1 Three steps in CBT – The importance of detailed awareness

Cognitive behavioral therapy, CBT, is a effective treatment method for decreasing psychological symptoms of ill health but also w way to develop your life in positive directions.


Step 1

A common first step in traditional CBT is to be aware of how you are doing/the mental status of your life at that moment, i.e. how you are feeling at a given time. If you want to improve your ability to be aware of this, you can try this exercise:

Try for one week to note down 3 times a day: morning, lunch, evening, what you are doing and how you rate your mental state/health/wellbeing on scale 1= worst possible state (if very low or around 5 for several days then seek local professional help immediately) to 10= best possible state at that time. You will be able to use this information in the exercise below.


Step 2

The seond step in traditional CBT is to be aware of your thoughts and the feelings they contribute to as well as what situation that triggered them.

A trigger is something that happened and/or something somebody said/did which make you react with thoughts and feelings that reinforce each other making you create a response. Common responses are: talk back, walk away, ruminate, withdraw, mourn, blame yourself, criticize yourself etc.

Go back to your diary over your activities and mental state for the last week (see exercises of last Thursday and Saturday) or/and create another one for the coming week.

Look at the diary where you rate your mental state high (above 7) and low (below 5) on the scale 1 to 10 and see if you can understand them better by using this formula:

Trigger: this happened…

Thoughts: the situation made me think…

Feelings: the situation and thoughts made me feel…

Response: this made me react by…

Below I will go through how you can use this information to improve your well-being.


Step 3

The 3d step in traditional CBT is about creating an alternative response to your thoughts in previous exercises, which in turn likely can create other, more positive and/or less intense feelings as well as other more adaptive behavioral responses.

This is vitally important!!! This since, in opposition to sensory stimuli or feelings, which you should trust to help you to orient=survive you in your daily life: “I have to step aside from that pole…” “There is a crossing…” “I am hungry…” “That car drove scaringly close…” etc., thoughts are just constructions of the mind, i.e. one, but only one, possible explanation of many = not the truth! Read this again!

Thoughts are not per se true, but just a version of the truth. If you really get this, it will most likely change your life! To identify alternative thoughts and hence liberate you from the conviction that there is just one truth.

Think about: is there another possible explanation: i.e. what are the proofs supporting your thoughts? Are there any possible proofs against your beliefs for your thought of the situation supporting a more positive interpretation (regardless whether if you believe them or not)?

Also, ask yourself – what would your best friend say as a possible alternate explanation/interpretation? If your child said the same negative/self-defeating thought to you, what would you reply? If/when you realize that thoughts are just constructions and only one version/possibility of the truth and NOT the truth, you will most likely feel more free. To be continued…


2 Worry-hour to handle worry and rumination

Worry and rumination create stress hormones as well as psychological pain. These two dimensions paired together can often escalate into intense suffering.

Try this: to take control of worrying/rumination it is important to assign a scheduled hour per day, yes, that is right – only one hour!, for non-urgent worrying/rumination, e.g. 10 AM.

It has to be the same time every day (alternatively during the same daily activity like going to work, during breakfast etc.) to ensure discipline. There are several reasons for this. Less than one hour of rumination and worrying is ‘normal’ – does not meet one of the criteria for obsessive compulsive disorder, OCD.

Also, the brain has an overall healthy function and that is to make you survive. Your brain also wants to solve the problems you encounter. One way of doing this is to look out for dangers and surprises.

However, if one has experienced scary dangers and surprises, this mechanism can become intensified and automated leading to rumination and obsessive worrying. During the other hours of the day you shall postpone your worrying/ruminating thoughts.

It is important to acknowledge the thought/the brain’s effort as it shows up – you cannot try to control the first thought since it is spontaneous, only the second.

Hence, kindly and gently steer the thoughts to the scheduled hour, e.g. by responding to it: “Thank you for reminding me – I will listen at 10 AM… tomorrow at 10 AM …later at 10 Am… …10 AM”

If you have problems with worry/rumination it can take you thousands of replies until the brain gives up since it really thinks you are in danger.

But it will eventually work or there is another complication! It is important that this hour is not too late in the evening, preferably no later than 6 PM, to ensure it will not disrupt your sleep with the stress hormones that will be produced.

This technique is of course impossible during acute crisis. Then instead immediately seek professional help! I will address this below as well as what to do during the worrying/rumination hour.


