Common Client Issues in Counselling An Australian Perspective Anxiety

40 Anxiety CHRISTINE ABSTRACT Anxiety is a leading mental health issue both in Australia and globally . It is important to distinguish between anxiety which serves a protective function and anxiety that may become an unproductive and sometimes debilitating issue . While our clients may not always fit diagnostic or other criteria for anxiety disorders , their health and wellbeing may be compromised by their various forms of anxiety . As counsellors , we need to be aware of the various factors , biological , psychological , social , developmental , and contextual , that may impact anxiety in our clients . Finally , when considering interventions , counsellors need to be aware of the different approaches and available and how they may best fit with the client circumstances . Learning Objectives Define anxiety and identify its various forms . Explore the different theoretical understandings . Evaluate the efficacy of different interventions for anxiety . Develop an approach for assessing and responding to anxiety in a counselling setting . INTRODUCTION What is anxiety ?

What are its nature , types , degree , causes , effects , and responses ?

Anxiety may be seen as a natural response to stressful situations and be accompanied by feelings of worry , nervousness , apprehension ( Australian Psychological Society , 2022 ) When these feelings do not resolve after the stressful situation has passed , become excessive , or compromise the health and wellbeing of a client , there may be an anxiety issue needing intervention . These feelings of excessive worry may lead to avoidance of situations felt to be associated with the anxiety ( Beck , 2021 ) The risk is that this avoidance of internal and external stimuli decreases the healthy interaction a person has with their world and the people within it ( Australian Bureau of Statistics , In this way , the safety behaviours actually increase rather than decrease anxiety ( Centre for Clinical Interventions , 2021 ) Ultimately , clients experience anxiety within many situations they face . What is important for counsellors to identify are the potential factors that can lead to an increase in anxiety and interventions that have been found to decrease the impact of anxiety . Both are discussed later in this chapter . The interventions are explored through et ( 2019 ) analysis of approaches . It is important to distinguish between productive and unproductive anxiety . Not all anxiety is irrational , abnormal and neurotic the capacity to be anxious is a biological function necessary for survival ( 1988 , Our evolutionary history required the quick assessment of potential threats . Anxiety formed the 40

ANXIETY 41 basis of life or death decisions ( 2009 ) When walking into traffic we unconsciously respond using our evolved predatory defense ( Pine , 2016 ) treating the traffic as if a predator threatening our survival . We instantly stop our forward motion and return to safety . In contrast to the obvious external threat of traffic , we may also experience anxiety when internal signals indicate conditions such as low energy supplies , fluid imbalance , or hypothermia ( Pine , 2016 ) 2015 ) argued , not only is anxiety a normal emotion but it is adaptive since it promotes survival by inciting persons to steer clear of perilous places ( 319 ) It is also described as an inborn and adaptive emotion ( 2010 et , 2010 Ray et , 2017 ) Clients usually only seek assistance for their anxiety when it moves beyond a response to events they face . This persistence impacts the client in a variety of ways , including reducing their engagement in their world ( Stein , 2016 ) and may eclipse critical priorities ( 2012 , including education , career , relationships , leisure activities , and feelings of contentment . Whilst anxiety might be seen as common , the distress , impairment , and reduced quality of life require attention and interventions to reduce its impact ( 2012 ) Fear appears to be at the centre of all anxiety issues ( 2009 et , 2009 et , 2015 Paz , 2015 et , 2014 Stein et , 2007 ) So the words fear ' and anxiety are often used interchangeably . Further , in the literature no distinction is made between the subjective states of fear and anxiety , or the different systems involved in each ( Pine , 2016 ) It is perhaps more accurate , according to and Pine ( 2016 ) to consider both fear and anxiety as both mental states and subjective feelings . These states and feelings are underpinned by different behavioural and physiological responses . This distinction highlights the differences between feelings of fear , which arise when a threat is either immediate or imminent to the client and specific in nature , and anxiety , which arises when the threat is uncertain or is distal in space or time or further away from the client ( Pine , 2016 , 1084 ) Additionally , anxiety is not circumstance or , rather it is in nature ( Stein , 2016 Pine , 2016 ) A further distinction is between or trait anxiety ( being prone to anxiety due to a tendency to respond to various situations with concerns and worry , anxiety ) and anger or state anxiety ( current anxiety that tends to be transitory after the situation passes , dental anxiety ) 2015 et , 2020 ) Anxiety is also used as a clinical term to suggest a particular type of mental disorder category , as described in the ( World Health Organization , or ( American Psychiatric Association , 2022 ) Different forms of anxiety are categorised according to their intensity , usually expressed as mild , moderate , or severe . Distinctions are also made based on the characteristics of each presentation of anxiety . Depending on the presentation , anxiety may be categorised into form that something isjust not right with situations such as giving a speech , sensations such as fear of falling , or fear of animals or insects such as cats or spiders as part of stress disorder ( acute , associated with flashbacks , and can be triggered to the level of the panic attack by stimulus like a car backfiring complex ( consequence of repeated or chronic and repeated losses leading to the person organising their life around survival ( Schwartz , 2021 ) obsessive compulsive disorder ( OCD ) that a catastrophe is waiting to happen and can be forestalled by the use of rituals such as putting things in a particular order or scrubbing the hands alongside or part ofa medical issue ( 2009 ) The general diagnostic criteria for anxiety include feeling very worried or anxious most of the time finding it difficult to calm down

42 feeling overwhelmed or frightened by sudden feelings of intense experiencing recurring thoughts that cause anxiety , but may seem silly to others avoiding situations or things which cause anxiety ( social events or crowded places ) experiencing ongoing difficulties ( after a traumatic event ( et , 2019 , The Australian Psychological Society ( 2022 ) adds characteristics of difficulty concentrating , restlessness , rapid heartbeat , trembling or shaking , feeling lightheaded or faint , numbness or nausea , sweating . Clients may also experience nausea , stomach pains , tension in neck and shoulders , sleep issues , and irritability as anxiety builds ( Australian Government , Department of Health and Aged Care , 2019 ) Rather than focusing on specific anxiety disorders as per ( APA , 2022 ) and ( WHO , 2022 ) this chapter takes a broader approach to include aspects of anxiety which involve biological , psychological , social , developmental , and contextual elements as well as their interplay . This aligns with and ( 2005 ) suggestion that looking at common processes involved in the establishment and maintenance of related issues can lead to more effective and impactful interventions . Learning Please watch What is anxiety ?

to gain further understanding of the variety of presentations of anxiety and their impact . Please pay particular attention to the movement between natural anxiety and diagnosable conditions of anxiety . One or more interactive elements has been excluded from this version of the text . Vou can view them online here ?

PREVALENCE Anxiety is considered a common mental health issue both in Australia and globally . In its 2022 World mental health report , the World Health Organization ( WHO , noted both the commonality of anxiety and its increase by 25 during the first year ofthe pandemic . The Australian Bureau of Statistics ( ABS ) reported or million people in Australia reported anxiety in the 12 months of ( The ABS figures were further broken down into panic disorder ( agoraphobia ( social phobia ( anxiety disorder ( obsessive compulsive disorder ( and post traumatic stress disorder ( These figures represent people who have been diagnosed however , they do not represent people who may have diagnosable anxiety yet remain undiagnosed or those whose anxiety is not at the level required for diagnosis . RISK FACTORS The World Health Organization ( WHO , identified a diverse set of individual , family , community , and structural circumstances that all contribute to mental health . Additionally , the combination of life experiences

