When Conor Farrell had his first panic attack in his late 30s, he immediately knew one thing for sure: he never wanted to have another one.
"It was one of the most horrifying experiences I've ever had," the now 43-year-old says. "I thought I was going to have a heart attack, I thought I was dying."
The combination of a traumatic work experience and issues in his personal life seemed to be the trigger and he saw the panic attack as a clear sign that he needed to seek help.
"My first thought was 'right, I can't live with this, What do I need to do to fix it?'," he says, "I'll spend the money, whatever it takes."
Anxiety is the most common mental health condition in Australia, and as a result, countless services and so-called experts have popped up claiming to have the cure. There are mindfulness apps, life and wellness coaches, and a slew of wellness gurus promoting everything from meditation to herbal remedies.
And that's not even mentioning the spectrum of psychiatrists, psychologists, psychotherapists and counsellors.
It's enough to make your head spin, even if you aren't already in the midst of an anxiety crisis. So, how do you know where to begin and what's worth handing over your hard-earned cash for?
Different things work for different people
Four years on from that first panic attack, Connor is now a well-versed traveller when it comes to the crowded and often bumpy anxiety treatment landscape.
"I've tried pretty much everything, whether it's pharmaceutical or non-pharmaceutical solutions," he says. "My approach was just come at me, all the information, and let's just see what happens."
The first panic attack wasn't his last, and the anxiety symptoms have continued, but after years of trial and error, he's now got a toolbox of resources to manage them.
"When I'd meet someone who mentioned they have anxiety, I'd immediately go 'oh I have anxiety, what do you do for it?'," he says.
He's now found a "really good" psychologist through the recommendation of a mutual friend, but only after trying out three other therapists who weren't a good fit.
There's also a particular voice actor on the Headspace app that he connects with, and he uses cognitive behavioural therapy, self-management strategies, and medication when he needs it.
Conversely, he says mindfulness — one of the most common strategies recommended for anxiety — doesn't come easily to him. "The first thing people tell you to do is focus on your breathing, but it didn't always help me when it was really bad," he says.
As an alternative, he's found focusing on doing something with his hands, whether it be threading a button or playing a game on his phone can help take his focus away from a looming attack.
In the early days, he saw his psychologist every couple of days. Now, it's every few weeks for a general check-in. "In my opinion, everyone should have a therapist if you can afford to get that care," he says. The process to find one, however, isn't always easy — as he learnt first-hand.
"If you've got compounding mental health issues, it can be really, really hard to motivate yourself to even find a good GP," he says.
"Then additionally, finding a good psychologist, it's exhausting, just getting the motivation to pick up the phone or go to an appointment. It's quite a mountain you're facing when you're at the start."
Let's unpack what the different 'ists' do
Most people seeking treatment for anxiety will at some point be referred to a psychiatrist, psychologist, psychotherapist or counsellor. While the titles sound similar, and they are all ostensively trained in treating mental health, there are some major differences.
Psychiatrists are specialist doctors trained specifically in mental health diagnosis and treatment. They have medical degrees, and as such, are able to prescribe anti-anxiety medication and, if needed, organise hospital admission. Like other practitioners, they may also use "talking therapies" like Cognitive Behavioural Therapy (CBT).
Clinical psychologists are experts in mental health, trained to understand and relieve mild to severe psychological issues. To become a clinical psychologist, practitioners must undergo at least eight years of training.
According to the Australian Clinical Psychology Association, a clinical psychologist can "assess the causes of psychological distress" and "help develop a management or treatment plan for stabilisation or recovery".
The profession is regulated by law and psychologists are required to be registered by the Psychology Board of Australia.
Both psychiatrists and psychologists, along with registered mental health nurses and social workers, are covered by the government's mental health care plan scheme, which allows participants to claim back some of the cost of up to 20 sessions with a registered mental health professional each year.
In order to access the scheme, patients must first undergo an assessment with a GP to establish a likely diagnosis and determine what form of treatment will be most helpful. GPs can also treat mild to moderate anxiety, and like psychiatrists, are able to prescribe medication.
The third category is psychotherapists and counsellors. Counsellor is often used as a catch-all title to describe a range of practitioners offering talking therapies. Both psychotherapist and counsellor are unregulated terms, so it's useful to establish what qualifications and accreditation someone has before booking an appointment.
Many of these practitioners are well trained in treating mental health, but most psychotherapists and counsellors are not covered by the mental health care plan.
The Psychotherapy and Counselling Federation of Australia (PACFA), a peak body for the sector which sets professional standards for its members, defines the two roles like this:
Counselling is a "safe and confidential collaboration between qualified counsellors and clients to promote mental health and wellbeing, enhance self-understanding, and resolve identified concerns." Psychotherapy, on the other hand, is a "holistic engagement that focuses on mental, emotional, relational or spiritual health".
To become an accredited clinical member of PACFA, practitioners must have a degree qualification and a minimum of 750 hours of experience working with clients. Registered clinical psychotherapists must also undergo substantial specialised training.
Dr Di Stow is a counsellor working with anxiety in Hobart and the president of PACFA. She says the difference between the two really comes down to approaches. The type of therapy used — referred to as a modality — depends on the client's needs and the practitioner's training.
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Ultimately both counsellors and psychotherapists, she says, "work to help people get better from their mental health challenges" but counsellors may be more focused on working with people in the short-term to resolve immediate issues, whereas psychotherapists might take a longer-term approach.
But that's not always the case. "As a counsellor, I have long term clients who do very deep work, and I have people who need only come for a short term because of a particular need or issue," she says. "These days with the availability of our psychology colleagues being months and months of waiting, I think the priority is making sure you are able to get an appointment to start doing this important work."
