Where there’s a health problem you’re almost bound to find a solution, or something claiming to be one. Some of these are well researched and have a strong evidence base as to their effectiveness, others less so. In this Guide I’ll provide you with some insights into the main approaches where treatment for worry and anxiety is guided, shaped or directed by a therapist.
Western cultures have developed a strong tendency to externalise treatments. We rub on ointments, take tablets, inhale sprays and swallow liquids, for example. These methods are often quick, sometimes effective and they don’t require much from us in terms of cost or effort. What’s more, we tend to have more faith in such things, probably much more than we have in ourselves as agents of change. But none of these approaches is especially effective when it comes to treating anxiety, particularly in the long term, because this requires a form of treatment that comes from inside ourselves.
Don’t misunderstand me, I do think medication has a place in relieving the symptoms of anxiety but I also know it can never stop you from worrying and it certainly won’t get to the bottom of why you are anxious. There may be circumstances where anxiety medication alone is sufficient to get you over a bad patch, but where anxiety is a long-term feature its effectiveness is likely to be limited to the time you take it.
It’s not my intention to list the various anti-anxiety medications their effects and side effects. You can very easily find this information via any search engine. What I will say is medication might be right for you if your anxiety is so severe that you simply can’t function properly. If used in combination with psychotherapy, the effects may be even more beneficial.
But I’m guessing you want to know the alternatives to medication and the longer term solutions? Well the good news is there are several perfectly viable alternatives to medication that come without the risks and the side effects. What’s more, it’s only the psychological therapies that will help provide you with life-long solutions to your anxiety problems.
When it comes to the so-called talking therapies, there are lots of options. In the United Kingdom for example, the Department of Health provides a list of over 40 psychological therapies, and that’s a lot to get your head around. Fortunately, The National Institute for Health and Care Excellence (NICE) has the job of reviewing all the available evidence about treatments for physical and mental conditions; it then provides guidance about which treatments should be used. This is highly significant with regard to psychological therapies and one in particular, known as Cognitive Behavioural Therapy (CBT).
Because of its importance I plan to spend some time describing CBT and I have several reasons for do so. First, as indicated, CBT figures large in the NICE guidelines for the treatment of anxiety disorders and moderate to severe depression, which means it works. Actually, it is generally regarded as one of the most effective treatments available for worry, anxiety disorders and depression.
Other Reasons to Commend CBT:
- it has a proven track record which is still developing
- success rates for all psychological conditions are good
- it is inexpensive and often of relatively short duration (as few as 6 sessions lasting around an hour for mild cases, but usually 10-20)
- it is empowering and effective as a self-help strategy and provides skills (a toolkit) for use well after therapy has concluded
- it is safe and natural and there are no side-effects
- it is increasingly being offered as an online option
The most common approach is one-to-one with a therapist, but CBT can be offered as a part of group therapy, a self-help book, or as an interactive computerised program (CCBT). For example:
These are currently approved for use by the NHS and may be prescribed by your GP and supervised by them or an appropriate practitioner. These are effective and useful options to consider if the idea or the practicalities of meeting regularly with a therapist don’t suit.
How Does CBT Work?
CBT is a treatment approach based around the relationship between thoughts (cognitions) and the behaviours stemming from these. By focusing on particular thoughts and beliefs known to negatively affect your mood and behaviour your therapist, should you use one, collaborates with you in order to overcome your problem(s). The intention of therapy is to reveal how your beliefs, thoughts and ways of coping coexist in a kind of vicious circle. The intention thereafter is to establish alternative and more adaptive ways of coping.
CBT is based around four general principles:
- your anxiety is due to interpreting situations, people or events as more dangerous or threatening than they actually are
- your thoughts, feelings, symptoms and behaviour are interlinked.
- you will benefit from a clear understanding of the factors that keep you feeling anxious
- you need to make changes in order to reduce your anxiety
Structure is a key ingredient. If you choose to go down the CBT route you’ll find there are no couches to lie on and no encouraging you to talk about whatever comes to mind while the therapist takes notes. This doesn’t mean it is cold and heartless. Structure is known to be one of the most helpful aspects of therapy and because CBT is time limited it provides an essential beginning, middle and end.
