high when a benign internalized object offering security (that is the sum of the precipitates of positive relationship experiences in childhood) could not be formed in the course of the patient's development” (Mentzos, 2011, p. 118; Grimmer, 2007, 2013, p. 190 f.).

Patients with structural disorders (see Sect. 4.4) built up a rigid defense system in response to narcissistic insults, situations of shame, lack of support, the threatened loss of caregivers, a reaction to devaluation, or as a reaction to physical or sexual violence. As a child, they learned to give no power to their negative emotions and protect themselves by adapting, splitting off their feelings, or defending them through grandiosity. They have, therefore, not been able to learn to deal appropriately with feelings of shame, insecurity, despair, and loneliness. Instead, they play the role assigned to them by their caregivers. The more strongly anxious patients defend their negative emotions, the more likely it is that the anxiety disorder results from a structural disorder or part of a trauma-related disorder.

Panic attacks typically occur when the patient fails to cope with a current conflict using the old solution of adaptation, perfectionism, or compensation through grandiosity.

Central idea

Patients with panic attacks are trapped in a conflict; the old defense through denial does not lead to the desired success. But a new adequate solution would bring up feelings of shame, insecurity, real fear, devaluation, or abandonment. These negative emotions would trigger panic attacks in the patient.

The inner compulsion to deny negative emotions often suppresses a real threat in patients with panic attacks (see case examples 51, 52, and 53 above). For example, a patient with a visual defect had only 15% vision. But he still worked on the computer all day. As his eyesight continued to deteriorate, he developed panic attacks. Another man had been in group psychotherapy for three years because of panic attacks. His panic attacks only disappeared when he told the therapist about his alcohol problem, visited a group for people with addiction disorders, and became abstinent (see case example 110 in Sects. 10.6.2 and 10.9). A teacher developed panic attacks after developing visual problems due to progressive multiple sclerosis. But she continued to drive bravely in the dark at night. An advertising clerk feared she would have panic attacks at work and lose her job. She and her employed husband organized such a tight schedule for the care of their toddler that the slightest disturbance was not allowed to occur at her place of work. Of course, that didn't always work. A year later, she separated from her husband, reduced her pressure to adapt, and her panic attacks disappeared.

Central idea

Therapists experience a dilemma when treating anxious patients. They look for “the conflicts behind the panic attacks”. They then find out, for example, that their patient cannot assert or distance herself in her conflicts due to fixations in childhood. Promoting self-actualization in conflicts then actualizes the particular negative emotion, which threatens the patient’s defense and triggers her panic attacks. She latently develops a negative transference toward the therapist. The therapist often responds with negative countertransference. In the end, a hidden power struggle impedes progress in therapy.

Recommendation

In disorder-specific psychodrama therapy for people with panic attacks, the therapist begins by making the patient’s dominant dysfunctional defense pattern—self-protection through adaptation, perfectionism, or grandiosity—the object of therapeutic communication. In doing so, he works explicitly metacognitively (see Sect. 2.14).

The patient should develop a problem awareness of her denial in dealing with her negative feelings. It can be done as follows:

1. 1.

   The patient and the therapist sit on two chairs facing each other during a therapeutic conversation.

2. 2.

   The patient describes her anxiety states. In the ‘psychodramatic conversation’ (see Sect. 2.8 and Fig. 2.9), the therapist symbolizes the scene from her everyday life that triggered the panic attack using two additional empty chairs in the therapy room. One chair represents the patient as the one affected by the anxiety attack. The opposite chair symbolizes the element that makes the situation restrictive, for example, the queue in the supermarket, the tram, or a threatening object, for example, a dog. By externally representing the symptom scene with chairs, the patient develops internal distance to her psychosomatic resonance pattern in the situation causing panic. She gets into the observer’s position to her inner process of developing self-image and object image in this situation.

3. 3.

   The therapist asks the patient about her internal self-regulation during her last anxiety attack: “How did you deal with your panic attack?” The patient usually tries to be brave and strong during a panic attack. She doesn't let on anything. The need to be strong, however, increases the fear of breakdown. The therapist: “You are pretending as if nothing happened and fighting bravely against your fear! Nobody should notice that you are struggling! I call this self-protective behavior. I am placing this chair next to you to represent your self-protective behavior!”

4. 4.

   The therapist and the patient identify the particular type of self-protective behavior and name it individually as self-protection through adaptation’, ‘self-protection through perfectionism’, or ‘self-protection through grandiosity’. They immediately work out the positive function of the defense pattern in the holistic process of the patient’s self-regulation (see Sect. 4.8) patient's dysfunctional metacognitive behavioral pattern: In self-protection through adaptation, the patient automatically turns the supposed expectations of other people from her surroundings into her expectations of herself. She tries to fulfill them, does not allow herself to show any ‘weaknesses’, and continues functioning as if nothing is happening, even when overwhelmed. In defense through grandiosity, the patient must always be fabulous and someone who can and does everything. Weaknesses and mistakes are not allowed. The defense helps to suppress negative feelings such as helplessness, anger, failure, or loneliness. The therapist confirms the self-stabilizing function of the patient's defense: “You put on a brave face and pretend as if nothing has happened, even when you suffer from existential fear! You are a courageous fighter against negative feelings”.

5. 5.

   The therapist repeatedly points to the chair for her self-protection when the patient is talking about her pathological fears in everyday life or when she is behaving in a self-protective manner in the therapeutic relationship and suggests: “Now you think, feel, and act again from your self-protection.” Thus, the patient internally links the abstract term ‘self-protective behavior’ with her psychosomatic resonance pattern in the external conflict situation that triggers her panic attack.

6. 6.

   The therapist lets the patient move to the chair for self-protection when she acts out her defense in the therapeutic relationship. While in the chair of the self-protective behavior, she should re-enact the psychosomatic resonance pattern in self-protection in the as-if mode of play and complete it into a holistic psychosomatic resonance pattern (see Sect. 2.7). The therapist helps her in this process as a metacognitive doppelganger (see Sect. 4.8). He then lets her move back to the chair of healthy adult thinking.

7. 7.

   Together with the patient, the therapist explores the genesis of her self-protective behavior: “How old is your self-protective behavior? Where did you learn to continue functioning by pretending in front of people as if nothing happened? And to try with all your might not to reveal your inner distress and not to attract negative attention?” In doing this, the therapist describes the patient’s interaction pattern in her defense system. The patient links her interaction pattern of old defense with appropriate memories from childhood. The patient often replies: “I've always done it this way.” The therapist: “And when was that the first time?” The patient then narrates a matching memory from her childhood. This shows that her self-protective behavior was a sensible and appropriate solution in childhood so that she would not lose any caregivers and survive mentally. By linking her current defensive behavior with the appropriate childhood memories, the patient gains inner access to her internal process of self-development in her current external situation and to her creative ego (see Sect. 6.1).

   Central idea

   The connection with the genesis shows that the negative affect of the patient in her conflicts in childhood was fear only in the case of a neurotic disorder. Whereas in the case of a structural disorder, it was often the feeling of shame, loneliness, powerlessness, betrayal, abandonment, helplessness, or confusion. The way through the dominant defense pattern of denial opens the therapist’s path to the patient’s underlying psychodynamic processes.

8. 8.