With demand for mental health services soaring since the pandemic, a recent survey by the Australian Psychological Society found one in three psychologists were so busy they'd had to close their books to new clients. The situation in regional and rural areas is even more dire, with many forced to wait months for an appointment.
But when it comes to counsellors and psychotherapists, a workplace survey undertaken in late 2020 by PACFA found 63 per cent said they could see a new client within seven days, and 23 per cent could accommodate an urgent request within 48 hours.
"It's better to see someone sooner, a counsellor or psychotherapist, while you're waiting to see a psychologist … rather than to see nobody for months and months," Stow says.
So, how do you know what practitioner is right for you? Stow says talking therapies like counselling and psychotherapy are best suited to people with mild to moderate conditions, while psychiatrists and psychologists are better equipped to treat those with severe symptoms, where a formal diagnosis is required.
"We are very clear about referring clients on if indeed their issues, concerns or problems are beyond our scope of practice," she says.
Anxiety is a spectrum, and so are the treatments
If you have a cold, you don't go to the emergency room. You may go to your GP or manage it at home with over the counter medication. Likewise, you're not lining up at the pharmacy if you break your leg.
You can view anxiety through a similar lens: symptoms come in different shapes and severity and the treatment needed differs accordingly.
If you require medication, your options are limited to a GP or psychiatrist. If your symptoms are milder, the options are more varied. And while it might be hard to determine where you sit on the scale, qualified professionals should let you know if they think you fall outside their scope and help refer you elsewhere.
It's a question Michaela Buck, a professional coach based in Germany, regularly has to assess when she meets with a new client.
"If in the first conversation, the potential coachee mentions that the Ukraine war has triggered something in them, for example, then I have a red flag because this is probably beyond coaching," she says. "If it's visible that [the issue] connects to deep-seated emotions, then coaching isn't the right choice."
Unlike psychologists and psychiatrists, coaches are not suitable in a mental health crisis. Instead, Buck describes coaching as a partnership centred around goal-setting and solutions.
"Therapy is more about healing pain and working with trauma, coaching is more future-focused," she says. As an example, she outlines a situation where someone is experiencing performance anxiety at work and wants to overcome it.
"We spend a lot of time creating the goal, and this more than saying 'I want to be free of anxiety'," she says.
This might look like visualising what achieving their desired future will look like — "How would you realise if you've overcome your anxiety?" — and establishing how to measure progress.
Importantly, in Australia, the coaching industry is unregulated which means anyone can call themselves one.
Organisations like the International Coaching Federation (ICF) set standards for their members — such as a minimum number of experience hours and certain training — but there is no government oversight.
The organisation also sets its own ethical standards, including the requirement for coaches to work within their scope of experience and refer people onwards if needed, but there is no requirement for non-members to abide by them.
"A well-trained coach knows what to ask in the first contact to understand what the anxiety is about," says Buck, who is an ICF member.
Options can be a good thing, and not all of them cost money
Working through anxiety doesn't always mean talking with a professional. It may look like mindfulness and meditation practice at home, exercise, journalling or, as Conor found, working with your hands.
This idea is at the centre of art therapy — a method of treating psychological issues with visual art-making, drama, dance, movement or poetry. While often thought of as most useful to children or older people in dementia care, Conny Weyrich, a Melbourne-based creative coach and art therapist, says it can be beneficial for people of all ages.
Weyrich's previous career in the corporate world has made her particularly interested in working with professionals who have what is often described as "high-functioning anxiety". "They perform perfectly at their jobs, but there is a high cost to that," she says.
According to Weyrich, art-making can aid with anxiety in two ways. On one hand, the creative process itself can help regulate symptoms and bring people into the present moment. "When we interact with materials, your senses are really in the here and now which is a respite for an anxious brain that is ruminating on past events or worrying about the future," she says.
It's also a way to explore the mind through expressing certain events and experiences in art. "A real strength of arts-based approaches is we can externalise something like anxiety," she says. "I might invite someone to represent their anxiety through an image or create an avatar in sculpture, and then we can place that externalised model of anxiety outside ourselves and we can look at it from different angles."
The amount of talking in each session varies, and sometimes — especially when a lot of the art practice happens in between appointments — Weyrich says her work closely resembles counselling. But like with most treatments, she says, it all depends on what works for the client.
According to a guide published by mental health organisation Beyond Blue, there is currently not enough evidence to say whether art therapy is effective at reducing anxiety symptoms.
But Dr Grant Blashki, the lead clinical adviser at Beyond Blue, says, ultimately, there's no "one-size-fits-all solution" when it comes to anxiety.
"It's about finding the type of support that matches your personal needs at the time, and that can take time to work out," he says.
While the cost of regular treatments can be a hurdle for many people, there are also a range of free resources available to get the ball rolling.
A good first step may be booking in for a discussion with a bulk-billing GP or checking out what information is available through organisations like Beyond Blue or Headspace (if you are under 25). These organisations can provide free help over the phone, online, and in some cases, in person.
There are also a number of anxiety treatment programs available online. The Department of Health's Head to Health database provides links to a number of online therapies.
Even though it's not always easy to know where to start, Blashki says the key is just taking that first step — and then committing to the process of figuring out what works for you.
Reflecting on his journey so far, Conor shared a similar message. "It can feel a bit exasperating when you're reading the same articles over and over again and they're all saying the same thing, but there are so many different techniques for different people," he says.
"You've just got to keep talking to people, keep motivating yourself to get the treatment — you've got to battle through the muck to get there, but it's super worth it."