ANXIETY 43 and genetic predisposition may increase anxiety into a more intense form of anxiety ( 2010 ) These diverse factors are included when assessing anxiety from a perspective ( 1977 ) Anxiety , from this perspective , is seen as a combination of the biological factors of the person , the psychological factors of the person , and their reciprocal interactions with the social aspects of the person ( 1977 ) This can be complemented by developmental theories from ( ecological model ) and ( transactional model ) These models emphasise the importance of seeing the factors within the broader context and culture of a person life . These factors interact and develop over the lifetime of the person and are unique to the historical time ofthat person ( et , 2017 ) While any person can develop anxiety , there are some additional risks based on specific characteristics . It is beyond the scope of this chapter to discuss all the potential risk groups and factors . However , some are discussed next . GENDER The ABS ( 2022 ) reported that gender comparisons show females are more likely than males to develop anxiety ( 21 compared to ) Drilling further down into the statistics , females were more likely than males to have social anxiety ( compared with ) and stress disorder ( and ) ABS , 2022 ) This is a consistent finding in the research on anxiety ( Patel , 2020 ) These differences may be due to biological differences in brain structure which are impacted by genes , hormones , and environment . role expectations , power dynamics , vulnerability to impacts violence and sexual assault , and other risk factors may also impact . These factors may be combined with misogyny , discrimination , being seen as inferior to males , and lower rates of pay that affect females ( Rodgers et , 2020 ) Gender is a complex and not yet clearly understood dynamic of anxiety . AGE In the year old age group in Australia , almost a third ( were identified as having anxiety , including of females ( ABS , 2022 ) Anxiety may be compounded by sleep issues . This is particularly relevant to this age group due to the brain development at this time . Issues with sleep can be exacerbated by social media and other technologies , and potentially associated cyberbullying ( Patel , 2020 ) and ( 2015 ) reported that anxiety issues start in childhood and adolescence or early adulthood , peak in middle age , then tend to decrease with older age . This pattern was identified in epidemiological studies and supported by and Stein ( 2016 ) who further argued that it is important to identify people at risk and commence interventions as early as possible . Longitudinal studies , according to Pine and Fox ( 2015 ) typically suggest that adults who exhibit chronic anxiety had experienced it from childhood . It is , therefore , not surprising to find the age group of year old has a high rate for anxiety . It is also important to consider that anxiety may arise in later periods due to exposure to accidents , illness , and other issues . So anxiety , whilst most prevalent in earlier stages of life , can continue or arise in later stages . Additional areas of concern for youth include separation anxiety , selective mutism , social anxiety , and generalized anxiety ( Kendall , 2020 ) Excessive and developmentally inappropriate anxiety from actual or imagined separation from caregivers in youth over six years old is seen as separation anxiety . As and Kendall ( 2020 ) noted , similar separation anxiety before six years old is considered developmentally appropriate . Social anxiety may arise in youth as avoidance of social situations , avoiding asking questions in class , difficulties with starting or joining conversations , and is present both with adults and peers . Selective mutism is a failure to speak in certain situations despite being able to speak in others . It is important to note that when youth have one form of anxiety , they have a roughly 80 chance of a anxiety issue of another form ( Kendall , 2020 ) concern in the youth age group is the increased risk of and suicide . While the median age of suicide is years , there is a higher rate of suicide in youth ( Suicide Prevention Australia , 2022 ) This

44 is something to be mindful of at any age but is particularly important as the brains of youth develop , impulse control and risk analysis may be low , and feelings and isolation can be overwhelming . IDENTIFICATION The ABS ( 2022 ) reported that of people who identify as gay , lesbian , bisexual , asexual , pansexual , or queer reported anxiety . People in these groups may encounter stigma , prejudice , and discrimination leading to a social environment that can be both stressful and hostile ( Hill et , 2020 ) These phenomena may present in medical treatment that is culturally insensitive or misinformed , violence and harassment , lack of family support , and workplace mistreatment ( Rodgers et , 2020 ) SOCIAL CIRCUMSTANCES There are a range of social circumstances that potentially affect the prevalence . People living in one parent family households with dependent children ( reported anxiety ( ABS , 2022 ) Low socioeconomic status contributes to higher rates of anxiety ( et , 2014 ) Existential concerns can trigger anxiety . These concerns may include not leading a meaningful life or the eventuality of death ( Pine , 2016 ) Stressful events which are ongoing uncertain may also trigger anxiety , for example , being a new parent , work changes , relationship issues , and the death of loved ones ( et , 2019 ) FAMILY FACTORS Based on epidemiological studies , heritability of anxiety issues is estimated to be between ( et , 2015 ) Factors increasing anxiety risk for children include parental anxiety issues ( Baum , 2012 et , 2020 ) and certain parental personality disorders ( cluster A and cluster ) 2010 et , 2020 ) Children are also at an increased risk of a variety of mental health issues , including anxiety , through childhood maltreatment and neglect ( Chu et , 2013 et , 2015 ) physical punishment in childhood ( 2012 ) and or overly harsh parenting style ( 2012 ) Attachment research has highlighted the increased risk of anxiety issues in children with an anxious attachment style ( 1973 ) This includes all forms of insecure attachment as these styles raise anxiety sensitivity and contribute to viewing others as undependable , result in chronic anxiety , increase difficulty in emotional regulation , and cause cognitive errors about threats ( et , 2010 ) Similarly , separation anxiety ( from major attachment figures ) has been studied by researchers as a form of persistent , developmentally inappropriate anxiety ( et , 2013 Comer , 2010 ) The authors report that one third of childhood separation anxiety persists into adulthood ( Comer , 2010 ) while et al . 2015 ) reported over 43 of lifetime separation anxiety had an onset after 18 years of age . Separation anxiety can also reform into other forms of anxiety and depression . ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES et al . 2019 ) reported high levels of psychological distress , including feelings of anxiety , in Aboriginal and Torres Strait Islander peoples . The identified causes of anxiety in this group of peoples needs to be understood through the existence of trauma , and social , historical , cultural , and spiritual factors . These causes include racism and discrimination , loss of cultural identity , being away from country , and not being able to have ceremony . Further information on this issue can be found in the Trauma Animation below .

ANXIETY 45 One or more interactive elements has been excluded from this version of the text . You can view them online here ?

CULTURALLY AND LINGUISTICALLY DIVERSE ( People from culturally and linguistically diverse ( backgrounds represent a significant group within Australia . The ABS ( 2021 ) reported just over million ( of the population ( almost 26 million ) were born overseas ( ABS , 2022 ) A range of issues may arise from being in the group and may contribute to anxiety or other mental health issues . These include increased stigma in their native cultures around mental health issues as well as concerns about trust and confidentiality when interacting with providers of health services ( Baker et , 2016 ) This lack of trust is particularly understandable for those who have experienced human rights violations and persecution leading to their relocation ( Phillips , 2015 ) Trauma , and its associated anxiety , may arise from a variety of causes in their as poverty , political unrest , gang violence , and natural disasters ( Amnesty International , 2022 ) Appreciating such potential for trauma may be contributing to presenting anxiety is an important aspect of working with people from . INDIVIDUAL ATTRIBUTES Many individual attributes contribute to anxiety risk . For example , and ( 2012 ) found behavioural inhibition , such as clinging to familiar others in the presence of strangers , was specifically predictive of social anxiety . Tendencies towards perfectionism , being easily flustered , timid , inhibited , having low , wanting to control everything can contribute to anxiety in childhood , adolescence , and adulthood ( Beyond Blue , 2022 ) So too can certain thinking styles including anticipating the worst , and persistent negative . These can occur alongside difficulty accepting uncertainty , low , sensitivity to internal physical responses , such as increased heart rate , and misinterpreting these physical symptoms as indicating something catastrophic ( APA , 2022 ) A tendency to misinterpret ambiguous situations contributes to a range of emotional issues including anxiety in both social and forms . This tendency for misinterpretation also contributes to specific issues such as body ( et , 2021 ) Body is related to physical appearance interpretation bias ( reduced positive and increased negative ) This interpretation bias promotes social anxiety which also has a higher fear of negative evaluation ( Fang Hoffman , 2010 ) COPING MECHANISMS Some coping mechanisms work well to reduce the development and impact of anxiety . These are often referred to as adaptive coping mechanisms . They sit alongside protective factors to reduce the risk of developing ongoing anxiety . However , clients will often be drawn to coping mechanisms that may negatively impact their anxiety . Some coping mechanisms that place a client at greater risk of anxiety include the use of substances such as alcohol , cannabis , amphetamines , sedatives , emotional eating , gambling , and so forth . These can reduce effects initially but increase the anxiety when the effects ofthe coping mechanism begin wearing off ( et , 2019 ) A common coping mechanism is avoidance . Avoidance is mentioned by researchers such as et al . 2021 ) and features in the diagnostic criteria for anxiety disorders ( APA , 2022 WHO , The

