Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
Anxiety is a most complex and multifaceted feeling which can be experienced as a fear that has
overtaken the sense of objective danger. The aim of this essay is to understand the day to day
aspects of anxiety and what keeps it going, looking at the situations and symptoms which an
individual appraises as dangerous thus setting up a maintenance cycle of anxiety and furthermore
reflecting on the background beliefs and assumptions which may underlie the problems an individual
experiencing anxiety is facing and where such beliefs and assumptions may have stemmed from.
Moreover the link between thoughts, feelings, physiology, behaviour and environment and how
these interact with each other in different ways and trigger one another off will be explored in order
to discern the different role each of these elements play in the maintenance of anxiety and what us
as therapists can do to help the client with their difficulties.
Additionally the therapeutic relationship will be reviewed considering both ethical and therapeutic
aspects of the process moving onto an assessment of various strategies and techniques to assist a
client understand and cope with their anxiety.
There have been many formulations as to the origins of anxiety starting with Psychoanalysis which
stresses the pivotal role of childhood experiences and how they can manifest themselves later
as anxiety which is seen as caused by unresolved, unconscious conflicts between the desires of
the id, ego, and superego. Biomedical psychologists are more likely to focus on the importance
of biological factors such as hormones and neurotransmitters whereas Behaviourists would
believe that experience has an important impact on anxiety, but they would not credit events
from one’s youth as being particularly powerful. Cognitive psychologists emphasize the
influence of the way people process information and they would attribute an anxiety disorder to
an unhealthy and irrational way of thinking or to specific irrational thoughts.
Page 1 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
‘In more recent models, anxiety is understood to arise when an individual has certain beliefs
about the dangerousness of situations which hold important individual meaning for that person.
Once situations, events, sensations and mental events are seen as dangerous, a complex web of
emotions, actions, physiological reactions and thoughts is formed.’ (D. Sanders & F Wills, 2003,
p. 3). This complex web of elements cited above may stand out in various degrees according to
the specific type of anxiety problem: in General Anxiety Disorder the emphasis is placed on the
cognitive component which takes the form of relentless worries even though physical and
emotional symptoms are present. In contrast when experiencing a panic attack a person focuses
on the physical symptoms and on the emotions of anxiety and fear without being aware of the
cognitive component of their experience. In social phobia and agoraphobia the behaviour of
avoidance will predominate whereas obsessive compulsive people will engage in many
behavioural rituals and compulsions.
There are many physical symptoms to anxiety, i.e. palpitations, increased heart rate,
shortness of breath, muscular twitches or numbness in hands and feet, headaches, the inability
to concentrate, loss of appetite, increased bowel frequency or stomach pains and cramps to
name a few but the role within vicious cycles of anxiety will vary depending on each individual’s
interpretation and response to the symptoms. Some people will read their increase in heart
rate, muscle tension, sleep difficulties and tiredness as a sign of being over stressed and tired
with life whereas for another client, the same set of symptoms, such as experiencing
palpitations could mean something is seriously wrong.
Page 2 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
Alongside the preoccupation and fixation with the concept of danger mentioned above,
clients suffering of anxiety will underestimate their own capacity to cope with situations,
ignoring the wealth of internal resources or that other people are likely to help. When anxious
and distressed ‘negative automatic thoughts’ such as overestimations or over–generalisations
seem to occur spontaneously and uncontrollably and the individual is on the lookout for any
signs of danger, identifying danger in situations which others may completely ignore.
‘The problem in anxiety is that our appraisals are often out of proportion to the true danger of
the event, and therefore the evasive actions may be unnecessary and unhelpful. When anxious
people will avoid situations, get out of the situation at the first sign of anxiety, breathe heavily in
order to calm down, gain reassurance from another person, focus entirely on the self in order to
keep in control and avoid being seen in a negative light’(D. Sanders & F Wills, 2003, p. 23).
An important factor to be taken into consideration is that many clients struggling with anxiety
will seek reassurance from their therapist passing thus the responsibility of making decisions
onto them resulting in clients not gaining in confidence and independence and getting stuck in a
cycle of worsening anxiety. The therapeutic relationship must be one of collaboration, where
therapist and client work reciprocally, keeping an awareness of the interpersonal exchange at all
times, observing and commenting on the client’s way of being and on the interaction between
that and the counsellor’s way of being. Sometimes a client may seem stuck, unable to see
alternatives to beliefs and thoughts and the therapist can offer a different perspective and look
at a situation from another angle. Likewise the client may as well see and offer different ideas to
those of the therapist. In counselling for anxiety it is important that the therapist develops a
Page 3 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
conceptualisation or formulation of the clients’ specific difficulties basing it on the client’s
unique individuality and experience of anxiety but nevertheless refer to a specific model and
mode for therapy. It is also very important that the therapist is aware of his own, personal ways
of dealing with anxiety as there may be times when they may echo the client’s coping mode
which can possibly hinder therapeutic endeavours.
