Presenting Problem of Severe Anxiety

A Presenting Problem of Severe Anxiety – Stage 2 Essay: Group 2; Essay Number 3

For the sake of conserving space I am going to assume that the examiner has access to the background information provided for this essay and so, although I will refer to the information provided, I do not propose to repeat the essay brief here (there is not a title as such). Secondly, I will refer to the client as Miss Summers in my response to her email enquiry. The website given in the response is fictitious. The letters after my name are that part of my real qualifications that appears relevant to hypnopsychotherapy practice.

The Reply

The response below attempts to first reassure the client and give hope without being unrealistic or misleading in terms of probable outcomes. For clients with issues of anxiety psychoeducation and reassurance is crucially important (Daitch, 2011). After providing initial reassurance, the response deals with more pragmatic issues. In this way, the response aims to balance providing support, reassurance and approachability with essential information such as fee structure.

“Dear Miss Summers,

Thank you for your email enquiring about help with your current situation. Firstly, in making this initial contact you have made what is often the most difficult step towards leading the life that you would like. Secondly, may I assure you that anxiety conditions, whilst distressing and debilitating if left untreated, are perfectly amenable to treatment, and whilst a complete remission of your symptoms cannot be guaranteed, there are very good reasons to be optimistic about achieving a very significant reduction in your symptoms, leading to a dramatic improvement in your quality of life. It may be reassuring for you to know that in any one year about 20% of the population will suffer from an anxiety condition of one form or another and that such conditions are highly treatable. May I suggest that you call me so that we can have a brief chat and set up an initial appointment for you at which we can discuss your needs in greater depth. My terms and conditions and fee structure can be found on my website at www.wharton-hypnotherapy.co.uk. It would be useful if you could review this information before you call so that I can answer any questions you may have before we book your initial consultation.

I look forward to speaking to you soon.

Kind regards,

Barry Wharton BA, CSci, FIBMS. CHP(NC)”

The Initial Consultation

My approach to the client’s case is modelled on the case formulation approach described by Eells (Eells, 2015). In her book, she offers a structured approach to case formulation which helps to ensure that in the initial stage of consultation essential information relevant to the client’s problem is not overlooked. The approach leads on naturally to a consideration of possible diagnoses, an explanatory hypothesis of the problem and potential interventions. Elements of the process are revisited as appropriate in an iterative fashion as therapy progresses and new information becomes available.

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Initial information gathering would include an exploration of the client’s medical history and in particular, whether the client has received therapy for her issue in the past. This should include whether she has seen a GP, psychiatrist or therapist regarding the presenting issue and any medication. This leads on to an exploration of the client’s mental health history and many of the questions expanded on below might be answered in this part of the consultation. Other important information includes the client’s domestic circumstances and family circumstances, including familial incidence of similar anxiety issues. The initial consultation also needs to explore whether panic per se is a significant component or the symptomology since anxiety is more successfully treated once panic is controlled. (Lynn et al., 2010). It is also crucially important to exclude any possible organic cause of the anxiety. (Lynn et al., 2010, Daitch, 2007)

In her email the client mentions issues of severe anxiety. She also speaks of coping issues “I am struggling to cope with work”. The client appears to experience situational anxiety “I find that I am terrified in meetings” and seems to have low self-esteem or rejection issues “I knew he would be disappointed in me”. The client also sates “I am always worried that I might have an accident, so I need to be near a toilet.”

I would first like to take each of these statements in turn and examine them to establish what information or inferences they provide beyond the factual content itself. This approach leads naturally to further questions that would need to be asked during the initial consultation.

The client states at the onset that she is “suffering with severe anxiety” and immediately follows this statement with “I am struggling to cope with work”. This raises a number of questions.

Firstly, the client only gives one specific example of when the anxiety arises and talks of her intense fear in meetings and her coping strategy of withdrawal. Considered alone, this may be suggestive of situational anxiety or specific phobia and the client would need to be asked about the wider aspects of her anxiety, such as whether it is present most of the time or only in specific situations. It also needs to be established whether her anxiety is general, in other words does she worry about things in general. These specifics can help to distinguish between General Anxiety Disorder (GAD), Social Anxiety Disorder (SAD) or Situational Anxiety/Specific Phobia (SP). This distinction is important since, although interventions for anxiety disorders share many similarities, there are also important differences in approach depending on the particular issue (Daitch, 2011).

