Counselling for Anxiety Problems

Books

Diana Sanders & Frank Wills

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  • Counselling in Practice

    Series editor: Windy Dryden

    Associate editor: E. Thomas Dowd

    Counselling in Practice is a series of books developed especially for counsellors and students of counselling, which provides practical, accessible guidelines for dealing with clients with specific, but very common, problems. Books in this series have become recognized as classic texts in their field, and include:

    Counselling with Dreams and Nightmares

    Delia Cushway and Robyn Sewell

    Career Counselling

    Robert Nathan and Linda Hill

    Counselling Couples

    Donald L. Bubenzer and John D. West

    Counselling People with Communication Problems

    Peggy Dalton

    Counselling for Family Problems

    Eddy Street

    Counselling for Stress Problems

    Stephen Palmer and Windy Dryden

    Counselling People on Prescribed Drugs

    Diane Hammersley

    Counselling for Fertility Problems

    Jane Read

    Counselling for Psychosomatic Problems

    Diana Sanders

    Counselling for Grief and Bereavement

    Geraldine M. Humphrey and David G. Zimpfer

    Counselling for Eating Disorders, second edition

    Sara Gilbert

    Counselling Survivors of Childhood Sexual Abuse, second edition

    Claire Burke Draucker

    Counselling for Depression, second edition

    Paul Gilbert

    Counselling for Post-Traumatic Stress Disorder, second edition

    Michael J. Scott and Stephen G. Stradling

    Counselling for Alcohol Problems, second edition

    Richard Velleman

    Copyright

    View Copyright Page

    List of Figures and Tables

    List of Figures

    List of Tables

    Preface

    We were both very pleased to be invited to write a revised edition of Richard Hallam's original book, Counselling for Anxiety Problems, first published in 1992. We have worked together on a number of projects, including writing Cognitive Therapy: Transforming the Image, published by Sage in 1997, which aims to present counsellors with the developments in cognitive therapy which, we believe, make it more attractive for counsellors to use or to integrate with their practice. The opportunity to work on Counselling for Anxiety Problems follows on from our theme and interests: to promote the successful developments in cognitive therapy for anxiety problems in a way which is accessible and attractive to the counselling world. We are convinced by the strong evidence that cognitive therapy offers a realistic and effective therapy for our many clients burdened by anxiety problems, while at the same time being aware of the criticisms and dangers inherent in adopting one approach too rigidly. We hope to present the balance of our thinking in this book.

    As Richard Hallam states in the preface to the first edition: ‘All of us can empathize with what it might be like to suffer from an ‘anxiety problem.’ Anxiety is second to depression as one of the most common psychological problems for which people seek help, from their GPs, counsellors, psychologists, psychotherapists and psychiatrists, and can be pervasive and disabling. Anxiety is an experience of many dimensions, affecting our physiology, feelings, behaviour and patterns of thinking, and is both triggered and maintained by environmental factors. There are many different manifestations of anxiety, the main ones being panic disorder, agoraphobia, specific or social phobias, obsessive compulsive disorder, post traumatic stress disorder, acute stress disorder, generalised anxiety disorder and anxiety problems related to medical conditions or substance abuse. Whatever our feelings and beliefs about the value of diagnosis and diagnostic categories, understanding the kinds of problems our clients are experiencing is vital to being able to offer appropriate solutions. The approach in therapy and counselling for anxiety problems varies for different types of anxiety, and what works for one problem may well be counterproductive for another. This book therefore separates different types of anxiety problems, and describes specific counselling approaches for the different problems, rather than considering anxiety as a single problem.

    Why Cognitive Therapy for Anxiety?

    In this book, we aim to offer an overview of anxiety problems, to look at how cognitive therapy seeks to understand and conceptualise anxiety, and to offer practical guidelines for working with anxious clients generally, and with different forms of anxiety. The reader may stop at this point and ask whether they wish to subscribe to a cognitive approach to anxiety problems. We would urge that the approach is fully understood and evaluated, for both its strengths and weaknesses, before the reader makes up his or her mind. Why cognitive therapy for anxiety? Firstly, cognitive therapy for anxiety problems has improved in leaps and bounds over the past decade, enabling psychological therapists* to have greater understanding of the problems and offer more targeted therapeutic interventions. This is particularly true for some of the most difficult and complex types of anxiety, such as obsessive compulsive disorder and severe agoraphobia. The essence of cognitive therapy is to understand the meanings that thoughts, events, ideas, physical symptoms or behaviours hold for clients. A careful and detailed understanding of meanings, and specific work targeting meanings that are unhelpful, outdated or out of proportion, is central to cognitive therapy, and we have many ideas and tools at our disposal to help us, and our clients, to do this work. Secondly, good research shows that cognitive therapy is effective in helping people recover from anxiety disorders (Clark, 1999a) and cognitive approaches emerge as the treatment of choice for anxiety (Roth and Fonagy, 1996; DeRubeis and Crits-Christoph, 1998; Department of Health, 2001). Thirdly, it is a parsimonious form of therapy, and clients can feel much better, as well as addressing underlying problems, in relatively few sessions. Fourthly, cognitive therapy is not simply a short-term fix for symptoms (Wills and Sanders, 1997), but can offer clients a real understanding of why they are anxious, what is important to them, and what keeps the anxiety going, in terms of both present and past experience.

