CBT for Anxiety: How It Works & Examples

What Is CBT?

Cognitive behavioral therapy is a type of psychotherapy that can be provided in individual or group sessions with a licensed therapist. CBT therapy understands that thoughts, feelings, and behaviors are linked, and that changes in one of those areas will affect changes in the other two.

CBT sessions focus on teaching people skills to interrupt and change negative or problematic thoughts and behaviors that feed into mental health problems. Cognitive behavioral therapists tend to be more structured in their approach, using sessions to teach specific CBT skills and concepts and encouraging the client to apply what they learn in between sessions.^1,2,4

How Is CBT for Anxiety Different From Other Approaches?

CBT stands apart from other approaches for anxiety due to its structured, dual approach that creates tangible results quickly. Where other approaches may focus only on cognitive aspects of anxiety, like the worried thoughts and feelings, CBT will place high importance on the behavioral aspects. When the person changes their behaviors, they can greatly reduce their overall symptoms of anxiety.

“For people with anxiety who are trying CBT, it helps because negative thoughts cause people to have negative emotions, which lead to destructive behaviors. CBT focuses on identifying unhealthy thought processes and correcting one’s thoughts and beliefs to stop them from escalating to feelings of anxiety or an unhealthy behavior in response to the felt anxiety.” – Matt Grammer, MA, MEd, LPCC-S, CEO and Founder of the Kentucky Counseling Center

What Anxiety Disorders Can CBT Treat?

CBT is considered an evidence based practice and has been found to be especially effective in treating several types of anxiety disorders.^2,4 In fact, CBT is widely recognized as the “gold standard” in anxiety treatments, as no other therapy has as much research supporting its effectiveness.

CBT is effective in treating anxiety disorders like:

• Generalized anxiety disorder
• Panic disorder
• Specific phobias
• Social anxiety disorder

CBT is also used to treat other disorders which have anxiety as a common symptom, including obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).

Common CBT Techniques for Anxiety

Once problematic thought and behavior patterns have been identified, CBT therapy will focus on teaching skills to help people replace these patterns with other, more helpful patterns. CBT therapy tends to be very solution-focused, with the therapist working closely with the client towards specific goals.¹

Here are some common CBT techniques used to treat anxiety symptoms:^2,4,5,8

Anxiety Psychoeducation

For any disorder, CBT will provide a level of psychoeducation to inform the client about their particular anxiety disorder, how symptoms form, how they are maintained, and the proposed course of action. This phase of treatment could only take a few minutes or a few sessions, depending on the complexity of the situation and someone’s understanding of their anxiety.

Pattern Tracking

The goal of CBT treatment is to reduce symptoms and improve functioning by changing thought and behavior patterns. To help achieve that goal, early treatment is often focused on helping clients recognize these patterns and find ways to stop them before they become problematic.^7,9,10

Common CBT pattern tracking assignments include logs where clients are asked to track their:^1,9

• Thoughts they have throughout the day, especially during times they experience stress or anxiety (e.g.,  any “what-if” thoughts that increase anxiety)
• Emotions they experience and the intensity of these emotions (e.g., slight nervousness vs complete panic)
• Behaviors and responses when anxious, and any consequences or rewards these behaviors lead to (e.g.,  noticing avoidance relieves short term anxiety but increases long term anxiety)
• External or internal circumstances that cause specific thoughts, feelings, and responses (e.g.,  anxiety triggered by certain social situations or when thinking about the unknown)

Thought Stopping

Once awareness of patterns is developed, CBT therapists may begin to teach specific skills to interrupt and replace some of the client’s patterns. Many CBT skills focus on helping clients interrupt unhelpful thought patterns, but some also focus on helping clients interrupt unhelpful patterns of behavior. Once interrupted, the client learns ways to replace these thoughts and behaviors with patterns that are more helpful.¹

Thought stopping is a skill that involves using a verbal or visual mental command when experiencing unhelpful thoughts that interrupts them. This may be the word “Stop” or “No,” or imagining an image of a stop sign when a person begins replaying an embarrassing moment or worrying about something that hasn’t happened yet.⁹

Reframing Thoughts

Reframing is a skill that involves interrupting an unhelpful thought and then trying to rethink it in a more helpful way. For example, a person could reframe an anxious thought about an upcoming doctor’s appointment by thinking about the ways it could benefit their health.