When developing a plan to tackle the anxiety problem the therapist should look both at the
here and now and what is keeping the problems going in the present but also at the factors in
the client’s past that have contributed to making them vulnerable to their particular difficulties.
Usually the first step is to start working at a symptomatic level asking the client to speak about a
recent example when they experienced the anxiety problem and guiding them through a
detailed description. Questions about what they noticed first as they began feeling
anxious(identifying physical symptoms), what went through their minds as they felt the
symptoms ( identifying thoughts), how they felt in themselves ( identifying feelings) or what
they did (identifying behaviours) are asked enabling both counsellor and client to observe how
one thing triggers the next. ‘Anxious thinking and anxious predictions underlie all the anxiety
problems, and therapy very often starts with client and therapist working together to
understand thoughts, images and beliefs which are driving to anxiety, and come up with more
helpful reappraisals ‘ (D. Sanders & F Wills, 2003, p. 83). The client is encouraged to treat their
anxious thoughts and predictions as hypotheses to be tested rather than facts, with the purpose
of exploring the link between events and the client’s interpretation of them. The counsellor
must make sure that he is perceived as empathetic and non- judgmental by their client and aim
Page 4 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
at pointing out that there are many alternatives that may influence their anxious reaction with
no right or wrong way of seeing things. To facilitate the process of challenging and modifying a
client’s anxious thoughts and predictions a counsellor can apply the techniques of guided
discovery using Socratic questioning, and/or behavioural experiments.
Socratic questioning focuses the client’s attention on relevant information which they may
have not previously been aware of, where the therapist uses a question and answer format that
enables the client to look at things from different angles and understand that the way people
perceive things to be is but one way in a sea of uncertainty. The purpose of guided discovery is
to teach clients how to question their own thoughts and beliefs themselves, reducing thus the
potency of the anxious thoughts.
Behavioural experiments are a various range of tasks aimed at helping the client test out
thoughts and beliefs so that their relative validity and truth are explored. They may be seen as
an opportunity for the client to asses if their fear is exaggerated with a powerful effect on the
individual’s beliefs should the fear be disconfirmed, or alternatively the client learns how to deal
with difficult situations or discover they do indeed have many internal resources that can help
them cope with a situation that may have seemed catastrophically to begin with. It is important
that the client keep a diary to record thoughts, specific predictions and outcomes of the
experiments.
For some clients the techniques described above may prove to be highly useful in enabling
them to change their anxious thinking pattern however there are certain people for whom
verbal discussions will not be as potent, reason for this being that they may be encoding
Page 5 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
memories and meaning in images and bodily sensations rather than in words or alternatively
they have developed an intellectualising coping strategy where they avoid emotion by excessive
talking. Sometimes images can be more charged with meaning than words are, giving power to
underlying fears so that it becomes difficult for the client to express these fears in words. It may
also be the case that a client has a felt sense of fear or another emotion, with the feeling
element being predominant and not accessible in words.
In these situations the counsellor will help the client get in touch with the emotionally charged
image, asking them to describe it in greater detail with the purpose of exploring its personal
meaning, implications and origins.
Anxiety has often been described as a feeling however there are practitioners who will look at
anxiety as a blockage to feeling or even as an absence of feelings altogether. When the
counsellor sees anxiety from this angle they will encourage their clients to consider what the
actual feeling which they are blocking with anxiety is and reflect on alternative feelings such as
anger, hurt, isolation, rejection or loneliness to name a few. This will enable the client to
confront their actual feelings and open the door to profound in depth understanding of their
difficulties thus significantly reducing anxiety and panic.
There are a number of useful strategies the clients may make use of on their own or with the
help of a mental health practitioner in order to tackle anxiety and stress problems and they
include various relaxation techniques such as mindfulness, guided imagery, meditation, listening
to relaxation CDs or calming music, , biofeedback, controlled breathing, hypnosis, etc.
