People with panic disorder suffer severe attacks of anxiety which can make them feel as though they are having a heart attack or are going crazy. Symptoms include heart palpitations, chest pain or discomfort, sweating, trembling, dizziness, difficulty breathing and feelings of losing control.

Panic disorder involves at least one of these attacks followed by a month or more of persistent concern about either a) having another attack, b) worry that the attack means he or she is going crazy or has severe health problems, or c) a significant change in behaviour as a result of the attack (e.g. avoiding places where an attack might occur).

The American Psychiatric Association (2000) defines a panic attack as fear or discomfort that arises abruptly and peaks in 10 minutes or less, and can occasionally last for hours. They are usually unpredictable, and this can lead a sufferer to avoid certain places or situations where a panic attack may occur and from where escape would be difficult or embarrassing.

There are three types of panic attacks:

1. Spontaneous (uncued) panic attacks: These forms of attack seem to come “from out of the blue” and are not triggered by any situation in particular. They tend to occur during period of sleep or when relaxing.
2. Situational (Cued) panic attacks: Occur mostly in a situation where a previous attack has occurred.
3. Situational pre-disposed panic attacks: While being pre-disposed to having a panic attack in a certain situation, the person may or may not have an attack either in the situation or immediately afterward (http://www.panicanxietydisorder.org.au Retrieved 23 July 2009).

Although panic attacks sometimes seem to occur out of nowhere, they generally happen after frightening experiences, prolonged stress, or even exercise. Many people who have panic attacks think they are having a heart attack and often end up at the doctor or emergency department.

Even if tests show nothing out of the ordinary, the person will still worry, and this further elevates their anxiety levels. Marcks, Weisberg and Keller (2009) suggest that individuals with panic disorder experience considerable impairment and disability including occupational difficulties, impaired wellbeing and reduced quality of life.

Heightened awareness, referred to as hypervigilance, with regard to any change in the normal function of the human body, will be noticed and misinterpreted as a possible life threatening illness. Normal changes in heartbeat, such as when climbing a flight of stairs or after exercise, are often interpreted by someone who has recently experienced a panic attack as an impending heart attack or the onset of another panic attack. Some sufferers worry so much they may leave their job or refuse to leave home to avoid future attacks. This can lead to a diagnosis of panic disorder with agoraphobia. 

The Panic Cycle:

1. Perceived Threat
2. Apprehension or worry (about having a panic attack or about distressing situation) 
3. Body sensation (e.g. heart palpitations, chest pain or discomfort, sweating, trembling, dizziness)
4. Interpretation of sensations as catastrophic

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Parents can play the key role in initiating and generating behaviour change in their children. Parents have the potential to inspire their children directly (by applying reinforcers and other behaviour modification strategies) and indirectly (by providing a safe, supportive and encouraging environment). As counsellors, working with parents can enhance our potential to promote successful outcomes for our child clients.

Respect for the client (parent and child) is essential for encouraging positive relationships. Experienced counsellors will include parents (as appropriate) in child focused counselling so that the parents’ skills and experience can be incorporated into interventions, and counselling strategies can be smoothly transferred to the home environment. 

If counsellors are unable to work with parents they may find that their work with the child is undermined or sabotaged by a parent who feels neglected or uninvolved. In addition, parents could remove their child from counselling if they believe their child is becoming too close to the counsellor, and perceive this closeness as a threat to them. 

When parents (who are clients) approach the counselling environment their experience will largely depend upon whether they are voluntary or involuntary clients. The counsellor must be prepared for the different reactions that parents can present with.

For example:

Parents may be defensive, scared, suspicious, guilty, shameful or angry. They may also be anxious and confused.  As identified in the Bristol Inquiry on Support and Counselling for Parents in Acute Health Care Settings, (1999, p 7-10),  conducted in the UK, for parents a lack of familiarity, not understanding the system, and not knowing who to ask questions of can be stressful. Isolation from their usual social network, external family and other resources will also increase their stress levels.

If the parents are involuntary clients, and have lost their role as a parent; this could alter the parents’ view of themselves as protectors and nurturers; hence the relinquishment of their parental responsibilities to an outsider could have a profound effect on how they now perceive themselves and this will directly affect their behaviour towards the counsellor.

Waiting has been identified as one of the most stressful parts of the process for parents who are waiting to hear news regarding decisions relating to their children. Families can often feel forgotten or neglected by the system. Manifestations (Bristol Inquiry 1999) of waiting when an outcome is not known can include fear, fatigue, anxiety, lack of concentration, restlessness, inability to eat or drink, anger and frustration.