3 Worry – useful or not?

Worry hour is a tool to handle anxiety and rumination, but also when stuck in unproductive problem solving, mourning a loss etc. by reducing the time spent on non-urgent unproductive or hurtful thoughts to maximum one scheduled hour per day.

This is of course impossible during acute crisis, then immediately seek professional help!, or when your stress level for other reasons are above 8, like having hot affects, see last post on feelings. This can be explained by an overactive sympathetic nervous system creating a locked position that just tumble the thoughts.

Then you can get a relief by instead accepting the thoughts, but still try not to listen. Instead, repeat to yourself. “These thoughts are just symptoms of acute stress/distress. I am not in the position to find a solution right now, but later when I am calmer.” Instead, try the stress management techniques for acute stress from Tuesday last week.

During the worry hour try to divide the thoughts/themes into whether they are productive/useful or unproductive/unhelpful:

Productive/useful thoughts are about things you have an impact on or are likely to happen so that it is beneficial for you to consider your alternatives.

Unproductive/unhelpful thought are about things/themes you have no control over or are unlikely, like worrying if a meteorite will crash into you from outer space as you read this, since this is both unlikely and nothing you will be able to act upon until it is too late.

However, shielding the planet from meteorites is important for among others NASA, hence the theme is productive for them and they have developed a program and protocol of what to do if/when this happens, by e.g. monitoring the space. More about what to do during the worrying hour below.


4 Productive worry = problem solving

This section continues on what to do during the worry hour, more specifically identifying if your thoughts are productive and/or unproductive.

During the worry hour, write down for every theme what is the theme, what the disturbing thought, the what if… and the result/catastrophe that you fear, if it is productive or unproductive and hence what you should do, see below, how much time you spent with the theme in total, how you manage to get out of the thought as well as how you feel after the thought/theme have left you.

For the productive/useful thoughts: use traditional problem solving: think of your possible solutions, including actions that need to be taken by you, and weigh them against each other to get a prioritized action plan. Note, productive thoughts/themes are only productive if you are under 8 in stress level since you then have access to your brain’s problem-solving abilities.

If your stress or emotional level is above 8 – do the techniques in earlier stress post to bring you down to a level where you can listen, reason and talk to yourself.

Remember, the thought is only productive until you have decided on an action. After that it is unproductive again until you have gotten new information or there are some other developments over time. More about what to do with your unproductive thoughts below.

One day when you have your worry hour and you do not feel the need to worry or use the time for problem-solving – congratulations! You then do not have to use the worry hour that day, you cannot save it, but instead you just gained an hour where you can do other things that makes life enjoyable for you.


5 Handling Anxiety – exposure

This post continues on what to do during the worry hour, more specifically what to do after identifying which of your worry-themes are productive and/or unproductive, see definitions introduced in earlier posts.
After identifying and analyzing your unproductive/unhelpful thoughts/themes according to earlier posts, you can choose among several strategies.

Here comes exposure, a favorite within traditional CBT. Note, you only should try this after learning how to calm yourself and if uncertain or feeling fragile together with a licensed therapist:

Make an imaginal exposure by really entering into the worst possible scenario. Make sure you before doing this have learnt the techniques for calming yourself when experiencing anxiety/stress posted earlier.

If you for example have a fear of flying due to fear of being in a plane crash, it is a rather unproductive worry since you have no control of the plane and it is highly unlikely. Statistically, it is more likely to be in a car accident than in a plane crash.

Visualise the worst possible scenario, imagine in details how it feels to be in the situation: what you and others around you would think, feel, say and do, and keep asking yourself what is the worst with experiencing this while visualizing, breathing calmly and being relaxed.

Continue until you have visualized all of your imagined worst-case scenarios as they come to mind. You will likely realize that the worst case, even if hypothetically terrible (it will not likely happen), did not create the kind of reactions you feared, but instead that the anxiety or fear loosened its grip of you.

Recall that if your level of discomfort is 8 or higher, revert to the stress management techniques posted earlier. Remember, if you feel fragile, it is better that you do these kinds of exercises together with a licensed therapist. Always ask beforehand what methods they use since it can vary a lot.

More strategies about what to do with unhelpful/unproductive thoughts as well as about exposure below.


