Cognitive behavioral therapy (CBT) has become the leading treatment for anxiety, and with good reason. Research indicates that CBT can be an effective treatment for anxiety after as few as 8 sessions, with or without any form of medication (4). Due to the high prevalence of anxiety disorders (18% of adults in the United States meet criteria for an anxiety disorder over a 1-year period ), it's valuable to have a strong understanding of best practices for its treatment.
This guide will provide a general overview of CBT for anxiety disorders without delving too deeply into any single diagnosis. Of course, one size doesn't fit all. It's important to be flexible and use your best clinical judgement when working with clients. One size doesn't fit all.
CBT works by identifying and addressing how a person's thoughts and behaviors interact to create anxiety. Therapists work with clients to recognize how negative thought patterns influence a person's feelings and behaviors. Here's an example of how two different people can react to a situation differently based upon their thoughts:
|Situation: You are required to give a presentation in front of a large group.|
|I'll practice and do great!||confident, anticipatory||Practices and completes the presentation without problem|
|I bet I make a fool of myself in front of everyone.||anxious, worried, scared||Puts off practicing, attempts to get out of doing the presentation.|
With CBT, a therapist attempts to intervene by changing negative thought patterns, teaching relaxation skills, and changing behaviors that lead to the problem worsening. To help provide motivation for treatment and get a client on board, providing psychoeducation about anxiety is the first step of treatment.
Treating Anxiety with CBT
Clients who seek treatment for anxiety often have limited knowledge about their problem. They might know that they're afraid of snakes, large groups of people, or cars, but that's about it. Others might have a constant feeling of anxiety without really knowing what it's about. It's a good idea to start by discussing triggers, or sources of anxiety. What are the situations when a person feels most anxious? What do they think, and how do they respond in these situations? How is it affecting their life?
After a client has had an opportunity to discuss their own anxiety, it will be valuable to help them learn about anxiety in general. Anxiety is a feeling of intense discomfort, which drives people to avoid the feared stimuli. Anxiety is defined by avoidance.
It's important for clients to understand that every time they avoid an anxiety-producing situation, their anxiety will be even worse the next time around. The brain sees it like this: "When I avoid this situation, I feel better. I guess I should try to avoid it next time too." Look at this graph to help visualize how it works:
Education about the Yerkes-Dodson law can help a client to understand why they have anxiety, how it is hurting them, and how a certain amount of anxiety can be beneficial. The Yerkes-Dodson law states that too little or too much anxiety are both harmful, and that a person reaches optimal performance on a task with a moderate level of anxiety.
Someone who has no anxiety has little motivation to keep up with their responsibilities and someone with too much anxiety will attempt to avoid the situation, or perform poorly due to their symptoms. However, someone with a moderate level of anxiety will be motivated to prepare, concentrate, or do whatever is necessary for their particular situation without becoming debilitated or avoidant.
|Situation: You are required to give a presentation in front of a large group.|
|No Anxiety||Moderate Anxiety||High Anxiety|
|A presentation you say? Eh, whatever. I'll wing it.||I know I can do this, but I need to be prepared. I'll plan and practice before I have to speak.||This is too much. I'm going to look like a fool. How can I get out of this? I feel sick just thinking about it.|
Next, it'll be important to educate your client about symptoms and common reactions to anxiety. Everyone deals with their emotions differently, so help your client identify what they do when they're anxious. Give examples such as tapping feet, pacing, sweating, becoming irritable, thinking about the situation non-stop, insomnia, nausea, nail biting, avoidance—anything that will help your client become more aware when they are experiencing anxiety. It's important that your client recognizes when they feel anxious, because the next step will be for them to intervene during those situations.
Challenging Negative Thoughts
Before challenging thoughts will be effective, clients need to understand the relationship between thoughts, feelings, and behaviors. It can be helpful to provide examples, and to discuss examples from the client's personal experiences.
Ask the client to practice identifying their thoughts by practicing in session, and then completing a thought log for homework. A thought log requires a client to describe situations that they experience, record the thought they had during that situation, and then the resulting consequence (both a behavior and emotion). Without practice identifying how thoughts and emotions are linked, the most important thoughts will pass by unnoticed and unchallenged. In this case, the client should focus on thoughts that contribute to anxiety.