Reframing can help people adjust their thoughts in ways that reduce anxiety and lead to more effective responses. Reframing works by helping to introduce more rational thinking patterns during times when a person’s thinking has become overly emotional.^1,6,9 Grammer states, “Reframing thoughts is beneficial to those who struggle with their self-esteem. A person who undergoes this type of technique is asked to challenge a certain view they have of themselves to check if it’s real or not.”

Challenging Thoughts

Challenging thoughts involves testing the accuracy of a thought through rational processes like listing evidence that the thought is true or untrue, or considering other viable explanations. Challenging anxious thoughts can reduce anxiety and also reduce irrational and impulsive decisions during times of stress or worry.

For instance, listing the evidence for and against a certain belief or assumption is a common CBT method of challenging irrational thoughts. This skill can help people recognize when their thoughts might be distorted because of their anxiety, instead of automatically believing they are true.^6,9

Exposure Tasks

Because anxious people tend to avoid situations that make them anxious, exposure tasks are often recommended to limit avoidance, reduce anxiety, and build confidence. Exposure tasks involve gradually facing feared situations and building up to more intensely feared and avoided situations.^6,9

For example, a person afraid of public speaking might start by practicing a speech in front of one or two friends and progress to speaking to a small group at work. CBT therapists also teach clients relaxation skills (like deep breathing or muscle relaxation) to prepare for these exposures. Exposures work by helping people gain confidence in their ability to face their fears, while also developing the skills to better manage their anxiety.¹⁰

Problem Solving

Problem solving involves clients being encouraged to think through the options and evaluate the potential short- and long-term consequences of each option. Because many anxiety-driven behaviors are focused only on finding short-term relief, these skills are needed to help them make better decisions.

For instance, canceling plans might be tempting for someone with social anxiety because it would mean avoiding an uncomfortable situation but it can lead to isolation, depression, and even more social anxiety in the long run. Using a problem solving approach could identify these consequences ahead of time, helping a person avoid making a poor choice in the moment.

Behavioral Activation

Anxiety tends to make people less active socially and behaviorally. People may think that doing less and avoiding their problems lowers anxiety, but it actually increases symptoms. Therefore, therapists will work to get the person going places, doing things, and engaging with others to lessen the impact of anxiety.

Relaxation Skills

Exposure and behavioral activation activities will induce higher levels of anxiety in the short-term. Learning and using relaxation skills can help to cushion the impact of anxiety and decrease symptoms sooner and more efficiently.

Journaling

Asking the client to journal their thoughts, feelings, and behaviors is a frequently used CBT tool. The process can help the client understand themselves and their experience, but it can also help the therapist better understand the person and their point-of-view. Using anxiety journaling prompts can be a great way to start tracking your symptoms and understand what may be the underlying triggers associated with your anxiety symptoms.

Will These Techniques Work for Everyone?

Grammer cautions, “CBT techniques are tools that are helpful, but their effectiveness depends on the person who’s undergoing the treatment. Some CBT techniques and methods might not lessen one’s struggle with anxiety, while some CBT methods can help efficiently. It’s up to the patient and therapist to learn which techniques work for them and which don’t.”

How Does CBT Treat Anxiety?

CBT addresses anxiety by helping people make changes to the way they think and behave during times when they are anxious. CBT aims to help people interrupt and change the worried thoughts that feed into anxiety, while also helping to reduce avoidant behaviors. Together, these changes help reduce anxiety without the use of medication, and lessen the impact of anxiety for the client day-to-day.^2,4,5

CBT Helps Reduce Anxious Thought Patterns

CBT describes anxious thoughts as “thought distortions” or “negative automatic thoughts,” which are believed to increase anxiety. These include worried “worst-case scenario” or “what if…” thoughts that many people ruminate on when they feel anxious, and other negative thoughts a person has about themselves or their lives. With the help of CBT skills, it is possible to stop and change these thoughts into more positive, helpful thoughts that reduce anxiety.^2,4,5,6,7

Here are some examples of how CBT can help to interrupt negative or distorted thoughts that feed into anxiety:^8,9

Magnification

Magnification is overfocusing or giving too much attention to an unimportant detail, or to something that is unlikely to happen.

• Example of magnification: Focusing on one small mistake you made in an hour long presentation.
• CBT intervention for magnification: Zooming out to focus on the big picture, or to notice other, positive parts of the presentation, which can help to reframe negative thoughts about the presentation.

Fortune Telling

Fortune telling is making predictions about the future without having sufficient information or evidence.