Secondly, the client appears to link her inability to cope at work with her anxiety issues. Stress itself can precipitate anxiety and Weitzenhoffer states “Anxiety can best be described as an emotional response to stress.” (Weitzenhoffer, 2000). Hence the question arises as to whether the pressure of coping with workload and perhaps work/life balance (or more importantly imbalance) issues are causing stress which is leading to anxiety, or whether her anxiety per se is making it difficult to cope with what otherwise would be manageable work demands. It is therefore important to ask the history of the anxiety problem to establish whether it is primary to her coping problems or the reverse is the case. This is crucial, as the approach to helping the client would differ significantly depending which was primary, as is addressed later. Asking the client when the anxiety started and what its precipitating factors were will help to address this question. GAD and SAD usually start early in life (mid to late teens) and would therefore precede her coping issues in school, whereas if her anxiety is secondary then stress at work and other pressures would precede the anxiety.

The client’s fear of “having an accident” is one characteristic of SAD (classified as F40.1 Social Phobia in the ICD-10) (Cooper, 1994). However, teaching seems an odd choice of career for someone with this condition which usually starts in the teens, although late onset is a possibility (Daitch, 2011). Although the client’s statement is suggestive that this specific fear is secondary to the anxiety, it would be important to explore this issue further with the client to exclude the possibility of a medical cause of this problem, for example IBS. A client with IBS who needs frequent toilet visits would as likely as not be anxious for this reason alone, although this seems unlikely against the background of the rest of the information provided by the client.

Her statement regarding situational anxiety in meetings is not particularly illuminating in the absence of information on the time line of her issue and answers to the questions asked above regarding the broader circumstances (or not) in which she experiences the anxiety.

The client states that she refused the invitation of a date by an attractive colleague because “I knew he would be disappointed in me”. This could indicate that she has separate issues of low self-esteem, but equally this expectation of negative assessment by others also fits with SAD (Freeman and Freeman, 2012).

Finally since anxiety is frequently comorbid with depression (Eysenck and Keane) p667 and other conditions such as substance abuse and eating disorders (Davey and British Psychological Society, 2014) p148 the presence of other coexisting conditions needs to be kept in mind and the client’s general affective disposition assessed at least informally.

In summary, the information provided by the client at this point suggests two possibilities.

1. The client’s symptoms include many of the characteristics of Social Anxiety Disorder and this problem would explain her difficulty in coping with both work and other social situations where she feels judged. The differential diagnosis rests on the underlying cause of the anxiety being a result of fear of the scrutiny and negative judgements of others (Daitch, 2011) p137.
2. Pressure of workload and other factors (undisclosed) are leading to stress which in turn is causing anxiety and this is leading to her problems of coping with work.

The options above are offered as working hypotheses regarding the nature and aetiology of the client’s anxiety issues. Other questions to be explored during the initial consultation, and later as therapy progresses, include precipitating factors, origins, client resources and obstacles to progress within the context of the client’s issue (Eells, 2015).

It is very important at this stage to be mindful that initial working models depend on the information presented, and to remain open to modifying models as further information is revealed as part of the therapeutic process. For example, a disclosure by the client during the first consultation that she had broken with a long-term partner six months earlier, who had subsequently committed suicide leaving a note that his life was worthless without her, would put a completely different complexion on her anxiety issues, and would raise a rather different set of questions. The working model can only be as good as the data that leads to its formulation and must be subject to continuous review and reappraisal as therapy unfolds.

Importantly, the working model is not meant to provide a diagnostic label per se, but rather and ideally “the explanation contains a cohesive and cogent understanding of the origins of the problems, the conditions that perpetuate them, the obstacles interfering with their solution and the resources available to address them” (Eells, 2015) p107. (Note that Eells uses the term “explanatory hypothesis” rather than working model). In this respect, it provides a territorial map of the client’s problem that can be used as an aid to discussion and selection of therapeutic options and approaches with the client.