Once the client has practiced identifying their negative thoughts and they've become somewhat proficient at recognizing them, it will be time to begin challenging these thoughts. After having a thought that contributes to anxiety, the client will want to ask themselves: "Do I have evidence to support this thought, or am I making assumptions? Do I have good reason to be anxious?". Look at the following example:
|Situation: You are required to give a presentation in front of a large group.|
|I'm going to mess up and make a fool of myself.||This is scary for me, but I've never seriously messed up a presentation before. Even if I do, what's the worst that could happen? Everyone will forget in a day or two.||You're nervous, but not to such a debilitating level. You follow through with the presentation. Now the next time will be easier!|
In practice, challenging long-held beliefs can be very difficult. One technique to help ease this process is for clients to ask themselves a series of questions to assess their thoughts. Here are some examples:
"Is there evidence for my thought, or am I making assumptions?"
"What's the worst that could happen? Is that outcome likely?"
"What's the best that could happen?"
"What's most likely to happen?"
"Will this matter a week from now, a year from now, or five years from now?"
See the following worksheet for a list of questions that a client can keep to remind themselves of questions for challenging their negative thoughts.
After successfully challenging an old belief, your client will need to replace it with a new belief. I want to emphasize that the new belief does not need to be full of sunshine, rainbows, and happiness. Sometimes, the best replacement thought is just less negative. Some situations really are scary, and denying that won't do any good. The idea is to think neutrally rather than negatively, and to put fears into perspective. Someone suffering from extreme anxiety usually perceives a situation as more dangerous than it really is.
Exposure Therapy / Systematic Desensitization
The basic idea of exposure therapy is to face your fears. When someone exposes themselves to the source of their anxieties and nothing bad happens, the anxiety lessens. This doesn't mean that you should throw someone with a fear of spiders into a room of tarantulas and lock the door (though some have had success with this—it's called "flooding". We don't recommend it unless you really know what you're doing). Instead, you'll gradually work your way up to the feared stimuli with the client in a process called systematic desensitization.
The first step of systematic desensitization is to create a fear hierarchy. Identify the anxiety you would like to address with your client, and then create a list of steps leading up to it with rankings of how anxiety-producing you think the situation would be. Here's an example:
|Fear Hierarchy for a Spider Phobia|
|Situation||Fear Ranking (1-10)|
|Listen to a story about finding a spider||2|
|Rest a picture of a spider on my arm||4|
|Sit in a room with a nearby spider in a cage||6|
|Let the spider out of the cage, but keep it at a distance||8|
|Let a spider walk across my arm||11|
Now, before following through and exposing a client to these stimuli, they must learn relaxation techniques to learn during the process. These can include deep breathing, progressive muscle relaxation, or meditation. They're described in detail in the next session of this guide.
Finally, the client will follow through with the fear hierarchy (with the clinician's assistance). The goal is for the client to be exposed to stimuli that are only moderately anxiety-producing while using relaxation skills to manage their response. Eventually, the client can move on to the more challenging situations that they identified in the fear hierarchy.
The exposure process should happen over the course of several sessions, and the client should be allowed to become comfortable at each stage before moving on. The clinician will present the feared stimuli and ask the client to use a relaxation skill. Eventually, the stimuli can be removed and the process should be discussed.
If it becomes difficult to move between stages, try coming up with an in-between stage that's less anxiety-producing. For example, if touching the spider is too much, let it walk nearby without making contact. There shouldn't be any surprises during systematic desensitization—the client should be comfortable and know exactly what's coming. Additionally, know when to stop. Does the client need to reach the point where spiders can crawl on them, or is tolerating them near by enough?
Relaxation skills are techniques that allow a person to initiate a calming response within their body. Everyone has their own preferences and skills that they find work best for them, so expect some trial and error before finding the technique that fits with each client. Two of the most commonly used and effective relaxation skills are deep breathing (1) and progressive muscle relaxation (2).