• Example of fortune telling: Believing that a blind date will be painfully awkward or uncomfortable without knowing or meeting the person.
• CBT intervention for fortune telling: Imagining positive outcomes or interactions for the date or using mindfulness to bring your attention to the present, instead of focusing on the future.

Mind Reading

Mind reading includes thoughts that assume knowledge about what another person thinks or feels, or what their motives were for a certain choice.

• Example of mind reading: Believing that a friend didn’t call you back because they are mad at you and don’t want to be friends anymore.
• CBT intervention for mind reading: Considering alternative, less personal, reasons for why they didn’t return your call (i.e. they were busy, forgot, etc.).

Comparisons

Comparisons involve unhelpful comparisons a person makes between themselves and others that make them feel more insecure, inadequate or anxious.

• Example of comparisons: Comparing yourself at work to someone who has been doing the job for 5 years longer, and feeling like a failure as a result.
• CBT intervention for comparison: Imagining a stop sign in your mind when you catch yourself making unhelpful comparisons, and working to refocus your attention to other thoughts when this happens.

Emotional Reasoning

Emotional reasoning is the tendency to believe something is true or will be true simply because of an emotion a person has.

• Example of emotional reasoning: Becoming convinced that a meeting will go poorly simply because you are dreading it.
• CBT intervention for emotional reasoning: Monitoring and tracking your anxious thoughts by writing them down in a log, which will help you become more aware of this distortion.

Filtering

Filtering occurs when a person discounts and ignores certain information that doesn’t fit with other thoughts, beliefs or feelings.

• Example of filtering: Believing that others don’t like you and discounting the many friends and family members that love you, and also the people you’ve had positive interactions with.
• CBT intervention for filtering: Listing all of the “evidence” that supports the belief that people don’t like you, as well as the evidence that conflicts with this belief can help you challenge irrational thoughts and beliefs.

CBT Reduces Behaviors That Lead to Anxiety

CBT therapists also help people identify behavior patterns that may be causing problems or making their problems worse. Problematic behaviors are identified by evaluating both the short and long-term consequences of a given behavior. Often, problem behaviors reduce anxiety in the short-term (by providing immediate relief) but increase it in the long-term, while also creating other unwanted consequences.

Problematic behavior patterns in people with anxiety disorders could include:

Avoidance

Avoidance coping, or avoiding situations, places, or things that trigger anxiety can offer short-term relief for anxiety, but tends to make symptoms worse in the long-term.

• Example of avoidance behaviors: Canceling plans with friends because of feeling anxious or insecure about rejection.
• CBT intervention for avoidance: CBT often uses exposure therapy to encourage anxious people to gradually face their fears, while also teaching them relaxation skills to manage their anxiety.

Control

Anxious people sometimes resort to controlling strategies to manage their anxiety and feel more secure when uncertain.

• Example of control behaviors: Needing to follow a rigid routine or schedule when stressed or anxious in order to feel more in control and less anxious.
• CBT intervention for control: a CBT therapist might encourage a person to change their routine or schedule in small ways as a form of exposure therapy. Over time, this can help them feel more confident in their ability to adapt to change.

Distraction

Distraction involves doing or focusing on things in order to avoid anxious thoughts or feelings.

• Example of distraction: Needing to keep the TV or radio on in the background to avoid the anxious thoughts that pop up during quiet times.
• CBT intervention for distraction: CBT teaches alternative skills that can be used instead of distraction, including skills to help them interrupt, challenge, and change anxious thoughts into ones that help them feel calmer.

Projection

Projection involves redirecting anxiety or other emotions outward to another person or situation.

• Example of projection: Snapping at your partner because of feeling anxious and on-edge about a big project at work.
• CBT interventions for projection: CBT would encourage a person to identify the real trigger or cause of the emotions, and to deal with this head-on by examining the specific thoughts and fears feeding into the anxiety. A CBT therapist might also help the person challenge these thoughts or come up with actionable steps they can take to successfully complete the project.

Procrastination

Procrastination involves delaying or putting off a task because of anxiety.

• Example of procrastination: Waiting until the night before a big project is due before starting on it.
• CBT interventions for procrastination: A CBT therapist might help a person identify procrastination patterns, when and where they are most likely to show up, and how to resist urges to procrastinate. For example, a person might be encouraged to break the task up into smaller parts that are easier to complete, instead of doing the whole task at once.

