Case
Patient Sarah, 28 years old, is a female, from a midwestern town in the US. She’s had anxiety since childhood, but lately it’s became more severe. She had tried therapy and medication before but they hadn’t helped. Now she finds it hard to leave the house, constantly preoccupied with imagining negative possible scenarios.
She mentioned that her childhood was relatively happy, and support and attention from family could be used to decrease vulnerability.

Symptoms and diagnosis

The patient has trouble sleeping, a racing heart, is constantly on edge, avoids social situations, has difficulty leaving the house, has worrying thoughts, started to have panic attacks. Has a history of anxiety-related problems in childhood. As a child, she would worry about small things such as meeting new friends or getting a bad grade.
Based on the stated symptoms and the client’s background it is logical to assume that the client suffers from an anxiety disorder, particularly from a general anxiety disorder. Although some of the symptoms correlate with other types, for example, panic attacks are not in the symptoms’ list in DSM-5 for general anxiety disorder, but for panic attacks disorder, and social avoidance could be found as a symptom of social anxiety disorder. Nevertheless, when distinguishing GAD from other types it’s important to take into account the nature of the client’s worries and in which areas of life it manifests. For instance, social anxiety is centred around feeling shame or being judged by people around (Liebowitz, 2010). But in this case, in social situations, patient worries come not from fear of being judged by people, but from being overwhelmed by the activity itself. Panic attacks, similarly, had manifested as a symptom of chronic GAD and had appeared later in life. Also, the patient frequently shows most of the symptoms required to be diagnosed with GAD: excessive worries on various topics which are hard to control, problems with sleep, worries negatively affecting a person’s life and restricting them from living life to its fullest (DSM-5-TR). Additionally, the patient had a history of anxious behaviour from early childhood. That’s why the exact diagnosis would be GAD. In that scenario, trouble with leaving the house or avoidance of social situations could be the client’s safety behaviours as a coping mechanism to avoid potential stress (Robichaud, et al., 2019).

Explanation of Anxiety through biopsychosocial model and Adlerian theory

When it comes to anxiety treatment, CBT therapy is the most popular type. CBT focuses on dealing with symptoms, changing maladaptive thought patterns, and teaching coping and stress relief technics (Newman & Fisher 2010). However, in this paper, I would like to review the Adlerian approach.

One way of understanding anxiety disorder is by using the biopsychosocial model of well- being. BPSM is client-centred and it takes into account the biological, psychological and social aspects of the individual. Such an approach coincides with the Adlerian main idea of viewing a patient as a whole. BPMS recognises 3 sources of anxiety.

The first is biological, a person could have a genetic predisposition towards heightened emotional reactivity (American Psychiatric Association, 2013; Newman et al., 2013). Moreover, due to the neuroplasticity of the brain, a traumatic event in childhood could alter brain structure. Early life exposure to stress factor could influence the healthy function of prefrontal–hippocampal–amygdala circuits, which takes part in emotional processing, learning and self-regulation (Smith & Pollak, 2020). This correlates with Adlerian theory, that a child’s yet not developed fully brain connections, under the effect of stress could develop unhealthy neural connections and thinking patterns, thus could lead to developing anxiety (Adler, 1927).

In the chosen case the patient shows symptoms of developing anxiety in early childhood. Genetic factors paired with some stressful social situations could lead a patient to lose confidence in herself when meeting new children and create anxiety over the social aspect of life. Which manifested in her adult life as avoidant behaviour. As a result, the patient could have a decrease in oxytocin level, which is used in processes of social bonding, managing stress, and regulation of neural and behavioural responses to stressful situations (Poulin & Holman, 2013). To confirm the hypothesis the patient should test for related hormones and get a brain scan. Using the Adlerian approach, it is necessary to educate the patient on the biological aspect of GAD, in order to use it as a motivational factor to work on rewiring the brain, which is possible due to plasticity. This could give purpose to the patient to change behaviour and alleviate the stress factor of being “sick” by normalizing their experience.

Two others sources of anxiety by BPMS are Psycho-social factors.
It is important to look at environmental conditions and social aspects. Family plays a key role in a child’s development. Through interactions within the family, the child adapts social- behavioural schemas, feeling of belonging which later shapes the ability to feel related to peers, how they view others and the world (Curlette & Kern, 2010). Applying this to a given case, good relationships with family could be used as a tool to help the patient in dealing with stress. Family can provide emotional support. At the same time relationships between family members and childhood experiences needed to be examined further throughout the therapy in order to identify particular factors which could lead the patient to develop anxiety in childhood. The therapy plan will be viewed in the next section.
Another key factor is the social/cultural aspect, for example, in this case, it would be helpful to share the statistic, that in the US GAD is more common among White women (8,6%). This knowledge can help the patient to feel less alone and isolated (Alur-Gupta et al., 2021).

Therapeutic plan

In short, Adlerian therapy is a holistic method, where a client is viewed as a whole. The process is client-centred, actively engaging the client in reviewing thought and behaviour patterns and working on it towards progress with encouragement from the therapist (Adler, 1927).

