Cognitive Behavioral Therapy (CBT) is a type of mental health treatment used by counselors, psychologists, and other trained professionals. CBT is a highly effective form of treatment for a range of anxiety disorders including Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, and Specific Phobias.
CBT treatment is usually provided in weekly hour-long therapy sessions, where a practitioner helps clients learn skills to manage their symptoms and improve their functioning. There is no set time frame for standard CBT treatment but it is generally a shorter-term treatment averaging between 8-20 sessions. The focus of CBT treatment is on finding practical solutions to the problems a client is currently experiencing.
Central Concepts of CBT
Cognitive Behavioral Therapy emphasizes that thoughts have a significant impact on feelings and behaviors (Cognitive element), and also that behaviors are influenced by external rewards and consequences (Behaviorist element). The blending of these two theories results in an understanding that there is a complex interdependent relationship between thoughts, feelings, and behaviors and that these are also influenced by external factors.
CBT is a therapy that addresses anxiety by helping people make changes to the way they think and behave during times when they are anxious. Because of the way thoughts, feelings and behaviors are linked, changes in any one are thought to effect changes in the other two. Specific patterns of thoughts and behaviors are thought to be closely related to anxiety, and these are often a main target in CBT treatment.
Thought Distortions
CBT therapists call unproductive thoughts “thought distortions.” Thought distortions are patterns of inaccurate or unhelpful thinking. Thought distortions are more common during times when people experience stress or difficult emotions.
Common thought distortions for people with anxiety disorders, include:
Magnification: Over focusing or attributing too much importance to specific details. For example, being overly self-conscious about something others would likely not notice.
Fortune Telling: Believing that one can predict what will happen in the future. For example, being convinced that you will fail a test and be kicked out of college.
Mind Reading: Believing that one can read another’s mind. For example, convincing yourself that your friends are all mad at you for missing a party.
Jumping to Conclusions: Making premature assumptions or predictions. For example, assuming your girlfriend is breaking up with you when she asks to talk.
Emotional Reasoning:Believing that something is true because of an emotion. For example, believing a meeting will go poorly just because you are dreading it.
Filtering:Discounting or ignoring certain information that doesn’t fit with other thoughts. For example, believing your presentation was awful even though others praised you after.
Problematic Behavior Patterns
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 are those that might help reduce anxiety in the short-term but increase it in the long-term, while also creating other unwanted consequences.
Common problematic behavior patterns in people with anxiety disorders are:
Avoidance: Avoiding situations, places, or things that trigger anxiety. For example, a person with social anxiety making an excuse to not come to a party.
Control: Overly rigid or controlling behavior in some area of life. Example: an anxious parent not letting their child play outside.
Distraction: Becoming occupied with something to avoid anxious thoughts and feelings. For example, staying busy to avoid thinking about something stressful.
Projection: Snapping at others because of feeling anxious and on-edge. For example, overreacting to a significant other when anxious about work.
Procrastination: Delaying a task because of anxiety. For example, waiting until the night before a big project is due before starting.
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 practitioner working closely with the client towards specific goals.
What Anxiety Disorders Can CBT Treat?
While CBT is used to treat a variety of mental health issues, there is especially strong evidence that it is effective in treating anxiety disorders.10 Anxiety disorders include a cluster of mental health conditions characterized by excessive nervousness or worrying, and CBT can be used to treat each of these disorders. In fact, CBT is widely recognized as the “gold standard” in anxiety treatments, as no other therapy has as much research supporting its effectiveness.
Anxiety disorders that CBT can treat include:
- Generalized Anxiety Disorder
- Panic Disorder
- Specific phobias (ie: Agoraphobia)
- Social Anxiety Disorder
CBT is also effective in treating anxiety when it is a symptom of another mental disorder, including:
- Posttraumatic Stress Disorder
- Obsessive-Compulsive Disorder
Common CBT Techniques & Skills for Anxiety
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. The more a client can self-monitor (track) their patterns, the more prepared they will be to interrupt and replace these patterns later in treatment. CBT therapists work collaboratively with clients in sessions to help identify these patterns and may also recommend certain “homework” assignments to their clients.
Common CBT assignments include logs where clients are asked to track:
- 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)
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.
