Learn to Cope with Anxiety (Part 2)

Cognitive-Behavioural Therapy (CBT)

Copyright (c) Donald Robertson, 2009.  All rights reserved.

(Read part 1 of this article first.)

Cognitive-behavioural therapy (CBT) works by asking you to change your thoughts and beliefs (“cognition”) and to act differently (“behaviour”) in order to change the way you feel (“emotion”).

Behaviour

CBT will normally encourage you to systematically face your fears, both during and between sessions.  To remember this people sometimes imagine the word “FEAR” stands for “Face Everything and Recover.”  At first, your instincts may be to avoid or distract yourself from things that you’re anxious about, so it often requires motivation, planning, and initially some help from your therapist, to consistently do the opposite.  Sometimes overcoming anxiety properly may require additional practical strategies, such as problem-solving or assertiveness, and CBT may also involve learning and practising these skills.

Thinking

CBT will also normally involve keeping a record of the thoughts that cause anxiety and carefully evaluating them by asking what effect they have and what evidence there is for and against them.  To remember this people sometimes imagine “FEAR” stands for “False Evidence Appearing Real.”  The success of CBT therefore depends on your willingness to act differently and your ability to develop the “mind-set” of catching and correcting negative automatic thoughts. 

In CBT you will be asked to actively collaborate with your therapist and to make a conscious effort to overcome your problem.  Your job in therapy is to learn certain skills and techniques which your therapist will teach you.  To paraphrase the ancient proverb: “Therapy helps those who help themselves.”  CBT therefore places much more emphasis on self-help than most other forms of psychotherapy or counselling.  Your role is compared to that of a scientist carrying out experiments to test different predictions or “hypotheses”.  However, your “laboratory” will be your own daily life, your experiments will involve changes in your own behaviour, and the predictions being put to the test will be the automatic thoughts which make you anxious.  CBT will help you to gain insight into your own mind, not by passive “armchair” speculation, but by giving you a series of practical experiments to test out the accuracy of your anxious thinking by modifying your behaviour in certain situations and monitoring the results.

Steps in Cognitive-Behavioural Therapy

CBT tends to progress in steps and stages and usually takes somewhere between 6-20 sessions.  It’s very important that you arrive on time for appointments and remember to complete any homework given in order to make the best use of the time available.  There are different strategies which your therapist may use in CBT but some typical steps have been described as follows, 

1. Learning about your symptoms and correcting basic misconceptions
2. Beginning to understand the link between anxious thoughts and feelings
3. Recording specific negative thoughts in a notebook or special CBT “thought form”
4. Learning to dispute the main negative thoughts and to replace them with alternative ones
5. Employing “behavioural experiments” to test out the accuracy of underlying negative assumptions
6. Preparing to maintain your improvement long-term, without the aid of a therapist

We all have thoughts going through our mind throughout the day, sometimes called our “stream of consciousness”.  These thoughts can take the form of words or sentences we say to ourselves, known as “internal dialogue”, or mental pictures, e.g., memories of the past, images of anticipated events in the future, or simply fantasies or daydreams.  These thoughts and images are the “raw data” to be observed and recorded by you as a “personal scientist” in CBT.  Because people don’t normally think negative things on purpose and they just seem to enter the mind spontaneously, we call the thoughts that make people anxious “negative automatic thoughts”.  People often don’t remember their dreams until they make an effort to write them down and negative automatic thoughts during periods of anxiety can be just as difficult to recall later.  People are often distracted by their feelings, and thoughts may seem to come out of the blue.  Hence, it’s very important to try to observe your thoughts at times when you become upset, and to write them down as soon as possible. 

If your thoughts were completely logical and in proportion to the facts of the situation then therapy might focus on helping you to solve the practical problems causing your realistic anxiety.  However, most people who suffer from extreme or chronic anxiety tend to find that their perspective on things has become distorted by their feelings and their thoughts and beliefs are not completely accurate or realistic anymore.  CBT therefore tends to involve challenging faulty thinking by questioning its logic or carefully weighing up the evidence.  For example, people often think that they are going to faint or have a heart attack when they are having a panic attack.  This isn’t true, because the evidence shows that they have had many panic attacks in the past but have never fainted (or died!) before, so their anxiety is made worse by unfounded fears.  Learning to repeatedly evaluate the logic and evidence, in the right way, can permanently change your thinking during similar situations in the future, in a way that greatly reduces anxiety.