Phases are: establishing trustful relationships with the patient, gathering information about the patient, processing and interpreting the collected data and guiding the client towards behaviour changes (Ansbacher, 1974).
For the first phase sessions should be scheduled to talk in depth about the client’s life, tasks, problems the client faces every day, social-development history, the client’s take on her mental state before and now, personal feelings and all thoughts about the situation as well as medical history. Based on newly collected information together with the patient a plan of treatment will be constructed, where we will explore and collaboratively work on false thought and behaviour patterns. In therapy, we will put focus on unfolding the client’s perception of social and environmental belonging. Additionally, we will work on developing mutual respect in the client-therapist relationship which will help the client to gain self- confidence and find motivation from within. Next, we will identify the patient’s goals and reveal the purpose of the patient’s behaviour. Also, we will identify the strong sides of the client and empathise with them, as well as pinpoint aspects of life where the client feels uneasy and stressed and address them. (Feltham et al., 2017). Throughout the whole process, the client will be encouraged and praised to help the client feel in control over the situation and to develop the ability to help herself (Jokinen & Hartshorne, 2022). Moreover, through therapy, the client will learn to accept failure, and the uncertainty of life, accept her condition and work on re-joining areas of life that were disconnected. Another interesting tool which can be used with the client is music. The client can interpret the lyrics of music chosen for the session, use music as a relaxation method, play music from childhood to recall memories and feelings, find a specific song which represents her emotional state now and then analyse it together. (Kluetz, 2015). After gathering enough data and pinpointing goals and life challenges, together with the client an assignment which challenges the client’s old thought and behaviour patterns will be set up and the patient will try to act out new behaviours and views on life (Carlson, et al., 2006a).
When developing a client-therapist relationship it is also important to take into account professional and ethical considerations. According to the American Counselling Association (2014) and the British Association for Counselling and Psychotherapy (2018), fundamental principles of ethical work are autonomy of the client’s free will, beneficent and non- maleficent intentions to helping the client without harming, maintaining the sense of fidelity to honour professional commitments, providing therapy with justice and equality for all patients, practicing veracity, and maintaining a sense of self-respect. These principles are crucial in building healthy relationships with a client in order not to overstep personal or client boundaries and not to develop unhealthy relationships. Developing a healthy relationship is beneficial in the Adlerian framework because it is one of the motivational and educational points for a client (Adler, 1927). Linking this to the chosen case, a healthy client/therapist relationship will encourage the patient to develop a social interest in a provided safe and accepting environment. This will help the client to work on the social aspect of the issue and allow them to make their own decisions, which are respected and encouraged. Later with more developed self-confidence a client will be able to transfer this experience into real life social interactions and continue developing social interest, which was modelled by the therapist (Millar, 2017).

Evaluation of Adlerian therapy

It is hard to find a meta-analysis on the effectiveness of the Adlerian approach due to the psychoanalytical nature of the therapy. Nevertheless, there are numerous research papers and case studies on that topic. For example, several studies on developing healthy mental states in adolescents in order to help them fight psychological problems and anger-infused behaviour by applying Adlerian therapy showed positive results and efficacy of the approach (Badejo and Bola, 2020; Boxer, et al., 2005). Another research by Keshavarzi et al., (2016) showed a significant increase in emotional regulation abilities.
However, there is plenty of indirect evidence of the effectiveness of Adlerian therapy. One notable example is a series of research by Prochaska & Norcross (2010) where they asked a panel of 62 psychologists to give their opinion on what the ideal approach to therapy should look like. In their conclusion, they described an approach which includes biological, psychosocial aspects, client-centred, psychoeducational, directive and future/present-oriented approaches. This coincides with Adlerian principles and is based on the same main ideas.
No doubt that the Adlerian approach is worth considering when choosing a therapy. Additionally, there are many case-based types of research and other indirect evidence of the efficacy of Adlerian methods. For instance, the Adlerian approach allows incorporating multicultural, cognitive, and systematic counselling perspectives (Watts, 2013). Additionally, it shares the same key factors of successful psychotherapy with transtheoretical studies (Carlson, et al., 2006a).
That evidence should be taken into account even though in the current climate there is a lack of meta-analyses and efficacy studies. With more attention to that problem, it might move specialists in the field to continue research and provide much-needed data.

References

Adler, A. (1927). Understanding Human Nature. Trans. Colin Brett. Oxford: Oneworld Publications. https://familycouselling.files.wordpress.com/2018/10/adler- understanding-human-nature.pdf

Alur-Gupta, S., Lee, I., Chemerinski, A., Liu, C., Lipson, J., Allison, K., Gallop, R., & Dokras, A. (2021). Racial differences in anxiety, depression, and quality of life in women with polycystic ovary syndrome. F&S reports, 2(2), 230–237. https://doi.org/10.1016/j.xfre.2021.03.003

American Counseling Association. (2014). Ethical & professional standards. https://www.counseling.org/knowledge-center/ethics

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Ansbacher, H., L. (1974). Individual Psychology: The Adlerian and Jungian schools. Basic Books.