Possible Interventions

Many studies suggest that CBT is the treatment of choice for anxiety disorders. (Freeman and Freeman, 2012, Lynn et al., 2010, Nash and Barnier, 2008).

Mellinger, writing in Handbook of clinical Hypnosis, supports this view but presents evidence for the increased efficacy of CBT type interventions when augmented with hypnosis (Lynn et al., 2010). He advocates an approach which he calls Self-Control Relaxation Training (SCRT) which helps to regulate breathing, engage the client in body scan activities and encourages the client to focus on present moment awareness. The approach seems to embed many of the elements used in mindfulness approaches to treating stress and anxiety. Mellinger states that when the approach is combined with psychoeducation and cognitive restructuring it is effective in treating most anxiety disorders.

Bryant, writing in the Oxford Handbook of Hypnosis (Nash and Barnier, 2008) supports this view and, in keeping with a behavioural approach, considers anxiety is a learned response in terms of classical (respondent) conditioning. He argues that any successful treatment of anxiety can be conceptualised as extinction on conditioned responses and advocates exposure based approaches.

Weitzenhoffer (Weitzenhoffer, 2000) suggests that anxiety can be considered to manifest at three levels:

1. Neuroendocrine
2. Motor/visceral
3. Conscious awareness

and argues that successful treatment needs to address each component. He suggests a hypnotic approach involving “fractionation”. In this approach, it is suggested to the client whilst in trance, that their anxiety symptoms should decrease both in frequency and severity. A progressive halving of symptoms is suggested in this approach so that once success is achieved a further halving is suggested and so on. The teaching of self-hypnosis helps to facilitate the process by allowing the client to work on the issue between sessions with the therapist.

Daitch (Daitch, 2011) favours an integrative approach including psychoeducation, relaxation techniques, behaviourally based interventions such as exposure treatment, elements of CBT. Mindfulness based approaches and hypnosis amongst others. She argues that psychoeducation is “an essential step of any treatment (p33) and should include a discussion of the nature and causes of the problem, available approaches to treatment and other resources such as self-help books and recordings and support groups. Knowing that others share the condition helps to reduce any sense of isolation. Relaxation techniques, including aspects of mindfulness, help to counteract the physical aspect of anxiety as it has been argued that anxiety cannot co-exist with relaxation. (Daitch, 2007) Relaxation techniques can be used with or without trance and the client can be encouraged to use a technique or techniques on a daily basis, as well as to combat anxiety when it arises.

For the sake of this essay I am going to start by assuming that the initial consultation confirms that the client appears to be experiencing social anxiety disorder as from the evidence available this seems to be the most probable scenario.

I would first discuss the client’s experience with her and try to reassure her that her condition is not uncommon and that there is good evidence to be optimistic that she will respond to treatment (Daitch, 2007). It is really important at this stage to establish with the client what her priorities are and give her a sense of control and ownership of her therapy as far as is practically possible.

In the initial sessions, I would focus on setting some basics for the therapeutic work to follow.

Any client with an anxiety condition is likely to benefit from relaxation and so my initial approach to therapy would be to use a progressive relaxation approach such as the National College Induction technique (Brookhouse, 2015)(p37). During this first session, I would also use guided imagery to help the client to establish a “safe place” using as many sensory modalities as possible, and associate the image of this safe place with the feeling of physical relaxation. At some point it may be worth exploring setting an anchor with the client (Brookhouse and Biddle, 2013) so that they could use their “safe space” to elicit a felt sense of relaxation to help her to deal with stressful situations such as meetings where she normally experiences anxiety. It would also be useful to teach the client a simple relaxation technique that could be used unobtrusively at any time that she felt anxious or was in a situation which normally provokes anxiety. There are a great many relaxation techniques available, and Daitch lists ten different approaches (Daitch, 2011), but a simple approach based on mindfulness that can be used anywhere is to focus on the breath. Inhalation stimulates the sympathetic nervous system which is activated in the fight/flight response underpinning anxiety. In contrast exhalation activates the parasympathetic limb of the autonomic nervous system which slows the heart rate as well as creating a feeling of calmness due to its modulating effect on the release of stress hormones (Hanson, 2009). As a consequence, a cycle of breathing which emphasises exhalation has a calming and relaxing effect. A simple technique is to breath in slowly and deeply over three seconds, hold the breath for three seconds and then breathe out slowly and deeply over six seconds. The cycle is then repeated a few times until the anxious reaction calms. Such an approach can be used unobtrusively at almost any time and in any circumstances. The technique is similar to “square breathing” described by Daitch (Daitch, 2011) but emphasises exhalation.