Sometimes people already know very well that their anxious thoughts are faulty.  They might say, “I know that I’m not going to die but I can’t help feeling that way.”  According to CBT, there are often two modes of thinking going on at different times in cases of anxiety: a “normal” mode and an “anxious” (or “danger”) mode.  When you’re sitting in the therapist’s consulting room, feeling “normal”, you might look back on periods of anxiety as irrational because in threatening situations you entered an “anxious mode” of thinking in which irrational thoughts and images temporarily seemed much more plausible to you.  The more anxious someone feels, the more plausible the thoughts of looming danger tend to seem at the time.  The aim of CBT is to change your patterns of thinking during periods of high anxiety, in the heat of the moment, and to help restore your “normal” or “rational” mode of functioning.  During periods of anxiety, people also tend to feel that negative thoughts and images are important or helpful, that they need to focus on them in order to solve a problem or overcome a threat.  However, when you’re looking back on things later, from your “normal mode”, you may realise that worry or focusing on risks does more harm than good, and tends to enflame anxiety further.  CBT will often ask you to weigh up the “pros and cons” of certain patterns of thinking to make it easier for you to recall the evidence that dwelling on anxious thoughts “isn’t worth it”, during fearful situations.

Although it involves challenging both your passing thoughts and deeper assumptions, CBT isn’t about telling you what to think, quite the opposite, it’s about helping you to think for yourself.  The logic and evidence that you’ll be evaluating will be based on your own observations.  So it’s important to realise that you’ll be encouraged to engage in a kind of debate with yourself, rather than with the therapist.  Sometimes this has been described as a debate between your “anxious self” and “rational self”, meaning the two modes of functioning mentioned above.  One of the very first steps in CBT involves learning to “distance” yourself from your negative automatic thoughts rather than identifying with them, i.e., to see them as “just thoughts” rather than facts about your situation.  For example, someone who feels anxious about money might catch themselves thinking “Oh my god, I’m going to lose everything and go bankrupt!”  If they can learn to respond by saying, “That’s just my anxiety talking; I’m blowing the risk out of proportion”, then they will have achieved psychological distance from the original thought rather than taking it literally and responding as if it were definitely true.  “Catastrophic predictions” like these usually involve taking a slim possibility and re-acting as if it were a probability, or even a certainty.  CBT may involve learning to habitually “stop and think” when automatic thoughts appear and to nip them in the bud before you get swept up in them.

Thinking Errors

Once you have started gathering the “raw data” by observing what thoughts and images actually go through your mind before, during, and after, an episode of high anxiety, you will then begin to spot certain typical “thinking errors” or styles of thinking.  Anxiety distorts thinking and tends to be maintained by faulty thinking in a kind of vicious circle.  However, people tend to report very common patterns of thinking during anxiety, for example,

1. “Catastrophising” or predicting the worst.  People tend to dwell on the worst-case scenario when nervous or afraid, and exaggerate the probability of things going wrong, thinking they might die, have a breakdown, or be left financially destitute or socially abandoned, etc.
2. Selective thinking or tunnel vision.  Anxiety, probably for evolutionary reasons, tends to narrow the focus of attention which is drawn to potential threats or signs of danger creating a biased or imbalanced perspective.  This means we lose sight of the bigger picture, though, and overlook positive things, strengths, and opportunities, which could make us feel slightly better about our situation.
3. Over-generalisation or always-and-never thinking.  Worry often involves generalising from a single bad example and assume that things will always turn out badly, or that people always respond the same way without exception.
4. Discounting or trivialising the positive.  When anxious, people tend to dismiss opportunities out of hand, or trivialise strengths that they possess.
5. Mind-reading or putting words in people’s mouths.  When socially-anxious, we tend to assume the worst about what people are thinking, especially when we think we’ve done something they could criticise.

Memorising the names of these and other common thinking errors makes it much easier to catch yourself in the act of anxious thinking, spot specific problems and correct them more quickly.  Learning to say “Ah, I’ve caught myself catastrophising again!” is another way to get into the habit of distancing yourself from your anxious mode of thinking.

Facing your Fears (Exposure)

The only way you will truly know that you have overcome anxiety, in most cases, is by learning to face your fears.  As the saying goes, if you fall off your horse, the best thing to do is get right back in the saddle.  We naturally feel like avoiding situations or experiences that make us anxious but doing so tends simply to make things worse.  People are often surprised to find that when they face their fears, in the right way, their anxiety reduces.  Therapists call this “exposure” to the feared situation or experience and it’s the basis of most CBT for anxiety.  This does not normally mean “throwing yourself in at the deep end”, which is called “flooding” yourself with anxiety, because that can be too overwhelming.  Most exposure in CBT involves carefully planning gradual steps and stages in advance so that you don’t “bite off more than you can chew”.  Research suggests three main things happen during exposure,

1. There seem to be biological reasons why anxiety (“nervous arousal”) tends to reduce during exposure; even animals become less anxious when they repeatedly face their fears.
2. People learn through trial and error to behave slightly differently each time, solve practical problems, and improve skills and confidence, e.g., a socially-anxious person might gradually figure out better things to say and do if they lose their place when public speaking.
3. People gradually re-evaluate their thinking in the situation and tend to modify their predictions and assumptions, e.g., by facing their feelings in the right way someone with panic attacks might gradually persuade themselves that the sensations are not dangerous and they can cope better than they predicted.