Badejo, A., Bola, L., S. (2020). effect of adlerian therapy on the psychosocial challenges of secondary school adolescents. European Journal of Educational and Development Psychology, 8(4), 17-25. https://www.eajournals.org/wp-content/uploads/Effect-of-

Adlerian-Therapy-on-the-Psychosocial-Challenges-of-Secondary-School- Adolescents.pdf

Boxer, P., Goldstein, S., E., Musher, E., Dara, D., Eric, F., Heretick, D. (2005). Developmental Issues in School-Based Aggression Prevention from a Social Cognitive Perspective. The Journal of Primary Prevention, 26(5), 383-400.DOI:10.1007/s10935-005-0005-9

British Association for Counselling and Psychotherapy. (2018). BACP ethical framework for the counselling professions. https://www.bacp.co.uk/events-and-resources/ethics-and- standards/ethical-framework-for-the-counselling-professions/

Carlson, J., Watts, R. E., & Maniacci, M. (2006a). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association. https://awspntest.apa.org/doi/10.1037/11363-000

Carlson, J., Watts, R., Maniacci, M. (2006b). Adlerian Therapy and the Transtheoretical (Common) Factors (excerpted from Adlerian Therapy: Theory and Practice, APA 2006).https://www.researchgate.net/publication/335587157_Adlerian_Therapy_and_the_Tra nstheoretical_Common_Factors_excerpted_from_Adlerian_Therapy_Theory_and_Pra ctice_APA_2006

Curlette, W., L., & Kern, R., M. (2010). The importance of meeting the need to belong in lifestyle. Journal of Individual Psychology, 66(1), 30–42. https://hdl.handle.net/20.500.12259/50224

Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th edition, text revision.). (2022). American Psychiatric Association Publishing. https://doi- org.uniessexlib.idm.oclc.org/10.1176/appi.books.9780890425787

Feltham, C., Hanley, T., Hanley, T., & Winter, L., A. (Eds.). (2017). Part V: Theory and Approaches. In The SAGE handbook of counselling and psychotherapy. Sage.

Jokinen, R., R., & Hartshorne, T., S. (2022). Anxiety Disorders: A Biopsychosocial Model and an Adlerian Approach for Conceptualization and Treatment. The Journal of Individual Psychology 78(2), 155-174. doi:10.1353/jip.2022.0022.

Keshavarzi, S., Azar, E., F., Mirnasab, M., M., Gargan, R., B. (2016). Effects of Transactional Analysis Programs on Adolescents’ Emotion Regulation. International Journal of Psychological Studies, 4(8), 51-59. DOI:10.5539/ijps.v8n4p51

Kluetz, S. L. (2015). Adlerian approach to anxiety reduction using music as a therapeutic tool. Adler Graduate School of Minnesota. https://alfred adler.edu/sites/default/files/Kluetz%20MP%202015.pdf

Liebowitz, M. (2010). The emergence of social anxiety disorder as a major medical condition. In H. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier
(Eds.), Anxiety Disorders: Theory, Research and Clinical Perspectives, 40-49. Cambridge: Cambridge University Press. doi:10.1017/CBO9780511777578.006

Millar, A. (2017). Adlerian therapy. In Feltham, C., Hanley, T., Hanley, T., & Winter, L., A. (Eds.). (2017). Part V: Theory and Approaches. In The SAGE handbook of counselling and psychotherapy. Sage.

Newman, M., G., & Fisher, A., J. (2010). Expectancy/Credibility Change as a Mediator of Cognitive Behavioral Therapy for Generalized Anxiety Disorder: Mechanism of Action or Proxy for Symptom Change? International journal of cognitive therapy, 3, 245–261. https://doi.org/10.1521/ijct.2010.3.3.245

Newman, M., G., Llera, S., J., Erikson, T., M., Przeworski, A., & Castonguay, L., G. (2013). Worry and generalized anxiety disorder: A review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment. Annual Review of Clinical Psychology, 9, 275–297. https:// doi.org/10.1146/annurev-clinpsy-050212-185544.

Poulin, M. J., & Holman, E. A. (2013). Helping hands, healthy body? Oxytocin receptor gene and prosocial behavior interact to buffer the association between stress and physical health. Hormones and Biology, 63, 510–517. https://doi.org/10.1016/j.yhbeh.2013.01.004

Robichaud, M., Koerner, N., & Dugas, M., J. (2019). Cognitive Behavioral Treatment for Generalized Anxiety Disorder: From Science to Practice. Routledge. https://doi- org.uniessexlib.idm.oclc.org/10.4324/9781315709741

Smith, K., E., Pollak, S., D. (2020). Early life stress and development: potential mechanisms for adverse outcomes. Journal of Neurodevelopmental Disorder 12, 34. https://doi.org/10.1186/s11689-020-09337-y

Watts, R. (2013) Adlerian Counseling. The Handbook of Educational Theories, pp. 459-472.https://www.researchgate.net/profile/Richard-Watts- 2/publication/265161122_Adlerian_counseling/links/5409cfe30cf2d8daaabf981b/Adl erian-counseling.pdf