6 Unproductive worry

This section continues on what to do during the worry hour, more specifically what to do with unproductive themes/topics, see earlier posts. You can choose among several strategies:

  1. If stressed, calm yourself by pointing out that the thoughts are likely consequences of stress and hence see the worry-theme as a mainly stress symptoms and not as real concerns. Instead of entering into the thoughts, try to revert to for example mindfulness techniques, see separate posts, while focusing on your breathing, take a walk or distract yourself with an activity that demands your full attention. Also, see stress management techniques posted earlier.List the likelihood and evidence that supports that your worry/fear theme is true and/or will likely happen. Then also list statistics and proof that do not support your worst fear with this. thought. Then develop a nuanced mantra, an alternative thought, covering both sides, such as: Even if it is scary to fly since I have no control over what will happen, I still will do it because it is unlikely something will happen and regardless, I will not let my fears make me avoid doing things I want to in life.
  2. After deciding to do or not to do an exposure, see post last week, or when the worry hour is over: try not to enter into the unproductive worry themes but instead talk to yourself in a comforting and self-supportive way about how unhelpful it is to use more time on thoughts/things that are unlikely or where you have no/minimal impact or control. Do this in a considerate and self-compassionate way and kindly distract yourself without going further into the thoughts.An important reason for the worry hour is that you learn that thoughts can be postponed – and if they can be postponed, they can also be altered and replaced. Remember, you do not control the first thought that enters your mind, but you can learn to control the second one.


7  Exposure Therapy to overcome Anxiety

Exposure therapy has for many decades been one of CBT’s most powerful and effective methods to help clients, who limits their life by avoiding objects, activities and situations they fear, to confront their fears.

The foundational reasoning is that the normal human tendency/learning strategy of avoiding what is feared can reduce fear in the short run, but in the long run often makes fear worse, restricts one’s life and also has a tendency to spread to more areas of life over time.


Imaginal Exposure

Imaginal exposure is about exposing oneself to one’s fears by visualizing the feared object, activity or situation.

Here comes more details about how to make an exposure to overcome fears and avoidance behaviors. Under the section Feelings there are important dimensions to consider before and after making an exposure.
Remember: if you feel fragile or concerned, then these kinds of exercises are best done together with a licensed and experienced CBT-therapist.

To make an exposure – example fear of flying:

Sit in a quiet place and close your eyes. Imagine being in a plane. Look around you to make sure you fill the scenery with details.

Then imagine how it would feel to, for example, crash or be ill. Start with what would be the first signs of something is going wrong: Is it turbulence, a thunderstorm, terrorists or are you fearing having a panic attack or going mad in some way?

Imagine in details how it feels to be in the situation: what you and others around you would think, feel, say and do while you breath calmly and relax your body.

Then, as you see this worst scenario in front of you, think about what is the worst with this happening and imagine this visually happening by seeing it in front of you and then ask yourself again what will be the worst with that, for example maybe you will die, what wold that look like and what would be the worst about that: you will miss your family – and what would be the worst about that… Continue until the end of that thought line and until you have visualized all of your imagined worst-case scenarios.

Recall, if your level of discomfort is 8 or higher, revert to the stress management techniques posted earlier, see under stress.

You will likely realize that the worst case, even if hypothetically terrible, did not happen – you are still alive and did not experience the kind and intensity of reactions you feared. For anxiety and fear to diminish this has to be repeated several times during the week.


Exposure In Vivo

Exposure in vivo is about confronting in reality the feared object, activity or situation. I have chosen the fear of riding in an elevator as an example.

The first step is to make an exposure hierarchy like the one in the picture. The exposure hierarchy consists of feared activities with regard to what is feared ranked as steps on a scale of 1 minimal level of experienced distress to 10 – the maximum level of distress, SUDS – subjective units of distress scale. Hence, the exposure hierarchy shows different feared scenarios at the step of self-rated level of discomfort of actually doing the posted action.

Thereafter, activities on level 4 to 7 are performed, if necessary using the anxiety/stress reduction techniques under Stress. The activities are repeated several times, days and weeks until the level od SUDS is at 3 or lower. What often happens is that the whole flight of steps will sink/decrease making each activity less feared than originally thought.

Remember: if you feel fragile or concerned, then these kinds of exercises are best done together with a licensed and experienced CBT-therapist.


8 Principles for effective Anxiety reductions

It is thought that during exposure people learn new associations with regard to what they fear. This new learning can overrule old learning such as a spontaneous fearful reactions.