    * We use the term ‘psychological therapist’ as a generic term to encompass counsellors, psychotherapists, psychologists and others offering psychological therapies.

    Having extolled the virtues of cognitive therapy for anxiety, we are by no means underestimating the potential for other therapies to significantly help anxious clients. Therapists from different disciplines, be they humanistic, psychodynamic, interpersonal, integrative or cognitive analytic, have their various understandings of anxiety disorders, and can help clients to understand and work with anxiety in different ways. All therapies, we believe, aim to encourage understanding of meanings, but within different conceptual models. In non-cognitive therapies, there is less ‘benchmark’ research evidence to demonstrate effectiveness. We suspect that this is mainly because the outcome variables, often of symptom reduction, running through randomised controlled trials of anxiety treatments, are different to the outcome variables of non-cognitive therapy. The recent publication in the British Medical Journal of studies looking at the effectiveness of counselling for depression is a welcome addition to the research on counselling (Bower et al., 2000; Ward et al., 2000). We hope to offer, in this book, both a ‘purist’ cognitive understanding of anxiety disorders, based on both clinical and empirical evidence, and ideas and focus from other disciplines. However, we also believe that if cognitive therapy is practised well, it automatically includes many of the active ingredients of other forms of psychotherapy, particularly the qualities of the therapeutic relationship necessary for any therapy to succeed. Cognitive therapy has been called ‘the integrative psychotherapy’, integrating ideas and approaches from many other therapies, within a cognitive framework or conceptualisation (Alford and Beck, 1997).

    Counselling and Cognitive Therapy

    How do cognitive methods fit within the counselling world? Demands are growing for counselling to be more accountable and to ‘prove itself’, particularly in one of the main settings in which British counselling takes place, the National Health Service, where evidence-based practice and accountability are required. As cognitive therapy was formed within the research-minded orbit of Beck and his colleagues (Wills and Sanders, 1997), it has benefited by being able to claim much evidence for effectiveness (Department of Health, 2001). In some cases, the strong evidence for cognitive therapy has been used as evidence against other therapies, and we have watched with increasing alarm as otherwise rational people have spoken of counselling and cognitive behavioural therapy (CBT) in oppositional terms. The writing partnership between the two authors (and hence the approach of this book) is based on the concept that counselling and CBT are complementary skills which empower each other. Diana is a counselling psychologist who finds that cognitive therapy is a powerful aid to her practice. Frank is a counsellor who has found that the psychological dimension of cognitive therapy has sharpened and amplified his counselling practice. Both authors have considerable experience in training and have found that good counselling skills greatly enhance the quality of cognitive therapy practice (Wills and Sanders, 1997).

    In operating in the middle ground between counselling and cognitive therapy, there is always the danger of succeeding only in offending both parties. Our basic position is that if counselling is to become truly ‘post-tribal’ then the focus should be on what different models can learn from each other (Inskipp and Proctor, 1999). While this position will be exemplified throughout the book, a few tasters here might persuade the doubtful reader to read on. Counselling can learn from cognitive therapy the use of structure, the concentration on generalising the gains of therapy outside the sessions and building ongoing evaluation into sessions. Cognitive therapy can learn from counselling that psychological theory can only take you so far, that clients are essentially individuals who often do not react in textbook fashion, and that self-awareness and good skills add immensely to the interpersonal reality of sessions.

    Overview of Counselling for Anxiety Problems

    This second edition of Counselling for Anxiety Problems has a number of key themes, which are different from the first edition, based on thinking and research in the field over the past decade. We focus on developments in describing and conceptualising individual anxiety problems, enabling counselling to be more targeted on the specifics of the problems. We describe counselling protocols for different anxiety disorders, and look at the pros and cons of protocol-based counselling. We bring new thinking in cognitive therapy, including the specifics of thinking in anxiety, the anxiety equation, concepts of safety behaviours where people's attempts to cope with anxiety become part of the problem, and developments in using ‘behavioural experiments’ as ways of helping people test out their fears and develop new ways of seeing that are less laden with anxiety.