46 tendency to avoid situations that trigger anxiety , rather than facing such situations , can result in an increase of anxious indicators ( 2012 ) LIFE EVENTS While many life events may involve or contribute to anxiety , this chapter focuses here on four examples of life events where anxiety can arise . The first two relate to common developmental a baby , and ageing . These show that specific life events that are developmentally common can give rise to anxiety containing both general and specific aspects . The second two relate to specific issues that give rise to both general and specific forms competition , and test anxiety . Having a baby The impact of having a baby is . One impact can be maternal anxiety which may arise or increase in the period ( Seymour et , 2015 ) Seymour et 2015 study of 224 Australian mothers of infants ( aged months ) identified that 18 had mild to extremely severe symptoms . The flow on effects of this anxiety included fewer close , warm and affectionate interactions with their infants alongside less involvement in their infant learning activities such as playing indoors and reading stories . When depression was evident , there was also a sense of lower efficacy and satisfaction as a parent , and high parental hostility . Factors that contributed to maternal anxiety included lower educational attainment , perceived need for social support , poor couple relationship , difficult child behaviour , and poor quality of sleep . Ageing Older people often experience anxiety alongside other issues related to both physical and mental health . Of import , according to and Lee ( 2020 ) anxiety disorder , for example , has a more severe course and impact . Additionally , exists in the causal relationship between anxiety and cognitive impairment . Impaired cognitive performance increases anxiety on one hand and chronic anxiety states may increase the risk for central nervous system damage due to the impact of chronically elevated cortisol , blood pressure , or excessive benzodiazepine prescriptions . An earlier study by et al . 2008 ) showed prevalence rates of anxiety disorder for those in residential community care to be similar to the general population . In older people , however , they identified additional anxieties connected to in the quality of life , cognitive impairment , increased health care , and poorer functional recovery after disabling medical events such as stroke . What is also important to note is that those people in the age group have a different profile to those under 60 years old including higher rates of uncontrolled worry and different worry content . Athletic competition Given Australia is such a sporting nation , it seems relevant to include something on the anxiety associated with athletic competition . Athletes experience anxiety from factors faced by the general population as well as factors , such as pressure to perform , public scrutiny , career uncertainty or dissatisfaction , and injury ( Vu , 2021 ) Specific forms that may be experienced by athletes include anxiety ( related to the injury not being able to compete ) somatic state anxiety ( where a fear of failure or internalizing worries is expressed physically ) cognitive state anxiety ( where hope for success is reduced due to the memorable expression of anxiety ) and competitive anxiety ( which tends to increase before and during competitions and when those contests are away from home ) Vu and ( 2021 ) stress the importance of responding to both the general and specific contributors to anxiety in athletes . This principle seems more widely applicable to clients who have anxiety so they are not responded to with generic interventions but ones which are tailored to their specific needs .

ANXIETY 47 Learning activity Please watch this video LIAM . Anxiety does stop foryour career . One or more interactive elements has been excluded from this version of the text . Vou can view them online here ?

Consider how the impact of anxiety and panic attacks had on Liam career and life in general , What strategies are useful for Liam ?

How might you use these strategies in your work with clients ?

Test anxiety Test anxiety has been selected as an example as some readers of this chapter may be students affected by this form of anxiety . This specific form of anxiety is an important one to consider as it impacts on the capacity of a person to engage successfully with studies . and ( 2017 ) argued that test anxiety is a transitory or state anxiety related to possible negative consequences of failure on an exam as opposed to the more stable trait test anxiety in which the predisposition is to interpret test situations as overly threatening . Understandably , assessments , such as end of semester exams or other summative tests and assessments , especially those described as capstone assessments , elicit more test anxiety than assessments . Interestingly , and ( 2017 ) identified anticipatory test anxiety actually commenced at the beginning of the semester and then modestly increases as the tests approached . A useful set of study tips from Therapist Aid can assist in managing text anxiety . WITH OTHER ISSUES While we may see the statistics reported so far as indicative of anxiety alone , anxiety often with other issues in both biological and psychosocial domains ( WHO , This interplay supports a thorough approach to understanding the individual circumstances of each client . It also counters the notion that anxiety is an intrapsychic issue alone . This discussion identifies three separate forms of potential with a variety of medical issues that can contribute to , or exacerbate , anxiety as complex anxiety , one form of anxiety with other forms of anxiety ( 2015 ) with other mental health issues . Medical issues Medical issues can be , depending on what they are and their impact . As an example , research into rheumatoid arthritis ( et , 2012 ) used two scales to assess the level Depression , Anxiety , Stress Scale ( DASS ) and Hospital Anxiety and Depression Scale ( In the sample of 169 people in both the United Kingdom and Australia , showed severe or extremely severe anxiety on DASS while showed mild to moderate anxiety . This represents about a 50 increase over general population figures for

48 anxiety . On the , showed anxiety only while showed possible probable anxiety and depression . Equally , cardiac issues can be . For example , et al . 2022 ) followed up cardiac arrest patients at and 12 months from hospital . In the follow up of months , 15 of the 125 people ( 12 ) had problems on the anxiety scale and 16 of the 108 people ( followed up at 12 months . These anxiety rates were higher than the depression rates of at months and at 12 months . Other specific examples of medical issues that have shown a connection with anxiety are hypothyroidism or thyroid ( Stein 2016 ) diabetes , asthma , heart disease ( et , 2019 ) paediatric cardiac diagnoses including anxiety and ( Patel et , 2017 ) childhood absence epilepsy ( epilepsy without the seizures ) Vega et , 2011 ) epilepsy , and cerebral palsy ( et , 2020 ) A specific and broader form of anxiety related to medical issues is health anxiety . This arises when a client has persistent and excessive fear of being seriously ill ( et , 2019 ) This may involve seeking more tests and examinations , using more health services and resources , and may exist with or without medical disease or diagnosis . Indicators of health anxiety include worry about health that quickly and repeatedly resurfaces after reassurance frequent attendance spending excessive time online searching for information ( health worries that lead to substantial functional impairment ( et , 2019 , More recently , in light of the pandemic , a different form has been identified which relates to health and medical ( Taylor , 2020 ) which is fear and anxiety about ( Lee et , 2020 ) A brief screen for this form of anxiety was developed by Lee ( 2020 ) A final form of anxiety discussed here is dental anxiety ( et , 2020 ) This form of anxiety is specifically mentioned as it affects between of the populations in a number of countries and cultures . It has significant impacts on the dental health specifically but more generally the medical , psychological , and social consequences can be significant ( et , 2020 ) Different forms of anxiety of one form with other forms of anxiety is prevalent and may be referred to as complex anxiety ( 2015 ) For example , health anxiety often with generalized anxiety , panic , and medically unexplained symptoms ( et , 2019 ) Health anxiety may include OCD , be a specific disease phobia , or when concerns extend beyond health alone ( financial , interpersonal , occupational ) it may be anxiety , and may involve panic attacks ( Harding et , 2010 ) Obsessive compulsive checking or obsessive behaviour are features of , a chronic fear of environmental degradation due to the sense that ecological foundations of existence are collapsing ( 2020 ) This of obsessive compulsive behaviours also exists with and . et al . 2021 ) found in their sample of 106 Danish outpatients 42 diagnosed with or complex also had panic disorder 25 diagnosed with and 22 diagnosed with complex also had agoraphobia diagnosed with and 15 diagnosed with complex had social anxiety disorder 21 diagnosed with and 13 diagnosed with complex had OCD .

