A Guide To Cognitive Behavioural Therapy For Anxiety

Feeling anxious is normal to a certain extent. You can feel anxious when taking a test or going for an interview. However, this kind of anxiety tends to motivate a person to do better, and ordinary anxiety comes and goes. It doesn’t interfere with a person’s everyday life.

Anxiety becomes a disorder when it is intense and long-lasting.[1] This type of anxiety interferes with a person’s everyday life. It may even prevent a person from leaving their home or from performing tasks or activities that others would deem completely normal.

When left untreated, anxiety disorders become worse. Although anxiety disorders can affect all genders, women are more susceptible than men, according to the APA (American Psychiatric Association).[2]

Anxiety: an evolutionary alarm

Anxiety is meant to alarm our physical sensors and alerts us of impending danger. It is supposed to prepare us to cope with a threat. When the body senses danger, the anxiety alarm is triggered, preparing the body into a fight-or-flight response.

The body will start by releasing hormones to trigger certain physical reactions. The heart follows by pumping blood faster to the muscles. Breathing will also be accelerated, resulting in symptoms like light-headedness if the extra oxygen isn’t consumed.

The digestive system also shuts down, and pupils dilate to allow better sight. Blood may also move to larger muscles (away from smaller vessels), resulting in a chilling sensation on the skin. This may cause sweating as the body anticipates action. In a nutshell, anxiety is an evolutionary alarm meant to protect us, not harm us.

However, there is a “disconnect”. Anxiety is an evolutionary alarm that protects us from physical threats, which are almost non-existent today. Our ancestors needed to run away from wild animals but you don’t need to run out of a job interview just because you feel nervous. A job interview isn’t a life-threatening situation.

In most cases today, anxiety is an oversensitive alarm, which can be frustrating if it keeps being triggered for no good reason. Luckily, we can learn how to respond differently and make anxiety an asset.

What is Cognitive Behavioural Therapy?

Cognitive Behavioural Therapy (CBT) is a form of therapy administered by a psychologist in a clinical setting or on an out-patient basis to deal with/change negative thoughts and behaviours. CBT focuses on a person’s problems, behaviour, and thought patterns.

Most people get 6 to 12 sessions of therapy, lasting approximately 50 minutes each. Therapists usually give their clients assignments to do, such as monitoring feelings and thoughts through the day or week and recording these in a diary.[3]

Benefits of CBT for anxiety

The benefits of using CBT to treat anxiety include, but aren’t limited to:

It is highly effective: Research indicates that CBT is 60%+ of those individuals who go through CBT experience significant improvements almost immediately.[4]
It is brief: Individuals just need 12 – 20 treatment sessions to enjoy significant improvement.
It is arguably the best long-term treatment for anxiety: While CBT is a highly effective short-term treatment, it teaches skills that will last with a person forever.

How does CBT for anxiety work?

CBT for anxiety works in three main stages that base itself solely on being aware of feelings and understanding why feelings come and go. These three phases should be listened to and accepted, and there are three ‘truths’ that the client and therapist work with:

1. Knowing that feelings will change

Feelings change over time: they are as fluid and fleeting as a change in the weather when you think about it. When dealing with anxiety, a person must focus on the feeling after the anxiety is gone.

Even if after all the relaxation and cognitive training work has been done anxiety sets in again, individuals should think and focus on how they will feel after the anxious spell has passed. This can take simple exercises like writing and imagining what you expect to feel when the anxiety is gone.

Try imagining what the very first indicator might be to show that feelings are starting to change. Feelings constantly shuffle, and just remembering that is useful. Anxiety will morph into calm and this leads to the next step of changing expectations.

2. “Thank you but you aren’t needed right now”

CBT also works by treating anxiety as a survival response, as opposed to an illness. But it is a reaction that can be more of a hindrance than a help: the threat it perceives may not actually be real.

The therapy allows selective responses based on if the anxiety is warranted or not. By acting contrary to how a person would in an emergency, the anxiety has no option but to fade away.

For instance, talking calmly and softly when anxious is contrary to normal behaviour in anxious situations. Such responses alter the fear response system, getting rid of anxiety.

One way to train anxiety to be selective and ‘behave’ is to give it feedback to let it know: “Thanks, but you’re not needed right now.”

3. Chase the fear

Anxiety stems from the fear of underlying consequences. A person can feel anxious about attending parties because they fear meeting people or being rejected. If a person describes their fear and the worst that can happen, the fear diminishes and seizes to exist. If you can survive a fear, you succeed in chasing that fear away.

How do CBT sessions work?

CBT sessions can take several forms. For instance, a therapist can have one-to-one or group sessions with individuals in similar situations. Individuals should meet CBT therapists 2-5 times weekly or every two weeks.

CBT sessions last 30-60 minutes and therapists are normally health professionals with specific training i.e., psychiatrists, psychologists, GPs, or mental health nurses.

Exposure therapy, which is a mechanism used in CBT.tend to last longer in session length to ensure anxiety reduces. The sessions can happen in a clinic, outside or at home, depending on the fears in question.

CBT attempts to “fix” maladaptive patterns of behaviour and thinking, which exaggerate the probability of negative outcomes increasing the feeling of anxiety. Anxiety disorders result in behavioural patterns like compulsive rituals, avoidance, and other “overly safe” behaviours to escape from situations that cause anxiety. These behavioural patterns stop a person from discovering that the “feared” outcome isn’t as bad as they think.