    The book is divided into two parts. Part I describes general issues and themes relevant to counselling clients with anxiety. We start with an overview of anxiety problems, what causes them, how they keep going, and how to distinguish the different forms. We outline the cognitive approach to anxiety disorders, and describe how different problems can be conceptualised. The book goes on to look at the therapeutic relationship when working with anxious clients, highlighting particular issues in developing a working alliance. The following chapters describe in detail how to assess anxiety problems, and the tools and techniques that can be used with anxious clients.

    Part II is devoted to the nuts and bolts of counselling with different types of anxiety, with separate chapters describing different anxiety disorders and how to adapt counselling accordingly. We cover problems of panic, agoraphobia, worry and general anxiety, specific phobias, social anxiety, health anxiety and obsessive compulsive disorder.* The book aims to provide an overview of working with clients with these problems, giving information about relevant research and further reading. The book concludes with an appendix of resources, self-help organisations, publications and web sites, with information for both counsellors and clients.

    The client studies throughout this book are ficticious characters, but are based on examples from our clinical experience, chosen to illustrate specific problems, issues and ways of working.

    * The problems of post traumatic stress disorder and general stress are well covered in Palmer and Dryden (1995) and Scott and Stradling (2000).

    Acknowledgements

    We have learned much of what we know about anxiety through our work with colleagues in Oxford and Newport, Wales, and through our clients, and we are very grateful to all concerned. We thank the kind souls who spent time reading and tactfully commenting on drafts: Jacqueline Tonin, Ann Perry, Brian Hunter, Kathy Baines, June Parkinson, Barbara Sanders and Norma Morrison, and thanks to Helen Jenkins for her help with references. We are, as always, supremely appreciative and grateful to our respective spouses – Diana to her husband, Mo Chandler, and Frank to Annie Wills – who have put up with us changing into preoccupied beasts during intensive writing phases, and helped us in all sorts of ways. We are of course appreciative of each other for negotiating and working collaboratively in this joint project. Alison Poyner and Louse Wise at Sage have been supportive and helpful throughout.

    Every effort has been made to trace all the copyright holders, but if any have been inadvertently overlooked the publishers will be pleased to make the necessary arrangement at the first opportunity.

    Figure 1.1C.A. Padesky and K.A. Mooney (1990), ‘Clinical tip.
    Presenting the cognitive model to clients', International Cognitive Therapy Newsletter, 6: 13-14. Huntington Beach, CA: Center for Cognitive Therapy. © 1986 Center for Cognitive Therapy. Reproduced with permission.
    Table 2.1S. Palmer and W. Dryden (1995), Counselling for Stress Problems. London Sage.
    A.T. Beck, G. Emery with R.L. Greenberg (1985), Anxiety Disorders and Phobias. A Cognitive Perspective. New York: Basic Books.
    Figure 2.3© 1995 Center for Cognitive Therapy.
    Figure 2.4C.A. Padesky and K.A. Mooney (1998), ‘Between two minds: the transformational power of underlying assumptions', workshop given at 28th Congress of the European Association for Behavioural and Cognitive Therapies. © 1995 Center for Cognitive Therapy. Reproduced with permission.
    Figure 2.5M. Fennell (1989), ‘Depression’, in K. Hawton et al. (eds), Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide, p. 171. Oxford: Oxford University Press. Reprinted by permission of Oxford University Press.
    Figure 6.3A. Wells and A. Hackman (1993), ‘Imagery and core beliefs in health anxiety: content and origins', Behavioural and Cognitive Psychotherapy, 21 (3): 265-74. Cambridge: Cambridge University Press.
    Figure 6.5A.T. Beck, A.J. Rush, B.F. Shaw and G. Emery (1979), Cognitive Therapy of Depression. New York: Guildford Press.
    A.T. Beck, G. Emery with R.L. Greenberg (1985) Anxiety Disorders and Phobias. A Cognitive Perspective. New York: Basic Books.
    D. Burns (1999), The Feeling Good Handbook, rev. edn. London: Penguin.
    Table 7.1APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Figure 7.1D.M. Clark (1986), ‘A cognitive approach to panic’, Behaviour Research and Therapy, 24: 461-70. Oxford: Elsevier Science. Reprinted with permission from Elsevier Science.
    A. Wells (1997), Cognitive Therapy of Anxiety Disorders. A Practice Manual and Conceptual Guide. Chichester: John Wiley & Sons Limited.
    Table 7.3APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Table 7.4A. Wells (1997), Cognitive Therapy of Anxiety Disorders. A Practice Manual and Conceptual Guide, pp. 113-18. Chichester: John Wiley & Sons Limited.
    Table 8.1APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Figure 8.1T. Ricketts and G. Donohoe (2000), adapted from A. Wells (1997), Cognitive Therapy of Anxiety Disorders, p. 204. Chichester: John Wiley & Sons Limited.
    Figure 9.1APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Table 10.1APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Figure 10.1D.M.Clark and A. Wells (1995), ‘A cognitive model of social phobia’, in R.G. Heimberg et al. (eds), Social Phobia: Diagnosis, Assessment and Treatment, pp. 69-93. New York: Guildford Publications.
    Table 11.1APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Figure 11.1D. Sanders (1996), Counselling for Psychosomatic Problems. London: Sage.
    P. Salkovskis and C. Bass (1997), ‘Hypochondriasis’, in D.M. Clark and C. Fairburn (eds), Science and Practice of Cognitive Behaviour Therapy. Oxford: Oxford University Press.
    Table 12.1APA (2000), Diagnostic and Statistical Manual of Mental Disorders: 4th edition text revision. Washington, DC: American Psychiatric Association.
    Table 12.2Obsessive Compulsive Cognitions Working Group (1997), ‘Cognitive assessment of obsessive-compulsive disorder’, Behaviour Research and Therapy, 35: 667-81. Oxford: Elsevier Science.
    Figure 12.2P. Salkovskis, E. Forrester, H.C. Richards and N. Morrison (1998), ‘The devil is in the detail: conceptualizing and treating obessional problems’, in N. Tarrier, A. Wells and G. Haddock (eds), Treating Complex Cases, p. 56. Chichester: John Wiley & Sons Limited.
  • Appendix: Books and Self-Help Organisations

