Cognitive behavioural therapy (CBT) can help you make sense of overwhelming problems by breaking them down into smaller parts.
In CBT, problems are broken down into 5 main areas:
- physical feelings
CBT is based on the concept of these 5 areas being interconnected and affecting each other. For example, your thoughts about a certain situation can often affect how you feel both physically and emotionally, as well as how you act in response.
How CBT is different
CBT differs from many other psychotherapies because it’s:
- pragmatic – it helps identify specific problems and tries to solve them
- highly structured – rather than talking freely about your life, you and your therapist discuss specific problems and set goals for you to achieve
- focused on current problems – it’s mainly concerned with how you think and act now rather than attempting to resolve past issues
- collaborative – your therapist will not tell you what to do; they’ll work with you to find solutions to your current difficulties
Stopping negative thought cycles
There are helpful and unhelpful ways of reacting to a situation, often determined by how you think about them.
For example, if your marriage has ended in divorce, you might think you’ve failed and that you’re not capable of having another meaningful relationship.
This could lead to you feeling hopeless, lonely, depressed and tired, so you stop going out and meeting new people. You become trapped in a negative cycle, sitting at home alone and feeling bad about yourself.
But rather than accepting this way of thinking you could accept that many marriages end, learn from your mistakes and move on, and feel optimistic about the future.
This optimism could result in you becoming more socially active and you may start evening classes and develop a new circle of friends.
This is a simplified example, but it illustrates how certain thoughts, feelings, physical sensations and actions can trap you in a negative cycle and even create new situations that make you feel worse about yourself.
CBT aims to stop negative cycles such as these by breaking down things that make you feel bad, anxious or scared. By making your problems more manageable, CBT can help you change your negative thought patterns and improve the way you feel.
CBT can help you get to a point where you can achieve this on your own and tackle problems without the help of a therapist.
Exposure therapy is a form of CBT particularly useful for people with phobias or obsessive compulsive disorder (OCD).
In such cases, talking about the situation is not as helpful and you may need to learn to face your fears in a methodical and structured way through exposure therapy.
Exposure therapy involves starting with items and situations that cause anxiety, but anxiety that you feel able to tolerate.
You’ll be exposed to an item or situation for a length of time and frequency recommended by your therapist.
After the first few times, you’ll find your anxiety does not climb as high and does not last as long.
You’ll then be ready to move to a more difficult situation. This process should be continued until you have tackled all the items and situations you want to conquer.
Exposure therapy may involve spending 6 to 15 hours with the therapist, or can be carried out using self-help books or computer programs. You’ll need to regularly practise the exercises as prescribed to overcome your problems.
CBT can be carried out with a therapist in 1-to-1 sessions or in groups with other people in a similar situation to you.
If you have CBT on an individual basis, you’ll usually meet with a CBT therapist for between 6 and 20 weekly or fortnightly sessions, with each session lasting 30 to 60 minutes.
Because exposure therapy sessions include time to expose you to the item or situation causing you anxiety, they will usually last longer.
CBT therapy may take place:
- in a clinic
- outside – if you have specific fears there
- in your own home – particularly if you have agoraphobia or OCD involving a specific fear of items at home
Your CBT therapist can be any healthcare professional who has been specially trained in CBT, such as a psychiatrist, psychologist, mental health nurse or GP.
The first few sessions will be spent making sure CBT is the right therapy for you, and that you’re comfortable with the process. The therapist will ask questions about your life and background.
If you’re anxious or depressed, the therapist will ask whether it interferes with your family, work and social life. They’ll also ask about events that may be related to your problems, treatments you’ve had, and what you would like to achieve through therapy.
If CBT seems appropriate, the therapist will let you know what to expect from a course of treatment. If it’s not appropriate, or you do not feel comfortable with it, they can recommend alternative treatments.
After the initial assessment period, you’ll start working with your therapist to break down problems into their separate parts. To help with this, your therapist may ask you to keep a diary or write down your thought and behaviour patterns.
You and your therapist will analyse your thoughts, feelings and behaviours to work out if they’re unrealistic or unhelpful and to determine the effect they have on each other and on you. Your therapist will be able to help you work out how to change unhelpful thoughts and behaviours.
After working out what you can change, your therapist will ask you to practise these changes in your daily life. This may involve:
- questioning upsetting thoughts and replacing them with more helpful ones
- recognising when you’re going to do something that will make you feel worse and instead doing something more helpful
You may be asked to do some “homework” between sessions to help with this process.
