By Kristina Schwalm-Bacquet, BSW, MSW, RSW
Welcome back to the fourth and final part of our 4 part series on anxiety.
I hope the first three parts of this series have provided a clear description of anxiety, and some steps to take to conquer it. This is only the beginning, but even these beginning steps can help minimize the impact and distress that anxiety creates.
Today we arrive on our last piece of this 4 part series: CBT Treatment for Anxiety Disorders & Symptoms. I will explain the cognitive behavioural approach to anxiety treatment, and aim to clarify how it works.
Dealing with the “C” – Cognition:
It is probably not overly surprising to anyone that Cognitive Behavioural Therapy is a therapeutic intervention that brings forth change in two main areas: cognition and behaviour. So, let’s first talk about the “C” of CBT. We know that the thoughts we have are the major driving force behind the emotional experience of anxiety.
Step 1: Identify emotion, thoughts and trigger events in each instance of anxiety
At the beginning of CBT treatment, we will start to watch for anxiety symptoms – big and small – when they pop up in our daily experiences. When we catch one, we want to examine it.
We want to identify what happened, i.e. the event that triggered the emotion. But the event is only half the story. That’s because two people might experience the same event and have very different emotional reactions. What’s more important is how we interpret the event. So, once we have identified the event we take an honest and careful look at all of the thoughts that provoked that anxious emotion. Identifying thoughts can be incredibly easy or difficult to do on your own, depending on a whole bunch of factors that are linked to various cognitive processes. It most often takes a bit of support from someone who is trained and comfortable with helping people to identify their moment-to-moment thoughts. So, don’t get disheartened if this seems impossible to you.
Step 2: Assess the thoughts
CBT has a multitude of tools to help weigh and assess the accuracy and utility of thoughts. For every given instance of anxiety that we can catch we look at a) are these thoughts truly accurate? and b) are they useful – do they actually keep me safe or just put me in greater danger by provoking the anxiety? Answering both of these questions can help to diffuse the thoughts and beliefs that tend to fuel the anxiety thought patterns. This part is tricky too and will likely require support.
Step 3: Do it over and over and over again.
We do this for three reasons. Each time we interrupt and challenge an anxious thought pattern we a) relieve some of the anxiety in the moment b) begin to form a new, less anxious pattern of thinking and c) are going to start to notice some themes in our thinking patterns, and thus, we can begin to identify the underlying beliefs that are provoking the anxious thoughts.
Step 4: Identify & Challenge Core Beliefs and Rules for Living that provoke anxiety.
If you remember back in Part 2 of this series we reviewed some of the beliefs that fuel anxiety. In CBT therapy, after identifying our day-to-day moment-to-moment thoughts (as noted above) we will then begin to acknowledge some themes in these thoughts. The themes will reveal some of our deeper underlying beliefs that are triggering the anxious thought patterns.
For example, if I have had a series of frightening life events, I might have come to believe that life on the whole is scary and chaotic. We would call this one of my core beliefs. Core beliefs are our most base and simple beliefs about me, other people and the world or life on the whole. If deep down I have come to believe that the world is scary and chaotic, I likely have developed some Rules for Living to try and manage this belief – ie. since, “the world is scary and chaotic” I should, “always be meticulously organized and in control.” Thus, as a result of the core beliefs and the rules for living that are attached to them, my day-to-day anxious thoughts are going revolve largely around preserving the rules for living, so that I don’t ever have to come face to face with reality as I understand it, “life is scary and chaotic”. I attempt to keep my rule for living fulfilled. However, just worrying about making sure it is fulfilled and moreover, if anything prevents me from following my rule, I will become pretty darn anxious. See the problem?
Getting to the belief systems is an essential part of the CBT process. If we don’t, we might dissolve some anxiety symptoms temporarily but the symptoms will likely pop up again – since the beliefs have not yet been reconfigured.
Dealing with the “B” – Behaviour:
The behavioural work that we do in anxiety takes a few forms and happens largely in conjunction with the cognition work.
Step 1: Increase healthy lifestyle
Water consumption, exercise, healthy eating, nutrition and good sleep are all incredibly important components of coping with anxiety. In CBT work with anxiety we will talk through healthy behaviours with regard to self-care and if necessary, seek referrals for a Naturopathic Doctor, nutritionist, fitness trainer and beyond.
Step 2: Learn and practice relaxation skills
While we do not necessarily use this practice to respond to anxiety symptoms right off the hop, we do introduce relaxation techniques to help bring down our baseline of stress levels in our day to day life. Progressive Muscle Relaxations and deep breathing exercises are a couple of useful tools to practice daily if you are suffering from anxiety.
Step 3: Behavioural Experiments
Remember those pesky Rules of Living and Core Beliefs we discussed in the “C” section? We will design some experiments to conduct in order to test out whether those beliefs are actually accurate. We get highly creative and find ways to test if, for example, “thinking about the worst case scenario makes it less likely to occur”. The rationale here is that actually experiencing a situation where our beliefs are proved inaccurate is an incredibly powerful tool to reduce the influence of the belief when it reoccurs.
Step 4: Prolonged Exposure
This is where we create a list of feared experiences, from things we fear just a little bit, right up to the really scary stuff. Then, we experience these ‘fearful’ things together. As scary as it sounds, it is actually avoiding our fearful situations that preserves the anxiety. When we confront and observe our feared situation (and don’t leave before our fear reduces), two things happen:
We begin to habituate to the feared experience. The human body can withstand high states of arousal for only a short period of time. So if we stay in a feared experience, eventually our body will regulate and the fear will reduce. This allows for the second piece of this therapy:
Reconfiguration of thought patterns. Because our arousal has come down and we are no longer in a fear state while in the presence of the feared stimulus, we begin to conceive of it as less scary. Ie. if I stay in an elevator until my fear goes down, I’m going to be slightly more skeptical of the thought, “In an elevator I am trapped with no way out” the next time I have it.
As scary as Prolonged Exposure might sound, remember that at this point you have done a whole bunch of thought challenging and your fears have been reduced already. Moreover, exposure work is always gradual and the fears you are confronting should never be more than you are prepared to handle. It should challenge you, absolutely, but you should not be putting yourself in actual danger or taking on anything that you just cannot fathom. If you work through the structure of the fear list that you and your therapist have created, each new accomplishment will feel motivating and propel you towards the next challenge. It can be incredibly exciting to watch that anxiety go down and your life become wider and less constrained by fear!
I hope you have enjoyed Part 4 and the entire series on Anxiety and Anxiety Disorders.
If you have questions or you’d like to make a comment, head over to twitter and find me @KristinaSchwalm, or to my website, CBTinTrinityBellwoods.com.
I maintain a regular mental health blog on the darouwellness.com site, so check back in for more on coping with anxiety, depression, insomnia, emotional difficulties, trauma and general coping and mental wellness.