Common CBT skills to help interrupt and replace unhelpful thought and behavior patterns include:
- Thought Stopping
- Reframing Thoughts
- Challenging Thought
- Exposure Tasks
- Problem Solving
Thought Stopping
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 thinking in unhelpful ways, such as imagining bad outcomes. The goal of thought-stopping is to interrupt the unhelpful thoughts early, before they begin impacting symptoms.
Reframing Thoughts
Reframing thoughts 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.
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. For example, a person might challenge an anxious thought like, “I am going to fail” by thinking of prior successes they’ve had or thinking about how much they have practiced and prepared. This skill can help people recognize when their thoughts might be distorted because of their anxiety, instead of automatically believing they are true.
Exposure Tasks
Because anxious people tend to avoid situations that make them anxious, exposure tasks are often recommended to reduce avoidance, reduce anxiety, and build confidence. Exposure tasks include gradually facing feared situations and building up to more intensely feared and avoided situations. 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.
Problem Solving
Problem solving involves clients being encouraged to think through the options they have to respond during times of anxiety by evaluating potential short-and long-term consequences of each option. For instance, canceling plans might be tempting for someone with social anxiety because it would result in immediate relief. But the long-term consequences might include feeling isolated, damaging important relationships, and even increased anxiety in the future. Problem solving can help people go through a more careful thinking process before making decisions during times when they are anxious.
Examples of Cognitive Behavioral Therapy 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.
Example of Exposure Therapy for Anxiety
Exposure therapy is a type of CBT therapy used to help people reduce avoidant behavior driven by anxiety. Exposure therapy involves weekly therapy sessions with a licensed professional. Sessions usually last 1-2 hours and occur weekly for a total of 9-12 sessions. 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 (virtual exposure).
Because exposure therapy involves facing feared situations, some clients do not complete treatment. Those who do, however, usually experience a significant reduction in symptoms.9 Over time, clients become de-sensitized 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.
Exposure therapy is most used with specific phobias (fears) or in situations where avoidance related to anxiety has become problematic.
Example of Exposure & Response Prevention
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.6
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.7 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.
Is CBT Effective for Anxiety Disorders?
CBT is highly effective in treating anxiety disorders and has decades of research providing evidence that it works.10 Because of this, CBT continues to be considered the “gold standard” of treatment for anxiety disorders. 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, but some of these studies have been scrutinized for being poorly designed. Recent research efforts have focused on a comprehensive review of existing research, with specific focus on research that meets current standards of assessment.
Some of the important reviews and meta-analyses completed in recent years include:
- A 2011 review of the existing research and evidence for CBT treatment finds it is the most effective treatment for anxiety disorders.10
- A 2018 peer-reviewed article calls CBT the “Gold Standard” for treatment of anxiety disorders, citing several studies.10
- A 2018 meta-analysis of only randomized control trials (considered the most valid) found that CBT significantly reduced anxiety symptoms and also that these improvements lasted even months after treatment ended.10
How to Find CBT Treatment for Anxiety
There are many therapists, psychologists, and other licensed professionals who have received training in CBT and who have experience working with people who have anxiety disorders. In many instances, health insurance will cover at least part of CBT treatment. If you have insurance, a good starting place is asking them to provide you a list of CBT specialists that are in-network.
Online directories 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, specialize in anxiety disorders, and who are in-network with your insurance. You can also ask your general practitioner for a referral.
Anxiety disorders are the most common form of mental illness, affecting one third of American adults at some point in their lives. Luckily, anxiety disorders are also highly treatable. While less than 40% of people with anxiety disorders seek treatment, those who do often experience a reduction, and sometimes resolution, of their symptoms.8
At-Home CBT Exercises for Anxiety
CBT therapy can only be provided by qualified and trained mental health professionals, such as psychiatrists, psychologists, and master’s level therapists.
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 5 at-home CBT exercises that could help people with anxiety:
1. Becoming Aware of Your Anxious Thoughts
Make a list of the thoughts that feed your anxiety, making it grow bigger and stronger. Become more aware of these thoughts and what situations tend to trigger them. You might even print off a tracker or use a journal to record these patterns throughout the day.
2. Evaluating 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 you have.
3. Using 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. Talking 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. Trying 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 feeling 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.
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 psychotropic medication.
