THE CASE OF SARA
Sara was an attractive woman in her early 40s. In a way, she represented a paradigm of the modern world. Everything in her life was stressful. She had been divorced for many years and her ex-husband was a devoted but unreliable partner who had a penchant for over-indulgence in alcohol. She never knew, when it came time for his weekend with the children, whether he would be up to it or not.
At work in a small but relatively successful business, her boss lacked leadership and communication skills. He generally hired people whom he knew and liked, regardless of their level of competency. When it came to conflicts among his employees, he invariably used avoidance as his default strategy.
At home Sara had two children – one adolescent boy with Attention Deficit Disorder whose teacher was always complaining about his academic performance, undone high-achieving but oppositional daughter who never let her mother get away with anything – neither the least compromise nor the slightest ambiguity in her statements.
Her male partners since her divorce tended to be fickle and uncommitted. They enjoyed her company but never gave her any sense of security or long-term commitment.
There is nothing spectacular in all of this – very ordinary modern dynamics. Yet almost everything in Sara’s life was a source of stress and she lived in a constant state of anxiety. Medication helped a bit but not enough to prevent her anxiety from transforming into depression from time to time; she would then have to take a sick leave.
Although the research on biological and psychological factors in anxiety is rich and informative, when we come to social factors, the terrain becomes much more murky. For example, neither of the two major textbooks of psychiatry, the American Kaplan 8c Sadocks and the British New Oxford Textbook of Psychiatry, have sub-chapters on social factors in anxiety. They are both rich, however, in headings such as “The Psychodynamics of Anxiety,” “Neuroimaging” and “The Neurochemistry of Anxiety.”
“Why is this?” one may ask. One possible answer is that stress and anxiety in our society are so prevalent that they are difficult to study – there are no possible control groups. Stress is seen as inevitable. Western social scientists are fond of studying psychiatric disorders in victimized populations such as the Palestinians in the Gaza Strip or the post-earthquake Pakistani population, but are less fond of looking honestly at our own social performance. When they do study Western societies, they are looking more for diagnosable psychopathology than the more universal malaise that affects us all.
What are the sources of anxiety in the modern world? In the following somewhat simplified schema, we will deal with some major categories of social factors.
Family Relationships
Some of the earliest research on this issue was done by Thomas Holmes and Richard Rahe ( 1967). They devised a Social Readjustment Scale, rating 43 different life events according to their disruptive effect on the average person’s life. They then gave a rating of “life-change units” for each of these events. In this scale, the highest rating went to the death of a spouse (100 points). Other relevant ratings in the area of family life were:
Divorce 73
Separation 65
Marriage 50
Pregnancy 40
Increased arguments with spouse 35
Trouble with in-laws 29
According to Holmes and Rahe, if a person accumulated more than 200 points in one year, they had a significantly increased risk of incurring both physical diseases, such as heart attacks, peptic ulcers and serious infections, as well as psychiatric disorders, such as anxiety disorders.
This study was done in 1967 when family institutions were more stable than they are today, 40 years later. If one now thinks of the rate of divorce and separation (67 percent over 40 years) as well as the increasing number of conflicts in homes and families, one should not be surprised by what appears to be an epidemic of anxiety. My clinical observations tell me that no matter how common divorce and separation are, they remain seriously traumatic for all parties involved.
In actual practice, each time there is a threat of separation or divorce, one can observe the anxiety level going up in all family members, especially in the children. When the actual negotiations get going and lawyers get involved, anxiety levels increase even more. The legal bills, bailiffs at the door, court appearances and back-room negotiations – each of these processes increases the level of anxiety.
As I read through the 43 life events of the Holmes-Rahe scale, I noticed something striking. There were no items involving parent-child conflict. In fact, in my psychiatric practice, many adults come to consult when the precipitating factor is difficulty in dealing with one or more children. This is obviously a relatively new phenomenon – or at least one that is increasing in frequency and intensity. Some of the many complaints contemporary parents have about their children include disobedience of the parents, going out with inappropriate partners, not following parents’ value systems, not being willing to give up drugs and alcohol, dropping out of school, and staying at home without working. I have even seen parents physically abused by children unwilling to control their frustration and anger. All of this contributes to increased anxiety levels.
Much of the research over the past decade involving Social Factors of Anxiety has used a tri-partite model of Stress, Social Support and Coping Mechanisms. The stress factors involved in causing anxiety are everything we discuss in this part of the series. Coping is largely a matter of individual adaptations to stress. Where our society has been most affected, however, is in the deterioration of social supports. As families have been pulled apart by dislocation and conflict, the basis of our security has been undermined. Often people find that they have to rely on institutional supports, which tend to be rigid, bureaucratic and ultimately uncaring. The group home is not like the family home, and nursing homes for the elderly are a serious step down in dignity from a loving, extended family.
