Cognitive Behavioural Therapy For Dummies
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Anxiety is a bully. And like most bullies, the more you let it shove you around, the pushier it gets. The principle of facing your fears until your anxiety reduces is one of the cornerstones of Cognitive Behavioral Therapy (CBT). Get to know the nature of anxiety and to identify the ways in which it pushes you about. Fundamentally, you can beat anxiety, like any bully, by standing up to it.

Acquiring anti-anxiety attitudes

Your thoughts are what count, because your feelings are influenced greatly by how you think. Feeling anxious increases the chance of you experiencing anxiety-provoking thoughts. Anxious thoughts can increase anxious feelings, and so a vicious cycle can develop. You can help yourself to face your fears by adopting the attitudes we outline in this section.

Thinking realistically about the probability of bad events

If you have any kind of anxiety problem, you probably spend a lot of time worrying about bad things that may happen to you or your loved ones. The more you focus your attention on negative events and worry about bad things being just around the corner, the more likely you are going to believe that they’ll actually happen.

Proving for sure that bad events won’t happen isn’t that easy, with or without a crystal ball, but you can acknowledge that you tend to overestimate the probability of bad things happening. Adjust your thinking appropriately to counterbalance for this tendency.

Counterbalancing your attitude is a lot like riding a bike with the handlebars offset to the left — to steer straight, you need to pull the handlebars to the right, otherwise, you keep veering off to the left. If you tend to always imagine the worst, straighten out your thinking by deliberately assuming that things are likely to be okay.

Avoiding extreme thinking

Telling yourself that things are awful, horrible, terrible or "the end of the world" only turns up the anxiety heat. Remind yourself that few things are really that dreadful, and instead, rate events more accurately as bad, unfortunate, inconvenient, or unpleasant, but not "the end of the world."

Extreme thinking leads to extreme emotional reactions. When you mislabel a negative event as horrible, you make yourself overly anxious about unpleasant but relatively non-extreme events, such as minor public embarrassment.

Taking the fear out of fear

When people say things like "Don’t worry, it’s just anxiety," the word just implies — wrongly — that anxiety is a mild experience. Anxiety can, in fact, be a very profound experience, with strong bodily and mental sensations.

Some anxious people misinterpret these intense physical symptoms as dangerous or as signs of impending peril. Common misreadings include assuming that a nauseous feeling means that you’re about to be sick, or thinking that you’re going crazy because your surroundings feel "unreal."

If you have concerns about your physical sensations you may consider seeing your family doctor prior to deliberately confronting your fears. Your doctor may then be able to advise you as to whether deliberately increasing your anxiety in the short term, in order to be free of it in the long term, is safe enough for you. It is rare for people to be advised against facing their fears.

Understanding and accepting common sensations of anxiety can help you stop adding to your anxiety by misinterpreting normal sensations as dangerous. The figure below outlines some of the more common physical aspects of anxiety.

Common physical sensations of anxiety. Common physical sensations of anxiety

Undoubtedly, anxiety is an unpleasant, sometimes extremely disturbing experience. However, evaluating your anxiety as "unbearable" or saying "I can’t stand it" only ramps up the emotional impact. Remind yourself that anxiety is hard to bear but not unbearable. It’s sometimes intense, but it’s temporary.

Attacking anxiety with CBT

The following are some key principles for targeting and destroying anxiety.

Winning by not fighting

Trying to control your anxiety can lead you to feeling more intensely anxious for longer. Many of our clients say to us, "Facing my fears makes sense, but what am I supposed to do while I’m feeling anxious?"

The answer is . . . nothing. Well, sort of. Accepting and tolerating your anxiety when you’re deliberately confronting your fears is usually the most effective way of making sure that your anxiety passes quickly.

If your anxiety is more generalized, try to relegate it to the back burner of your mind. Carry on with mundane everyday tasks and let the anxiety burn itself out. Try taking the attitude "I can still function and do what needs to be done in the day even with feelings of anxiety." The less you focus on it, the less your brain feels like it’s got another problem to solve, meaning it is less stressed.

If you’re convinced that your anxiety won’t diminish by itself, even when you do nothing, test it out. Pick one anxiety-provoking situation that you normally withdraw from, such as using an elevator, traveling on a busy bus, standing in a crowded room, or eating alone in a cafe. Make yourself stay in the situation and just let your anxiety do its thing. Don’t do anything to try to stop the anxiety. Just stay where you are and do nothing other than feel anxious. Imagine the anxiety like waves crashing onto a beach and let the waves get smaller and smaller until they’re only a gentle ripple. Eventually, your anxiety will begin to ebb away.