   When asked about the age of the self-protective behavior, the patient visualizes painful memories of her past internally. In such a case, the therapist places an additional empty chair for the abandoned, abused, or ashamed child behind the chair for self-protective behavior. He symbolizes the ‘child’ by placing a doll on this chair. But he immediately asks the patient: “When you look at your inner child over there on the chair, what does that trigger in you emotionally?” It is not uncommon for the patient to answer: “I don't even want to look!” In this case, the therapist takes the chair for the child-ego and places it in the farthest corner of the room (see Sect. 5.8): “Is it better that way?” In this way, he acknowledges the retraumatizing quality of the patient’s childhood memories and stabilizes the patient’s inner distancing, and justifies it: “I suspect that the break down of relationships traumatized you as a child”.

9. 9.

   The therapist expressly explains to the patient that her secondary fear of panic attacks is justified: “You feel that your existence is threatened. Because you know that if you let your negative feelings surface, you will lose control of yourself”.

10. 10.

    The therapist and the patient work together to find solutions for dealing with panic attacks. The therapist sees everything that helps the patient to be in control as a solution. For example, many patients avoid situations that might trigger their panic attacks. In such a case, the therapist also appreciates the avoidance behavior as a solution and explains: “This solution is certainly not the best, but it is currently the best possible solution for you. Because your fear is a fear of annihilation”. The therapist asks the patient whether she has developed other ways of coping with anxiety. Perhaps, during a panic attack, the patient told another person that she was experiencing an attack at that moment. The therapist immediately says to the patient: “Your panic then became weaker! Because you no longer had to hide your negative feelings. You told the other about it. This is a new healthy adult behavior compared to the self-protection behavior you learned in your childhood”. The therapist symbolizes each solution of the patient with a building block and places it on the table in front of the patient externally.

11. 11.

    The therapist informs the patient, if necessary, of additional solutions that have helped other patients suffering from panic attacks in the battle against their fears.

12. 12.

    In the case of structural disorders, the therapist interprets the patient’s internal conflict with the help of amplifications (see Sect. 2.4.4). Together with the patient, he looks for a heroic figure from fairy tales, mythologies, or social contexts, who has experienced and overcome similar difficulties. For example, the therapist narrates the Grimm fairy tale ‘Of the one who set out to learn to be afraid’ to patients who fear intimacy and panic when they think of committing to a life partner in a long-term relationship. The hero in the fairy tale does not shudder during his many gruesome encounters with monsters, ghosts, and those executed. He only feels the fear he has longed for when he lies in bed with the princess at the end of the fairy tale. The hero apparently could not allow closeness and love (Horst Eberhard Richter, oral communication 1992). However, he was at least aware of his self-protection behavior and faced his problem. In doing so, he acted differently from the Wild West Heroes, who always ride off with unmoved faces after conquering the love of a woman. Patients who learned to adapt to almost anything out of compassion for a traumatized parent recognize themselves again in the Grimm fairy tale ‘The girl without hands’. This girl sacrifices her hands to save her father from the devil. But then she leaves home and marries a king. So she is honored for her noble sacrifice. However, when she has a child with this king, the appreciation from outside brings her inner self to life, and conflicts arise at the royal court. The mother-in-law, the self-destructive superego, wants to kill the young queen. She flees into the forest with her child. She sojourns in the woods for seven years. During this time, her hands grow back. The young woman thus learns, through better self-actualization, to take with her hands what she needs without self-punishment. Then she returns to the king healed. Such a fairy tale character can become a supportive fictional doppelganger for the patient. The therapist sets up another empty chair next to the patient for such a fairy tale character. He asks her to enter into a psychodramatic dialogue with this character to consult with her.

13. 13.

    When narrating stories from childhood, the patient sometimes has a flashback. The therapist stops such a pathological regression by telling her what her story triggers in him emotionally based on the ‘principle of response instead of interpretation’ (Heigl-Evers, Heigl, Ott and Rüger, 1997, p. 176 ff., see Sect. 4.13).

Case example 54

During the initial interview, a 45-year-old patient with agoraphobia (F40.0), Ms. A., reports that she has been suffering from panic attacks for about twenty-five years: “I will probably never get rid of them!” Two years ago, she suffered two attacks of palpitations, sweating, and hyperventilation at her workplace and has been unemployed since then. Her panic attacks start in situations where it would be noticed if she behaved differently than the people around her, for example, at the checkout counter in the supermarket: “I then feel more restless. My heart is racing. I can't do anything when it’s my turn and standing in front of the cash register. In the past, I've given my wallet to total strangers so they can pay for me. I then am no longer in control of myself. That has been the case with me for a long time. My anxiety attacks are now almost like a good friend you want to be around. Then I'm out of control.”

The therapist sets up two chairs a little away from the patient for the symptom scene (Step 2 of the 13 steps described above) and points to the first chair: “One of the chairs is to represent you when you panic in the queue in the supermarket. The other is for the people standing in a queue, in front of whom you don’t want to embarrass yourself!” The therapist places an empty chair next to Ms. A., the chair for her self-protective behavior (Step 3): “And then, like a brave heroine, you try with all your might to adjust to the expectations of others. You don't reveal any sign of struggle and withstand it all”. Ms. A.: “Yes, that requires so much strength, and I lack it!” (She cries).

Therapist (Step 10): “What solutions have you found so far to deal with an anxiety attack?” Ms. A.: “Nowadays, I am telling the others. When I had an attack in the waiting room at the employment office, and they wanted to get an ambulance, I told them: ‘I am familiar with such anxiety attacks. You don’t need to call for an ambulance.’ I know that it'll pass at some point! Even if I’m afraid of having a heart attack.” The therapist: “And was it better when you told the others?” Ms. A.: “Yes, then it became easier for me.” The therapist: “If you share your fear instead of hiding it from others, your fear will decrease. You have discovered a solution that, in my experience, also helps other patients to reduce their anxiety.” (Step 9) He points to the patient: “The solution comes from your healthy adult thinking. That’s what the chair you’re sitting on stands for”. Ms. A.: “But I’m incredibly embarrassed to say that I’m having a panic attack. I always try to behave normally, as one behaves in our society. I don't want to attract any attention.” Therapist (Step 3): “You then pretend as if nothing is happening and don't want to annoy other people.” He points to the chair representing the strict superego: “You obey your superego again, your inner governess! She says: ‘Don’t do that!’” Therapist (Step 10): “So you have already found three solutions for dealing with your anxiety attacks. Sometimes you are the heroine and pretend that you are not afraid.” The therapist grabs a few brightly colored building blocks and places a building block for each solution on the table in front of the patient: “But then you also avoid situations that cause you panic attacks. This is also a solution if you have existential fear. In addition, you sometimes express your need to other people. This will reduce your anxiety, and you won’t have to go to the hospital!”.

The therapist points to the chair representing ‘self-protective behavior’ (Step 7): “For how long have you been protecting yourself by adapting to the expectations of others? When did you find this solution for yourself” Ms. A.: “I never wanted to attract any attention, even as a child. That has always been the case with strangers. When I was a child, I had knock knees. But my mother wanted me to go to ballet class. Then I threw myself on the floor and screamed. I felt like I was being brought to the executioner for having knock knees. I was petrified. I didn’t have to go because of my screams! It was always difficult for me when I had to leave my protective home as a child. My mother didn't have much time. She spanked me when I scored a five on several dictations at school.”