ANXIETY 49 Other mental health issues Anxiety with a range of other mental health issues . The of anxiety and body has been discussed . This is a more obscure due to the low prevalence of body to be ( University , 2022 ) However , other forms of mental health issues have a higher prevalence rate . For example , et al . 2019 ) estimated that over half of those experiencing depression also experience anxiety . They also stressed that in some cases , the presence of one can lead to the onset of the other . Choi et al . 2020 ) add that 45 of those meeting the criteria for depression will meet the criteria for at least one anxiety issue . Wagner ( 2006 ) found of bipolar in children and adolescents with various forms of anxiety , including OCD , GAD , social phobia , panic disorder , and . Additionally , conduct disorder , and oppositional defiant disorder were found to with anxiety ( Wagner , 2006 ) Autism and were also associated with higher rates than in the general population ( et , 2018 ) Research suggests that anxiety forms part of many eating disorders , such as anorexia and bulimia . Anxiety has been reported in 50 of cases reviewed by and ( 2016 ) Anxiety often precedes the development of an eating disorder and may , therefore , predispose a person to an eating disorder ( Grave et , 2021 ) Anxiety may also arise as part ofthe eating disorder itself . For example , avoidance of socialising may arise not due to social anxiety but because of the difficulties eating in front of others or exposing their body shape . Avoidance of social eating and low were offered as potential links between from eating disorders and trait anxiety ( Forrest et , 2019 ) It is important to note that anxiety may resolve itself when the eating disorder is successfully treated ( Grave et , 2021 ) Case Study The Story The case study is an amalgam of clients with whom I have worked and represents a typical presentation of a client with anxiety . As you read the case study , please take a moment to identify the biological , psychological , social , developmental , and contextual issues , Jess presented to counselling with feelings of agitation , fears about the future , and concerns of repetitive patterns of behaviour that seemed out of their control . These thoughts of impending negative outcomes can make getting to sleep difficult due to a racing mind . Once asleep , Jess may find it difficult to remain asleep . Sometimes Jess has a nervous awakening accompanied by a racing pulse and a fearful feeling . Once awake , Jess can find it challenging to return to sleep . Jess has researched anxiety but knowing about anxiety , associated impulsive behaviour , and difficult feelings yet having little ability to control them , frustrated Jess , This often resulted in further feelings of shame and guilt . These impacts were negatively affecting Jess health and , employment , and relationships . Interrupted sleep affects daily functioning as Jess often feels tired and easily overwhelmed as the day progresses , This affects performance at work . There are also certain situations at work where things are more difficult such as meetings in smaller rooms , with certain people who may be aggressive or judgemental in their stance , and with demanding deadlines . Relationships also suffer is sometimes very reactive when tired or overwhelmed , and avoids social situations frequently , Often friends and family decrease their connection . Jess is now seeking assistance in order to minimise or resolve this lifelong issue . ANXIETY As seen in the introduction , conceptions are affected by the lenses through which we view it . In this section several key counselling theories are offered first . Corey ( 2016 ) is the main source for this comparison due to his extensive writing in the field of counselling theories and practice . The main theories covered are psychoanalytic , behavioural , cognitive behavioural , acceptance commitment , gestalt , humanistic , existential , and systems theories . The section then explores the biological aspects through the theory .

50 Psychoanalytic theory identifies anxiety as a feeling of dread resulting from repressed feelings , memories , desires , and experiences that emerged in the surface of awareness . At the core is a conflict between the id , ego , and superego for control of the psychic energy . Two forms of anxiety are reality anxiety and neurotic anxiety . Reality anxiety is proportionate to the degree of real threat from dangers in the external world . In contrast , neurotic anxiety arises when instincts ( id ) may get out of hand and create a scenario in which a person will be punished . Of import is the defense mechanisms a person uses to reduce anxiety ( Corey , 2016 ) Countering defense mechanisms and strengthening the ego are central to managing neurotic anxiety . Behavioural theory rests on conditioning operant or classical . Operant conditioning involves learning through consequences whilst classical conditioning involves automatic associations between a conditioned stimulus and a conditioned response , dog . To include social factors which affect people and their conditioning , the social learning theory was developed . Anxiety is seen as a conditioned response and to counter it , new conditioning needs to take place ( Corey , 2016 ) Cognitive behavioural theory incorporates feelings and thoughts in addition to the behavioural aspects of conditioning ( Corey , 2016 ) and Foa ( 2015 ) explain that anxiety results from thinking , feelings , or behaving . This includes a tendency to overestimate the possibility of negative outcomes . These automatic thoughts are often distorted and thus challenging the thoughts , feelings , and behaving are central to this approach . Acceptance and commitment theory takes a different approach to traditional cognitive behavioural theory . Anxiety is seen as a movement away from the present into the future . Controlling anxiety is seen as problematic so instead of focusing on the anxiety itself , acceptance and commitment theory engages the client in accepting thoughts and feelings without judgement and with curiosity , choosing directions for their life based on their values , and promoting action for change ( 2005 ) Mindfulness techniques and being present in the here and now are promoted ( Corey , 2016 ) In this way , acceptance commitment theory aligns with gestalt theory which also focuses on the here and now . Gestalt theory sees anxiety as resulting from the present and future being ( Corey , 2016 ) In this way , something that may or may not occur in the future becomes present as anxiety . Gestalt theory focuses on the present moment including immediate thoughts , feelings , and behaviours that lead to the anxiety ( Corey , 2016 ) Humanistic theory suggests anxiety is a part of living . However , it can negatively impact a person when they and apply conditional positive regard to themselves . This conditional state leads them to not accept the person they have become . It thwarts the tendency of the person and creates issues such as anxiety ( Corey , 201 ) as well as unconditional positive regard for oneself , form the basis of countering anxiety as congruence results . Existential theory also proposes that anxiety is a condition of living . Anxiety results from confronting the givens of existence , freedom , choice , isolation , and meaninglessness . These givens can result in anxiety as a person realises their mortality , confronts their pain and suffering , struggles for survival , or recognises their fallibility . As with other theories , existential theory differentiates normal from neurotic anxiety . Normal anxiety is an appropriate response to the event being faced whilst neurotic anxiety is out of proportion to the event . Neurotic anxiety is seen as not being within the awareness of the person and ( Corey , 2016 ) In relation to anxiety , existential theory suggests we reduce the neurotic anxiety whilst embracing the normal anxiety as part of life . Systems theories are mentioned here as family systems tend to create modelling from to children , often contain patterns of behaving aimed at reducing anxiety , and feedback loops that reinforce behaviours . The impact of families was discussed in the prevalence section but here it is important to note that most systems approaches aim to destabilise the current dynamics in order to promote more functional dynamics within the family , in order to reduce anxiety ( Corey , 201 ) Neuroscience has added much understanding of anxiety and other mental health issues . This is a reaching set of theories and beyond the scope of this chapter to explore in depth . However , one theory , the theory ( 2022 ) is offered here as it is central to working with clients . This theory also builds on the biological aspects discussed in this chapter , genetics , temperament etc . At the heart of theory is the notion that safety is a core determinant of human functioning . When

ANXIETY 51 humans feel safe , their nervous system is or calm . This allows the homeostatic balance of the person to be supported for health , growth , and restoration . Additionally , due to safety being experienced , the person can be more fully engaged with others and their world . The opposite occurs when people perceive they are not safe . An additional feature of the theory is the connection between calm resulting from safety and higher order thinking capacity . When in an unsafe or anxious state , the amygdala dominates processing and reacting . The amygdala also reduces or disconnects from the higher order thinking parts of the brain , leaving the person vulnerable to reactive states of being . Creating safety through connection to another person promotes of the other physiological state and promotes trust . The higher order thinking is more likely to come back online and engage in problem solving , creativity , sociability , and of health and wellbeing . ASSESSMENT As discussed earlier in this chapter , WHO ( suggests a approach for mental health . This approach is relevant for both assessment and interventions for clients , alongside both developmental and contextual issues . These will now be discussed and applied to the case study . Initial assessment of anxiety and its impact on the client life can be completed through observation by a counsellor ( the counsellor observes indicators of anxiety such as rapid breathing , racing thoughts , and so forth ) together with client ( the client describes their experiences of anxiety , including history , frequency , intensity , and impact ) While the client provides this , the counsellor may engage in specific questions based on their understanding of the impact and type of anxiety the client may be experiencing . These questions might be based on some of the formal inventories that can be used to assess anxiety . At this stage of assessment , as the therapeutic relationship is being developed , inventories may be less helpful as they may interfere with developing the relationship . They may also feel intrusive and robotic to clients in the early stages of working together . Subsequent assessment can involve ongoing observation and client supplemented with formal inventories . The Depression , Anxiety , Stress Scales ( DASS 42 ) is a 42 item inventory . In this full version , the anxiety scale assesses autonomic arousal , skeletal muscle effects , situational anxiety , and subjective experience affect . High scorers in the anxiety scale tend to show these characteristics being apprehensive , panicky , trembly , shaky showing awareness of dryness of the mouth , breathing difficulties , pounding of the heart , sweatiness of the palms being worried about performance and possible loss of control ( Psychology Foundation of Australia , 2022 ) The Depression , Anxiety , Stress Scales 21 ( DASS 21 ) is a shortened version of the full 42 item Depression , Anxiety , Stress Scales ( DASS ) and is more commonly used . The asks clients to assign a rating ( never , sometimes , often , almost always ) to each statement , I find it hard to wind down , I tend to to situations , I feel that I was using a lot of nervous energy . The outcomes of the scores on the DASS 21 can be normal anxiety ( mild anxiety ( moderate anxiety ( severe anxiety ( extremely severe ( This is a direct link to the DASS 21 . It is useful to be familiar with the DASS 21 items when working with clients . Additional inventories that can be applied in counselling include Generalized Anxiety Disorder Scale ( item related to the frequency of anxiety behaviours Generalized Anxiety Disorder Severity Scale ( item measuring both frequency and intensity of anxiety indicators