What Is the Effectiveness of CBT for Anxiety?

CBT is highly effective in treating anxiety disorders and has decades of research providing evidence that it works.^6,7 It is an evidence-based practice endorsed by the Substance Abuse and Mental Health Services Association and by the American Psychiatric Association, two of the leading authorities on mental health and addiction treatment.

Decades of research exists to support the efficacy of CBT for anxiety disorders and other common mental illnesses. Recent research efforts have focused on a comprehensive review of existing studies, and here’s what they’ve found:^2,4,5,6,7

• CBT is considered the ‘gold standard’ treatment for anxiety disorders because it has the most evidence to support it works to reduce symptoms in people with generalized anxiety disorder (GAD), panic disorder, specific phobias, and social anxiety disorder.
• CBT is also effective in treating obsessive compulsive disorder (OCD), especially when exposure and response prevention (a specific kind of CBT) is used.
• CBT has proven to reduce symptoms in people who struggle with posttraumatic stress disorder (PTSD), especially trauma-focused CBT for children and teens who are experiencing PTSD symptoms.
• CBT is effective in treating other common disorders including depression and mood disorders and substance use disorders.

Examples of CBT for Anxiety

Depending on the specific type of anxiety disorder a person has and the symptoms they experience, a slightly different form of CBT treatment may be recommended. Some forms of CBT have broken off to become their own distinct therapies but remain connected to the “family” of CBT treatments. Often, these separate subtypes of CBT have been thoroughly researched and found to be effective with specific types of anxiety disorders.¹

CBT for Social Anxiety

CBT can be quite helpful for social anxiety and social phobias. Each therapist will attack the condition in a unique way, but most will start with an assessment of the anxiety to understand the roots and the aspects that are triggering and furthering anxiety symptoms.

From there, treatment will focus on inspecting, challenging, and changing the client’s distorted thought patterns. Behavioral interventions that encourage the person to spend more time connecting and socializing with others will help desensitize them from their anxiety.

Example of Exposure Therapy for Anxiety

Exposure therapy is a type of CBT therapy used to help people reduce avoidant behavior driven by anxiety. It involves weekly therapy sessions with a licensed professional. Sessions usually last 1-2 hours and occur weekly for a total of 9-12 sessions. Exposure therapy is most used with specific phobias (fears) or in situations where avoidance related to anxiety has become problematic.^1,9

As a part of this treatment, therapists first help clients learn relaxation skills. These might include exercises like breathing or mindfulness or exercises that introduce calming thoughts.

Next, therapy would involve exposing the client to some of the triggers that cause mild anxiety, gradually working up to triggers that cause high levels of anxiety. The exposure can happen in real-life (in-vivo exposure), in a person’s imagination (imaginal exposure) or in computer simulations (through virtual reality exposure).

Over time, clients become desensitized to their triggers and experience less anxiety when confronted with them. They also develop better coping skills that help them stay calm during times when they do experience anxiety.⁹

Because exposure therapy involves facing feared situations, some clients do not complete treatment. Those who do, however, usually experience a significant reduction in symptoms.^2,4,6,7

Example of Exposure & Response Prevention for OCD

Exposure and Response Prevention (ERP) is a specific type of CBT treatment used to treat Obsessive-Compulsive Disorder (OCD). This treatment involves helping people learn skills to experience their obsessions (exposure) without engaging in repetitive compulsions (response prevention). Because compulsions are used by people with OCD to reduce anxious thoughts and feelings, this therapy involves teaching new ways to manage their anxiety. The client will also need to learn skills to resist the strong urges they will have to engage in the compulsive behavior.

Similar to exposure therapy, clients receiving ERP will develop a fear hierarchy to denote low, moderate, and high-level fears. Over the course of several sessions, the client will gradually work their way up to facing high-level fears, developing skills along the way that promote coping. This treatment has been researched and found to be one of the most effective methods of treating OCD. It typically consists of weekly sessions lasting 1-2 hours for about 12 weeks.^2,4,6,10

Example of Trauma-Focused CBT

Trauma-Focused CBT (TF-CBT) is one of the most effective therapy methods for helping children and teens with posttraumatic stress disorder.^2,4,6 This treatment involves individual, parent, and family therapy sessions and provides a structured approach to helping resolve trauma symptoms.

