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Presenting Issue of Severe Anxiety

A Presenting Problem of Severe Anxiousness - 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 therefore, although I am going to refer to the info provided, I really do not propose to do it again the essay short here (there is not a title as such). Secondly, I'll refer to your client as Miss Summers in my reaction to her email enquiry. The website given in the response is fictitious. The characters after my name are that part of my real requirements that appears highly relevant to hypnopsychotherapy practice.

The Reply

The response below attempts to first reassure the client and give desire without being unrealistic or deceptive in terms of probable outcomes. For clients with issues of nervousness psychoeducation and reassurance is crucially important (Daitch, 2011). After providing first reassurance, the response handles more pragmatic issues. In this manner, the response aspires to balance providing support, reassurance and approachability with essential information such as payment structure.

"Dear Neglect Summers,

Thank you for your email enquiring about benefit your present situation. Firstly, to make this first contact you have made what is usually the most difficult step towards leading the life span that you would like. Secondly, may I assure you that anxiousness conditions, whilst distressing and devastating if kept untreated, are properly amenable to treatment, and whilst an entire remission of your symptoms cannot be guaranteed, there are incredibly good reasons to be positive about achieving an extremely significant decrease in your symptoms, leading to a dramatic improvement in yourself. It may be reassuring that you should know that in any one year about 20% of the populace are affected from an stress condition of one form or another which such conditions are highly treatable. CAN I suggest that you call me so that people can have a short chat and set up an initial visit for you at which we can discuss your needs in higher depth. My conditions and conditions and payment structure can be found on my website at www. wharton-hypnotherapy. co. uk. It would be useful if you might 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 talking with you soon.

Kind respect,

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

The Primary Consultation

My method of the client's circumstance is modelled on the situation formulation approach defined by Eells (Eells, 2015). In her book, she offers a organised approach to case formulation which helps to ensure that in the initial stage of discussion essential information highly relevant to the client's problem is not overlooked. The procedure leads on obviously to a awareness 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.

Initial information gathering would include an exploration of the client's medical history and in particular, whether the consumer has received therapy for her concern before. This should include whether she has seen a GP, psychiatrist or therapist regarding the presenting concern and any medication. This leads to an exploration of the client's mental health history and lots of the questions expanded on below might be solved in this area of the consultation. Other important info includes the client's domestic circumstances and family circumstances, including familial incidence of similar anxiety issues. The original consultation must also explore whether stress per se is a substantial element or the symptomology since anxiousness is more effectively treated once worry is managed. (Lynn et al. , 2010). Additionally it is crucially important to exclude any possible organic cause of the anxiety. (Lynn et al. , 2010, Daitch, 2007)

In her email your client mentions issues of severe nervousness. She also speaks of coping issues "I am attempting to handle work". Your client seems to experience situational stress and anxiety "I find that I am terrified in meetings" and appears to have low self-esteem or rejection issues "I realized he'd be disappointed in me". Your client also sates "I am always concerned that I would have a major accident, so I have to be near a toilet. "

I would first prefer to take each one of these statements subsequently and verify them to determine what information or inferences they provide beyond the factual content itself. This process leads naturally to help expand questions that could need to be asked through the initial discussion.

The client state governments at the onset that she is "suffering with severe anxiousness" and immediately employs this affirmation with "I am battling to cope with work". This increases lots of questions.

Firstly, your client only provides one specific example of when the stress and anxiety arises and talks of her intense fear in meetings and her coping strategy of withdrawal. Considered together, this may be suggestive of situational nervousness or specific phobia and your client would need to be asked about the wider areas of her nervousness, such as whether it's present most of enough time or only in specific situations. In addition, it needs to be established whether her panic is general, quite simply does she be anxious about things in general. These specifics can help distinguish between General PANIC (GAD), Social Anxiety Disorder (SAD) or Situational Stress and anxiety/Specific Phobia (SP). This variation is important since, although interventions for panic disorders share many similarities, there's also important variations in approach with regards to the particular issue (Daitch, 2011).

Secondly, your client appears to web page link her inability to cope at work with her stress issues. Stress itself can precipitate stress and Weitzenhoffer state governments "Stress can best be described as an emotional reaction to stress. " (Weitzenhoffer, 2000). Hence the question comes up as to whether the pressure of coping with workload as well as perhaps work/life balance (or even more importantly imbalance) issues are creating stress which is resulting in anxiousness, or whether her stress and anxiety per se is which makes it difficult to cope with what often would be controllable work demands. It is therefore important to ask the history of the stress problem to establish whether it's main to her coping problems or the reverse is the situation. This is essential, as the method of helping your client would fluctuate significantly depending which was major, as is dealt with later. Asking the client when the anxiousness started out and what its precipitating factors were will help to address this question. GAD and SAD usually start early on in life (middle to late teens) and would therefore precede her coping issues in college, whereas if her stress and anxiety is secondary then stress at work and other pressures would precede the anxiousness.