52 Beck Anxiety Inventory ( BAI ) 32 item measuring severity of anxiety indicators Hamilton Anxiety Rating Scale ( 14 item measuring global anxiety in adolescents and adults Social Anxiety Scale ( 24 item measuring social anxiety or social phobia Overall Anxiety Severity and Impairment Scale ( OASIS ) item measuring indicators ofa broad range issues Spence Children Anxiety Scale a 44 item measure used in combination with the parent version for comparison purposes ( Spence , Generalized Anxiety Disorder Questionnaire for Adults ( item scale to assess the severity of generalized anxiety disorder symptoms on a point severity scale ( to very severe ) The items are frequency of worry , distress due to worry , frequency of associated symptoms , severity and distress symptoms , impairment in work , and impairment in social function . Wagner ( 2006 ) argued that due to the potential of ( I and II ) and anxiety issues , it is important to screen for both . Whilst bipolar disorder may be indicated by severe irritability or rapidly fluctuating mood , these indicators may mask underlying obsessive thoughts , worries , compulsions , somatic symptoms that indicate anxiety issues . The overall aim of assessment is to identify the forms of anxiety being faced by the client , their developmental issues ( such as age , onset , trauma , etc ) and which evidence and clinical based interventions may assist . It is also important to move beyond the anxiety itself and see what contextual events may be contributing and how to respond to these . Case Study Assessment The counsellor made a number of observations when interacting with Jess . These included fast pace speaking which appeared to be an attempt to capture the racing thoughts being experienced . Triggers included interactions with certain people , when work colleagues or friends raised their voices loudly , or provided critical feedback . Indicators anxiety was on the rise included sleep interruption due to a racing mind and circular thinking , associated fear of not being able to sleep , the general sense of concern which could quickly escalate to terror , physical indicators including wringing of the hands , shortness of breath , and affect that fluctuated from calm to agitated in a short period of time . This seemed consistent with complex responses and associated . Questions were asked to clarify the anxiety escalation including the physiological indicators of anxiety , psychological indicators of anxiety , and the affective indicators of anxiety . Jess was able to provide detailed accounts of specific instances where the anxiety was triggered . These accounts indicated was experiencing anxiety that could be triggered by a large range of situations . The assessment continued throughout the sessions , both initially and reviewed as sessions progressed . The anxiety Jess experienced was as complex anxiety with some features of , phobic ( fear of certain situations and people in particular ) rituals to calm the anxiety and obsessive thinking ( mainly cleaning ) and an inability to . Attachment issues arose as an additional consideration to be discussed in a later session . This was focused on once a stable attachment had formed in the therapeutic relationship . Prior to this time , Jess avoided talking about her early family experiences . However , the clue this may be an issue arose in Jess mention in initial sessions that this was a lifelong issue . Whilst no formal inventory was used initially , the questions from the DASS 21 and other scales were incorporated into the conversation . This decision was made due to the obsessive thinking displayed by the client . The guiding thought was the client would obsess over the results being presented in number form . This was based on Jess having discussed the desire to reduce the numbers whenever a quiz or inventory had been completed in the past .

ANXIETY 53 INTERVENTIONS While we may consider the existence of anxiety to be a modern condition , its roots go back to the Ancient Greek and Latin authors who reported pathological anxiety as medical disorders ( 2015 ) Since then , different theories have arisen based on different schools within counselling . Each school , as previously discussed , anxiety in its own manner . This is based on the core tenants of the specific school of thought . Putting aside the different conceptions , we now turn to the most effective approaches . These approaches are and shown to have efficacy ( et , 2019 ) Learning activity Before reviewing possible interventions , a special focus is placed on working with two groups of people . Aboriginal and Torres Strait Islanders . Culturally and Linguistically Diverse people ( To work effectively with Aboriginal and Torres Strait Islander people , we need to move into healing traditions that are effective rather than only applying approaches . A useful guide to review is Indigenous Healing Practice Training Standards . Please review these training standards and the approach suggested within them . When working with people who have a background , some guidelines are offered by the Department of Health , How can a culturally and linguistically diverse person with a mental health issue ?

Please review these guidelines . Learning activity Please review A guide to what works for anxiety An review . The table on page 19 highlights psychological interventions and offers a ranking of their usefulness and . The table on page 21 offers some complementary and lifestyle interventions . Please note the different recommendations for the various forms . TOP DOWN AND BOTTOM UP STRATEGIES Depending on the client and their anxiety , as well as other issues , we need to consider whether top down or bottom up strategies or a combination are the most useful . As noted in the neuroscience conception of anxiety , not all anxiety can be reached through the ' mind and instead comes from which needs to be dealt with indirectly ( 2022 ) can create anxiety sensitivity as discussed earlier . et al . 2016 ) and et al . 2017 ) argue for awareness of both top down and strategies for anxiety . This responds to the bottom up , sensory driven mechanism that selects stimuli based on their physical salience mechanism with variable selection criteria , which selects stimuli based on expectations , knowledge , and goals . While approaches , including and various forms of , may assist in general awareness and understanding of anxiety , the challenge is that bottom up mechanisms tend to bypass these thinking processes and automatically shift resources and focus to the stimuli which is perceived as a potential threat ( 2022 et , 2016 ) In the counselling context , this difference may be fed back by

54 clients when they state that they know about anxiety and still can not manage it . These quick response systems ( the amygdala in the brain ) have evolved to activate quickly to protect the person from threats , and the default of this process is to override conscious control ( 2022 ) As you will see in the case study , a combination and approaches can be helpful . As with all mental health issues our clients face , there is potential ambivalence about change . As ( 2012 , argued this ambivalence may arise when the negative effects of anxiety are countered by the familiar patterns that have a seductive quality . In response to this ambivalence , we can use motivational interviewing and an appreciation of the stages of change as underpinning models ( 2012 ) Further information on motivational interviewing can be found in this video while stages of change can be found in this video . Increasing protective factors applies to anxiety interventions as well as in general counselling . and Patel ( 2020 ) identify protective factors in three areas individual , family , and community . All combine to assist the client . As you read the lists offered by and Patel ( 2020 ) you will see that some target specific indicators of anxiety whilst others focus on broader issues to overcome adversity , adaptability , adequate sleep , conflict management skills , stress coping skills present relationship , cohesive family unit , higher parental education , parental employment and higher socioeconomic status , parental security , positive parenting , support from family networks , empowered social relationships , integrated ethnic minority groups , positive environment and the school system , social awareness and involvement , social responsibility , support from friends and the community ( 556 ) INTERVENTIONS We have many interventions available for assisting with anxiety . These may be particularly appealing for younger clients who may be and they are also useful for clients who wish to develop autonomy . Many of these interventions are free or low cost and can be used within counselling sessions by the client as tools . They can also be combined with counselling interventions ( et , 2020 ) For example , anxiety sensitivity is an aspect of anxiety that can be worked on in counselling sessions using technology . Anxiety sensitivity involves fear related to the sensations and behaviours associated with anxiety or , as et al . 2017 ) define it , fear of sensations . Anxiety sensitivity is a risk factor for anxiety issues ( et , 2017 ) The difficulty in countering anxiety sensitivity is that it tends to be automatic cognitive processing which is unconscious , efficient , unintentional , and uncontrollable and focuses attention on information ( et , 2012 ) To reduce anxiety sensitivity , the cognitive anxiety sensitivity treatment ( CAST ) focuses on the interoceptive conditioning that is a risk factor of panic disorders and separation anxieties ( et , 2021 ) This incorporates elements from two computer assisted programs anxiety sensitivity amelioration training ( which provides information on the nature of stress , effects of stress on the body , teaches participants about interoceptive conditioning along with instructions on exposure exercises , delivered via audiovisual computer presentations . anxiety sensitivity education and reduction of training ( which includes psycho educative elements , stress reduction training , interoceptive exposure exercises focusing on respiratory distress ( hyperventilation , breathing through a straw ) CAST incorporates the elements from both and in a more sophisticated computer presentation , video instructions of repeated interoceptive hyperventilation and straw breathing exercises , and quizzes testing comprehension of important material . The aspect of this approach is focused on the