The therapist positions two more empty chairs behind the chair for self-protective behavior (Step 8): “The first chair here represents you as the child who was not seen by the mother, was hit, and the second chair is for the angry child who threw herself on the floor when she didn’t want to go to ballet class.” Ms. A.: “Of course, the hitting wasn’t of any help. Even today, I feel insecure when I write and tend to look in the dictionary. Everything has to be perfect when I write something!” Ms. A. continues: “My mother worked thirty hours a week. Since I turned 11, she started seeking treatment every two years. She had ulcerative colitis. I haven't had any contact with her for eight years now. My mother cut contact when I asked if she could pick up my eight-year-old son from school every now and then. I was working part-time back then. But she refused to offer any help. I said to her: ‘But I was always with Grandma too. That wasn't a problem for her at the time at all!’ But my mother didn't want that.” On asking, the patient added: “I liked being with my grandma. She gave me a sense of security and stability. I didn’t feel so comfortable with my mother. I was insecure about the relationship. She just was busy with her psychoanalysis. She always claimed that Grandma had tied her and her siblings too tightly. Or her father was guilty of her suffering. Everyone else was always to blame, just not herself! My mother suffered from severe depression and often said she wanted to kill herself. She even threatened to poison us children. I was always suspicious and afraid when I ate the soup!” The patient laughs as she shares these memories.

The therapist points to the chair of the ‘unseen child’ (Step 5): “As a child, you were physically beaten and emotionally abused. This is called psychological trauma!” The therapist does not want the patient to regress too much into her traumatic experience. He, therefore, turns his attention to her self-protective behavior and interprets it positively as a self-stabilization technique developed by the patient in childhood: “Back then, in your childhood, it was important not to reveal your feelings. Otherwise, your mother would have only become angrier”. Ms. A.: “I sometimes think of my childhood when I read news about a mother who killed herself and her children.” Ms. A. smiles and asks almost cheerfully: “Shall I tell you more? I have even more horror stories!” The therapist replies seriously (Step 13): “No, that will be too much for me!” The patient starts to cry. It is only through this feedback that she recognizes how overwhelmed she feels. Ms. A.: “Yes, I realize I always had to be brave, always grit my teeth and push through!”.

Therapist: “That’s right, that helped you back then. But it must be challenging for you today when you tell other people you are having a panic attack. It is a great achievement for you if you do it anyway!” Ms. A.: “My mother always praised me a lot when I was reticent and good: ‘Oh, Sabine was perfect, I didn't hear her at all.’” Ms. A. cries: “The child in me doesn't like it at all! After that, it was always my goal to be as quiet as possible because she praised me: the quieter I was, the better!” Ms. A. cries cathartically: “It’s excruciating to talk about it. I was always completely distraught when my mother was upset, and I decided: ‘I’ll never do that again! I have to try to be even better.’” The therapist reassures the patient in her healthy adult thinking (Steps 4 and 8): “As a child, you learned always to pretend as if nothing had happened and be brave. But do you realize that you have found a new solution in the meantime? You now tell people around you about your fears and experience: When you communicate with others, you get help, which is very different from what your mother gave you in your childhood!” A deep, rich silence develops in the therapeutic relationship.

The therapist: “I feel we have worked out a lot today.” Ms. A.: “Today, at some point during the session, I was quite nervous again in my tummy when I told you about my mother! I have already thought I'd write it all down!” Therapist: “Yes, but please write it down in the third person. And write down only one traumatic event from little Sabine’s life […] and then immediately write what the child would have needed in the situation instead! If you like, you can bring these little stories and share them with me next time.” The therapist and the patient agree to meet for three more sessions to plan and initiate therapy.

Exercise 17

You can not understand the chair work in working with anxious patients just by reading. Therefore, practice the suggested method by acting psychosomatically. Have one of your colleagues role-play an anxious patient. In the first exercise, confront the ‘patient’ only verbally when you are talking to her about her defenses through conformity, perfectionism, or grandiosity. You will notice: Your colleague feels criticized and devalued in the role of the patient. In the second exercise, represent the patient’s self-protection externally with an empty chair next to the ‘patient’. Say the same sentences to the patient while pointing your hand at the chair of self-protection. You will notice: The ‘patient’ does not feel criticized. As a therapist, you feel free to communicate with her more openly about her defenses. In the third exercise, choose another patient and try using a different defense pattern at first (see Fig. 4.1 and Sect. 4.2) to loosen the fixation of the patient’s inner process of self-development. You will notice: the ‘patient’s’ anxiety level rises immediately. The joint therapeutic work becomes muddles.

It usually takes 10–15 sessions before the steps of metacognitive therapy described above positively affect patients suffering from panic attacks. This is because the patient has to connect the names and functions of the ego states with her own emotional experience (see Sects. 4.7 and 4.8).

The chair work has a therapeutically positive effect on people with panic attacks for the following reasons:

1. 1.

   Patients with panic attacks experience ego confusion between healthy adult thinking and self-protection through adaptation or grandiosity. The patient acts out her defense pattern in the equivalence mode: “The world is what it is. No one in this world wants to know anything about my feelings.” The external distance to her self-protective behavior represented by the other chair allows the patient to distance herself also internally from her defense through denial. This helps her become aware of her rigid defense.

2. 2.

   The patient and the therapist look at her self-protective behavior from the outside and give it a name. In doing so, she connects the psychosomatic resonance pattern of the defense in her memory to the name ‘self-protection’, and not to the name ‘panic attack’. Thus, the new psychosomatic resonance pattern links differently with other resonance patterns in memory centers.

3. 3.

   If necessary, the patient acts out her self-protective behavior in the as-if mode when changing roles (see Sect. 2.6). In this way, acting out her defense pattern, she completes the neural connections between the memory centers of her sensorimotor interaction patterns, physical sensations, affect, linguistic concepts, and thoughts into a holistic psychosomatic resonance pattern. This helps her to gain ego control over her self-protection and defense through denial (see Sects. 4.8 and 4.9). She learns to think of her defense in the as-if mode. She understands her defensive behavior as an internal representation and no longer as a real reaction caused by the external situation. She gets into a yes-but position about her self-protective behavior: “Yes, I protect myself through grandiosity, but I have to be careful not to overwhelm myself with it.”

4. 4.

   The patient learns to notice it even sooner when she is thinking in her self-protection mode again in everyday situations. If necessary, she can look for new, more appropriate ways of perceiving and behaving in her everyday life.

The metacognitive disorder in anxiety patients with structural disorder (see Sect. 4.4) must be treated explicitly metacognitively. The procedure is similar to the treatment of patients with personality disorder and comprises the following steps (see case example 55 in Sect. 6.6).

Central idea

The defense in patients with anxiety actualizes in the current therapeutic relationship or current everyday conflicts. Therefore, the therapist must focus their work on the patient’s self-regulation in the present. He initially does not work on the patient’s trauma or deficit experiences from childhood.

1. 1.

   The therapist makes the patient’s dominant defense, her self-protection through adaptation or grandiosity, the focus of therapeutic communication and represents it externally with an empty chair (see Sect. 4.8).

2. 2.