Deep breathing (also known as diaphragmatic breathing) requires a client to take conscious control of their breathing. They will learn to breathe slowly using their diagram to initiate the body's relaxation response. There are many variations of this skill, and we've shared one easy-to-use method below:
- Sit comfortably in your chair. Place your hand on your stomach so you are able to feel your diaphragm move as you breathe.
- Take a deep breath through your nose. Breathe in slowly. Time the breath to last 5 seconds.
- Hold the breath for 5 seconds. You can do less time if it's difficult or uncomfortable.
- Release the air slowly (again, time 5 seconds). Do this by puckering your lips and pretending that you are blowing through a straw (it can be helpful to actually use a straw for practice).
- Repeat this process for about 5 minutes, preferably 3 times a day. The more you practice, the more effective deep breathing will be when you need it.
Instructions: Deep Breathing
Deep breathing can be valuable in the moment when confronting something anxiety-producing, or in general as a way to reduce overall stress. It will be valuable for your clients to practice deep breathing daily even when they're feeling fine—the effects can be long-lasting.
Progressive muscle relaxation (PMR) requires a bit more effort than deep breathing, but it can significantly reduce feelings of anxiety (2). PMR requires the user to go through a checklist of muscles that they will purposefully tense and then relax. Using this technique will create a feeling of relaxation, and it will help to teach a client to better recognize when they are experiencing anxiety by recognizing the tension in their muscles. Because the script is lengthy, we have included it in a printable format below.
1. Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61(4), 611-619.
2. Dolbier, C. L., & Rush, T. E. (2012). Efficacy of abbreviated progressive muscle relaxation in a high-stress college sample. International Journal of Stress Management, 19(1), 48-68.
3. Kessler R. C., Chiu W. T., Demler O., & Walters E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders. National Comorbidity Survey Replication Archives of General Psychiatry, 62(6), 617-27.
4. Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4), 595-606.
Two strategies often used in CBT are Calm Breathing, which involves consciously slowing down the breath, and Progressive Muscle Relaxation, which involves systematically tensing and relaxing different muscle groups.What are the 5 types of coping strategies for anxiety? ›
- Keep physically active. ...
- Avoid alcohol and recreational drugs. ...
- Quit smoking, and cut back or quit drinking caffeinated beverages. ...
- Use stress management and relaxation techniques. ...
- Make sleep a priority. ...
- Eat healthy foods. ...
- Learn about your disorder.
The Coping Skills: Anxiety worksheet describes four strategies for reducing anxiety. Strategies include deep breathing, progressive muscle relaxation, imagery, and challenging irrational thoughts.What are the 5 steps of CBT? ›
- Step One – Make A List.
- Step Two – Record Unproductive Thoughts.
- Step Three – Create Replacement Thoughts.
- Step Four – Read Your List Often.
- Step Five – Notice And Replace.
What are examples of cognitive behavioral therapy? Examples of CBT techniques might include the following: Exposing yourself to situations that cause anxiety, like going into a crowded public space. Journaling about your thoughts throughout the day and recording your feelings about your thoughts.What is the 3 3 3 rule for anxiety? ›
Look around you and name three things you see. Then, name three sounds you hear. Finally, move three parts of your body — your ankle, fingers, or arm. Whenever you feel your brain going 100 miles per hour, this mental trick can help center your mind, bringing you back to the present moment, Chansky says.What is the 5 4 3 2 1 coping technique for anxiety? ›
This technique asks you to find five things you can see, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste. Using this with someone who feels anxious will help to calm them down and reduce their feelings of anxiety.What are 4 major causes of anxiety? ›
- past or childhood experiences.
- your current life situation.
- physical and mental health problems.
- drugs and medication.
- learning about anxiety.
- relaxation techniques.
- correct breathing techniques.
- cognitive therapy.
- behaviour therapy.
- dietary adjustments.
- Keep Your Blood Sugar in Check. ...
- Avoid Stimulants. ...
- Get Enough Sleep. ...
- Just Breathe. ...
- Practice Mindfulness. ...
- Exercise. ...
