Initial Stages of Therapy
When starting therapy for anxiety, clients can expect a process that is collaborative and tailored to their unique needs.
- Building Rapport: The initial sessions often focus on building a trusting relationship between the therapist and client. This involves the therapist actively listening, showing empathy, and creating a safe space for the client to share their experiences.
- Understanding the Client’s Perspective: Therapists will seek to understand the client’s specific experiences of anxiety, how it manifests in their life and what they have already tried to manage it. This may involve discussing recent episodes of fear, worry, or panic.
- Goal Setting: A key element is setting goals for therapy. This involves identifying what the client wants to achieve, and how they will know when therapy is successful. In solution-focused brief therapy (SFBT), the therapist will ask about the client’s preferred future. Goals are individualized for each client, and the focus may be on increasing positive affect rather than reducing negative emotions.
- Normalising Anxiety: Therapists will often explain the nature of anxiety, helping clients to understand that it is a normal human experience and that it can be managed. This can help reduce feelings of shame or isolation.
- Assessing Motivation and Hope: Therapists may assess the client’s motivation for change, their hope for improvement, and their confidence in therapy. If a client has doubts about the therapy, the therapist will acknowledge these and explore them further, perhaps using scaling questions to assess the client’s hope.
- Identifying Triggers: The therapist may work with the client to identify specific triggers or situations that cause anxiety. This may be a situation that interferes with the client’s goals, causes distress, or occurs frequently.
- Agreeing on an approach: The client and therapist may discuss various therapy options and agree on the most suitable. For example, the therapist may give the client a choice of two or more different approaches and ask them which they feel will be most helpful.
Progressive Sessions
Therapy sessions are often linked to build a progression towards positive change:
- Exploring Past Coping Strategies: The therapist will help the client explore what they have already tried to manage their anxiety. This is not to criticise the client but rather to assess what has worked and what has not. For example, they may ask about strategies used to avoid anxiety, or to manage anxious thoughts, and how these have affected the client’s life.
- Creative Hopelessness: In some approaches, such as Acceptance and Commitment Therapy (ACT), therapists may use techniques to highlight how past attempts to control anxiety have been unsuccessful and may even be part of the problem. This is called “creative hopelessness”, and is intended to motivate the client to try new strategies. The aim is to help clients become aware that continuing with the same strategies will not lead to the results they desire.
- Introducing New Strategies: The therapist introduces new strategies such as acceptance, mindfulness, or defusion. The client may use experiential exercises to learn new ways of relating to their thoughts and feelings.
- Focusing on Values: In approaches such as ACT, the therapist will help the client to identify their core values. These values may include family, relationships, work, or spirituality. The goal is to help the client live in a way that is consistent with what truly matters to them.
- Practising New Skills: Therapy involves learning and practicing new skills, and this often includes ‘homework’ activities that are completed between sessions. These activities may involve mindfulness exercises, or trying new behaviours. Clients may record their experiences with different activities and bring them to therapy for discussion.
- Rewriting Negative Stories: Clients may be invited to reframe negative stories or thought patterns into more positive ones. This can help them view their experiences in a different way.
- Working with Imagery: Therapists may guide clients through imagery-based exercises to help them approach difficult emotions in a new way. These exercises may involve bringing up difficult memories, or feelings, with the intention of noticing them and accepting them rather than trying to change them.
- Addressing Barriers: Therapists and clients work together to address any barriers that may be preventing progress. This can involve finding ways to work through difficult thoughts or emotions. Therapists may also support clients to embrace challenges and see them as part of progress rather than as a set-back.
Tools and Techniques Used
Therapists use a variety of tools and techniques, depending on their chosen approach and the client’s needs:
- Eliciting Questions: Therapists may ask questions to encourage clients to think about their preferred future, such as “What would you like to see instead of the problem?”.
- Questions About Details: Therapists may ask for detailed descriptions of specific actions and events, such as “What exactly did you do differently?”.
- Verbal Rewards and Competence Questions: Therapists use positive reinforcement by offering compliments and asking questions such as “How did you manage to come here today?”.
- Scaling Questions: Therapists may use scaling questions to assess progress, confidence, hope or motivation, for example “On a scale of 0 to 10, where 10 is your ideal, where are you today?”.
- Future-Oriented Techniques: Therapists may invite clients to think about the future to help them find solutions and set goals. For example they may invite the client to describe a day in their life one year in the future.
- Mindfulness Exercises: Clients may be guided through mindfulness exercises such as breathing and meditation.
- Defusion Techniques: Therapists may teach clients to defuse from difficult thoughts and feelings, noticing them as just that – thoughts and feelings, and not facts. This may include techniques such as labelling the thought, or thanking the mind for the thought.
- Values Clarification: Therapists may use exercises to help clients identify their core values.
- Experiential Exercises: Clients may be guided through exercises to help them fully experience difficult thoughts and emotions. This may include inviting clients to bring up difficult memories, or sensations, without the need to avoid or change them.
- Homework Assignments: Therapists may assign homework to encourage clients to practice the new skills between sessions. This may include journaling, or making a note of values-based actions.
- Imagery work: Clients may be guided through exercises which involve use of imagery.
When Coaching Solutions May be Offered
Coaching solutions may be integrated into therapy at various stages, depending on the therapist’s approach:
- When clients have gained some skills and want to apply them in their lives. Once the client has an understanding of their own anxiety and has acquired some strategies, coaching can help them implement these into practical situations. The therapist may help them identify goals, plan their actions, and overcome any barriers.
- When the client wants to perform at their best. Coaching can focus on performance-related anxiety, helping clients to develop strategies to manage stress and improve their performance in situations that matter to them.
- When the client wishes to improve their overall well-being. Coaching can help clients identify their strengths and resources and build on these to improve their well-being in many aspects of life.
- When a client wants a more solution-focused and action-oriented approach. If the client is more interested in achieving tangible results and is ready to move towards implementing their goals, a therapist may offer coaching-based solutions alongside therapeutic practices.
Concluding Therapy
The decision to conclude therapy is collaborative. In an SFBT approach, the client is the expert and they decide when therapy is no longer needed.
- Client-Led: The client may be asked, “What would indicate to you that you’re doing well enough that you no longer have to come here?”.
- Reviewing Progress: The client and therapist will review the progress made and discuss strategies for maintaining positive changes.
- Focus on Independence: The therapist will encourage the client’s independence from therapy and help them develop the ability to use their skills effectively in future.
Summary
Working with a therapist for anxiety involves a collaborative and progressive process, tailored to the individual. Therapy begins with building rapport, understanding the client’s experiences and setting goals. Sessions progress with a focus on past strategies, introducing new tools and techniques such as mindfulness, defusion, and values-based living. Coaching may be offered when the client is ready to implement these skills into real-life situations. Therapists use a range of methods including questioning, imagery work, and homework to help clients reach their preferred future, with the client ultimately deciding when therapy should end.