Defeating fear with 'FEAR'

Perhaps the most reliable way of overcoming anxiety is the following maxim: FEAR — Face Everything And Recover. Supported by numerous clinical trials, and used daily all over the world, the principle of facing your fears until your anxiety reduces is one of the cornerstones of CBT.

The process of deliberately confronting your fear and staying within the feared situation until your anxiety subsides is known as exposure or desensitisation. The process of getting used to something, like cold water in a swimming pool, is called habituation. The principle is to wait until your anxiety reduces noticeably before ending your session of exposure – usually between 20 minutes and one hour, but sometimes more.

Repeatedly confronting your fears

As the following figure shows, if you deliberately confront your fears, your anxiety becomes less severe and reduces more quickly with each exposure. The more exposures you experience, the better. When you first confront your fears, aim to repeat your exposures at least daily.

graph of exposure therapy Your anxiety reduces with each exposure to a feared trigger.

Keeping your exposure challenging but not overwhelming

When confronting your fears, aim for manageable exposure, so that you can successfully experience facing your fears and mastering them. If your exposures are overwhelming, you may end up resorting to escape, avoidance or safety behaviors. The flipside of choosing overwhelming exposures is taking things too gently, which can make your progress slow and demoralizing. Strive to strike a balance between the two extremes.

If you set yourself only easy, gentle exposures, you risk reinforcing the erroneous idea that anxiety is unbearable and must be avoided. The point of exposure work is to prove to yourself that you can bear the discomfort associated with anxious feelings.

Taking it step by step

Avoid overwhelming or underchallenging yourself by using a graded hierarchy of feared or avoided situations. A graded hierarchy is a way of listing your fears from the mildest to the most severe.

If you want to kill your fear, let it die of its own accord.

You can use the following table to list people, places, situations, objects, animals, sensations, or whatever triggers your fear. Be sure to include situations that you tend to avoid. Rank these triggers in rough order of difficulty. Alongside each trigger, rate your anticipated level of anxiety on the good old 0-to-10 scale. Voila! You have a graded hierarchy.

After you have confronted your fear, rate the actual level of anxiety or discomfort you experienced. Then, tailor your next exposure session accordingly. Most situations are not as bad as you expect them to be. In the unlikely event that the reality is worse than your expectations, you may need to devise more manageable exposures for the next few steps and work your way up the hierarchy more gradually.

Jumping in at the deep end

Although we caution about striking a balance between under- and overchallenging yourself, jumping in with both feet does have its benefits. The sooner you can face your biggest fears, the sooner you can master them. Consider whether you can climb to the top of your hierarchy straight away.

Graded exposure is a means to an end. Going straight to your worst-feared situation without resorting to safety behaviors can help you get rapid results, as long as you stick with the exposure long enough to discover that nothing terrible happens.

Shedding safety behaviors

You can overcome anxiety by turning your anxiety upside-down. The best way to make your anxiety go away is to invite it to do its own thing. The things you do to reduce your fear in the short term are often the very things that start you feeling anxious in the first place.

Recording your fear-fighting

Keep a record of your work against fear so you can check out your progress and make further plans. Your record can include the following:
  • The length of your exposure session
  • Ratings of your anxiety at the beginning, middle, and end of your exposure session
A record helps you see whether you’re sticking with your program long enough for your fear to subside. If your fear doesn’t seem to be reducing, make sure that you’re still trying hard enough to reduce your fear by getting rid of those safety behaviors.

Overriding common anxieties with CBT

The following outlines the application of CBT for some common anxiety problems. The CBT principles that we introduce you to here are the very best bet for overcoming most anxiety problems.

First, define what you’re doing to keep your anxiety alive in your thinking, and alive in your behavior. Then, start to catch your unhelpful thoughts and generate alternatives, and test them out in reality. Understanding where you focus your attention, and retraining your attention, can also be hugely helpful.

Socking it to social anxiety

Attack social anxiety (excessive fear of negative evaluation by other people) by drawing up a list of your feared and avoided social situations and the safety behaviors you tend to carry out.

Hang on to the idea that you can accept yourself even if other people don’t like you. Be more flexible about how witty, novel, and entertaining you have to be. Systematically test out your predictions about people thinking negatively about you — how do people act when you don’t try so hard to perform?