   In the following therapy sessions, the therapist repeatedly makes the patient’s aware when they act out their old self-protection through adaptation or grandiosity in their everyday life or the therapeutic relationship.

3. 3.

   The therapist asks about the age of self-protection. Then, he represents the defended experience of the child with an empty chair and puts a hand puppet or finger puppet for the inner ‘abandoned or ashamed child of the patient’ on top of it (see case example 55 in Sect. 6.6). He always asks the patient immediately: “Just look at the child that you were! What emotions does the little girl trigger in you?” If the patient cannot tolerate the sight of her inner child, it is a sign that the patient was traumatized in her childhood. The sight of her inner ‘child’ then corresponds to trauma exposure. In such a case, the therapist places the chair for the inner child far away in the corner of the room (see Sect. 5.8) and integrates trauma-therapeutic elements into the treatment.

Central idea

In more than a third of patients, the defense through denial enables self-stabilization in a trauma-related disorder. In such cases, the therapist reinterprets it positively and names the patient’s defensive actions in everyday life as ‘self-stabilization actions’. If necessary, the therapist integrates techniques of trauma therapy into his work.

1. 4.

   But often, patients with anxiety also feel ‘compassion’ or ‘sadness’ when they look at their inner child. In such a case, the therapist asks the patient to engage in a psychodramatic dialogue using role reversal: “Please tell this to your inner child!” In this process, the therapist, as an auxiliary ego, takes on each of the opposite roles. While enacting these roles, the therapist integrates all the relevant information he has already received from the patient into the play. The patient’s adult ego and the inner child are supposed to communicate their own wishes and life experiences with one another in the psychodramatic dialogue. In doing so, the ‘inner child’ and the ‘self-protective behavior’ learn to grant each other a right to exist.

2. 5.

   During debrief, the therapist appreciatively confirms any new steps the patient may take in dealing with herself: “I am very touched by the fact that you felt sad looking at your inner child. You are now developing new compassion for yourself! You did not have a good enough mother or a good enough father. Therefore, you must now learn to treat yourself with sufficient love and care!”

3. 6.

   The therapist recommends that the patient buy a doll for her inner child and regularly practice the dialogue between her adult self and the inner child even at home: “Talk to your inner child at home every day for five minutes. Ask how she is doing!” With the help of this exercise, the patient can establish a relationship with the little girl she was in childhood and develop new self-empathy.

Central idea

The patient has to improve the relationship between herself as an adult and her ‘inner child’. Her inner child should develop in therapy. The adult should become a good inner authority for the inner child, similar to good enough parents. The inner child becomes a symbol for the true self. Both can advise and help each other. This also applies to the time after the end of the treatment.

1. 7.

   In patients with structural disorders, self-protection through perfectionism or grandiosity is stabilized by a self-injurious superego. The therapist represents the patient’s self-injurious thinking externally with another chair opposite the patient (see Fig. 4.1 in Sect. 4.2). He gives it a personal name along with the patient, for example ‘blind accuser’ or ‘soul killer’. Both then continue to work consistently in a disorder-specific manner on dissolving the masochistic defenses (see Sects. 4.8, 4.10, 6.7, and 8.5). This loosens up the old masochistic self-censorship. This made sense in childhood to avert even greater damage (see Sect. 8.5). Therapeutic work on self-injurious thinking indirectly loosens the patient’s defense of self-protection through perfectionism or grandiosity.

2. 8.

   The therapist works with the patient to find out what support and stability would she have needed as a child during each of her traumatizing experiences and lets her write a coping fairy tale for that situation (see Sect. 5.14). This approach incorporates Moreno’s idea of surplus reality with the help of good objects. It implements Grimmer’s concept (2007, pp. 25, 37) of developing ‘good inner parents’ in patients with anxiety and is similar to an essential step in Pesso therapy (Schrenker, 2008, pp. 143, 204 f.).

3. 9.

   The patient writes a fictional letter to a significant person from childhood (see Sect. 5.11 and case example 55 in Sect. 6.6). The patient, as the adult she is now, communicates the contents of the letter to the caregiver from childhood in a fictional psychodramatic dialogue with role reversal. In this way, the patient integrates her old defense pattern and her new self-image into her old internal image of the relationship with this person and renews it (see case example 55 and Sect. 6.6).

4. 10.

   The patient integrates her improved self-actualization in external conflicts into her internal relationship images with people in the present with the help of psychodramatic dialogues using role reversal. Thus, she resolves her defense through projection and introjection in these relationships (see Sect. 8.4.2). This is how she gets to know the people in her life in new ways.

In patients with a social phobia (F40.1), according to the ICD-10, “the fear of being examined by other people […] leads to the avoidance of social situations” (see Sect. 6.2). Their masochistic relationship fears result in trying to master all situations perfectly. Any sign of insecurity destabilizes their defense system, including self-protection behavior and self-injurious thinking. Therefore, patients with a social phobia should be treated as described in Sect. 6.5. They should first undergo 10–15 sessions of individual therapy because of the masochistic fear of relationships (see Sect. 6.5).

Case example 55

After his state examination, Mr. B. had not applied for a job for a whole year. He seeks therapy “to find out why he is avoiding it”. In the initial interview, the therapist discovers that he experiences social phobia (F40.1) that encompasses all areas of his life. When encountering any new situation, Mr. B is ‘addicted to safety’ and thinks of how he can avoid being embarrassed beforehand. He, therefore, avoids even the most minor social challenges. For example, he panics when he imagines having to ask for a room in a hotel in French while on holiday in France. He lives with his girlfriend, who is a working doctor. Supposedly, this does not put him under any pressure.

During the first therapy session, the therapist sets up two empty chairs in the therapy room for the everyday situations that trigger fear in the patient (see Fig. 2.9 in Sect. 2.8). He also positions a third chair next to him for his self-protection behavior (1st therapy step in Sect. 6.5). This helps Mr. B. to understand his avoidance behavior as a self-discovered solution to the fight against his anxiety states. Mr. B. reads about ‘social phobias’ on the Internet at home. He accumulates knowledge and analyzes himself. But this knowledge does not change his avoidance behavior. When his girlfriend becomes pregnant, he decides, with the therapist’s help, to propose to her for marriage. Mr. B. had previously rated this action as ‘very difficult’ on a list of anxiety-inducing situations. His partner is thrilled. They get married. Mr. B. shares his experience: “Once I have promised something, everything works out well for me as it does for other people. It's always been that way. So then I have to!”.

In the fifteenth therapy session, Mr. B. reports with satisfaction: “My wife is in the last weeks of pregnancy. I am now coping with many situations on my list of problems. It is working well. My fears are like a ball of wool. I have to pull out one thread after the other and work on it!” The therapist hears this plan but feels uneasy. Because, in his experience, Mr. B’s general avoidance behavior changes little when he successfully masters individual situations. He, therefore, asks the patient: “How old is your self-protection behavior? How long have you been pretending as if it’s nothing when you're scared?” Mr. B.: “It was always like that, even as a child!” The therapist places a fourth empty chair behind the chair for the self-protection behavior, ‘for the little boy’ who was the patient in his childhood. Mr. B. shares humiliation experiences from childhood: “My older brother and my mother were very close to each other. They are quite similar! My mother is also a doer and tackles everything.” Therapist: “As ‘the sensitive one,’ you were the black sheep in the family!” Mr. B: “That's right, my brother always had to be the greatest. He capped me all the time. Once, when I had six firsts in my school report in elementary school, he wrote a one next to my grades in pencil in all the places where he had already had a first in the last five years. That was more than my six firsts. But my brother had never had six firsts on one report simultaneously!”.