Work
Next to conflictuel, unstable family life, working conditions rank second as contributors to stress. According to the Holmes and Rahe scale, we find the following rankings of life-change units:
Fired from job 50
Business readjustment 39
Change to different line of work 36
Change in responsibilities at work 30
Trouble with boss 23
Change in work hours or conditions 20
(Remember that it requires only 200 points per year to increase the risk of eliciting depressive or anxiety disorders.)
These rankings were done before the current wave of downsizing, mergers and “rationalizing” of business procedures. Each of these processes has enormously increased the frequency of these life-change events.
George Brown and Tirril Harris (1978), working out of the Maudslev Hospital in London, went one step beyond Holmes and Rane in their analysis and began looking not only at the life-changing events, but also at their meaning and context in the individuals’ lives. 1 hey thus divided events into those that caused primarily humiliation, those creating entrapment, loss events such as death and separation, and danger events. Loss alone did not provide a sufficient explanation for the causation of depression in their study. Humiliation and entrapment were necessary co-factors.
One can observe this phenomenon clearly in clinical practice. The humiliation involved in job loss is often considerable, even if the loss had nothing to do with personal incompetence or poor work relationships. Many feel trapped in jobs they hate but cannot leave because the alternatives represent too great a loss of revenue. It then becomes a choice between enduring a despised form of work or living in relative poverty – not an enviable choice to say the least.
Vignette:
Jim, a physically strong and personally charming man in his mid30s, hada well-paying job and a young family. Obviously skilled at what he did, he was promoted to a position considerably higher than his educational background would have justified. Then his company lost a few major contracts in an economic downturn. He was unceremoniously terminated with no promise of being rehired in the near future. The result was an almost instantaneous depression, which turned out to be very difficult indeed to treat. He ended up on a combination of three powerful anti-depressants and still remained fragile. In reality, he may not recover fully until he finds a suitable job replacement.
In contrast, I recently evaluated one client from North Africa. As the interview progressed, it became quite apparent that he was unable to function at anything like the efficiency required in the Western workforce and he knew it. Nevertheless, he had been working regularly for four years in his home country. “How did they keep you as an employee? ” I asked, both puzzled and intrigued. “They know my family and are like friends, so they wanted to maintain good relations. They just accepted me as I was and filled in for what I was unable to do.” This type of attitude is unimaginable in most Western companies. I have personally seen fathers and sisters firing their own family members when they didn’t like the jobs being done. All of this has enormous implications for our emotional well-being.
Some of the stressors at work are not as straightforward as job loss or demotion. They include elements such as authoritarian management style or its inverse – a lack of leadership by supervisory staff and job role ambiguity. Surprising to me at first, I have seen clients whose major problem seemed to he poor management at work. This can be manifested by insufficient training for a new employee, inappropriate job assignment, lack of coordination between various departments, and inaccessibility of relevant information to performing one’s job. Each of these elements may be extremely anxiety-provoking.
Companies in economic difficulties are particularly stressful for their employees. For example, if one is aware that his company plans to let go of 25 percent of its staff, everyone is on edge over whom that may be. Another anxiety-provoking situation is a merger, in which staff members of two or more companies are “jockeying” for positions. The conflicts thus engendered may be very severe. I’ve been in contact with situations in which physical violence and death threats emerged.
The insecurity of employment, short-term contracts and subcontracts, lack of social benefits, health insurance and retirement plans – each of these may add to the anxiety quotient.
Financial Stress
A few statistics:
* 43 percent of American families spend more than they earn each year.
* The average household in America carries some $8,000 in credit-card debt.
* American consumers owed $1 .97 trillion in October 2003. This represents $18,654 per household, not including mortgages.
* Personal bankruptcies have doubled in the past decade.
The fact is that most people in Western societies are living on the edge. This kind of existence is very fragile. For example, if someone loses his well-paying job and has to take a pay cut at his next job, his entire life structure may fall apart. The same thing may happen to a wage earner who falls sick and has insufficient insurance coverage. It’s very easy in this context to fall through the cracks and the price of this fall may not be just financial. The level of anxiety generated in these situations can be very intense indeed.
One of the very anxiogenic situations I come up against regularly in my practice is related to disability insurance. In this context, a client, no longer able to continue working, requests sickness benefits. As these claims are constantly increasing, especially with rising pressures and demands at work, insurance companies are challenging patients’ claims more and more frequently. They use their own medical specialists to discredit the clients’ illness and downgrade the seriousness of his condition. Often, regardless of the treating physician’s opinion, the insurance payments are cut off. In this way, a client and worker, believing that he had job security and disability coverage, is cut loose and left to fend for himself. This is indeed one of the most anxiety-generating situations I see. Interestingly, this was not even mentioned as a possibility in the Holmes-Rahe life events scale. In other words, it is a very new phenomenon.