At each session, you’ll discuss with your therapist how you’ve got on with putting the changes into practice and what it felt like. Your therapist will be able to make other suggestions to help you.
Confronting fears and anxieties can be very difficult. Your therapist will not ask you to do things you do not want to do and will only work at a pace you’re comfortable with. During your sessions, your therapist will check you’re comfortable with the progress you’re making.
One of the biggest benefits of CBT is that after your course has finished, you can continue to apply the principles learned to your daily life. This should make it less likely that your symptoms will return.
A number of interactive online tools are now available that allow you to benefit from CBT with minimal or no contact with a therapist.
Some people prefer using a computer rather than talking to a therapist about their private feelings. However, you may still benefit from occasional meetings or phone calls with a therapist to guide you and monitor your progress.
Find out more:
- self-help therapies
- Every Mind Matters: self-help cognitive behavioural therapy (CBT) techniques
Therapy for Anxiety Disorders
Want to control your anxiety, stop worrisome thoughts, and conquer your fears? Here’s how therapy can help.
Treating anxiety disorders with therapy
Whether you’re suffering from panic attacks, obsessive thoughts, unrelenting worries, or an incapacitating phobia, it’s important to know that you don’t have to live with anxiety and fear. Treatment can help, and for many anxiety problems, therapy is often the most effective option. That’s because anxiety therapy—unlike anxiety medication—treats more than just the symptoms of the problem. Therapy can help you uncover the underlying causes of your worries and fears; learn how to relax; look at situations in new, less frightening ways; and develop better coping and problem-solving skills. Therapy gives you the tools to overcome anxiety and teaches you how to use them.
Anxiety disorders differ considerably, so therapy should be tailored to your specific symptoms and diagnosis. If you have obsessive-compulsive disorder (OCD), for example, your treatment will be different from someone who needs help for anxiety attacks. The length of therapy will also depend on the type and severity of your anxiety disorder. However, many anxiety therapies are relatively short-term. According to the American Psychological Association, many people improve significantly within 8 to 10 therapy sessions.
While many different types of therapy are used to treat anxiety, the leading approaches are cognitive behavioral therapy (CBT) and exposure therapy. Each anxiety therapy may be used alone, or combined with other types of therapy. Anxiety therapy may be conducted individually, or it may take place in a group of people with similar anxiety problems. But the goal is the same: to lower your anxiety levels, calm your mind, and overcome your fears.
Online vs. in-person therapy
Accessing help online can help you avoid the expense and inconvenience of having to meet in-person and being in a familiar, comfortable environment can make it easier to talk openly about your issues. For many people with anxiety, online therapy can be just as effective as traditional, in-person therapy.
However, not all online therapy is the same. Communicating via a messaging app, phone, or email, for example, is no substitute for live face-to-face interaction using video chat.
Facial expressions, mannerisms, and body language are important tools in therapy. They allow your therapist pick up on any inconsistencies between your verbal and nonverbal responses, recognize things that you’re unable to put into words, and understand the true meaning behind what you’re saying. From your point of view, interacting face-to-face is crucial to building a strong connection with a therapist that so often determines the success of therapy.
Read: Online Therapy: Is it Right for You?
Cognitive behavioral therapy (CBT) for anxiety
Cognitive behavioral therapy (CBT) is the most widely-used therapy for anxiety disorders. Research has shown it to be effective in the treatment of panic disorder, phobias, social anxiety disorder, and generalized anxiety disorder, among many other conditions.
CBT addresses negative patterns and distortions in the way we look at the world and ourselves. As the name suggests, this involves two main components:
- Cognitive therapy examines how negative thoughts, or cognitions, contribute to anxiety.
- Behavior therapy examines how you behave and react in situations that trigger anxiety.
The basic premise of CBT is that our thoughts—not external events—affect the way we feel. In other words, it’s not the situation you’re in that determines how you feel, but your perception of the situation.
For example, imagine that you’ve just been invited to a big party. Consider three different ways of thinking about the invitation, and how those thoughts would affect your emotions.
Situation: A friend invites you to a big party
Thought #1: The party sounds like a lot of fun. I love going out and meeting new people!
Emotions: Happy, excited.
Thought #2: Parties aren’t my thing. I’d much rather stay in and watch a movie.
Thought #3: I never know what to say or do at parties. I’ll make a fool of myself if I go.