The therapist places the fifth chair opposite the patient ‘for the dominant brother’. As a doppelganger, he speaks directly to his brother’s chair: “Karl, I think that you could have given your little brother Rolf the privilege of being better than you at least once! Yeah, don't look like that! I don't think it's okay that you mess up the six firsts he got back then!” The therapist asks Mr. B: “What would your brother Karl answer now?” Mr. B: “Well, he would disagree and say: ‘But that’s true, he shouldn’t act like that here.’ The therapist gets angry as a doppelganger: “Karl, leave Rolf alone now!” The therapist gets up and turns his brother's chair: “Get out of this room now or just turn around! It's enough!” Mr. B.: “He won’t go. He will come to me, point at me, and grin.” The therapist turns angrily to the ‘brother’: “Well then, I'll get you out of the room now!” He takes the chair representing the brother and places it outside in front of the door. Mr. B. laughs: “He's going, but he's shouting stupid things from outside!” The therapist: “I suppose you were traumatized by your brother in your childhood. Your brother kept confusing you. Now, whenever you feel insecure in a relationship, your trauma film gets triggered, the shaming by your brother!”.

In the next therapy session, Mr. B reports: “I noticed that I was being avoidant again when I found myself in a problematic situation. But then I was able to catch myself. In another situation, however, I failed. I was annoyed with myself at a hardware store that I avoided everything again.” The therapist and the patient explore his defense behavior in this situation by setting up an empty chair for his self-protection behavior. Mr. B. felt insecure at the hardware store because his idea for constructing a changing table was probably not perfect. A vicious cycle developed: his feelings of insecurity were appropriate. However, he reacted to this feeling of insecurity with self-injurious thinking: “I am totally incapable!” He was internally paralyzed. As a result, he could not ask the seller about the ‘right kind of wood’. So he left the shop empty-handed. At the end of the therapy session, Mr. B. says sarcastically: “I aim to be infallible. Only then will I not be ashamed.” The therapist sets up another chair opposite the ‘brother’s’ chair: “This chair represents your self-injurious thinking, for your inner sadistic critic. The therapist doubles the sadistic critic: “I always say that! You are nothing! And you can’t do anything!” He turns to the patient: “Your insecurity about the changing table was appropriate. But your problem is: Whenever you feel insecure, you immediately slip into your trauma film and your self-injurious thinking and feeling.” Mr. B.: “I face the same challenge in my job search. I believe I have to be infallible even there!”.

After seven more sessions of chair work, the therapist suggests: “Perhaps you could write a letter to your brother without mailing it. Tell him how you have discovered the connection between your anxiety disorder and your childhood” (9th therapy step in Sect. 6.5). In the following therapy session, the patient reports with satisfaction right from the start: “It was good for me to write the letter. In the first part, I wrote a concise and clear summary of what I learned here. I also made a clear decision in favor of the diagnosis of ‘social phobia’. In the second part, I included my brother. That was more difficult. I still feel uncomfortable about blaming him!” The therapist: “Once again, I’m placing the chair for your self-injurious thinking opposite you. You obviously don’t need your brother anymore to devalue yourself today! You are doing it yourself!” Mr. B: “Yes, but with the letter, I had to do exactly the opposite of what I learned in my life! When writing the letter, I was downright skeptical about how it all fits together, my childhood, my family, and my current situation!”.

The letter from Mr. B. to his brother reads as follows: “In exploring the roots of my anxiety disorder and its development, I went back to my childhood as much as possible. My fears have been around for as long as I can remember. As you know, we were always competing against each other as little children, even if it was simply to get mom’s attention. As a young man, I certainly did not have an easy time surpassing you in something. You did everything to prevent it. You defined the ‘social norm’. You surpassed my successes, ridiculed them, or reinterpreted them as something completely normal. If I achieved something you couldn’t, you expressed your dissatisfaction openly. You either disrupted the family peace or just pissed me off. You taught me quite early on that I can never manage to be successful. And if I did, then it would only have painful consequences. These experiences taught me how to behave to receive praise and recognition. Instead of starting an already lost battle, it was better to submit to you and support your position. It was better to wait for what you were doing and then submit than go ahead myself. As a compass for my behavior in the respective situation, I acquired the finely tuned social anxiety that now causes me problems. In this way, I could avoid shameful defeats against you, secure peace in the family, and receive praise for it. However, I paid a huge price for this. I never learned autonomy. I never learned to develop my own will and wishes and to enforce them against resistance. One cannot lead an adult life like this.”

The therapist asks the patient: “What did you experience while writing your letter?” Mr. B: “In the letter, I left out all comments connected to the roles of my parents!” Therapist: “What do these comments sound like?” Mr. B.: “They were mostly about the duty to intervene! I loved my father, but he wasn’t around enough in my childhood. My father always woke up in the morning after we had already left for school. I’m not really disappointed with him. Because he didn’t do anything bad, he ‘just’ did nothing! I was already shy when I was in kindergarten. Once I dared to play on the carpet that was lying there. I then told this to my parents, and my father was delighted! He spontaneously gave me one euro! My brother was standing beside me, and he didn’t understand what had happened. He had no problems in kindergarten! It would have been good if my father had encouraged me more often! My father was rarely present, physically and mentally. And so, my mother was at home all day. But my brother was so captivating that he had my mother completely in his pocket. As a small child, he would immediately scream if she stopped the stroller, even for two seconds. That was always so. It’s amazing how much influence my brother has on my mother, even today. If my brother has a different opinion, she just changes her own mind.” In order to appreciate the patient’s inner progress, the therapist places a new empty chair next to his chair for the humiliated child (therapy step 3): “Today is the first time you are expressing serious reservations about your parents and sharing that, as a young son, they have let you down. I think your angry inner child is surfacing! This new chair represents this inner child.” Mr. B: “Yes, but I am having self-injurious thoughts again: ‘I haven’t learned to be self-sufficient. I cannot define success. I don’t feel angry if my position is thwarted.’ It is shameful that I have to learn the tasks of a three-year-old now at my age!”.

The therapist: “It’s true, you have to learn this. But if you sink into shame now, you are obeying your inner blind sadistic critic again!” The therapist asks the patient (therapy step 4): “Can you please look at the humiliated child you used to be? How do you feel about the child?” Mr. B: “I am ashamed I was a coward as a child!” The therapist (therapy step 5): “Please tell your child this!” Mr. B follows the request. Then he switches to the role of the ‘humiliated child’. The therapist takes on the role of the adult patient: “It is shameful that I have to learn the tasks of a three-year-old now!” Mr. B. in the role of the child: “Is it necessary to clarify this with the brother?” Mr. B. switches back to the adult role: “Yes, that’s the turn!” Mr. B. in the role of the child: “Do you think we can do it?” Mr. B. in the adult role: “Yes, of course! It isn’t easy, but we can do it. You will see!” Therapist to Mr. B: “After your difficult childhood, now is the time to become a good father to yourself!” Mr. B: “Yes, I needed more than I received! Unfortunately, I was in a family that is so different: They don’t have soft tones; they don’t even need them! My brother and mother do their thing and put all problems aside!”.