Emily is a bag of nerves. She used to run a small cake baking business but the tension and stress that came with it got too much. She knows she should have delegated more, but the perfectionist in her meant she’d do things herself and she’d end up baking, helping with deliveries and running the business. Emily has a teenage daughter, who gets frustrated with her mum. She’s always getting text messages from her mum asking how she is, where she is, and whether she’s alright? It’s embarrassing in front of her friends, but if she doesn’t answer or turns off the phone her mum goes ballistic with worry!
“Why do you text your daughter so much?” the therapist asks. Emily confesses that she worries constantly about her daughter’s welfare when she’s out. She thinks of all the terrible things that might happen to her daughter, then she tries to predict how best to handle these situations, what she might say and do and where it might lead. It’s exhausting, Emily says, and it’s why she wants help.
Emily sufferers from generalized anxiety disorder (GAD). It’s uncertainty that fuels her worry and she becomes overwhelmed by thoughts of terrible things that might happen.
Emily’s therapist will want to set some treatment goals but for these to make sense Emily will be asked to monitor and record her worrying over a week or so using a diary or possibly some recording sheets. The sorts of things Emily will record are:
- when and where she worries the most
- things she worries about most often
- recurring worry theme
- whether worries are real or imagined
Working with the therapist, Emily is then shown that her worry reveals three things. First, that uncertainty feeds worry and therefore anxiety. Secondly, worries fall into either a real or imagined category. If real, a problem-solving approach is needed but if imagined an approach that tackles worry is best. Thirdly, it is Emily’s beliefs about worry that help to maintain them.
Now the therapist will work with Emily to establish some treatment goals. These, the therapist says, should be SMART:
- Time limited
This means a goal such as ‘I just want to stop worrying’ is unattainable and impractical. In Emily’s case one of her more realistic goals might be, ‘to stop sending texts to my daughter when she’s out and to find ways of coping with my worry when she is.’ Emily will then develop her remaining goals according to her unique circumstances and needs.
Having set her goals Emily now moves to the therapy stage. In collaboration with her therapist Emily will now be reviewing the homework tasks she was set between sessions. The chances are Emily has been increasing her exposure to uncertainty and learning how to tolerate it by finding situations that actually stimulate uncertainty. In the first instance Emily might practice not checking for text messages every 5 minutes, or even turning off the phone for 30 minutes at a time. She will be told to expect anxiety, but her therapist has taught her a relaxation technique that will help to keep her calm. As she progresses, Emily will increase the number of uncertainties in her life. For example, she might check her email just once a day, or stop prevaricating and make decisions in a set amount of time, or go to the cinema in order to break her more predictable routines.
In summary, the routine for Emily’s sessions will go something like this:
- forms are filled in by Emily that will provide a way for the therapist to assess and measure symptoms and monitor progress
- Emily outlines the biggest problems she’s encountered over the past week, something the therapist calls “agenda setting”
- the therapist will “bridge” the previous session with this one by reflecting on positive and negative experiences and perhaps reminding Emily of certain important features regarding her situation
- self-help tasks in the form of “homework” will be negotiated and agreed
- Emily might be taught new skills that will help challenge or modify her beliefs and thinking patterns so they become more adaptive
- as the sessions draws to a close the therapist may ask Emily how she felt the session went, whether she has any questions or concerns, or anything she’d like to see changed
The Down Sides
CBT doesn’t suit everyone. It isn’t an easy fix and you have to commit yourself to a process that is sometimes challenging and uncomfortable. Some people find the emphasis on logic and structure too cold and they feel something is lacking in not addressing personal histories and emotions. CBT is effective but it does not solve personal problems and there is no cast iron guarantee that your worries and anxieties won’t return. However, if they do, you will have the skills to cope with them more effectively.
We’re all familiar with a basic form of counselling, the kind where one person unburdens their troubles to a sympathetic ear. This simple but very human act can provide relief and comfort and a way to vent stress that might otherwise build up.
These days counselling is big business. There are counselling services for virtually every facet of life ranging from debt relief, to relationships and right through to bereavement. And there are different ways of providing such services such as face-to-face, group, online and telephone counselling. Many medical centres, schools and businesses also retain the services of a counsellor. Despite this apparent endorsement of counselling skills there remains scepticism over its true nature and value, with some seeing the process as little more than a comforting conversation.