- Do What You Enjoy. ...
- Where to Get Help.
- Stay active. ...
- Steer clear of alcohol. ...
- Consider quitting smoking cigarettes. ...
- Limit caffeine intake. ...
- Prioritize getting a good night's rest. ...
- Meditate and practice mindfulness. ...
- Eat a balanced diet. ...
- Practice deep breathing.
It is based on the three "C's" of recovery calm your body, correct your thinking, and confront your fears.How do you calm someone with anxiety? ›
gently let them know that you think they might be having a panic attack and that you are there for them. encourage them to breathe slowly and deeply – it can help to do something structured or repetitive they can focus on, such as counting out loud, or asking them to watch while you gently raise your arm up and down.What are coping exercises for anxiety? ›
Strategies to cope with anxiety
Relax your body and muscles, and control your breathing. You can do this through exercises such as yoga, guided meditation, mindful meditation, and breathing exercises. Use visualizations, music, and meditation to relax and ease your mind.
- Fully Focus on Your Thoughts. CBT requires an intense focus on the thoughts that come to mind throughout the day. ...
- Schedule Your Day with Manageable Tasks. ...
- Relaxation Techniques. ...
- Reframe Your Thought Patterns.
Here's a simple CBT (cognitive behavioural therapy) technique to try out. Ask yourself three questions: what's the worst that could happen? What's the best that could happen? What's the most realistic outcome?What techniques do CBT therapists use? ›
- Cognitive restructuring or reframing. ...
- Guided discovery. ...
- Exposure therapy. ...
- Journaling and thought records. ...
- Activity scheduling and behavior activation. ...
- Behavioral experiments. ...
- Relaxation and stress reduction techniques. ...
- Role playing.
One popular technique in CBT is ABC functional analysis. Functional analysis helps you (or the client) learn about yourself, specifically, what leads to specific behaviors and what consequences result from those behaviors.Is CBT effective for anxiety? ›
CBT for anxiety can help alleviate anxiety symptoms associated with all of these disorders. CBT can eliminate the disorder entirely in some cases by helping the individual change their thought pattern and change their reaction to the triggers that used to cause anxiety and a feeling of doom or danger.What is 5 4 3 for anxiety? ›
5 things you can see: Your hands, the sky, a plant on your colleague's desk. 4 things you can physically feel: Your feet on the ground, a ball, your friend's hand. 3 things you can hear: The wind blowing, children's laughter, your breath.
“It is more than okay to not feel 100% all the time or to experience unexplained anxiousness. Take a moment to see it, absorb it, identify it. Accept it,” she added as she talked about the '3-3-3 rule' that “grounds us to the present moment creating mindfulness that helps us depart from unhealthy emotions”.What is the best anxiety therapy protocol? ›
Cognitive behavioral therapy (CBT) has become the leading treatment for anxiety, and with good reason. Research indicates that CBT can be an effective treatment for anxiety after as few as 8 sessions, with or without any form of medication (4).What is the 4 7 8 technique for anxiety? ›
The 4-7-8 breathing technique involves breathing in for 4 seconds, holding the breath for 7 seconds, and exhaling for 8 seconds. People may find it helps manage anxiety. This breathing pattern aims to reduce anxiety or help people get to sleep.What is the anxiety ladder technique? ›
The stepladder approach is a step-by-step way of helping children with anxiety. The approach involves tackling little things before you face really scary things. The approach encourages children to face their fears, rather than avoiding them. You can use the approach for different ages and anxieties.What is the first line intervention for anxiety? ›
Antidepressants are the first-line medications in the treatment of anxiety disorders.What emotions trigger anxiety? ›
A big event or a buildup of smaller stressful life situations may trigger excessive anxiety — for example, a death in the family, work stress or ongoing worry about finances. Personality. People with certain personality types are more prone to anxiety disorders than others are.What are the 6 common anxiety disorders? ›
There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, specific phobias, agoraphobia, social anxiety disorder and separation anxiety disorder.What is the root of anxiety? ›
There is a multitude of sources that could be triggering your anxiety, such as environmental factors like a job or personal relationship, medical conditions, traumatic past experiences – even genetics plays a role, points out Medical News Today. Seeing a therapist is a good first step. You can't do it all alone.What is an anxiety necklace? ›
Anxiety necklaces contain a long and thin metal mouthpiece that looks a bit like a whistle. You exhale into it, which promotes slow and deep breathing. When we feel stressed or anxious, our nervous systems are out of balance.What vitamins help with anxiety? ›
- Vitamin D3: Vitamin D3 can improve mood and energy, and it has been a must for many of my patients throughout the pandemic, says Dr. Madrak. ...