Emotions: Anxious, sad.
As you can see, the same event can lead to completely different emotions in different people. It all depends on our individual expectations, attitudes, and beliefs.
[Read: Anxiety Disorders and Anxiety Attacks]
For people with anxiety disorders, negative ways of thinking fuel the negative emotions of anxiety and fear. The goal of cognitive behavioral therapy for anxiety is to identify and correct these negative thoughts and beliefs. The idea is that if you change the way you think, you can change the way you feel.
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Thought challenging in CBT for anxiety
Thought challenging—also known as cognitive restructuring—is a process in which you challenge the negative thinking patterns that contribute to your anxiety, replacing them with more positive, realistic thoughts. This involves three steps:
- Identifying your negative thoughts. With anxiety disorders, situations are perceived as more dangerous than they really are. To someone with a germ phobia, for example, shaking another person’s hand can seem life threatening. Although you may easily see that this is an irrational fear, identifying your own irrational, scary thoughts can be very difficult. One strategy is to ask yourself what you were thinking when you started feeling anxious. Your therapist will help you with this step.
- Challenging your negative thoughts. In the second step, your therapist will teach you how to evaluate your anxiety-provoking thoughts. This involves questioning the evidence for your frightening thoughts, analyzing unhelpful beliefs, and testing out the reality of negative predictions. Strategies for challenging negative thoughts include conducting experiments, weighing the pros and cons of worrying or avoiding the thing you fear, and determining the realistic chances that what you’re anxious about will actually happen.
- Replacing negative thoughts with realistic thoughts. Once you’ve identified the irrational predictions and negative distortions in your anxious thoughts, you can replace them with new thoughts that are more accurate and positive. Your therapist may also help you come up with realistic, calming statements you can say to yourself when you’re facing or anticipating a situation that normally sends your anxiety levels soaring.
How thought challenging works
To understand how thought challenging works in cognitive behavioral therapy, consider the following example: Maria won’t take the subway because she’s afraid she’ll pass out, and then everyone will think she’s crazy. Her therapist has asked her to write down her negative thoughts, identify the errors—or cognitive distortions—in her thinking, and come up with a more rational interpretation. The results are below.
Challenging Negative ThoughtsNegative thought #1: What if I pass out on the subway?Cognitive distortion: Predicting the worst.
More realistic thought: I’ve never passed out before, so it’s unlikely that I will pass out on the subway.
Negative thought #2: If I pass out, it will be terrible!Cognitive distortion: Blowing things out of proportion.
More realistic thought: If I faint, I’ll come to in a few moments. That’s not so terrible.
Negative thought #3: People will think I’m crazy.Cognitive distortion: Jumping to conclusions.
More realistic thought: People are more likely to be concerned if I’m okay.
Replacing negative thoughts with more realistic ones is easier said than done. Often, negative thoughts are part of a lifelong pattern of thinking. It takes practice to break the habit. That’s why cognitive behavioral therapy includes practicing on your own at home as well.
CBT may also include:
- Learning to recognize when you’re anxious and what that feels like in the body.
- Learning coping skills and relaxation techniques to counteract anxiety and panic.
- Confronting your fears (either in your imagination or in real life).
Exposure therapy for anxiety
Anxiety isn’t a pleasant sensation, so it’s only natural to avoid it if you can. One of the ways that people do this is by steering clear of the situations that make them anxious. If you have a fear of heights, you might drive three hours out of your way to avoid crossing a tall bridge. Or if the prospect of public speaking leaves your stomach in knots, you might skip your best friend’s wedding in order to avoid giving a toast. Aside from the inconvenience factor, the problem with avoiding your fears is that you never have the chance to overcome them. In fact, avoiding your fears often makes them stronger.
[Read: Phobias and Irrational Fears]
Exposure therapy, as the name suggests, exposes you to the situations or objects you fear. The idea is that through repeated exposures, you’ll feel an increasing sense of control over the situation and your anxiety will diminish. The exposure is done in one of two ways: Your therapist may ask you to imagine the scary situation, or you may confront it in real life. Exposure therapy may be used alone, or it may be conducted as part of cognitive behavioral therapy.
Rather than facing your biggest fear right away, which can be traumatizing, exposure therapy usually starts with a situation that’s only mildly threatening and works up from there. This step-by-step approach is called systematic desensitization. Systematic desensitization allows you to gradually challenge your fears, build confidence, and master skills for controlling panic.