The client’s declared history further suggests that she may benefit from exercises directed at ego strengthening, and a suitable ego strengthening intervention such as one based on Hartland’s approach (Brookhouse, 2015) may be beneficially incorporated in a subsequent session.

It is important to assess the client’s response to the interventions offered. There are a huge variety of effective techniques available ( see for example Daitch’s Affect Regulation Toolbox. (Daitch, 2007)) and if one approach does not suit the client or seems ineffective, others can be explored until an approach is found that works for the particular client.

At some point during the progress of therapy exposure therapy may be a profitable approach. This is a technique employed in behavioural therapy that involves exposure of the client to the situations that precipitate the anxiety. Two approaches are used, gradual exposure (GE) and flooding. Both are based on the concept of extinction of conditioned responses. The intervention needs careful cooperative design between client and therapist in order to be effective (Daitch, 2011).

The alternative working model that was suggested was that the client’s anxiety is secondary to stress caused by workload and other undisclosed life pressures, and whilst based on the initial evidence presented this seems less likely, I will briefly address it here.

Where anxiety is secondary to stress, removal of the stressors is likely to be effective in significantly reducing the anxiety response if not resolving it completely. Were it to seem that this were the case, then the client’s coping strategies would need exploring. An approach to resolution of her issue would centre more on helping her to either organise her life differently to reduce the pressure (this may involve changing career as an option) or helping her to think and therefore respond differently to the stressors, and this clearly involves a cognitive behaviour approach.

An intervention including relaxation techniques would still seem appropriate in dealing with the immediate issues, but the ultimate objective would be to help the client to restructure her life and/or her thoughts and responses to her life events.

Finally, as with any therapeutic intervention the treatment plan must be fluid and responsive to the client’s reactions to the interventions, and to the evolution of the therapeutic process as it unfolds, and as new or additional information about the client’s problems are revealed.

References

Brookhouse, S. 2015. Foundation Course in Hypnosis and Psychotherapy. Loughborough: National College Ltd.

Brookhouse, S. and Biddle, F. 2013. NLP Practitioner Course. Loughborough: NCHP Ltd.

Cooper, J. E. (1994) Pocket guide to the ICD-10 classification of mental and behavioural disorders. Edinburgh: Churchill Livingstone.

Daitch, C. (2007) Affect regulation toolbox : practical and effective hypnotic interventions for the over-reactive client. 1st edn. New York ; London: W. W. Norton.

Daitch, C. (2011) Anxiety disorders : the go-to guide for clients and therapists. 1st ed. edn. New York ; London: W. W. Norton.

Davey, G. and British Psychological Society (2014) Psychopathology : research, assessment and treatment in clinical psychology. BPS textbooks in psychology Second edition. Chichester, West Sussex, United Kingdom: Wiley

Eells, T. D. (2015) Psychotherapy Case Formulation Theories of Psychotherapy Series Washington: American Psychological Association

Eysenck, M. W. and Keane, M. T. (2015) Cognitive Psychology : A Student’s Handbook. 7th edn. Hove, Sussex: Psychology Press

Freeman, D. and Freeman, J. (2012) Anxiety : a very short introduction. Oxford: Oxford University Press.

Hanson, R. (2009) Buddha’s Brain – The practical Neuroscience of Happiness, Love and Wisdom. Oakland: Raincoast Books.

Lynn, S. J., Rhue, J. W., Kirsch, I. and American Psychological Association. (2010) Handbook of clinical hypnosis. 2nd edn. Washington, DC: American Psychological Association.

Nash, M. R. and Barnier, A. J. (2008) The Oxford handbook of hypnosis : theory, research and practice. Oxford: Oxford University Press.

Weitzenhoffer, A. M. (2000) The practice of hypnotism. 2nd edn. New York ; Chichester: Wiley.