- Magnesium: ...
- Melatonin: ...
- Omega-3 fatty acids: ...
- Chamomile: ...
- Valerian root: ...
- Ashwagandha: ...
If you take magnesium as a supplement, studies that showed that magnesium can have anti-anxiety effects generally used dosages of between 75 and 360 mg a day, according to the 2017 review. It's best to consult a healthcare practitioner before taking any supplement so you know the correct dose for you.Is magnesium good for anxiety? ›
Medical research has linked magnesium to reduced anxiety. Magnesium helps you to relax by stimulating the production of melatonin and serotonin which boost your mood and help you sleep. Magnesium also reduces the production of cytokines and cortisol, which lead to increased inflammation and stress.What foods help with anxiety? ›
Foods naturally rich in magnesium may, therefore, help a person to feel calmer. Examples include leafy greens, such as spinach and Swiss chard. Other sources include legumes, nuts, seeds, and whole grains. Foods rich in zinc such as oysters, cashews, liver, beef, and egg yolks have been linked to lowered anxiety.What is the strongest anti anxiety herb? ›
- Best with ashwagandha: NOW Certified Organic Ashwagandha Extract.
- Best with passionflower: NOW Passionflower.
- Best with lemon balm: Mary Ruth's Lemon Balm.
- Best with rhodiola: HUM Nutrition Big Chill.
- Best with valerian root: Sundown Naturals Valerian Root.
Post-Panic Attack Symptoms
Feeling tired the day after a panic attack is completely normal. For some people, it takes days to recover from an anxiety attack. If you're dealing with a panic attack hangover, some symptoms may even linger.
Anxiety happens when a part of the brain, the amygdala, senses trouble. When it senses threat, real or imagined, it surges the body with hormones (including cortisol, the stress hormone) and adrenaline to make the body strong, fast and powerful.What are the 5 main coping strategies? ›
There are five main types of coping skills: problem-focused strategies, emotion-focused strategies, meaning making, social support, and religious coping.What are the 4 major coping strategies? ›
- Lower your expectations.
- Ask others to help or assist you.
- Take responsibility for the situation.
- Engage in problem solving.
- Maintain emotionally supportive relationships.
- Maintain emotional composure or, alternatively, expressing distressing emotions.
Emotion-Focused Coping Strategies
Other emotion-focused techniques for coping with stress include: Journaling about your emotions3. Practicing loving-kindness meditation to increase self-compassion. Using visualization strategies to increase positive feelings.
Among the more commonly used adaptive coping mechanisms are: Support: Talking about a stressful event with a supportive person can be an effective way to manage stress.
Relaxation. Engaging in relaxing activities, or practicing calming techniques, can help to manage stress and improve overall coping. Physical recreation. Regular exercise, such as running, or team sports, is a good way to handle the stress of given situation.What is the 3 3 3 coping technique? ›
It involves looking around your environment to identify three objects and three sounds, then moving three body parts. Many people find this strategy helps focus and ground them when anxiety overwhelms them.What are 3 unhealthy coping skills? ›
- Avoiding issues. ...
- Sleeping too much. ...
- Excessive drug or alcohol use. ...
- Impulsive spending. ...
- Over or under eating.
- Journaling. Journaling can be an excellent way to become more aware of and deal with painful emotions. ...
- Mindfulness meditation. Mindfulness meditation is a way to notice your emotions about a stressful event in a nonjudgmental way. ...
- Forgiveness. ...
- Acceptance. ...
- Talking about it.