Therefore it is vital that the counsellor has the necessary skills (clarification, paraphrasing, reflection of feelings, reflection of content, summarising and normalising to name a few), to assist the parent client/s to feel at ease in discussing the issues that have come about in their family.

To do this, the counsellor can begin to dispel the mystery of the counselling session by explanation of the counselling process. To take away the “unknown fear” is imperative to honest communication and building trust. This does not have to be a detailed version, but simply an explanation as to why they have attended counselling.

Remember, if the parents are voluntary clients they will know the reason why they have chosen to seek the assistance of a counsellor, but still may not be sure of the process. If the parents are involuntary clients, they also may not be exactly sure why they have to attend a counselling session, or what is expected of them and they may also not be aware of the counselling process.

Of a high priority to many clients are the boundaries of confidentiality. Clients must be aware at all times of the counsellor’s legal and ethical obligations to the community, the law and him or herself. Full disclosure of who could be privy to the counselling session is necessary to respect the rights of the client. 

A discussion of expectations should also be included in the initial stages. Many individuals who are not familiar with counsellors or the allied health industry have a skewed perception of what the counsellor can do. Some individuals accept no responsibility for their behavioural change and expect that the counsellor with his/her intimate knowledge of the human mind will enable the client’s issues to magically vanish by simply “chatting” and without any effort at all from the client.

Many counsellors will draw up a counselling contract with their clients. This is sometimes called a psychological contract, or an action plan. The importance of this document is to illustrate to the client that a verbal agreement which is then put in writing brings about clarification of what is expected from both the client (parents) and the counsellor; it adds accountability to the process and encourages motivated commitment from all parties to attempt to bring about some change in the situation or in a specific behaviour.

Sometimes the formality of the counselling session can increase the levels of anxiety for already anxious parents. When individuals are anxious they tend to breathe faster and take smaller shallower breaths. This reduces oxygen to the system; anxiety begins to rise, so we tend to breathe still faster to counteract the rising anxiety, so forms the vicious cycle of stress. Taking deep measured breaths activates the parasympathetic nervous system, which then triggers the brain to release dopamine to bring about a sense of relaxation and calm.

If parents seem to be anxious or overly stressed suggest a short break or a few minutes of deep breathing exercises. This can help to quickly reduce anxiety and build rapport between parent and counsellor through empathy. How counsellors behave towards parents and their style of interaction contributes to the effectiveness of the counselling sessions and is important for promoting positive outcomes.

Counsellors who are enthusiastic, self-confident, flexible, show ability for analytical thinking, are honest and compassionate, without being judgemental and with a sense of humour have been found to be the most effective  (Ollier et al., 2001).

The first meeting with the parent is of the utmost importance to creating a positive first impression and ensuring they will return. Regardless of whether the first appointment is made via phone or letter, it is vital that details are given to the parents as to how to get to the clinic or office. If possible the parking arrangements and public transport details could not only benefit the parents, but also be the foundation of a positive interaction at the first appointment.

Details of payment are also useful to ensure clients have a means of payment or if they are unable to make the payment at the appointment, to make other arrangements and not feel “caught out” on the day. To give a pamphlet or information sheet about the services that your or your organisation provides, some information about the organisation and information about the counselling process could minimise stress for parents and assist to put them at ease.

Creating a warm and welcoming office conveys a supportive atmosphere, compared to the infamous stark sterilization of hospital wards in days gone by. Ensure your desk is tidy and all client files are locked away. If younger children come with their parents, a box of soft cuddly toys or puzzles, books and games are a good combination to distract the young child while the parents can relax and talk to you.

Reduce distractions when you are with your clients. Divert phone calls so that you can give your client uninterrupted attention. This indicates respect and commitment to the parent. If you must take a phone call while with a client, keep it as short as possible.

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Online counselling, once termed alternative therapy, is now becoming a common practice preferred by both clients and therapists (Elleven & Allen, 2004). It has been praised for bridging the gap that existed with traditional face to face therapy around issues such accessibility, convenience, affordability and more.

Accessibility

Web counselling is easily accessible to all those who wish to use it. Online therapy overcomes barriers that may preclude others from seeking therapy. For example, individuals residing in rural or remote areas where there is no counselling services can benefit from the accessibility of online counselling. Those that are physically disabled or unable to leave their home can also easily access such services with little inconvenience. Those that have visual and hearing impairments can also benefit from such services.

Web counselling has also shown to be effective in encouraging children and teenagers to receive therapy as they seem to be more comfortable with using the internet (Shaw & Shaw, 2006). Anyone who has access to the internet can make use of such services at their convenience. Even if therapists are not available at all times, emailing for instance may give the client the perception that they are interacting with their therapist at the time of writing the email and sending it (Centore & Milacci, 2008).