    Books

    Flying? No fear! by Adrian Akers-Douglas and George Georgiou. Published by Summersdale, 2000.

    Living with Fear by Isaac M. Marks. Published by McGraw-Hill, New Edition, 2001. Manage your Mind by Gillian Butler and Tony Hope. Published by Oxford University Press, 1995.

    Mind over Mood. A Cognitive Therapy Treatment Manual by Dennis Greenberger and Christine Padesky. Published by Guilford Press, 1995.

    Overcoming Anxiety by Helen Kennerley. Published by Robinson, 1997.

    Overcoming Depression by Paul Gilbert. Published by Robinson, 2000.

    Overcoming Depression: A Five Areas Approach by Christopher Williams. Published by Arnold, 2001.

    Overcoming Low Self Esteem by Melanie Fennell. Published by Robinson, 1999.

    Overcoming Panic by Derrick Silove and Vijaya Manicavasagar. Published by Robinson, 1997.

    Overcoming Shyness and Social Phobia: A Step by Step Guide by Ronald M. Rapee. Published by Jason Aronson, 1998.

    Overcoming Social Anxiety and Shyness by Gillian Butler. Published by Robinson, 1999.

    Overcoming Traumatic Stress by Claudia Herbert and Ann Wetmore. Published by Robinson, 1999.

    Phobias: Fighting the Fear by Helen Saul. Published by Harper Collins, 2001.

    Fake the Fear out of Flying by Maurice Yeffé. Published by Robinson Publications, 2000.

    The Feeling Good Handbook (revised edition) by David Burns. Published by Penguin, 1999.

    Booklets published by Oxford Cognitive Therapy Centre
    • Managing Anxiety: A Users’ Manual
    • Overcoming Social Anxiety
    • Understanding Panic
    • Understanding Health Anxiety
    • Obsessive Compulsive Disorder
    • Managing Depression
    • How to Relax
    • Understanding your Reactions to Trauma
    • Overcoming Phobias

    These booklets are available from OCTC, Department of Psychology, Warneford Hospital, Headington, Oxford OX3 7JX.

    Tel: 01865 223986

    Web site: http://www.octc.co.uk

    Self-Help Organisations

    No Panic: self-help organisation for anxiety, including panic, OCD and phobias.

    Address: 93 Brands Farm Way, Randlay, Telford, Shropshire, TF3 2JQ.

    Tel: 01952 590545

    Fax: 01952 270962

    Web site: http://www.no-panic.co.uk

    Triumph Over Phobia: a network of self-help groups using behaviour therapy to help overcome phobias.

    Address: TOP U.K., PO Box 1831, Bath BA2 4YW

    Tel: 01225 330353

    Web site: http://www.triumphoverphobia.com

    National Phobics Society: help for many forms of anxiety and phobias. Address: Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester, M15 4ZY

    Tel: 0870 7700456 e-mail: natphob.soc@good.co.uk

    Web site: http://www.phobics-society.org.uk

    Fear of Flying Web Site

    http://www.flywithoutfear.co.uk

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