The client's concern with "having a major accident" is one feature of SAD (categorised as F40. 1 Social Phobia in the ICD-10) (Cooper, 1994). However, teaching seems an strange choice of job for someone with this problem which usually begins in the teens, although late onset is a likelihood (Daitch, 2011). Even though client's statement is suggestive that this specific fear is supplementary to the nervousness, it might be important to explore this matter further with the client to exclude the opportunity of your medical cause of this problem, for example IBS. A client with IBS who needs regular toilet appointments would as likely as not worry because of this together, although this seems improbable against the backdrop of the rest of the information provided by the client.

Her statement regarding situational anxiety in conferences is not especially illuminating in the absence of information on enough time type of her concern and answers to the questions asked above about the broader circumstances (or not) where she activities the nervousness.

The client states that she refused the invitation of any date by a stylish colleague because "I knew he'd be disappointed in me". This may indicate that she's distinct issues of low self-esteem, but similarly this expectation of negative examination by others also fits with SAD (Freeman and Freeman, 2012).

Finally since stress and anxiety is frequently comorbid with depression (Eysenck and Keane) p667 and other conditions such as drug abuse and eating disorders (Davey and English Psychological Contemporary society, 2014) p148 the presence of other coexisting conditions must be considered and the client's standard affective disposition evaluated at least informally.

In summary, the info provided by your client at this point suggests two opportunities.

  1. The client's medical indications include lots of the characteristics of Public Anxiety Disorder and this problem would describe her difficulty in dealing with both work and other cultural situations where she feels judged. The differential identification rests on the root cause of the anxiety being truly 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 is causing stress and this is leading to her problems of dealing with work.

The options above can be found as working hypotheses regarding the character and aetiology of the client's stress issues. Other questions to be explored during the initial consultation, and later as therapy progresses, include precipitating factors, origins, consumer resources and obstacles to progress within the context of the client's concern (Eells, 2015).

It is vital at this stage to be mindful that first working models depend on the information shown, and to remain open to modifying models as further information is revealed within the therapeutic process. For instance, a disclosure by the client during the first consultation that she experienced destroyed with a long-term partner six months previously, who had consequently committed suicide departing an email that his life was worthless without her, would put a totally different complexion on her anxiety issues, and would increase a fairly different set of questions. The working model can only just be as good as the info that leads to its formulation and must be at the mercy of constant review and reappraisal as therapy unfolds.

Importantly, the working model is not meant to provide a diagnostic label per se, but rather and preferably "the reason consists of a cohesive and cogent knowledge of the roots of the problems, the conditions that perpetuate them, the obstacles interfering using their solution and the resources available to talk about them" (Eells, 2015) p107. (Remember that Eells uses the word "explanatory hypothesis" alternatively than working model). In this respect, it provides a territorial map of the client's problem that can be used as an help to conversation and selection of healing options and strategies with the client.

Possible Interventions

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

Mellinger, writing in Handbook of scientific Hypnosis, helps this view but presents data for the increased efficiency of CBT type interventions when augmented with hypnotherapy (Lynn et al. , 2010). He advocates a strategy which he calls Self-Control Leisure Training (SCRT) which really helps to regulate breathing, participate your client in body scan activities and encourages your client to concentrate on present moment understanding. The approach seems to embed lots of the elements found in mindfulness approaches to treating anxiety and stress. Mellinger states that whenever the approach is combined with psychoeducation and cognitive restructuring it is effective in treating most stress disorders.

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

Weitzenhoffer (Weitzenhoffer, 2000) shows that anxiety can be viewed as to manifest at three levels:

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

and argues that successful treatment must address each component. He suggests a hypnotic procedure involving "fractionation". In this approach, it's advocated to the client whilst in trance, that their anxiousness symptoms should lower both in consistency and severeness. A progressive halving of symptoms is advised in this process so that once success is achieved an additional halving is advised etc. The coaching of self-hypnosis really helps to facilitate the process by allowing your client to work on the issue between trainings with the therapist.

Daitch (Daitch, 2011) favours an integrative approach including psychoeducation, relaxation techniques, behaviourally established interventions such as vulnerability treatment, elements of CBT. Mindfulness founded approaches and hypnosis between others. She argues that psychoeducation is "an important step of any treatment (p33) and really should include a conversation of the nature and factors behind the trouble, available approaches to treatment and other resources such as self-help literature and recordings and organizations. Understanding that others share the problem really helps to reduce any sense of isolation. Rest techniques, including areas of mindfulness, help counteract the physical facet of anxiety as it's been argued that anxiousness cannot co-exist with relaxation. (Daitch, 2007) Leisure techniques can be utilized with or without trance and the client can be motivated to employ a approach or techniques on a daily basis, as well as to combat anxiousness when it arises.