Relaxation techniques can be employed as a behavioural experiment as well whereas the client
Page 6 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
can be shown that sometimes something as simple as changing their breathing pattern will
make them feel better. As an example a client may experience chest pains and fear that they are
having a heart attack whereas if shown that a change in breathing can increase or reduce the
pain it will enable them to see that what they were experiencing was not the symptoms of a
heart attack but rather of benign physiology in their breath pattern.
The counsellor has to proceed with caution when using relaxation techniques as in some
circumstances such as in panic attacks being aware of breathing and actively trying to relax will
actually trigger the attack. Another major disadvantage of using relaxation techniques is that it
may turn into safety behaviour and avoidance, preventing disconfirmation of anxious
predictions.
A practical approach a counsellor may take in order to support their clients with anxiety
difficulties is problem solving where clients are encouraged to work out practical and
psychological ways of dealing with problems by using both internal skills and resources or
requesting help from others. Client and counsellor will work together to identify the
components of the problem, setting out clear goals of what the later wants to achieve,
brainstorming a range of solutions to the problem and evaluating those solutions in order to
identify which ones might be helpful and which one to reject. The client will select a few
solutions to try out in first instance and puts them into practice referring to other on the list
should the ones picked first not be feasible or prove to be unhelpful.
There are times when therapy can help a client work on the present episode of a problem
however unless underlying rules and assumptions are tackled and worked through the client
Page 7 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
may experience similar problems in the future as unhelpful assumptions and rigid self- defeating
rules leave the client vulnerable to the risk of relapse. The therapist must approach working
with a client’s beliefs and assumptions with caution as these are very central to a person’s frame
of reference and it may feel threatening to have them exposed or challenged as it can imply that
a client has “got it wrong” for a long time. Empathy is key here, and the counsellor should not
convey the message that any of the client’s assumptions or rules has a value of “right” or
“wrong” but rather, using guided discovery clarify these rules and assumptions and find out how
the client thinks and the reason they think that way thus enabling the rules to be more explicit.
Sometimes simply identifying underlying rules and assumptions will enable a client to change as
they will see how unhelpful is to hold such extreme, rigid black and white rules.
‘The overall aim is for the client to test the assumptions empirically, to find out the relative truth,
helpfulness and unhelpfulness of the rules, and, if found not to measure up, to come up with
alternatives.’ (D. Sanders & F Wills, 2003, p.105).
Homework has been found to be another predictor of successful therapy as it encourages an
ethos of self- help with a focus on learning things that are useful to life in general. Both client
and therapist work together to devise what would be helpful to work on in the week in the form
of reading, filling in diaries to record thoughts and feelings, listening to therapy sessions tapes or
other behavioural experiments with the purpose of working on the experiential mind as well as
the rational where things are tried out to see how they work, i.e. learning by practice, not just
talking.
Page 8 of 9
Diploma in Counselling Skills and Theory: Unit 4, Module 4
Course Code: LONDO2S 18EAST
Student: Mihaela Grecu
Word count: 2688
Essay Title: What are the main ethical and therapeutic considerations when entering into a
relationship with a client who is experiencing severe anxiety attacks?
Furthermore it is important to make clients look at anxiety positively as more often than not
their aim is an anxiety free state and will be fearful of anxiety returning. Speaking in terms of
bodily changes from an evolutionary perspective where a series of bodily changes occur that
include dilation of pupil, altered brain waves, a rise in sweat gland activity, a rise/fall pattern in
heart rate and a blanching of the extremities so that momentarily our perceptions are
sharpened, our decision making abilities are improved, strength is increased, and the danger of
bleeding is reduced considerably may enable the client to look at anxiety with a more rational
outlook. It can be emphasized that the above bodily reactions are a sign that a person has an
innate survival of the fittest capacity because when our ancestors were challenged by a tiger,
the ones who survived were suddenly able to see and hear exceptionally well, make very fast
decisions, become unusually strong, and not bleed as easily as usual. This perspective can
change a client’s negative associations with anxiety.
In conclusion anxiety is a feeling that may seem to be flooding us into our whole selves,
affecting many aspects of our being. In the paper above I have endeavoured to describe the
many facets of how a person’s life may be affected by anxiety and to paint a picture of the wide
variety of techniques and methods that may be used to work collaboratively with clients. I
believe I have reached my objective in what I hope to be a comprehensive layout of the
multifaceted difficulty anxiety is.
Bibliography
Reeves A. (2018) An Introduction to Counselling and Psychotherapy, London: Sage
Sanders D. & Willis F. ( 2003) Counselling for Anxiety Problems, London: Sage
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