ANXIETY 55 nature of stress , its effect on the body , and dispelling the myths regarding the immediate dangers of stress . It highlights that anxiety may be a conditioned fear . This fear response elevates the anxiety sensitivity . Other possibilities for effective programs and apps include program Social Anxiety program Wellbeing course Anxiety and Worry program PANIC STOP ! app GAD Online program SAD Online program Anxiety forum ( Australian Government , Department of Health and Aged Care , 2019 ) Counsellor reflection While there is no approach to intervening with anxiety and associated issues , it is useful to apply an integrative approach . That way , we can tailor interventions to incorporate both the interventions and the clinical evidence we develop as counsellors . As an example , after 30 years in the field , I have experienced varying levels of success with clients who have anxiety using the approaches from cognitive behavioural theory . In part , this can be attributed to the complex clients I have worked with who need assistance with both their anxiety and contextual issues , including home and financial insecurity , domestic violence , and other issues . The combination of evidence and clinical based interventions can be tailored to the client specific presentation of anxiety as each presentation of anxiety requires its own focus , responding to generalized anxiety is different to obsessive compulsive issues developmental issues , such as age of the client may be incorporated , counsellors work with play therapies to create safety for children while they may incorporate reminiscence therapy with older people specific attributes of the client , thinking biases , behavioural actions , emotional or specific circumstances of the client , health and wellbeing , financial issues , substance and behavioural addictions . The complexity of the interactions between the circumstances and the client attributes , as well as the form of anxiety that is specifically identified , provide clues for what may be effective for that client . It is also worth noting that direct focus on anxiety may lead to its escalation . This is where motivational interviewing or ACT focus on values and present moment acceptance can be helpful . An additional clinical intervention I have found useful is the narrative therapy process of the issue at hand so the client can separate themselves from the issue . It is also useful to draw on narrative alternative story which focuses on potential change rather than problem saturation . GENERAL PRINCIPLES UNDERPINNING SPECIFIC INTERVENTIONS One of the important aims of this book and this chapter is to offer an integrative approach in tailoring

56 interventions to the client . On this basis , we now turn to a number of general principles that can assist counsellors when working with clients with anxiety . IO . 11 . 12 . 13 . Establish and maintain a safe and regulated therapeutic relationship with the client . Therapeutic relationships are particularly important for clients who have anxiety as they provide safety ( 2022 ) They can also provide a secure attachment for the client . Obtain a comprehensive history from the client as this allows identification of factors , developmental and contextual factors , their , and their impact ( WHO , Provide a referral to the client for medical evaluation , in case specialised interventions are required . Reassure the client that anxiety is an important survival response ( and can assist the client to rethink anxiety and its usefulness ) A useful addition is the anxiety from narrative therapy ( 2019 ) allows the client to gain some agency over the anxiety and appreciate its purpose in their lives . Provide strategies for the client to be in the present moment rather than caught in their anxiety which is . ACT and other approaches incorporating mindfulness emphasise the importance of this strategy . Provide strategies to assist the client when their anxiety is too high for strategies ( including grounding , breathing , relaxation , expulsive such as skipping , singing , or similar ) et , 2016 ) These strategies can assist the client to break the cycle of avoidance and escalation . Assist the client to identify the sources of anxiety and how to manage them more directly . An anxiety or exposure hierarchy is useful to identify the sources along with an extra column for specific strategies to assist the client . Having this in written form means the client can consult this when higher levels of anxiety exist which compromise the strategies . Worry coping cards are an electronic version that can be integrated into the last column . Assist clients to assess evidence for anxious thoughts and beliefs can be beneficial ( is the best source for this strategy ) By focusing on the evidence , there is a redirection away from the anxiety and an awareness that the anxious thoughts may have no foundation . Provide expanded physical awareness activities so the client moves beyond their own tendency to anxiety sensitivity ( focus on areas of the body where there is no anxiety ) Ask the client to imagine this issue in months then months time and whether this aligns with what the client wants in their life . This is motivational interviewing and works to reduce the impact of the anxiety and offers the option that this can be managed . It also builds a commitment to change . Refocus the client on what sort of life they wish to have ( using ACT strategies of focusing on values ) Focusing on strengthening protective factors can also assist . Establish a broader and more nuanced vocabulary for affective states ( often clients with anxiety have limited and descriptions of their feelings , such as awful , terrible , intense ) Pine Fox , 2015 ) Increase emotional management strategies to intervene as low as possible when anxiety is building ( dialectical behaviour therapy is useful here ) Case Study Integrative interventions

ANXIETY 57 A combination of the top down and bottom up interventions was employed with Jess . tended to overthink and , cognitive strategies alone were not sufficient to assist . Additionally , the aspect was not effectively attended to through cognitive approaches alone . In part , this was due to the rapidity of responses to emotional stimuli . Emotions had generally been considered as negative and threatening rather than . Jess had researched anxiety and could not understand why knowing about anxiety was not enough . around the automatic and sometimes exaggerated perception of threat was discussed . This was ( a narrative therapy term ) as anxious brain so that Jess could distinguish between the response of anxious brain and the more deliberate and slower thinking brain . An analogy of the light switch was used when the amygdala ( anxious brain ) was switched on , the neocortex ( thinking brain ) switched off . So once the body was in an anxious and aroused state , the thinking and logical state was compromised . The importance of the anxious brain in protecting and keeping Jess safe was discussed alongside balancing that protective aspect with engaging the thinking brain to evaluate the perceived or actual threat . Jess was particularly vulnerable to anxiety when with certain people ( family members and manipulative friends ) in certain social situations ( groups of friends , family get , work colleague gatherings ) and where substances such as alcohol and marijuana were used solo or together . Jess suggested that keeping away from these situations was best . However , we discussed how avoidance actually promoted the anxiety aspect of these situations . Instead , we discussed ways could use appropriate boundaries , such as timekeeping and leaving when uncomfortable , avoiding the use of substances at these events , and ways to manage anxiety if it arose at these events . We also discussed preparation for such events through relaxation techniques such as focusing , grounding , and breathing . MEDICATIONS The primary psychotropic medications that are used to assist in anxiety management include ( 2020 Choi et , 2020 Pine , 2016 et , 2020 ) which can assist reduction of anxiety in some clients ( 2020 , 2020 Choi et , 2020 in Pine , 2016 ) 2020 Choi et , 2020 Stein , 2016 et , 2020 ) and tricyclic antidepressants ( 2020 ) However , we need to be clear that some medications are for certain forms of anxiety . As an example , et al . 2019 ) created a table showing the different forms of medication and the specific forms of anxiety they address . As with most medication , its efficacy alone is lower than when it is combined with counselling ( Stein , 2016 ) et al . 2017 ) also highlight that medication requires careful consideration as once it is stopped , most gains from the medication are lost and may also remove the gains from counselling . Learning activity Please guide to what works for anxiety . The table on page 20 highlights medical interventions and offers a ranking oftheir usefulness and . Case Study Returning The use of medication as an adjunct to counselling was discussed with Jess in the first few sessions . This was to assess the openness to a holistic approach to interventions . Jess did not want to use any medication on an ongoing basis but did feel that the use of a relaxant might be of assistance when the anxiety was too high during the day or at night when sleeping was difficult . An appointment with Jess was made between sessions and a script was accompanied by the warning that the addictive quality of the relaxant and of the underlying anxiety could be problematic . Jess committed to counselling in order to explore the underlying issues prompting anxiety . The counselling sessions allowed Jess to appreciate the underpinning issues causing anxiety ,