Another equally toxic scenario happens when a supervisor wants to get rid of an employee and the employee is protected either by an individual contract or a union bargaining agreement. The supervisor then begins accumulating a dossier: he notes every possible error or failure on the part of his employee. At times, he may even set up situations designed to make the employee fail, such as giving him work beyond his competency level or an excessive amount of work. Invariably this leads to a poisonous work climate and incredible psychological pressure on the employee.
Related to these situations and equally anxiogenic are the judicial procedures connected to labor relations and workers’ compensation. Since the processes involved are long and complicated, as are most Western legal procedures, the problems often drag on for years without resolution. The persons involved find their lives put on hold while the judicial authorities slowly and painstakingly try to figure out the appropriate remedy. In the end, the problem is rarely resolved and the wise participant finds his own solution. The less wise one may, out of desperation, act in a violent or self-destructive way, which can have tragic consequences.
The Logistics of Modern Life
National Geographic News in 2005 reported that Americans, on average, are sleeping one hour less per night that they did 20 to 30 years ago. This is not at all surprising.
Although there are government regulations that limit official work hours, there are a lot of unofficial tasks that modern life imposes. From unending paperwork and helping children with schoolwork to driving children to their extra-curricular and sports activities, and helping elderly parents with health and living arrangements, the list of tasks can easily become overwhelming.
We are told that we need to multitask, but even that approach is not enough. It is not unusual to find parents overstressed and out of breath running from one activity to another and unable to wind down. The child walking to school with a backpack more suitable for a U.S. Marine and the teenagers trying to keep up with all their communications by frantically text messaging their friends on their cell phones are symptoms of this deep malaise. I like to call this the “Manhattan Syndrome.” In New York City, one can see rushed employees at noon gulping down their lunches while hurrying to their next appointment. What a lifestyle!
To cope with this frenetic pace, a number of activities and practices have arisen in recent years. We now find a host of techniques like tai chi, chi-kong, various forms of Buddhist and Hindu meditations, and relaxation methods – all designed to de-stress. Yoga has become a growth industry with a vast infrastructure of schools, magazines, teachers associations and seminars across North America and Europe.
Spirituality and Anxiety
One of my mentors from the “good old days” of philosophy and political activism was Irving Yalom, a brilliant psychiatrist from the West Coast. He had written the definitive textbook on Group Psychotherapy, which I used “religiously” in group therapy practice before going on to researching some of the newer and more spectacular group therapies emerging in the fertile terrain of the 1970s in California.
The book that most affected me at the time, however, was Existential Psychotherapy. I was hoping that this approach might be a good alternative to Psychoanalytic Therapy, with which I was becoming increasingly disillusioned. Not only was psychoanalysis proving to be less effective than I expected, but I was also beginning to find the concepts wearisome and overdone.
Somewhat naively but with great alacrity, I plunged into the first edition of Existential Psychotherapy, hoping to find the answers I had been looking for to make my practice more intellectually satisfying and more effective. Instead I met with another major disappointment.
The basic theory of Existential Psychotherapy involves four ultimate concerns: death, freedom, isolation and meaninglessness. Each of these concerns is considered a major source of anxiety and dread. Death anxiety, the awareness of the inevitability of death, is seen as the prototype of all forms of anxiety. According to the existentialist perspective, it is the source of most human angst and suffering.
As I was reading this, I remembered my stay in East Jerusalem just before I accepted Islam. By this point, I had finished medical school and had seen many people facing death. They all, without exception, had fear in their eyes as I interviewed them. Then I met a very old Palestinian man with Parkinsonism and chronic lung disease who was obviously in his last miles. He would greet me every day as I walked up the Mount of Olives to do mv errands calling me, “AlKennedy? (Canadian), since all he knew of me was where I was from. Despite his illnesses, his eyes were luminous and I detected no fear in his being. I was impressed! Not everyone lives with fear of death, I realized.
The existential school considers even freedom as terrifying because it implies “no ground – a void, an abyss.” Isolation is another concern. “No matter how close each of us becomes to another, there remains a final, unbridgeable gap,” according to Yalom. If we constitute our own world and then must die, as the existentialists believe, then meaninglessness becomes a fundamental part of existence.
What a bleak picture indeed! What could be more anxiety provoking than believing that we are headed ultimately into a “black hole,” literally and figuratively? This “atheistic” worldview is indeed terrifying.
Once our iman (faith) develops, however, the darkness is turned upside down. Death then becomes a door to a better world in the hereafter. Our freedom is contained within our relationship with a Greater and Wiser Power and our isolation disappears within the context of our relationship both to Our Creator and to other created beings. And, of course, everything then takes on meaning within the Grand Scheme of Things.
There is now considerable scientific evidence ofthe value of this kind of spirituality in people’s lives. In an article published in Hospital Journal in 1989, Jane Kaczorowski studied 114 adults diagnosed with cancer. “A consistent, inverse relationship (P