TF-CBT is delivered over 8-25 sessions, usually offered on a weekly basis. Individual sessions are targeted towards changing unhelpful thoughts (like self-blame) the child may have about the traumatic event and working to find a more helpful framework. Parent sessions typically are focused on helping the parent work through their own reactions to provide proper support to the child, and combined sessions focus on encouraging the parent to model this support.

Early treatment involves a lot of education and skills training, teaching children skills to cope more effectively with difficult thoughts and feelings that traumatic memories trigger. The client then works to develop a trauma narrative, or a detailed account of the traumatic memory, which is reviewed several times in sessions with the therapist, and later with the caregiver. This narrative helps children process, work through, and heal from the traumatic event.

What Are CBT Sessions Like?

The best CBT sessions will be engaging and personalized to help complete the person’s treatment goals. The therapist will take on the different roles of teacher, teammate, and cheerleader, depending on the circumstances of the day.

A lot of the session will be spent discussing the thoughts, feelings, and behaviors during the last week and their impact on the present. Part of the session will focus on planning CBT interventions to be used during the coming week.

First CBT Session

The first CBT sessions can cover a lot of details. The therapist will try to learn as much relevant information as possible to gain a thorough understanding of the client, their symptoms, and their goals. They will also outline the expectations of treatment and a proposed course of treatment. All initial therapy sessions should have a discussion about confidentiality, consent, and relevant policies.

Coming Up With a CBT Treatment Plan for Anxiety

Every CBT therapist should create a treatment plan in collaboration with the client with information about their symptoms, goals, and treatment plans. Some therapists will create in-depth written documents and others will simply have a conversation about the plan.

The treatment plan should include realistic goals with a tentative time frame of completion. It should be modifiable and referred to frequently in sessions.

How to Find CBT Treatment for Anxiety

Many therapists have received training in CBT and have experience working with people who have anxiety disorders. In many instances, health insurance will cover at least part of CBT treatment, either in-person or through online CBT. If you have insurance, a good starting place is asking them to provide you a list of CBT specialists that are in-network. An online therapist directory can also be a good resource for finding local therapists. Most directories have search filters that allow you to narrow your search to therapists who have experience in CBT and treating anxiety.

CBT Apps for Anxiety

In addition to speaking with a therapist, it can be helpful to learn more about CBT apps like Sanvello, Happify or Wysa that have additional tools to help you practice CBT skills and techniques between sessions.

CBT Exercises for Anxiety to Try at Home

While it is not possible to do CBT treatment on your own at home, there are some CBT exercises that could be helpful to some people with anxiety. These include activities and skills that focus on becoming more aware of thoughts, feelings, and behaviors, and making changes when those patterns are contributing to anxiety.

Here are five CBT techniques for anxiety that you could try at home:⁹

1. Become Aware of Your Anxious Thoughts

Make a list of the thoughts that feed your anxiety, the thoughts making it grow bigger and stronger. Become more aware of these thoughts and what situations tend to trigger them. You might use a CBT app or a journal to record these patterns throughout the day, such as the Bloom app.

2. Evaluate Your Behaviors

Make a list of things that change about your behavior during times when you are anxious and evaluate each, considering whether it is helpful or unhelpful. Remember to consider both the short-term and long-term effects each behavior has. You can also use this model to help you make decisions, thinking through the potential consequences of each option.

3. Use Positive Affirmations

Write positive affirmations on post-it notes and strategically place them around your home or office. These could be small mantras or phrases that remind you to breathe, take a break, or prompt you to name one thing you are looking forward to.

4. Talk to Yourself Like a Friend

Self-criticism is a pattern found in many mental health issues, including anxiety. Often, people speak to themselves in ways they would never speak to anyone else. Combat this negative self-talk by talking to yourself in the same way you would talk to an anxious friend during times when your anxiety spikes.

5. Try an Opposite Action

Because behaviors, thoughts, and feelings are all connected, acting bravely or confidently during times when you are anxious can sometimes make a big difference. This technique is sometimes called “opposite action” and can be used to counteract difficult feelings through behaviors that seem opposite to what you would normally do when you feel this way. For instance, when you feel like isolating, finding a way to connect with others (e.g., volunteer work or taking a walk with a friend) may help shift your mood.

Final Thoughts

CBT is a highly effective treatment for anxiety disorders and is offered in most places around the country by therapists and other qualified professionals. CBT works to reduce symptoms and improve functioning by helping people make targeted changes to the way they think and respond when they are anxious. CBT can be used as a standalone treatment or in combination with other treatment options, including medication.