For the sake of the essay I am going to begin by assuming that the initial appointment confirms that the client is apparently experiencing social panic as from the data available this appears to be the most probable scenario.

I would first discuss the client's experience with her and make an effort to reassure her that her condition is not unusual and that there is good facts to be optimistic that she'll react to treatment (Daitch, 2007). It is actually important at this time to establish with your client what her priorities are and give her a feeling of control and ownership of her remedy as far as is basically possible.

In the initial sessions, I'd focus on placing some principles for the healing work to follow.

Any client with an panic condition is likely to benefit from leisure and so my initial method of therapy would be to use a progressive relaxation approach including the National School Induction technique (Brookhouse, 2015)(p37). During this first session, I'd also use guided imagery to help the client to determine a "safe place" using as much sensory modalities as possible, and relate the image of this safe place with the sensation of physical leisure. At some point it might be worth exploring establishing an anchor with your client (Brookhouse and Biddle, 2013) so that they could use their "safe space" to elicit a felt sense of rest to help her to deal with nerve-racking situations such as meetings where she normally experience anxiety. It would also be useful to teach your client a simple rest technique that might be used unobtrusively anytime that she felt stressed or was in a situation which normally provokes nervousness. There are a great many relaxation techniques available, and Daitch lists ten different solutions (Daitch, 2011), but a simple approach based on mindfulness that can be used anywhere is to give attention to the breathing. Inhalation stimulates the sympathetic stressed system which is turned on in the attack/flight response underpinning stress. In contrast exhalation activates the parasympathetic limb of the autonomic anxious system which slows the heartrate as well as creating a feeling of calmness due to its modulating influence on the release of stress hormones (Hanson, 2009). As a result, a pattern of deep breathing which emphasises exhalation has a calming and relaxing effect. A simple technique is to breath in slowly and gradually and deeply over three seconds, contain the breathing for three seconds and then breathe out slowly and deeply over six seconds. The routine is then repeated several times until the stressed reaction calms. This approach can be used unobtrusively at almost any time and in virtually any circumstances. The strategy is similar to "square respiration" referred to by Daitch (Daitch, 2011) but emphasises exhalation.

The client's declared history further suggests that she may reap the benefits of exercises fond of ego building up, and the right ego strengthening intervention such as one predicated on Hartland's methodology (Brookhouse, 2015) may be beneficially integrated in a succeeding session.

It is important to examine the client's respond to the interventions offered. There are always a huge variety of effective techniques available ( see for example Daitch's Have an effect on Regulation Toolbox. (Daitch, 2007)) and when one approach does not suit the client or seems ineffective, others can be explored until a strategy is found that works for the particular client.

At some point through the progress of therapy exposure remedy may be considered a profitable approach. That is a technique employed in behavioural therapy that involves exposure of the client to the situations that precipitate the panic. Two approaches are employed, gradual coverage (GE) and flooding. Both derive from the concept of extinction of conditioned replies. The treatment needs careful cooperative design between client and therapist in order to be effective (Daitch, 2011).

The alternative working model that was advised was that the client's anxiousness is secondary to stress brought on by workload and other undisclosed life pressures, and whilst predicated on the initial information shown this seems not as likely, I will quickly address it here.

Where nervousness is supplementary to stress, removal of the stressors may very well be effective in significantly minimizing the nervousness response if not resolving it completely. Were it to seem to be 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 supporting her to either organise her life diversely to reduce the pressure (this may involve changing job as a choice) or helping her to think and therefore answer in another way to the stressors, which clearly includes a cognitive behavior approach.

An treatment including leisure techniques would still seem to be appropriate in dealing with the immediate issues, however the ultimate objective is always to help your client to restructure her life and/or her thoughts and responses to her life happenings.

Finally, much like any therapeutic intervention the treatment plan must be fluid and attentive to the client's reactions to the interventions, and the development of the restorative process as it unfolds, so when new or additional information about the client's problems are disclosed.


Brookhouse, S. 2015. Basis Course in Hypnotherapy and Psychotherapy. Loughborough: National University 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 consumer. 1st edn. New York ; London: W. W. Norton.

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

Davey, G. and English Psychological Society (2014) Psychopathology : research, diagnosis and treatment in medical psychology. BPS textbooks in psychology Second model. Chichester, Western world Sussex, UK: 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 Mindset : A Student's Handbook. 7th edn. Hove, Sussex: Psychology Press

Freeman, D. and Freeman, J. (2012) Stress : an extremely short benefits. Oxford: Oxford University or college Press.

Hanson, R. (2009) Buddha's Brain - The useful Neuroscience of Joy, Love and Knowledge. Oakland: Raincoast Catalogs.

Lynn, S. J. , Rhue, J. W. , Kirsch, I. and American Psychological Relationship. (2010) Handbook of scientific hypnosis. 2nd edn. Washington, DC: North american Psychological Connection.

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

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

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