Although people often avoid facing their fears there are also many people who do appear to face their fears repeatedly, in daily life, but don’t get better.  This has long been known by therapists as the central “paradox” of anxiety.  For example, some actors go through their whole career experiencing stage fright before every performance.  That’s probably because certain “maintaining factors” are preventing them from growing more confident with experience.  Likewise, someone who ignores positive comments and dwells on criticism might be thinking in a way that maintains anxiety or someone who always clings on to a friend for support during a panic attack might never give themselves a chance to learn that they won’t actually faint if left to stand alone, and are behaving in a way that maintains anxiety.  CBT tries to analyse the thoughts and behaviours that happen during anxious situations so that these barriers to progress can be removed.  Some of the things people habitually try do during anxious situations, such as continually seeking reassurance from others or averting their gaze from certain things, are called “safety-seeking behaviours”.  These are unhelpful ways of coping, psychological “crutches”, which actually make anxiety worse in the long-term.  CBT will attempt to identify them and help you stop depending upon to get through things.

Homework

Homework is very important in most CBT.  This usually consists of self-help techniques and experiments that you use between sessions, or self-monitoring exercises in which you record your experiences.  At the start of each session, your therapist will get into the habit of asking you to report on your homework, and this will be reviewed with new assignments set toward the end of each session for the week ahead. 

1. Begin by adopting the AWARE strategy described at the end of this pamphlet.  Accept your feelings of anxiety, watch them in a detached way, try to act in a normal, healthy way, as if you weren’t anxious by gradually facing your fears, repeat this persistently, and expect progress.
2. Next, take responsibility for your thoughts, actions, and feelings.  Instead of saying, “He/she/it upsets me”, try to say “I’m making myself upset about him/her/it” instead.  Emphasise verbs (doing) instead of nouns (having), e.g., say “I am depressing myself” instead of “I have depression”, and ask yourself specifically “how” you’re doing it, instead of asking unanswerable “why” questions like “why me?”
3. Be honest about the personal meaning of your fears by asking yourself what it is about the situation that you’re really afraid of.  When people say “What if…?” this often serves as a subtle way of avoiding spelling out the underlying fear that would answer their own question, i.e., it implies an unspoken catastrophe.  If you take time to articulate your underlying fears you will often begin to see them as unfounded or excessive.
4. Next, expand your point of view by generating alternatives.  Practice thinking of as many alternative ways of interpreting situations, or viewing them, as possible.  What’s the most realistic and helpful alternative to the anxious mode of thinking?
5. Before you face any problems, get into the habit of focusing on your positive strengths and opportunities.  Ask yourself “What do I have going for me here?” in dealing with the situations that make you anxious.  This will help overcome negative bias and helps prevent you from under-estimating your ability to cope.
6. To stop catastrophising, ask yourself what’s the worst thing that could realistically happen and think it through carefully several times, looking at the bigger picture, and the longer-term view.  Even if the worst-case scenario happens, how could you cope with it or recover?  Would it really be as bad as you assumed? 
7. Focus on what’s probable rather than what’s possible, to prevent “What if…?” thinking.  Once you’ve considered the worst-case scenario, estimate how likely it is to happen as a percentage probability, presumably quite low.  Next, compare that to the best-case scenario; what’s the best thing that could realistically happen and how likely is it as a percentage?  Write all this down if possible and finally consider the likely-case scenario; what’s the most realistic thing that will probably happen?  The most probable scenario is usually somewhere between the worst and best possibilities.

To get the most out of CBT, try to help yourself and focus on the opportunity that therapy presents to give you a sense of hope.  Take things gradually, in steps and stages.  Anxious people tend to try to force changes to happen too quickly, but you’re more likely to succeed if you have a plan of action for overcoming anxiety gradually over several weeks or months.  Try to get other people involved, like family members, and ask them to support you by reminding you to do your CBT homework.  Talk to your therapist; tell them anything you think they need to know to help you.