A trained therapeutic counsellor is very different to someone who might use counselling skills as a volunteer or as a part of their job. But, there are many different models and variations of counselling, and this can make things confusing. What’s more, there can be considerable overlap in the variety of techniques used and the language employed. So rather than spend time distinguishing between psychodynamic, Gestalt, transactional analysis, and all the other approaches, I’m going to attempt a summary of the broad nature and purpose of counselling as to how it might apply to your situation with anxiety.
In general terms your counsellor will want to help you explore the ways in which your feelings, experiences and behaviour contribute to the issues troubling you. Your discussions will aim to help you to find some clarity and possibly resolution in this regard. This will be made all the more easy because you know everything you say is completely confidential. Your therapist is not there to judge you nor for that matter to advise or tell you what to do. At some points you may find their apparent lack of commitment a little frustrating, but actually this frustration is an echo of your own situation and circumstances. One of the differences between a trained therapist and someone who is just trying to help, is the therapist keeps their beliefs, their value system and the way they live their life, out of the discussion.
Counselling then is a helping approach that encourages you to talk openly and frankly about various aspects of life. These explorations may lead to insights due in part to the way the therapist revisits key issues and encourages you to examine them from different perspectives. Reframing issues can reduce confusion, lessen tension and lead to clarity.
Does Counselling Work?
The answer isn’t as straight forward as you might think. Various controlled studies suggest that counselling is both popular and effective but when it comes to questions about the therapeutic nature of counselling and how its effects should be measured, things get a bit foggy. For example, some people argue counselling should be measured as objectively as possible, using standardised scores. Others see assessing the clients feelings as more significant.
This, to a great extent, reflects some of tensions that currently exist with regard to how or whether counselling can be compared with something like medicine where large randomly controlled trials and objective measures form the criteria for success. Counselling may well see its role, and therefore its criteria for success, in very different ways. Rather than setting out to cure a disease process or alleviate its symptoms the goal for counselling may be for the client to reframe their issue and become more accepting of it.
Even so, if you’re considering counselling the evidence from small controlled trials in medical settings suggests that it is as effective as antidepressant medication. The significance for anxiety sufferers is that these same medications tend to be prescribed for anxiety states.
There are several YouTube clips available on differing approaches to counselling but I think this introductory teaching video on The Counselling Process is a good starting point. It’s targeted at trainee counsellors but it provides a good general insight into what you might expect.
Hypnosis for Anxiety
I’ve included hypnotherapy in this chapter for two reasons. First, I get lots of questions about its effectiveness and this is no doubt due to the second point which is that it’s a fairly heavily promoted technique for a range of anxiety-related disorders. As a stand alone therapy in its own right I personally find it too narrow in scope to address issues of worry and anxiety, although as an adjunct (one tool amongst others) it may have its uses.
Hypnotherapy techniques vary somewhat but typically they involve a preliminary phase of assessment, rapport building and dealing with any misconceptions or concerns about hypnosis.
The next phase is along the lines of combining relaxation with the use of some internal focus and imagery, a process often described as hypnotic induction. The treatment phase extends hypnotic induction by using relaxation, imagery and suggestions to facilitate change, or sometimes to access unconscious memories or mechanisms that have a bearing on the problem. Finally, post-hypnotic suggestions are used in order to reinforce therapy. This is also a time for building belief in change and for establishing self-confidence in the client.
Hypnosis used for symptom relief is different to that for resolving memories and personal conflicts. Suggestive hypnosis is frequently applied to conditions such as social anxiety and smoking, but also to conditions and disorders that are aggravated by psychological factors. Here we can think of things such as migraine, certain skin complaints and irritable bowel syndrome. This mind-to-body link underpins the approach to clinical hypnosis. The strong associations we form during a difficult experience and our emotional reaction to it may set up a scenario whereby the same or similar situations are responded to with some degree of anxiety.
All of which leads me to the question, does it actually work? There is some evidence to suggest that hypnosis can help to reduce anxiety but studies and results to date tend to be underwhelming in terms of their scope and quality. A systematic review published in 2009 by the University of York, also found little persuasive evidence of the overall effectiveness of hypnosis. This may appear a gloomy assessment but it simply reflects the situation as it currently stands. We shouldn’t write hypnotherapy off but until such time we can establish a clearer understanding of its active components (i.e. what it is that is meant to work) and there are some well-controlled large clinical trials to support it, hypnosis is probably best thought of as an option that you may feel is worth a try, particularly if it forms part of a wider formal treatment approach.