58 misinterpretation of body signals via , strategies to challenge the anxious brain as it took over with thoughts that led to behaviours Jess did not wish to engage in , and safety was established and maintained through a secure therapeutic relationship . Healing was a longer term process given the early onset of anxiety and the reinforcing factors in Jess relationships . Through Jess persistence and willingness to continue in counselling , a point was reached could anticipate situations and how to manage them . Jess also learnt how to manage the immediacy of anxiety when it surfaced and how to use bottom up strategies to settle the nervous continues to have a productive life which is less affected by anxiety and associated issues . CONCLUSION This chapter introduced the different forms of anxiety and highlighted that not all anxiety is neurotic or unhelpful . The chapter discussed the complexities of anxiety , including its with a variety of medical issues , other mental health issues , and between the different forms of anxiety . The impacts in its various forms may impact all aspects of a client life . It is therefore crucial for counsellors to understand the circumstances in which the client finds themselves . Equally important are the client thinking , behaving , affect , and coping responses . There are multiple interventions available to clients both within a counselling context and in other healing . Our role as counsellors is to appraise best fit for our client , in a collaborative and approach . RECOMMENDED RESOURCES This section highlights some of the resources available to you when working with anxiety issues . It is recommended that you also see the list of references for this chapter as it offers many resources for your use . RESOURCES Creating a story of safety A guide to managing anxiety . Video . 2009 ) The anxiety workbook New panic to . Quarto Publishing Group USA . This is a useful workbook for clients as part of counselling processes . According to my own reading and that of many clients I have referred to this book , it is readable and informative . Coping with anxiety A useful resource for both counsellor and client use . Beyond Blue As there is often a and depression , Beyond Blue has developed resources for both . Black Dog Institute offers information on anxiety and also other mental health issues . This includes a mental health assessment tool . Centre for Clinical Interventions . clinician resources demonstration videos for counsellors . by Headspace Head to Health website which provides valuable information on technology and applications that can assist both counsellors and clients . Kim , Ed . 2020 ) Anxiety disorders Rethinking and understanding recent discoveries . Springer . Government , Department of Health . 2022 ) Anxiety disorders .

ANXIETY 59 SANE . SANE is an organisation that works for people with complex mental health issues . This is a useful site for many clients and provides resources and communities with whom they can connect . The Centre . Various videos on the application of narrative therapy to issues . Whilst narrative therapy is not mentioned in the et al . 2019 ) analysis offered in this chapter , it has been found effective in many domains of counselling practice . Of particular note is their work on creating cultural resonance with Aboriginal and Torres Strait Islander peoples . Therapist Aid is an excellent website that offers many worksheets for use in counselling . This link takes you directly to the dialectical behaviour therapy worksheets . GLOSSARY OF TERMS Forms of anxiety response to stressful situations accompanied by feelings of worry , nervousness , apprehension and anxiety about chronic fear of environmental degradation due to the sense that ecological foundations of existence are collapsing form of anxiety that something is just not right phobic associated with situations such as giving a speech , sensations such as fear of falling , or fear of animals or insects such as cats or spiders complex stress disorder ( and stress disorder ( and acute anxiety , associated with flashbacks , and can be triggered to the level of the panic attack by stimulus like a car backfiring health and excessive fear of being seriously ill obsessive compulsive disorder ( that a catastrophe is waiting to happen and can be forestalled by the use of rituals , such as putting things in a particular order or scrubbing the hands psychotropic medication that affects behaviour , mood , thoughts , or perception , including , and mood stabilisers separation arising when separation from major attachment figures occurs test transitory state anxiety related to possible negative consequences of failure on an exam Diagnostic tools is the abbreviation for the Diagnostic and Statistical Manual of Mental Disorders . This text is a classification guide for psychiatric disorders and is used within clinical psychology , psychiatry , and research . The current manual is in its edition . is the abbreviation for the International Classification of Diseases . It is now in its edition . REFERENCES American Psychiatric Association . 2022 ) Diagnostic and statistical manual of mental disorders Text revised version ( Amnesty International . 2022 ) Refugees , asylum seekers , and migrants . Shear , El . 2008 ) Generalized anxiety disorder severity scale validation in older adults . The Psychiatry , 16 10 )

60 , Lee , 2020 ) Anxiety disorders in the elderly . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . 2020 ) Cognitive behavioral therapy , cognitive therapy and acceptance commitment therapy for anxiety disorders Integrating traditional with digital treatment approaches . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . 2009 ) therapy with adults . John Wiley Sons . Taylor , 2020 ) Fear and the Disorders , Australian Bureau of Statistics . ABS ) July 22 ) National study of mental health and wellbeing , release Australian Bureau of Statistics . Cultural diversity . Australian Government , Department of Health and Aged Care . 2019 ) Anxiety disorders . Australian Psychological Society . 2022 ) disorders . A . 2018 ) The presence of and anxiety symptoms in autism spectrum disorder Clinical presentation and . Frontiers in Psychiatry , Baker , Proctor , Ferguson , 2016 ) Engaging with culturally and linguistically diverse communities to reduce the impact of depression and anxiety A narrative review . Health Social Care ) 24 ( 2020 ) Role of in anxiety disorders . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . 2020 ) Current and novel drugs for anxiety disorders . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . 2015 ) Epidemiology of anxiety disorders in the century . Dialogues in Clinical Neuroscience , 17 ( Beck , 2021 ) Coping with anxiety . 2012 ) Developmental epidemiology disorders . Child and Adolescent Psychiatric Clinics America , 27 ( Beyond Blue . 2022 ) Clark , A . 2013 ) Adult separation anxiety disorder in . Clinical Psychology Review , 33 ( 973 ) Attachment and Loss Vol . Separation . Basic Books . Patel , 2020 ) Risk factors and prevention strategies for anxiety disorders in childhood and adolescence . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . Allan , Schmidt , 2017 ) Combined and intervention for anxiety sensitivity Pilot randomized trial testing the additive effect of interpretation bias Research , 85 , Centre for Clinical Interventions . 2021 ) What are safety behaviours ?

Choi , Kim , 2020 ) anxiety and depression Clinical and conceptual ANXIETY 61 consideration and treatment . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . Chu , Williams , Harris , Bryant , 2013 ) Early life trauma predicts reported levels of depressive and anxiety symptoms in nonclinical community adults Relative contributions of early life stressor types and adult trauma exposure . journal of Psychiatric Research , 47 ( 2012 ) Behavioral inhibition and risk for developing social anxiety disorder A study . journal of the American Academy of Child Adolescent Psychiatry , 51 ( 10 ) Comer , 2010 ) The epidemiology of anxiety disorders . In Simpson , Anxiety disorders Theory , research , and clinical perspectives ( Cambridge University Press . Corey , 2016 ) Theory and practice and psychotherapy ( Cumming , Emery , Tennant , A . 2012 ) Depression and anxiety in patients with rheumatoid arthritis prevalence rates based on a comparison ofthe depression , anxiety and stress scale ( DASS ) and the hospital , anxiety and depression scale ( Psychiatry , 12 ( Pine , 2009 ) What is an anxiety disorder ?

