Cognitive Behavioral Therapy (CBT) is a specific type of treatment used by psychologists and counselors to help with mental health issues, like anxiety. The name says it all; CBT addresses the thoughts and behaviors that contribute to mental health symptoms.
CBT is a well established evidence based or empirically validated treatment. This means the approach can be trusted, because it has been tested and proven in research trials. Further, as a practicing psychologist with an emphasis in anxiety and stress disorders, I’ve seen the success of CBT in the talk therapy setting.
But … how does this happen?
Unlike some types of talk therapy, the CBT approach looks at the current issues or symptoms, and applies a specific, timely, problem solving approach. For anxiety disorders, clients are taught what happens in the anxious brain, how this creates anxious thoughts, and triggers physical symptoms in the body. With this understanding, clients are then taught CBT skills to treat their anxiety symptoms.
It’s important to remember that not all skills will work for every person. Much like a carpenter using a tool, if one skill doesn’t work, set it down and pick up another to see if it helps. So what are some CBT skills to treat anxiety thoughts?
Skill 1: Identify your Worst Case Scenario Thought
Anxious thoughts follow the same theme: The worst case scenario becoming true. Sometimes this worst case scenario is obvious, sometimes it requires a little exploration. But it is always there.
For example, during a panic attack the worst case scenario thought is, “I’m going to die” (usually because having a panic attack feels like a heart attack). Or if there is social anxiety about giving a talk at work, the underlying thought could be “I’ll fail, and everyone will know I’m a fraud.” These are powerful thoughts, and very believable in the moment. However, when we pause, check in with ourselves, and are able to identify the worst case scenario in the moment, it helps reduce our anxiety.
Examples of some worst case scenario thoughts:
• I’ll die / accidentally kill someone
• I’m going to fail / They’ll see me fail
• I’m weak / Others will know I’m weak
• I’m stupid / Others will know I’m stupid
• I can’t handle it / do it / tolerate this
• This proves no one cares about me
Why does identifying the worst case scenario thought work?
There’s a popular phrase to explain why this skill helps: You gotta name it, to tame it. Research from Dr. Daniel Siegel, M.D. explains that this skill allows one part of the brain to release “soothing neurotransmitters” to the part of the brain that is creating the anxiety. That’s incredible! By simply naming the worst case thought, your brain will go through a process that allows it to settle down.
Skill 2: Externalization
There are many types of externalization skills, but they all have the same goal: Understanding anxiety thoughts are a symptom of a diagnosis, and not reality. When we externalize anxiety thoughts and see them as a set of symptoms, we automatically stop internalizing them. This reduces the intensity of our anxiety in the moment.
There’s a trap everyone falls into when it comes to anxiety thoughts: If I think it, it must be true. Well, this simply isn’t … true. Anxiety thoughts are the result of our brain trying to protect us from a potentially dangerous situation. Work speeches, bus rides, even leaving the house can be seen as a dangerous situation. Therefore, anxiety thoughts are highly biased. Unfortunately in these cases, when the brain designates something as a potentially dangerous situation, it’s hard to dismiss the thoughts easily. They’re sticky. Externalization helps to counter this in two steps.
Step 1: Know it is impossible to prevent anxious thoughts from appearing in the mind.
Many clients assume they are responsible in some way for having anxious thoughts in the first place. They think they are “bad” or “crazy” and criticize themselves, usually unconsciously. Nothing could be farther from the truth. Believing you have the ability to prevent anxious thoughts from happening “is like saying you have the ability to control if you feel the sensation of wind on your face.” (quote from Marsha Linehan, Ph.D.) We can only control how we respond to anxious thoughts when they appear. To do this, the most helpful response is to start seeing anxious thoughts as a symptom of an anxiety diagnosis, instead of an underlying bias, if I think it, it must be true.
Step 2: Use any of the following skills to externalize thoughts:
• Imagine the thought being spoken in a funny or cartoon-like voice
• Give the anxious thoughts a name, as though a different person is saying them. For example, “Oh that’s just Anxious Eddy again.”
• Visualize a box labeled, “Anxious Thoughts” and “place” each thought in this box
• Visualize the thought being written down on a paper note. Watch the paper drift away.
• Mentally label the thought as future tripping (assuming the worst about the future) or catastrophizing (assuming the worst in the present moment). Repeat the labeling until the anxiety goes down.
Remember, externalization is most effective when these two steps are applied in order. First, accept anxious thoughts are going to happen. You can only control how you respond to them. Second, use one of the above skills to help view the thoughts in a more effective way, creating distance between you and the anxiety.
This mental distance helps to reduce the intensity of the anxiety. Recall, externalization is not supposed to stop the thought, or challenge the thought. It is designed only to reduce the intensity of the anxiety. Think of it as a calming technique.
Skill 3: Intentionally Worrying
Yes, this actually works … when done correctly. For those that identify as “worriers” scheduling worry time is an effective skill. While it might seem paradoxical to set aside time and force worry thoughts to happen, the research for this practice is compelling.
What does this skill look like?
Set aside 10-15 minutes once or twice a day. During this time period intentionally worry. It’s important to not think of reassuring thoughts or non anxiety thoughts during this time. Focus only on the worry thoughts. This is the time to worry about everything, even allowing yourself to worry if you are doing the exercise wrong! If needed, repeat the same worry thoughts over and over until time is up. The goal is to worry as intensely as possible.
Why does this work?
It’s surprisingly hard to only worry for 10-15 minutes. When people worry during the day, there are regular attempts to reassure themselves after they think of something stressful. For example, thinking “I’m going to screw up” might be followed up with a reassuring “stop thinking that, just get through it.” This back and forth pattern (worry thought followed by a reassuring thought) is what contributes to getting stuck in worry. Only worrying breaks this pattern. Plus, constantly worrying over the same thought can become boring.
Also, after having a designated worry time, people are more likely to dismiss worry thoughts that happen outside of this window. Over time, clients report that when a worry thought comes up, they’ll think to themselves “forget it, I’ll worry about it during my worry time.”
Summary
These skills are only a small piece of the CBT approach to treat anxiety disorders. However, each listed technique is capable of creating change by approaching anxiety thoughts in a more helpful way. If you are experiencing anxiety, give each skill a try (at least a week) and see what impact it can have for you.
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