First sessions are question-asking sessions to uncover an individual’s life, background, experiences, social life, work, or events related to their problems. The sessions also discuss an individual’s expectations about CBT.

After the first session, the therapist will seek to discover if CBT is an appropriate treatment after the initial assessment. If not, they can recommend other treatments.

Further sessions are meant to break down an individual’s problems. You will need to analyse your feelings, thoughts, and behaviours alongside your therapist to determine if they are realistic and the effect they have. Your therapist will help you find ways of changing unhelpful behaviours and thoughts.

Each future session will then include a discussion of progress after effecting recommended changes. Your therapist will make changes/suggestions based on progress. He/she will use techniques like cognitive restructuring, which are meant to make you a logical or critical thinker.

The sessions will include therapeutic exposure to fears. The gradual and supervised exposure will make you more prepared after going through cognitive restructuring. You should also expect to learn how to maintain gains in the long-term or ways of dealing with anxiety symptoms whenever they re-emerge.

Online CBT: There are many interactive online tools that can be used to conduct CBT with little to no contact with therapists. The NHS has a list of online tools and apps. However, it is highly beneficial to meet with a therapist to monitor and guide your progress.[5]

What is exposure therapy?

CBT has many forms. Exposure therapy is a type of CBT used to treat people with OCD or phobias. Sometimes it is better to face fears in a structured way (through exposure therapy) than talking about the fear.

Exposure therapy puts a person in situations that trigger anxiety for one or more hours until the anxiety subsides by a significant amount. Therapists also give exposure exercises that should be repeated a few times a day. The exercise progresses in difficulty as a person is able to handle more difficult situations.

We are all faced with, and exposed to incremental but tolerable challenges. For instance, someone who fears cats can be asked to look at a cat from a safe distance, and then touch the cat with one finger, then two, and so on. Breaking down exposure makes it more manageable.

In extreme cases of anxiety, exposure is usually incremental but prolonged, such as several hours a day. Exposure can begin with a third party, like a family member or friend touching a cat before assigning the task to the child. Some medications can be administered to reduce anxiety and make therapy more tolerable.

In general, exposure therapy for individuals with anxiety is a daunting task – however, as the fear diminishes, the effort becomes worthwhile.

What is cognitive restructuring?

Cognitive restructuring identifies and disrupts irrational thoughts (cognitive distortions) like over-generalisations and negative self-talk responsible for causing anxiety. The psychotherapeutic process teaches you to test irrational thoughts against facts/real-life evidence and construct a realistic attitude.

Cognitive restructuring is done during or after upsetting situations to overcome distress (anxiety/fears) and learn from such situations.

Which factors influence how many sessions are needed?

Since everyone is unique, some people deal with anxiety faster than others. The most common factors influencing the number of CBT sessions needed for anxiety include:

1. Severity of anxiety

Mild anxiety, which is uncomfortable but manageable, will obviously require fewer sessions than severe anxiety, which is more frequent and extremely difficult to control without professional help.

2. How long they have been living with anxiety

For instance, persons who have been experiencing anxiety for a long time (lifetime) may require more sessions. The desired results also count. Individuals interested in getting rid of anxiety completely must receive longer and more comprehensive sessions.

3. Other therapies

Another element which may affect the number of sessions needed is if the individual is currently on any other form of medication (for example, anti-depressants) or if they are undergoing another form of counselling such as family therapy, group therapy, or dialectical behavioural therapy.

4. Personality

A person’s confidence, life situation, personal learning style, and characteristics may also dictate the number of CBT sessions needed. For those who consider themselves as extroverts, fewer sessions may be needed if the patient feels comfortable talking about their problems.

5. Substance abuse

Anxiety disorder commonly arises in dual diagnosis and often coincides with substance abuse disorders or those who have overcome their addictions and are in rehabilitation. Your CBT therapist will be able to work with you to not only address your anxiety but to help you on your road to rehabilitation.

Disadvantages of CBT for anxiety

Like any other treatment therapy, CBT has some cons:

First and foremost, CBT is hard work
It takes a lot of effort to learn new life skills
It can take longer than anticipated
CBT also requires a person to face their fears
It can cause triggers
It requires commitment (to the cause and to each session)
It can be expensive for private CBT
CBT from public health services often entails a long waiting list

CBT treatment for children with anxiety

Through CBT, children with anxiety are introduced to the idea that they are in charge and capable of handling anxiety. Treatment labels anxiety as a bully that can be “plotted” against and stopped.

It all begins with understanding the “bully” and how he/she works. Treatment proceeds with mild exposures for a child to learn to tolerate anxiety until it disappears instead of avoiding, escaping or engaging in other behaviours that reinforce fear.

How to challenge unhelpful thoughts

We tend to overestimate threats and underestimate our abilities to deal with those threats. Our thoughts are our biggest obstacles. Identifying and challenging unhelpful beliefs helps to balance perspectives that provoke anxiety.

If you get unhelpful thoughts often, challenge them by asking yourself some questions. For instance, an anxious person should challenge their anxiety by asking themselves if they have any evidence supporting those unhelpful thoughts. It also helps to look at the situation differently.

Banishing thoughts that increase anxiety also goes a long way. Instead of thinking there is something wrong, such thoughts should be replaced with the acceptance that anxiety is normal but short-term.