Convenience

Online therapy is convenient. Both the therapist and the client have the convenience of corresponding with each other at a range of variant times. This style of therapy can take away the hassle of scheduling and setting appointments more common in traditional settings. This also creates an opportunity for the therapist to extend their services to more clients as appointments can be potentially scheduled over 24 hours and reach a larger geographical region.

For those individuals who are ambivalent about therapy or who may be uncomfortable with traditional models of therapy, may find online counselling more suitable whereby it has been found that online therapy is preferred by those who are uncomfortable with talking face to face with someone about their problems or who are suffering from social phobias, agoraphobias or anxiety disorders (Gedge, 2009).

Affordability

Web counselling has been shown to be more economical for both the therapist and the client. Especially for those therapists who are unwilling or cannot afford to rent commercial space thereby lowering overhead costs of capital, property, commuting and administration procedures when compared to traditional counselling services (Centore & Milacci, 2008).

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Below are four examples of some useful techniques in grief counselling that stem from a range of different theoretical frames.

Cognitive restructuring

The underlying assumption with this approach is that our thoughts influence our feelings; particularly the secret self scripts that are constant in our minds. It is not unusual for the grieving person to experience some irrational self scripts, (e.g. “I’m all alone” or “no one will ever love me again”) as they get overwhelmed by the reality of the loss.

The role of the counsellor is to identify these thoughts of the client, challenge them for accuracy and help the client replace those thoughts with more functional and realistic ones. This technique is particularly useful in challenging feelings of false guilt.

Writing

Writing can be used to help the survivor express their feelings and thoughts more freely. Such free expression is a crucial gesture in grief recovery.  For example, having the client write a letter to the deceased can help them take care of “unfinished business” as they get an opportunity to express things that were left unsaid before the loss.

If and when appropriate, the counsellor can encourage the client to write extensive and honest letters to promote an authentic and free expression of thoughts and feelings.

Role playing

Role playing is particularly effective in helping the client adjust to the new environment after the loss of a loved one by helping them build the skills and recognize their ability to make new adjustments and move on with life as normal. The counsellor can be involved in role playing either as a facilitator or to model possible new behaviours for the client.

Evocative language

The counsellor may choose to use “tough” words (e.g. “your son is dead” rather than “you lost your son”) to encourage a greater revelation of the reality of the loss, thus inducing relevant feelings to help the client experience and express painful emotions that need to be felt after a loss. This should only be applied after a healthy rapport and trust has developed between the client and the counsellor or else it may be viewed as insensitive by the client.

As such, timing is an important factor when using this technique. The counsellor can also encourage the survivor to speak of the deceased in past tense. This serves as a constant reminder that the loss has occurred thus promoting a real acknowledgement and growing acceptance of the loss.

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Conflict is part of any interpersonal relationship and occurs as a result of differences in opinions. People differ in values, dreams, desires and perceptions. Therefore, we are all bound to encounter conflict at some point in our lives (Long & Young, 2007). Conflict can range from less serious mild disagreements to more intensely heated arguments.

Previous research has found that marital conflict often stems from unmet needs, wants, and desires. From this perspective, marital conflict is defined as a process of interaction in which one or both partners feel discomfort about some aspect of their relationship and try to resolve it in some manner (Hamamci, 2005). When one person needs or wants something badly enough, and the other person is unwilling or unable to meet that need, resentment will often grow.

Then, if one were to add the power of an unruly tongue, the situation will usually become ripe for very destructive forms of conflict. To look at it pragmatically, romantic relationship conflict will often happen when one member of the couple perceives inequity or experiences an imbalance in rewards or benefits from being in the relationship whereby it is perceived by one member of the couple that the other only cares about his/ her individual needs (Long & Young, 2007).

The negative consequences of conflict are probably familiar to all of us. Conflict can cause psychological pain that manifests in withdrawal and distance, depression, anxiety and/or aggression. Not only between the couple but also with those who are living around them (Choi, 2008).

However, there are also constructive outcomes to conflict in romantic relationships. For instance, people who continue to relate to one another despite their conflict may build greater trust and confidence in each another and become more apt in their ability to resolve their problems (Johnson, 2007). However, reoccurring conflict is usually a symptom of a problem in the romantic relationship and therefore should be addressed intentionally by the couple.

The role of the counsellor, when dealing with couples who are experiencing conflict, is to help them identify the source of such conflict and its style to assist them in implementing skills to resolve the disagreements (Relationships Australia, 2009).

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