Helping people with Anxiety

Anxiety is a very broad term, but psychologically we can think of three different types.

Isolated panic attacks (such as a specific phobias of heights or spiders),
Panic with in-between background anxiety (such as social phobia), and
Constant background anxiety (such as worry, sometimes called 'Generalised Anxiety')

Working with the last two is more complex, but this is often the form of Christian worries about sin, purification and hell.

Isolated Panic

In the first case, the person is fine in-between and the panic attacks are in response to well-defined stimuli. Common examples are spiders or heights or snakes. For some reason, people tend not to have phobias of carpets or baked beans - so there is quite a lot of cultural context here!

Simple Panic can be helped by even an inexperienced therapist using a simple CBT [Cognitive Behavioural Therapy] model and a few sessions should be enough. There are good self help books available too which, as long as they are based on CBT principles and the person actually does the tasks in the booklet, can be enough.

Some models are listed in the references below, such as the 'hot-cross-bun' model (1) and the Five Areas Approach (2), both of which are based upon the psychological underpinning model 'Clark's Model of Panic' where the key aspect is the 'interpretation of physical sensations as catastrophic'. In other words, it starts with a bodily sensation such as 'I feel funny/sweaty/sick' which then becomes 'I feel as though I am going to die' which then becomes 'I AM going to die!' and then panic ensues!

Background Anxiety

In the other two types of anxiety, the situation is more complex. Where there is significant anxiety between panic attacks, this suggests that there is an ongoing anxious thinking style even when away from the stimulus. There may also be counterproductive behaviours scanning for threats, compulsions believed to reduce risk or reassurance seeking - these are called 'safety behaviours' because the person believes they make them more safe.

Recovery from these types of anxiety will take longer [10-20 sessions] and need a good therapist. This is because it is more than just 'face the fear and do it anyway' but will require addressing the safety behaviours and anxious thinking style too. The information below is aimed at people who have a fair amount of counselling or pastoral experience.

Core principles for working with Anxiety

A. Get the temperature of the session right - it cannot be an academic discussion as this is really just avoidance, but it cannot be full-blown panic either. Try to ensure that there is an element of stimulus and anxiety in the session (armpits should be a bit sweaty!), and reflect to the person how their anxiety changes in session as thoughts and behaviours are challenged.
B. Watch out for subtle safety behaviours, as it is these that keep the anxiety at a background level between panic attacks. It is the little things like carrying a water bottle ('for my dry mouth...') that will stop the person from fully learning that their physical sensations are just physical sensations rather than the sign of impending doom. If you do not tackle these behaviours, the person will remain with a background anxiety and will relapse.

Specific points about social Phobia

A. Watch out for contamination of the social environment by the person that has unintended consequences - for example wearing extra clothes so sweaty armpits don't show seems a good idea but actually can make you sweat more and draw attention to you on a hot day. These behaviours are perceived to reduce social risk but actually make them more likely to be thought of as 'odd' by another person
B. Beware of alcohol use. This may happen before a social encounter to give 'Dutch courage', or be used later in the evening to help them switch off before bed as people with social phobia often get anxious doing a 'post-mortem' of the day ('did I do OK, did anyone notice?').

Specific points about Hypochondriasis/Health Anxiety

A. The person will be seeking reassurance from medical tests and opinions. As a potential 'expert' or someone with perceived experience in helping people, your opinion as to the risk of a particular situation may be sought. Never offer it! Instead use this as an opportunity for good therapy using Socratic questioning - 'what do you think?', 'how will you feel if I reassure you, and for how long?'
B. Make good use of behavioural experiments, for example hyperventilating (both of you should do this!) to prove that all that happens is you feel nauseated and no one has a heart attack. There is a great book on Behavioural Experiments [4] in the footnotes, with examples for each disorder.