Therapist: “Do you notice that today is the first time you define yourself positively in relation to your family? It is new that you see yourself as ‘the one with the low-tone voice!’” The therapist switches to the role of the patient's adult self and repeats the patient's last sentences. Mr. B. in the role of the humiliated child: “I feel very sad, I feel scared of being excluded! I don't even want to hear it! What matters is that I belong! I prefer to pretend and ignore things like the others!” Therapist (2nd therapy step): “Now you are in your trauma film! You realize that you were lonely and abandoned when you were a child! Why don’t you step into the role of the angry child and tell me what you feel there?” Mr. B. blossoms in the role of the angry child (therapy step 5). He spontaneously interrupts the therapist, who has taken on his adult role, and vehemently demands of his adult self: “For heaven's sake, fight back!” During the debriefing, Mr. B says: “As an angry child, I realized that I didn’t have to wait for you to finish my role. It was amusing to be able to act in this way!” The therapist and the patient agree that he should add critical comments about his parents to the letter he wrote for his brother at home.

In the therapy session that follows, the therapist asks right at the beginning: “What did you experience when you included your criticism of your parents in the letter to your brother?” Mr. B.: “That was difficult. For example, I asked myself why my father stopped paying attention to me. Did he have too little empathy, or was he simply not interested in me?” Mr. B.’s father died ten years ago. The therapist seizes the opportunity for a fictional clarification of Mr.B’s relationship with the father (therapy step 9): “You could ask him this in a role-play!” Finally, Mr. B. is ready to do so. He sets up two empty chairs in the room, one for himself and one for his father. He then explains to the “father”: “I have thought a lot about my anxiety disorder and realized that the reasons for it are connected to my childhood too. Why didn't you pay attention to me more often? Why weren’t you there for me?” During role reversal, Mr. B. does not understand what the son means in his father’s role: “I love you and your brother Karl. Really, I love you too!” Again in his own role, Mr. B. says uncertainly: “Yes, that's true. But I needed more love!” Mr. B. looks confused and turns to the therapist: “Perhaps all of this is not as true as I thought it would be!”.

The therapist: “I believe that is your self-injurious thinking again, the voice of your blind inner critic who says to you: ‘Rolf, you are just imagining it!’ Mr. B., can you go back to the chair of your adult thinking and counsel yourself from there in the conversation with your father? Coach yourself! Rolf knows that he needs more support from his father. But that part of him is blocked. It is taboo for him to think and say it openly!” Mr. B. switches to the chair of his healthy adult thinking and turns to Rolf: “Rolf should express more of what he feels!” The therapist, as an implicit doppelganger: “Yes, and perhaps use an example to clarify what he means!” Mr. B: “Yes, that's good, the example with the chocolate!” Therapist: “Tell that to Rolf!” Mr. B encourages ‘Rolf’, who is having a fictitious conversation with his father: “Talk more about your feelings and explain it to him using an example!” Mr. B. switches back to his role as the protagonist on stage and says to his father: “You don’t understand me. The point is that you should have stepped in! For example, when we were driving around once. Karl and I each got half a bar of chocolate. I was afraid Karl would start an argument because he only had as much chocolate as I did. So I gave him a piece of my chocolate as a precaution so that he would have more. Mom praised me back then for my generosity! You should have intervened at that point!” Mr. B. switches to the role of father. The therapist asks: “Could I just try something different?” He takes on the protagonist’s role and verbalizes, as a doppelganger, the patient’s thinking, feeling, and sensing while rehearsing in the as-if mode of play (see Sects. 2.4.3 and 8.4.2, 6.6th step of psychodramatic dialogue): “Yes, but in reality, I wasn’t generous at all. Because I only did that out of fear of an argument with Karl. I was afraid that Karl would humiliate me again and that I would then be all alone!” Mr. B. as the father: “Yes, that wasn’t fair! You should have defended yourself!” The therapist laughs sarcastically while in the role of Rolf: “That’s fantastic! But I just couldn’t do that! Mom wanted me to act like that too! I had no chance against Karl! He always made me feel small! And that too with mom’s support! Mom still does what he wants even today!” Mr. B. as the father: “Yes, I'm sorry!” The therapist as Rolf: “But why didn't you say anything! Were you a coward?” Mr. B. as the father: “Well, in the end, I separated from your mother. Before that, there were a lot of arguments between us. But you are right, for the first fifteen years of our marriage, I was always submissive, maybe for far too long. And I should have supported you so that both you brothers were treated fairly.” The therapist as Rolf: “Then you are a bit like me, always evading conflict!”.

During the debriefing, Mr. B. said: “What was most important to me in the play was that, in my father’s role, I felt unconditional affection for my sons and the will to take them seriously. But as a father, I was awkward and didn’t know how to do it. My father set out to be different from his father. My grandfather returned from the war late. My father had always argued with him. His father, my grandfather always made authoritarian decisions. My father didn’t want to let me down. But he simply didn’t stand up to my mother. Something similar happened between him and my mother as it did between my brother and me. My father never got a say in matters at home and thus turned to work. He was a workaholic and, in addition to his job, worked for the Red Cross all the time.” During role reversal in the fictional psychodramatic dialogue with his father, the patient expanded his internal object image of his father and, thus, resolved his defense through the projection of rejection.

After the birth of his first child, Mr. B. took over the care of his son as well as the role of housekeeper and ended the treatment. His wife started full-time work as a teacher. Mr. B. declined the offer to continue therapy in a group format.

In the end, the patient did not achieve his original goal of being able to take up a job after completing his studies. But, he faced the challenges of marriage with his long-term girlfriend, had a son with her, and decided to look after the child as a househusband. The therapist graded this solution as a therapeutic success because the patient violated all norms and values of his family of origin by implementing this new life plan. His family had been organized as a narcissistic system. Growing up also means that one sins against the norms and values of the family of origin at least once (Klaus Stangier, 1991, verbal communication).

The therapy model described in Sect. 6.5 can also be used to address distress caused by exam nerves:

Case example 56

In supervision, a therapist reports on the crisis intervention with a 48-year-old woman with long-term examination anxiety (ICD F40.2) and a structural disorder (see Sects. 4.4 and 6.2). In the first interview, the patient mentioned that she had to take a pedagogical exam a week later. It would need her to demonstrate her practical skills in front of other people. She was feeling terrified at the thought of having to do so. The therapist uses the therapy model described above and reports: “The patient had been in treatment with other therapists for twenty years. However, after only one hour of therapy, this was the first time in her life that she had passed an exam. She was quite afraid during the exam. But unlike before, she went to the exam and didn’t run away from the exam room! I think the chair work helped her structure her thoughts and feelings. It was important that I symbolized her self-protection with a chair and saw her as a heroine in the fight against her mental collapse. I then coached the heroine. The structured image of her ego states during the chair work demystified her fear! It was important to organize her inner world: ‘That belongs here, that goes there!’ As a therapist, I always pointed with my hand at the chairs in doing so. The patient shared all of her previous therapy experiences with me. She bundled them together and coached herself. The positive revaluation was extremely important. I appreciated her perseverance as a heroine and didn’t just look at her deficiencies. Eventually, she held on to her self-coaching skills in the real test.”