Refocus your attention on the world around you and the people you interact with, rather than on yourself. Once you’ve left the social situation, resist the tendency to play your social encounters back in your mind.

Waging war on worry

To wage war on your excessive worry, resist the temptation to try to solve every problem in advance of it happening. Try to live with doubt and realize that the most important thing is not what you specifically worry about but how you manage your worrying thoughts. Overcoming worry is the art of allowing thoughts to enter your mind without trying to "sort them out" or push them away.

Pounding on panic

Panic attacks are intense bursts of anxiety in the absence of real danger and can often seem to come out of the blue. Panic attacks often have very strong physical sensations, such as nausea, heart palpitations, a feeling of shortness of breath, choking, dizziness, and hot sweats. Panic sets in when people mistake these physical sensations as dangerous and get into a vicious cycle because these misinterpretations lead to more anxiety, leading to more physical sensations.

Put panic out of your life by deliberately triggering off panic sensations. Enter situations you’ve been avoiding and resist using safety behaviors. Realize, for example, that feeling dizzy doesn’t cause you to collapse, so you don’t need to sit down, and that other uncomfortable sensations of anxiety will pass without harming you. Carry out a behavioral experiment to specifically test out whether your own feared catastrophes come true as a consequence of a panic attack.

Assaulting agoraphobia

What is agoraphobia? Georgina was afraid to travel far from her home or from familiar places she felt safe in, which are common characteristics of agoraphobia. She feared losing control of her bowels and soiling herself. She had become virtually housebound and relied heavily on her husband to drive her around. She learned about the nature of anxiety and developed the theory that, although she may feel like she is going to soil herself, her sensations are due largely to anxiety and she will be able to "hold on."

To gain confidence and overcome agoraphobia, develop a hierarchy of your avoided situations and begin to face them, and stay in them until your anxiety reduces. This may include driving progressively longer distances alone, using public transport and walking around in unfamiliar places. At the same time, work hard to drop your safety behaviors so you can discover that nothing terrible happens if you do become anxious or panicky, and ride it out.

Dealing with post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) can develop after being involved in (or witnessing) an accident, assault, or other extremely threatening or distressing event. The symptoms of PTSD include being easily startled, feeling irritable and anxious, memories of the event intruding into your waking day, having nightmares about the event, or feeling emotionally numb.

If you have PTSD, you may be sustaining your distress by misunderstanding your normal feelings of distress in response to the event, trying to avoid triggers that activate memories of the event or trying too hard to keep yourself safe.

To combat PTSD, remind yourself that memories of a traumatic event intruding into your mind and feelings of distress are normal reactions to trauma. Allowing memories to enter your mind and spending time thinking about them is part of processing traumatic events, and a crucial part of recovery. Many people find that deliberately confronting triggers or writing out a detailed first-person account can be helpful. At the same time it’s important to reduce any excessive safety precautions you may have begun to take.

Depending on the nature of your trauma and the severity of your symptoms, your best bet may be to seek a CBT therapist with expertise in treating PTSD. A trained therapist can help you ground yourself after exposures and be alongside you as you confront disturbing memories. Don’t hesitate to get professional help with what may now feel overwhelming.

Hitting back at fear of heights

Begin to attack a fear of heights by carrying out a survey among your friends about the kind of feelings that they have when standing at the edge of a cliff or at the top of a tall building. You’ll probably discover that your sensation of being unwillingly drawn over the edge is very common. Most people, however, just interpret this feeling as a normal reaction.

Put this new understanding into action to gain more confidence about being in high places. Work through a hierarchy of entering increasingly tall buildings, looking over bridges and climbing to the top of high cliffs.

About This Article

This article is from the book:

About the book authors:

Rhena Branch is an accredited CBT practitioner, supervisor and trainer who has trained hundreds of counselors. She is currently a lecturer at the University of East Anglia.

Rob Willson, PhD, is a cognitive behavioural therapist with over 25 years experience. He teaches and supervises internationally on CBT for OCD and Body Dysmorphic Disorder (BDD).

Rhena Branch is an accredited CBT practitioner, supervisor and trainer who has trained hundreds of counselors. She is currently a lecturer at the University of East Anglia.

Rob Willson, PhD, is a cognitive behavioural therapist with over 25 years experience. He teaches and supervises internationally on CBT for OCD and Body Dysmorphic Disorder (BDD).

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