Specific points about Post-traumatic Stress Disorder

A. If properly planned, it can be helpful to go out and about doing behavioural experiments in the feared and avoided locations. However, be aware of genuine risk or assault if you are in a more risky part of town. There is only so much trauma that can be processed in an armchair. However, don't pressure people to do this before they are ready.
B. Watch out for secondary depression. PTSD sufferers can often have a completely healthy background with good self esteem and no risk factors. When they cannot 'snap out of it' like they have done before, they may process this by having thoughts like 'I must be weak/useless/no good' and this is the start of depression. You still treat the PTSD first, but this needs acknowledging in the formulation.
C. If their PTSD is 'complex' which is a term used when the person has had childhood trauma [for example sexual abuse] or they were entrapped at any point [eg taken hostage], then you should specifically work in a 'trauma informed' way and undertake specific training for this.

Specific points about Obsessive Compulsive Disorder

A. The issue here is not about the obsessions and compulsions, which are obvious and the person knows they are irrational. Instead, look for the deeper fears about the power to harm others or have power over others. This might sound odd, but ask anyone with OCD what their deepest fear is... This is why OCD is so hard to treat - the presumed costs to them are huge. Read up about 'insurance policy' analogies.
B. Ask about internal compulsions such as counting and saying prayers as well as the obvious ones like washing and checking. These are harder to treat, but the same principles apply. You may need to make a loop tape of counting or prayers to over-expose them and habituate the response.

Specific Points about Background Worry

In these situations, there is rarely a panic attack, but then there is rarely peace. Examples are the worry process in generalised anxiety disorder and the rumination process in chronic depression or dysthymia. The key here is not to get drawn into exactly what it is the person is worried about or ruminating on as, no sooner than you have helped them deal with this, that it is replaced with another problem. They are expert brainstormers - the more they think, the more things they find! Instead, you have to get them to commit to get away from the individual worries or concerns and instead focus on the form/style of thinking being exhibited and see that as the problem.

We cover this in The Worry Book [5] where we use a model by by Mark Freeston in his book Overcoming Worry [6] . This helps the person see that they oscillate between worrying too much [which they know makes them feel bad, but they feel they have to because they have over-inflated positive beliefs about the power of worry to solve problems] and trying not to worry at all [because as they start worrying to much, they panic about the possible outcomes and 'avoid' them by 'trying not to worry']. 'Trying not to worry' is actually one of the subtle safety behaviours I mentioned above, and is joined here by other subtle internal behaviours like distraction. As above, these safety behaviours need to be challenged and the person exposed to over-worrying to see that it really makes you feel bad but nothing happens. Likewise, they need to learn to act on decisions rather than worrying about them, and a graded hierarchy can be set up like any other exposure.

Christian Application

Should Christian Counsellors get involved with complex anxiety disorders? By all means! Not only will working with such cases really sharpen your skills in a way that working with depression sometimes cannot. Even if you do not feel skilled enough to tackle them, you can work alongside a CBT therapist. If doing this alongside work, it is important to understand the approach they are taking to some degree.

There is a great need for therapists who are good at working with anxiety. Anxiety disorders lie at the root of much depression, as they make the person drop out of the things that could have given them life like hobbies, jobs and church. Also, if we do not understand the more complex anxiety disorders, we run the risk of making the problems worse by providing reassurance, not picking up subtle safety behaviours and joining the person in their stuckness. Finally, if the person does need to see a psychologist, your informed involvement in the case will be a great witness and a chance for networking with your local NHS hospital.

1. Mind over Mood, Greenberger and Padesky
2. The Five Areas Approach, Dr Chris Williams, www.fiveareas.com and www.livinglifetothefull.com
3. Cognitive Therapy of Anxiety Disoder, Adrian Wells. John Wiley and Sons, Chichester.
4. Oxford Guide to Behavioural Experiments in Cognitive Therapy, Bennett-Levy. Oxford University Press
5. The Worry Book, Will van der Hart and Rob Waller. IVP
6. Overcoming Worry, Kevin Mears and Mark Freeston, [a self help book part of the popular 'overcoming' series]. Robinson

Rob Waller, 25/01/2009

Search