The therapist continues: “It was healing for the patient to have felt understood during the session! But it was also good for me as the therapist to have a positive understanding of the patient’s defenses. As a result, I had a range of intervention options. This also relieved my internal tension as a therapist. I was pleased and honored that I was allowed to participate in the patient’s deep and intimate internal process! As a therapist, I wasn’t only empathetic as usual. That was liberating.” Supervisor: “Yes, otherwise, as therapists, we tend to identify with the patient’s suffering ego and store all of the patient’s information and fears in our body. In metacognitive work, however, all fears and information are represented externally in the therapy room with chairs, and the patient’s defensive behavior is assigned a positive function within the framework of the patient’s self-regulation. The therapist and the patient stand shoulder to shoulder and look from the metaposition at the disturbing defense pattern. In doing so, you, as a therapist, remain open and curious about what is happening.”

Central idea

In metacognitive therapy, the therapist symbolizes the patient’s defense patterns externally with chairs in the therapy room and addresses them in conversation with the patient. The therapist develops empathy, both for the patient’s self-protection and for the patient’s healthy adult thinking. The therapist no longer responds to her defenses with negative countertransference. His dual compassion helps the patient develop empathy for herself like a good enough mother.

6.8.1 The Therapy of a Patient with Social Phobia by Moreno

In 1936, Moreno (1945, p. 11 ff., 1959, p. 221 ff.) described the treatment of ‘anxiety neurosis’ in a 27-page case report. His patient, Robert, suffered from work disturbances, a constant urge to urinate, pain in the cardiac region, and the constant fear of being unable to accomplish his goals. In addition, he was obsessively afraid of attracting attention in his social circle. He feared that he would be late, his shoes would not have been cleaned, his tie would be outdated, and his car might stop working because it had not been checked at the gas station, among other things. The symptoms reported by Moreno meet the criteria of a social phobia (ICD F40.1). At the beginning of psychodrama therapy, Moreno centered his work entirely on the ‘Psychopathology of Interpersonal Relationships’. This is the title of his case description. Moreno hypothesized that the patient's disturbance stems from his unconscious identification with his father and mother. But they hated each other. They had argued constantly and were finally separated (Moreno 1945, p. 14f.): “Obviously he tried to adapt himself to his father and mother in an original way by internalizing each of their idiosyncracies into a part of his self, thus proving that they did not have to separate, and could live in harmony within him” (Moreno 1945, p. 22). Moreno didn’t know anything about defenses. Nevertheless, there was a profound truth in his interpretation. His patient Robert had identified with the defense patterns of his mother and his father and had to resolve them.

Back then, Moreno was not yet familiar with the role reversal between the protagonist and his opponent, played by an auxiliary ego. He had his patient Robert ‘portray’ himself in role-plays. In other sessions, he also let him play the roles of his father and mother. In his parents’ roles, the patient quickly recognized: “That is not my father, that is me… Oh, that is me, not my mother. When he enacted his father, he discovered that he felt just like his father about his mother, and when he enacted his mother, he discovered that in some respects he felt just as his mother did” (Moreno, 1945, p. 13 ff.).

Moreno (1959, p. 238) had the patient play the roles of fictional restrictive authority figures even in fantasy play. For example, the patient Robert played the role of a judge against a shoplifter, the role of a prosecutor against a criminal, and the role of a Mephisto. At the time, Moreno (1945, p. 27) was amazed that the patient played the dominant male roles with such enthusiasm. He suspected that his patient Robert “…discloses selective affinity for roles which place him in a position to torture others, … The therapeutic theater gives him a creative excuse to let himself go, and perhaps the enjoyment he has in performing and the completion of detail with which he enacts roles through gestures and words indicate the role he would like to play in life.” Presumably, unlike Moreno supposed, enacting the roles of strict authority figures had a positive therapeutic effect on the patient. Because the patient possibly gained specific control over the stringent demands of his superego and was thus able to put them into perspective.

Moreno also let the patient ‘Robert’ re-enact conflict scenes from his everyday work life and marriage without reversing roles. In doing so, he invented the technique of soliloquy: he interrupted the patient while enacting his conflict situations and asked him to say out loud what he thought and felt when he acted and reacted in the situation. Moreno let him mentalize out loud (see Sect. 2.2) in the role of his inner self-image in the play. In this way, the patient completed his relational psychosomatic resonance pattern in play into a holistic resonance pattern comprising sensorimotor interaction patterns, physical sensations, affect, linguistic concepts, and thoughts (see Sect. 2.7). Moreno (1959, p. 231) noted: “Soliloquy makes the experience much clearer than it was at the time of the actual event.” Here, too, Moreno met his patient Robert’s playfulness with unjustified skepticism. But, he didn’t appropriately appreciate the patient’s internal process of self-development, the development of internal self-image, and internal object image in the as-if mode of play (see Sect. 2.5). Instead, he complained: In psychodrama, “the others […] have to adapt to Robert at his will, […] the switch from one state to the other, his change in his position in the room, his twists and turns in dialogue, and his impulse to stop when he finds it desirable”. At the end of the therapy, Moreno worked behaviorally with a kind of desensitization technique: he built more and more complications into the patient's fantasy play and adapted the play scenes to resemble the patient's everyday situations: “Objects, events, and people were carefully put in the way of his unlimited urge to explain and display himself” (Moreno, 1959, p. 347). In this case study, unlike in other case studies, Moreno did not report whether the patient’s symptoms had improved due to the therapy.

6.8.2 The Treatment of Specific (Isolated) Phobias

Patients with specific (isolated) phobias (ICD F40.2) have repressed the original conflict that generated fear in the past. They have shifted the emotion of fear to another relatively insignificant external object (Mentzos, 2011, p. 110). The longer an isolated phobia persists, the more the affected people avoid the fearful situation as a preventive measure (Mentzos, 2011, p. 110). The fears then often lead to general avoidance behavior. A secondary fear of anxiety attacks arises in patients with panic attacks.

Chronic anxiety is treated according to the method described in Sect. 6.5. If the phobic symptoms have only existed for a short time, the avoidance behavior is not yet burned into the patient’s self-regulation. In such a case, the therapist can apply the approach used in treating neurotic behavior. He resolves the defense through repression with the help of psychodramatic dialogue (see Sect. 8.4.2) and changing to the scene of the origin of the patient’s chronic anxiety (see Sect. 2.4.4): (1) He lets the patient re-enact the situation that triggered her anxiety in the present in a completely ‘normal’ psychodramatic manner. (2) He asks the patient, ‘How old is your fear of not meeting the expectations of those around you?’ (3) By changing the scene, he lets the patient return to the origin of the fear and enact the conflict situation at that time. Thus, the patient links her sensorimotor interaction pattern and affect in the scene of phobia to a frightening childhood experience. According to Leutz (1974, p. 147), the therapist should resolve the ‘causes of the anxiety disorder’ in this way.