Systematic desensitization involves three parts:
- Learning relaxation skills. First, your therapist will teach you a relaxation technique, such as progressive muscle relaxation or deep breathing. You’ll practice in therapy and on your own at home. Once you start confronting your fears, you’ll use this relaxation technique to reduce your physical anxiety response (such as trembling and hyperventilating) and encourage relaxation.
- Creating a step-by-step list. Next, you’ll create a list of 10 to 20 scary situations that progress toward your final goal. For example, if your final goal is to overcome your fear of flying, you might start by looking at photos of planes and end with taking an actual flight. Each step should be as specific as possible, with a clear, measurable objective.
- Working through the steps. Under the guidance of your therapist, you’ll then begin to work through the list. The goal is to stay in each scary situation until your fears subside. That way, you’ll learn that the feelings won’t hurt you and they do go away. Every time the anxiety gets too intense, you will switch to the relaxation technique you learned. Once you’re relaxed again, you can turn your attention back to the situation. In this way, you will work through the steps until you’re able to complete each one without feeling overly distressed.
Facing a fear of flying
Step 1: Look at photos of planes.
Step 2: Watch a video of a plane in flight.
Step 3: Watch real planes take off.
Step 4: Book a plane ticket.
Step 5: Pack for your flight.
Step 6: Drive to the airport.
Step 7: Check in for your flight.
Step 8: Wait for boarding.
Step 9: Get on the plane.
Step 10: Take the flight.
Complementary therapies for anxiety disorders
As you explore your anxiety disorder in therapy, you may also want to experiment with complementary therapies designed to bring your overall stress levels down and help you achieve emotional balance.
Exercise is a natural stress buster and anxiety reliever. Research shows that as little as 30 minutes of exercise three to five times a week can provide significant anxiety relief. To achieve the maximum benefit, aim for at least an hour of aerobic exercise on most days.
Relaxation techniques such as mindfulness meditation and progressive muscle relaxation, when practiced regularly, can reduce anxiety and increase feelings of emotional well-being.
[Read: Relaxation Techniques for Stress Relief]
Biofeedback uses sensors that measure specific physiological functions—such as heart rate, breathing, and muscle tension—to teach you to recognize your body’s anxiety response and learn how to control it using relaxation techniques.
Hypnosis is sometimes used in combination with CBT for anxiety. While you’re in a state of deep relaxation, the hypnotherapist uses different therapeutic techniques to help you face your fears and look at them in new ways.
Making anxiety therapy work for you
There is no quick fix for anxiety. Overcoming an anxiety disorder takes time and commitment. Therapy involves facing your fears rather than avoiding them, so sometimes you’ll feel worse before you get better. The important thing is to stick with treatment and follow your therapist’s advice. If you’re feeling discouraged with the pace of recovery, remember that therapy for anxiety is very effective in the long run. You’ll reap the benefits if you see it through.
[Read: Finding a Therapist Who Can Help You Heal]
You can also support your own anxiety therapy by making positive choices. Everything from your activity level to your social life affects anxiety. Set the stage for success by making a conscious decision to promote relaxation, vitality, and a positive mental outlook in your everyday life.
Learn about anxiety. In order to overcome anxiety, it’s important to understand the problem. That’s where education comes in. Education alone won’t cure an anxiety disorder, but it will help you get the most out of therapy.
Cultivate your connections with other people. Loneliness and isolation set the stage for anxiety. Decrease your vulnerability by reaching out to others. Make it a point to see friends, join a self-help or support group, or share your worries and concerns with a trusted loved one.
Adopt healthy lifestyle habits. Physical activity relieves tension and anxiety, so make time for regular exercise. Don’t use alcohol and drugs to cope with your symptoms, and try to avoid stimulants such as caffeine and nicotine, which can make anxiety worse.
Reduce stress in your life. Examine your life for stress, and look for ways to minimize it. Avoid people who make you anxious, say no to extra responsibilities, and make time for fun and relaxation in your daily schedule.
Authors: Melinda Smith, M.A., Robert Segal, M.A., and Jeanne Segal, Ph.D.
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Get more help
Managing and Treating Anxiety – Treatment options for anxiety, including exercise and breathing techniques. (Better Health Channel)
Anxiety – Worksheet to help you cope. (Centre for Clinical Interventions)
Cognitive Behavioral Therapy (CBT) – Including its use as a therapy for anxiety. (Royal College of Psychiatrists)