Depression , 26 ( 12 ) Stein , 2016 ) Anxiety . The Lancet , 388 ( 10063 ) 16 ) 2015 ) A history of anxiety From Hippocrates to . Dialogues in Clinical Neuroscience , 17 ( Wilhelm , 2021 ) Interpretation bias across body , social anxiety and generalized anxiety multilevel , diffusion model account . Cognitive Therapy and Research , 45 , Cath , Hox , van den , 2015 ) Updated of classical fear conditioning In the anxiety disorders . Depression and Anxiety , 32 ( Paz , 2015 ) Fear generalization and anxiety Behavioral and neural mechanisms . Biological Psychiatry , 78 ( 2005 ) Acceptance and commitment anxiety disorders . New Harbinger Publications . 1977 ) The need for a new medical model A challenge for . Science , 196 , Fang , 2010 ) Relationship between social anxiety disorder and body disorder . Clinical Psychology Review , 30 ( Forrest , Ortiz , Brown , Smith , 2019 ) Bridging eating disorder symptoms and trait anxiety in patients with eating disorders A network approach . journal of Eating Disorders , 52 , 2010 ) Anxiety as a signal , symptom , and syndrome . In Simpson , Anxiety disorders Theory , research , and clinical perspectives ( Cambridge University Press . Grave , 2021 ) Complex cases and in eating disorders . Assessment and management . Springer . Harding , Fallon , A . 2010 ) Understanding health anxiety . In Simpson , Anxiety disorders Theory , research , and clinical perspectives ( Cambridge University Press . 2019 ) Health anxiety . 364 , Hill , A . Bourne , Carman , Lyons , A . 2020 ) Private Lives The health and wellbeing of

62 people in Australia . Monograph Series No . 122 . Australian Research Centre in Sex , Health and Society , La University . A . 2010 ) New concepts in the evolution and development of anxiety . In Simpson , Anxiety disorders Theory , research , and clinical perspectives ( Cambridge University Press . Foa , 2015 ) therapy for anxiety disorders An update in the empirical evidence . Dialogues in Clinical Neuroscience , 17 ( 2010 ) Axis II and anxiety disorders . In Simpson , Fernandez , Anxiety disorders Theory , research , and clinical perspectives ( Cambridge University Press . 2016 ) Epidemiology of eating disorders in Europe prevalence , incidence , course , consequences , and risk factors . Current Opinion in Psychiatry , 29 ( Pine , 2016 ) Using neuroscience to help understand fear and anxiety A framework . American journal of Psychiatry , 173 ( 11 ) Lee , A . 2020 ) anxiety scale A brief mental health screener for related anxiety . Death Studies , 44 ( Lee , Mathis , A . Gibbons , A . 2020 ) Incremental validity of anxiety explains depression , generalized anxiety , and death Disorders , 74 , David , A . 2017 ) Rethinking the model of health Understanding health as a dynamic system . Social and Personality Psychology Compass , 11 ( 2017 ) Does test anxiety increase as the exam draws near ?

Students state test anxiety recorded over the course of one semester . Personality and Individual Di , 104 , 2019 ) Narrative therapy ( American Psychological Association . Roque , A . 2020 ) Anxiety disorders and medical Treatment implications . In Kim ( Ed . Anxiety disorders Rethinking and understanding recent discoveries ( Springer . Simon , 2014 ) Neuroscience of fear extinction Implications for assessment and treatment of and anxiety related disorders . Behaviour Research and Therapy , 62 , 2021 ) Differences between and complex on section III personality traits . of , 12 ( Fernandez , Angel , 2014 ) Risk factors for the onset of panic and anxiety disorders in the general adult population A systematic review of cohort Disorders , 168 , Shear , 2010 ) Attachment , separation , and anxiety disorders . In Simpson , Anxiety disorders Theory , research , and clinical perspectives ( Cambridge University Press . Department of Health . 2022 ) How can I support a culturally and linguistically diverse person with a mental health condition ?

Kendall , 2020 ) Anxiety disorders in children . In Bui , Baker ( Clinical handbook of anxiety disorders From theory to practice ( Nature .

ANXIETY 63 , 2020 ) Anxiety and the ecological crisis An analysis of and climate anxiety . Sustainability , 12 ( 19 ) Lai , 2017 ) Psychosocial health and quality of life among children with cardiac diagnoses Agreement and discrepancies between parent and child reports . Cardiology in the Young , 27 ( 2015 ) Asylum seekers and refugees What are the facts ?

Fox , A . 2015 ) Childhood antecedents and risk for adult mental disorders . Annual Review of Psychology , 66 ( 2022 ) theory A science of safety . Frontiers in Integrative Neuroscience , Foundation of Australia . 2022 ) Depression anxiety stress scales ( DASS ) and Counselling Federation of Australia ( 2021 ) Indigenous Healing Practice Training Standards . Ray , Rai , 2017 ) Stress , anxiety , and A pharmacological analysis . In ( Anxiety ( Morgan , Wright , Allen , Purcell , 2019 ) to what works for anxiety An review . Rodgers , Berry , Fischer , 2020 ) Anxiety disorders A feminist ecological approach . In Bui , Baker ( Clinical handbook of anxiety disorders . From theory to practice ( Press . 1988 ) Anxiety and neurosis . Taylor Francis Group . De , 2020 ) Trait and state anxiety are mapped differently in the human brain . Scientific Reports , 10 ( 11112 ) Schmidt , 2021 ) The cognitive anxiety sensitivity treatment ( CAST ) in anxiety prevention Focus on separation anxiety and . European , 53 , van den , Van , van der Meer , van , Peters , Simons , 2022 ) assessment of quality of life after cardiac Care , 68 , Schwartz , A . 2021 ) The complex treatment manual An integrative , approach to trauma recovery . Seymour , Dunning , 2015 ) Maternal anxiety , risk factors and parenting in the first year . Child Care , health and development , 41 ( 2015 ) Genetics of anxiety disorders Genetic epidemiological and molecular studies in humans . Psychiatry and Clinical , 69 ( Scott , de Almeida , De , de , He , Murphy , 2015 ) and separation anxiety disorder across countries in the world mental health survey . 172 ( Spence , 1998 ) A measure of anxiety symptoms among children . Behaviour Research and Therapy , 36 ( 98 )

64 Stein , Simmons , 2007 ) Increased amygdala and insula activation during emotion processing in subjects . American journal of Psychiatry , 164 ( Lu , Levine , Walkup , 2020 ) Research review Pediatric anxiety disorders what have we learnt in the last 10 years ?

journal of Child Psychology and Psychiatry , 62 ( Suicide Prevention Australia . 2022 ) ABS 2021 Causes of Death Data . Jin , A . 2016 ) and factors in perception and attention in anxiety . Biological Psychology , 121 , Wide , 2020 ) Evaluating the validity of the index of dental anxiety and fear ( in adults with severe dental anxiety . European journal of Oral Sciences , 128 ( University of Technology . 2022 ) Body disorder . 2012 ) Automaticity in anxiety disorders and major depressive disorder . Clinical Psychology Review , 32 ( 2015 ) Assessment of the harmful psychiatric and behavioral effects of different forms of child maltreatment . jAMA Psychiatry , 72 ( 11 ) Vega , Guo , Vestal , Martin , Spann , 2011 ) Symptoms of anxiety and depression in childhood absence epilepsy . 52 ( Vu , 2021 ) Anxiety Recognition and treatment options . Psychiatric Clinics of North America , 44 ( Wagner , 2006 ) Bipolar disorder and anxiety disorders in children and of Clinical Psychiatry , 67 ( A . 2012 ) Motivational interviewing in the treatment . Publications , World Health Organization . The classification of mental and behavioural disorders Diagnostic research . World Health Organization . World Health Organization . World mental health report Transforming mental health for all . Executive summary . AUTHOR INFORMATION Christine has been engaged as an educator , academic researcher , and writer for over three decades . Her background in adult education featured in her 2020 on learning in tertiary education and is applied in learning processes in counselling education . During her career , Christine has been an educator in both VET and Higher Education , teaching from Diploma to Masters levels , in both independent higher education providers and universities . She worked for agencies and organisations for over a decade before setting up private practice on the Northern Beaches of Sydney . Clinical supervision of organisations and individual counsellors and psychologists has been part of her practice for over fifteen years . As an experienced counsellor , Christine specialised in issues such as trauma , crisis , complex family issues including domestic violence , loss and grief , and suicide prevention . MEd ( Adult ) Grad Cert Higher Education Academic Practice Grad Cert Higher Education ( Learning and teaching ) Grad Cert Helping Skills BEd ( Adult App . Psych ) Dip . Ind , Couple Family Therapy Dip Ad Ed ( Community ) Adv Cert in Dev Cert Pers .

ANXIETY 65 Please reference this chapter as , 2023 ) Anxiety . In , Machin du ( Common Client Issues in Counselling An Australian Perspective . University of Southern .