Working with clients struggling with anxiety? - here are 10 ideas
As practitioners, many of us regularly work with clients presenting with anxiety. Over the years I have gathered a “scrapbook” of ideas that seem to be important or work
well with clients – and I’d like to share these ideas with you.
Although many of these ideas are not necessarily connected to each other – I hope you will enjoy the serendipity of discovering some new ideas or being reminded of those you might have forgotten.
1. Psychoeducation is essential in working with anxiety
There are lots of things that clients need to know about anxiety. Information is essential. We mustn’t forget how frightening it is to experience one’s body apparently being out of control and being beyond our own reach or volition. Anxiety feels dreadful – no wonder people will do almost anything to relieve themselves of the anxious experience.
This is a key idea:
"Most of us will do 'anything' to relieve ourselves of the experience of being anxious."
Psychoeducation: Anxiety is adaptive and potentially selective
It is helpful for clients to know that their anxiety might, at one time, have been their salvation; and saved their bacon from being a tasty meal for a sabre-toothed tiger or a bear – especially in the Yorkshire region.
Those who were alert to threat would probably have survived better than those of us who are willing to kick back our heels and fall asleep in a deck chair with marauding predators around. Those that were alert, like a watchful meerkat, would have survived.
Worry and concern for the future was also an essential component when we ceased to travel the plains; when we ceased to be hunter-gatherers and began to farm our fields. Grain needed to be held back to be employed as seed for next year. This process demands concern for the future and not just living in the moment.
There is a key difference between fear and anxiety. Fear can be seen as being strongly “in the present” with a clear link between the emotion and the stimulus. For example, “I am frightened, that is because there is a tiger in the room”.
Anxiety is not present, but future-focused and has that quality of “What if….?”. “What if I get made redundant”, “What if I get found out?”, “What if my partner finds out?”
2. Anxiety: Perverted Problem Solving
Anxiety is seductive because many people believe that, by being anxious, they are achieving something. It is an agitated passive behaviour and achieves little.
” Worrying about my 18-year-old daughter out clubbing does nothing to protect her from harm – it is a behaviour that appears problem-solving, but this fails”.
Using an expression such as worry being “perverted problem-solving” can help confront the process if used in a collaborative and timely way.
An alternative intervention is to normalise:
Why wouldn’t you……..
Why wouldn’t you worry in such a situation – it seems natural and normal.
Why wouldn’t you……..
3. The Anxiety Crucible or Chalice and supporting belief.
Anxiety has content, process and supporting belief. To get to the root of a worry process it is essential to discover what the underpinning, supporting belief is that is keeping the worry engine going.
If I worry….......it means I’m a good Mum who cares. If I worry….......it means I’m alert to danger, and reduce the risk to me and my family. If I worry….......it means I’m doing something useful to solve the problem.
Logical flow charts can help – they engage thinking and reduce emotion. This is often called “The Worry Tree”.
Anxiety often involves catastrophic, exaggerated beliefs or predictions. An empirical approach can, at this point, be very helpful using the methodology of a twin-tailed hypothesis:
- Theory A – people are judging you harshly because you do have a strange nose
- Theory B – perhaps it is how you are thinking about the situation that is the problem?
Theory A versus Theory B, inviting the client to conceptulise the hypothesis, and then preferably to test it out is an effective way of working with some manifestations of anxiety.
Anxiety always involves future-focused thinking. We have discussed this above as we identified the difference between fear and anxiety. These future focussed “What if…?” betrays that fact that the person really struggles with coping with uncertainty. Could anxiety be seen as the inability to manage uncertainty?
Often, Anxiety involves negative, catastrophic mental images of imagined, terrible future events. I may have the thought “What if I lose my job?” but I am far more likely to have a mental image of me being homeless, living beneath the railway arches, with a malnourished dog for company, earning my living by busking with an old tin whistle.
6. What if……moving to……Then what
The key cognition in anxiety is always a “what if...?” cognition. The treatment focus in working with anxiety is to move the client from a catastrophic place to a place of problem-solving based rather than catastrophic predictions. This can involve the use of heightened examples – the client demanding of themselves to think, and to problem-solve what they would do if things went wrong in a particular way.
What if...? Then what I will do is ...........
The catastrophic future predictions are “always” wrong.
Things rarely, if ever, turn out exactly as predicted therefore the catastrophic predictions are frequently wrong – and a more adult response is to engage with the reality of the ensuing situation.
7. Lack of agency – taking traumatic thinking seriously.
Due to the physiological nature of anxiety, people often are lacking agency and the ability to think with clarity in the middle of the anxious situation. Those suffering with PTSD will often have a terrible, central existential thought lurking in the middle of the experience. “I thought I was going to die”. Notice that this is the same thought that might be in the middle of a panic attack. It is a catastrophic misinterpretation of physiological experiences – but it is still a belief that one’s time is up; the point being that this is a difficult thought to manage.
8. The Anxiety Equation – one of the most useful tools for clients
What is anxiety?
This equation gives a way of focusing on the anxious problem.
Is it a danger problem like a phobia? Danger problems require exposure treatments.
Is it a coping problem like GAD? Coping problems require behavioural experiments.
9. Anxiety is a full phenomenological rehearsal of life.
Those that have taken themselves through a future event in their imagination have given themselves already a powerful experience of this event and created a reinforcing memory of something that is yet to take place. Fantasising about what might go wrong in the future might look like an innocent activity – but rehearsing these future horrors does provide an embodied, almost lived experience of the actual event, as if it has happened.
10. The Seven “F’s” of the anxious response
I hope you have enjoyed this scrap-book of ideas.