Hence, it is important to maximize the ways that new learning occurs. This could be done by making sure that in the exposure sessions:

  • Have a variety of activities in the exposure hierarchy, both with lower and higher SUDS and for different length of time of actual exposure time
  • Make both in vivo and imaginal exposures in the same session
  • Do exposures at different locations, environments, rooms, time of day, different degree of awakedness/tiredness etc. This to avoid make the new learning dependent on a specific environment
  • Acknowledge and discuss to what degree the expected negative outcome actually happened and other surprising elements making the learning more explicit and reflected
  • Dare to experience what is feared, i.e. increasing uncertainty, for example in social phobia by daring to make social mistakes – the feared situation
  • Avoid safety behaviors such as distraction which hinders learning and instead dare to feel the feelings by rating fear instead of avoiding the experience
  • Continue live a life according to one’s desired values, not letting fears and anxiety run one’s life but accept them to be present in the background. This can load anxiety and fear with reactions of openness, curiosity and compassion. To accomplish this the feared object or activity is in exposure done together with valued activities
  • Discuss openly willingness to experience negative emotions or anxiety as a step to increase psychological flexibility and curiosity, i.e. allow the experience to be there and not fight it.


9 The importance of behaviors

The B in cognitive behavioral therapy stands for human behavior. One of the more fundamental tenets within this field is the concept of conditioning. This is a behavioral process where a response=behavior becomes more frequent or likely in a specific environment as a result of a reinforcement, such as a reward for a desired response. A human example is how being praised, which often feels good, leads to enhanced focus on performance.

The reverse is often true with different kinds of anxieties, that the presence and experience of punishments or unfortunate feared outcomes create anxiety for that and makes that behaviour less frequent. A common example is being ridiculed in front of others which often make us withdraw, pull back and avoid similar situations in the future.

Hence, conditioning can partly explain the natural instinct to avoid things that invokes anxiety. However, other important mechanisms then often lead to increased problems with anxiety, explaining the tendency for anxiety problems to spread to more areas, becoming more frequent and eventually leading to that the list of feared situations increases.
Why is this so?

It is thought that the build-up of anxiety is so unpleasant that one becomes something similar to addicted to the relief that follows after the intense built-up of anxiety. This in turn makes it more likely that the cycle repeats itself and spreads to more areas and also become more frequent.


10 Anxiety as a symptom not a cause

Another important view of anxiety in therapy is that anxiety, any kind, can be seen as a cover, a trigger – i.e. created as a response, as a consequence, for feelings that we have learnt are ‘forbidden’ in the sense that they will create consequences that are not tolerable for important person’s in our lives and therefore punished by them.

One example of this is a child who has been taught never to display emotions, for example anger, sadness or fear, since that will be punished by the caretaker, for example by withdrawing support, comfort, interaction or sending the child off in isolation to his/her room. This psychological and/or physical separation can be perceived as so devastating for a child who by nature and instinct is dependent on the caregiver.

Hence, a possible consequence of this is that the emotion is buried in the body. Unheard emotions then lie hidden in the body. Instead of the forbidden emotion, anxiety is produced when an event or situation triggers the forbidden feeling leading to anxiety which in turn leads to the unconscious use of defence mechanisms such as denial or regression – acting younger than one’s age. See more about defence mechanisms below.

The defence mechanism then coexists with the psychological symptoms. More about this complicated process to come…


11 Anxiety as defence against unwanted thoughts and feelings

A defence mechanism is a psychological strategy, a manner of thinking and behaving, that we unconsciously use.
Unconsciously means that most of us do not realize that we are using a defence mechanism in the moment to protect us from anxiety that arise from ‘unacceptable’ thoughts or feelings.

The aim of using a defence mechanism is to protect ourselves from anxiety or guilt that arise when we (the Ego in Sigismund Freud’s term) feel threatened or fear being judged by society and loved ones (Freud named this the Superego) or pressured by biological drives (Freud’s concept of the Id). Hence, anxiety according to this view of the human mind is a signal to the ego that the survival is in danger. According to Freud and followers the ego then uses unconscious defence mechanisms to avoid anxiety and to make us feel better.

The defence mechanisms are not under conscious control. They are one way of looking at how we distance ourselves from full awareness of unpleasant thoughts, feelings and behaviors. The usage of them is both natural and normal. It is when more primitive defences are used too frequently that anxiety disorders can develop.

Defence mechanisms are often learnt behaviors during childhood when fearing the consequences and reactions from our loved ones. Since it is about learnt behaviour, we can as adults get insights into this dynamic and thereby freeing us from problematic psychological symptoms as well as learn new, more adaptive defence mechanisms and behaviors.