Some psychodramatists also take a behavior-oriented approach in the psychodramatic treatment of specific (isolated) phobias. Straub, for example (Straub, 1972, pp. 72, 178 ff.), integrated the concepts of desensitization and conditioning from behavior therapy into psychodrama therapy: (1) The patients with a phobia choose someone (a relative or a caregiver) they know, who would have no difficulties in the frightening situation. For example, a woman with a phobia of cats chose her son. (2) The patient observed her son closely in his interaction with cats and memorized his behavior. (3) She practiced his facial expressions and gestures for herself in the role play, initially without imagining a cat. (4) In the next step, the patient imagined encountering a cat in a role play, but in doing so, she played the role of her son. As the son, she turned ‘to the animal just as he used to do’. (5) The patient then took on the role of her son when at home and, in his role, stroked her real cat, just as her son did. Straub (1972, p. 178 ff.) reports that her patient practiced this secretly without the family's knowledge: “Step by step, the patient learned how to interact with the cat via role-play […]. After seven months, she was ready not only to stroke the cat without fear, […] but by the end, she even felt a real affection for the cat.” Straub believes that taking on the roles of other people in “the technique of role change, was the decisive factor in this treatment. When thinking in the role of her son and emulating his behavior toward the cat, the patient was probably so detracted from her phobic fear that she was relaxed enough to carry out the movements observed in her son […] with the necessary calmness.”

Even in the therapy of “a twenty-year-old […] with severe exam phobia” and in other cases with phobias, Straub (1972, p. 179) used a similar behavior-oriented approach: “In each case, he designed a treatment plan with the patient and asked them to take on a person’s role in carrying out this plan, who they know will be without fear in situations which the patient has reacted fearfully. The patients usually practiced role change in a few sessions. They then carried out their treatment independently according to the plan using the behavioral technique of ‘self-regulation’”.

In the case of a patient with bacteriophobia and severe compulsive behaviors (see Sect. 7.4, case example 59), Straub (1972, p. 180 ff.) initially centered the treatment on eliminating the bacteriophobia. In the role plays, the patient played the role of a young girl, a school friend from the past. As a doppelganger, the therapist took on the role of another young girl in the patient’s role plays. In these roles, both made ‘half a dozen’ real trips to the town together. They used public transport, went shopping, ‘did not wear gloves (which the patient used to do) and touched anything’. First, the therapist did this in her role as the young girl, and then the patient did it herself. Later the patient did it first, and then the therapist. As a result, the patient’s phobic reactions had reduced radically, whereby she continued to play the role of her former school friend for herself ‘in the sense of fixed role therapy’ at home as well. Only later could she do so without playing the role of her school friend.

6.8.3 Other Psychodrama Therapists’ Approaches to Panic Attacks

Many psychodramatists (Leutz, 1974, p. 147; Grimmer, 2007, p. 31 f.) let their anxious patients directly re-enact the situations that triggered the panic attacks in a psychodramatic way. In doing so, they use a trick to avoid the occurrence of a panic attack: As the patient enters the panic-inducing situation in the play, she symbolizes her ‘fear’ externally as an object or person and thus turns fear into an object in the interaction. A group member takes on ‘the role of fear’ as an auxiliary ego. The externalization of fear enables the patient to enter a fictional psychodramatic dialogue using role reversal with her ‘fear’. The patient then negotiates with the ‘fear’ to find a compromise solution that is tolerable for both sides. Or the auxiliary ego, who plays the role of fear, compresses the protagonist's rib cage ‘as the fear does in the patient’. As a result, the protagonist usually begins spontaneously to fight the auxiliary ego physically and forces the ‘fear’ out of the group room through the door. The therapeutic idea here is: The patient should improve her self-actualization in relation to the symptom of ‘fear’ and integrate this experience as an action model into her inner conflict resolution processes.

Grimmer (2007) was the first to develop a theoretically justified concept of disorder-specific psychodrama therapy for anxiety disorders. He focuses his work on developing the patient’s good inner parenting roles. In this way, the patients should improve their self-empathy (Grimmer, 2007, pp. 25, 37; Grimmer, 2013, p. 194 f.). While re-enacting childhood scenes, the therapist lets the patient, for example, actively search for memories of earlier positive and helpful caregivers and play them out. If such memories are not present, the therapist introduces positive fictional figures as new resources and self-stabilizing inner objects. The therapeutic relationship is designed to be sustainable throughout.

Grimmer (2007, p. 23) does not work explicitly metacognitively (see Sects. 6.4 and 6.5). At the beginning of the therapy, the therapist does a ‘fear confrontation with the help of surplus reality’. The patient selects practical situations that trigger her fear and enacts them. The aim is a “systematic, careful encounter with the dreaded feelings of fear. This is intended to reduce the patient's constant self-observation” (Grimmer, 2007, p. 23). Grimmer also lets the patient depict her inner panic with the help of an auxiliary ego on the object level as ‘the role of fear’ (Grimmer, 2007, pp. 31 f., 35, 40 ff.). The patient then engages in a psychodramatic dialogue with the ‘fear’. During role reversal, she also takes on the role of fear herself. The therapist then verbally doubles her in the counter role of ‘fear’. However, he suggests to the patient that she has helpful intentions as ‘fear’: “Actually, I just want to help you!” Grimmer reinterprets the fear as an ‘over-committed helper’ or a ‘clumsy, awkward helper’. In doing so, he uses the therapeutical principle of ‘symptom utilization’ from hypnotherapy.

Grimmer's approach is similar to that in cognitive behavioral therapy. The anxious patient should replace the unfavorable thought content “the panic is suffocating me, I am dying of a heart attack” with a more appropriate cognition. Such a positive reinterpretation of panic as a ‘helper’ is therapeutically effective for anxiety patients with neurotic disorder (see Sect. 6.2). The therapeutic process follows the principle of ‘anger instead of anxiety’.

Case example 57

A 34-year-old patient with heart phobia begins a therapy session toward the end of the treatment with the statement: “My best friend has come back!” The therapist wonders: “Which best friend?” The patient pats the left side of his chest: “Well, here, my heart!” He continues: “Then I looked: where is the enemy? I noticed what was going on, and I fought back, boom, boom, boom!” The patient imitates a boxing match with his arms as he says this. During therapy, he recognized that his heart problems always occurred when he adjusted too much in his relationship conflicts and did not allow his anger. When his heart palpitations reappeared, he applied this knowledge. He replaced the old thought, “Help! My heart is racing. I'm going to have a heart attack!” with the thought, “My racing heart helps me to notice my anger. This always occurs when I've adjusted too much in a relationship. What relationship is it this time?” He found the right conflict partner and acted out his anger directly at the conflict partner in his fantasy. That stopped his heart from racing.

But, in people with structural disorder, panic attacks express the impending collapse of their internal defense system. Therefore, the explicit metacognitive approach mentioned in Sect. 6.5 is more likely to be indicated in the case of these patients. The utilization of the symptom of anxiety improves the patients’ self-actualization in conflicts. However, this then activates a masochistic self-censorship acquired in childhood. Thus, erroneous behavior is ‘punished’ by the destructive superego. The therapist must therefore also work on the defense through self-protection and masochistic self-censorship in the therapy process.

Exercise 18

You can understand these considerations and doubts by experiencing Grimmer’s approach using role plays. Step into the role of an anxious patient with structural disorder. You will notice that you experience ego confusion using the psychodramatic dialogue with role reversal with the ‘role’ of your fear.

Central idea

Patients with anxiety and structural disorder, trauma-related disorders, or personality disorders probably benefit more from the metacognitive therapy approach described here.