How to manage anxiety with three steps in CBT

This article How to manage anxiety with three steps in CBT, Cognitive behavioral therapy, is about how you can improve your life with effective strategies. CBT is an effective method for decreasing psychological symptoms of ill health but also for developing your life in positive directions.


The content of this article ‘How to manage anxiety with three steps in CBT’

This article explains 3 simple steps you can start practicing already today and change you life in positive directions:

What is anxiety

Anxiety as a symptom – not a cause

Anxiety as a defense against unwanted thoughts and feellings

What is the difference between anxiety and fear

How to manage acute anxiety

Step 1: Notice what is happening inside and outside of you

Step 2: Be aware of your triggers, thoughts, feelings and responses

Step 3: Create more adaptive responses


What is anxiety

Anxiety is the body’s natural response to stress.

Anxiety is experiecnig unease and apprehension about what is to come. It involes a mix of feelings such as fear, sadness, anger and distress.

Anxiety is one of the body’s most prominent respinse mechanisms for survival.

Anxiety is a fire alarm, signalling that something is happening that has to be dealt with.

Anxiety consists of patterns of physiological arousal in the body that many can relate to. Anxiety is diagnostic in different psychological anxiety disorders. Fear often leads to strong reactions.


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-up, a shield. In this view anxeity is a response to a trigger. This trigger created thoughts and feelings that we have learnt are ‘forbidden’ in the sense that we have reasons for fearing that they will create severe negative consequences for us. One common consequence is fearing that our thoughts, feelings and related responses are not tolerable for important person’s in our lives and we therefor fear to be punished and abandoned by them.

One concrete 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. Common punishments could be withdrawing support, comfort, interaction or sending the child off to isolation in his/her/their room. This psychological and physical separation can be perceived as so devastating for a child who by nature and instinct is dependent on and wants to be close to the caregiver.

Hence, a possible consequence of these forbidden reactions in the form of thoughts, feelings and behaviors is that they become supressed and buried unconciously and then lie hidden in the body. Instead, anxiety is produced when an event or situation triggers the forbidden thought, feeling and behvaior, which in turn leads to the use of defense mechanisms such as denial or regression – acting younger than one’s age. See more about defence mechanisms here:

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


Anxiety as a defense 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.


What is difference between anxiety and fear

Some practioners within the field of psychology think fear and anxiety are versions of the same state, but many disagree. Fear is usually aimed at a specific stimuli and situation with specific bodily reations. Hence, anxiety and fear are interrelated and overlap partially. For example, fear is a component aimed at a specific topic in many of the medical anxiety disorders such as panic attacks and fobias. Even if many of the sensations when experiencing anxiety or fear overlap, anxiety is not a feeling but a set of symptoms.


How to manage acute anxiety

Managing anxiety and emotions, so called affect regulation, is an important factor for better self-care. Important parts for calming anxiety and fear is practicing  changing focus to compassion as well as understading, validating and calming emotions.
Here are some techniques you can try:
1 Touch: caressing oneself or being touched by a loved one, such as cuddle up, keep warm, hugs etc.
2 Calm breathing – slowly breathing out longer than breathing in
3 Relaxation exercises
4 Naming emotions which in itself is calming, also by writing a diary, but also through practicing acceptance and validation. This can be done by reflecting upon: what emotions do I feel, how strong are they, where can I feel them in the body
5 Visualization exercises – imagery, writing letters, role play etc.
6 Practicing mindfulness: This can expand the tolerance needed to be able to stay in unpleasant inner experiences such as trauma or suppressed feelings. This can be done by developing an inner base of compassion, compassionately studying internal emotional turmoil instead of getting caught in pain and misery


Step 1: Notice what is happening inside and outside of you

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 and well-being on scale 1= worst possible state to 10= best possible state at that time. If you notice that you are rating yourself under or around 5 for several days, consider seeking local professional help immediately.



Step 2: Be aware of you triggers, thoughts, feelings and responses

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

A trigger is something that happened or something somebody said or did. The trigger makes 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 Step 1 or create a new one for the upcoming week.

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

Trigger: This happened:

Thoughts: The situation made me think “x”

Feelings: The situation and thoughts made me feel:

Response: This made me react by:

In Step 3 I will go through how you can use this information to improve your well-being.


Step 3: Create more adaptive thoughts and responses

The third step in traditional CBT is about creating an alternative thought and response to your pattern in Step 2, which in turn will create other, more positive and less intense feelings as well as more healthy 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…


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.

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.


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.

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.