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Therapy Options for Anxiety Disorders
By Melinda Smith, M.A., Robert Segal, M.A., and Jeanne Segal, Ph.D.
If you suffer from panic attacks, obsessive thoughts, unrelenting worries, or an incapacitating phobia, you may have an anxiety disorder. But you don’t have to live with anxiety and fear. Treatment can help, and for many anxiety problems, therapy is a good place to start. Certain types of therapy, such as cognitive behavioral therapy and exposure therapy, are particularly beneficial. These therapies can teach you how to control your anxiety levels, stop worrisome thoughts, and conquer your fears.
Treating anxiety disorders with therapy
When it comes to treating anxiety disorders, research shows that therapy is usually the most effective option. That’s because anxiety therapy—unlike anxiety medication—treats more than just the symptoms of the problem. Therapy can help you uncover the underlying causes of your worries and fears; learn how to relax; look at situations in new, less frightening ways; and develop better coping and problem-solving skills. Therapy gives you the tools to overcome anxiety and teaches you how to use them.
The anxiety disorders differ considerably, so therapy should be tailored to your specific symptoms and concerns. If you have obsessive-compulsive disorder, your treatment will be different from someone who’s getting help for anxiety attacks. The length of therapy will also depend on the type and severity of your anxiety disorder. However, many anxiety therapies are relatively short-term. According to the American Psychological Association, many people improve significantly within 8 to 10 therapy sessions.
Many different types of therapy are used to treat anxiety, but the leading approaches are cognitive behavioral therapy and exposure therapy. Each anxiety therapy may be used alone, or combined with other types of therapy. Anxiety therapy may be conducted individually, or it may take place in a group of people with similar anxiety problems.
Cognitive behavioral therapy for anxiety
Cognitive behavioral therapy (CBT) is the most widely-used therapy for anxiety disorders. Research has shown it to be effective in the treatment of panic disorder, phobias, social anxiety disorder, and generalized anxiety disorder, among many other conditions.
Cognitive behavioral therapy addresses negative patterns and distortions in the way we look at the world and ourselves. As the name suggests, this involves two main components:
Cognitive therapy examines how negative thoughts, or cognitions, contribute to anxiety.
Behavior therapy examines how you behave and react in situations that trigger anxiety.
The basic premise of cognitive behavioral therapy is that our thoughts—not external events—affect the way we feel. In other words, it’s not the situation you’re in that determines how you feel, but your perception of the situation. For example, imagine that you’ve just been invited to a big party. Consider three different ways of thinking about the invitation, and how those thoughts would affect your emotions.
Situation: A friend invites you to a big party
Thought #1: The party sounds like a lot of fun. I love going out and meeting new people!
Emotions: Happy, excited
Thought #2: Parties aren’t my thing. I’d much rather stay in and watch a movie.
Thought #3: I never know what to say or do at parties. I’ll make a fool of myself if I go.
Emotions: Anxious, sad
As you can see, the same event can lead to completely different emotions in different people. It all depends on our individual expectations, attitudes, and beliefs. For people with anxiety disorders, negative ways of thinking fuel the negative emotions of anxiety and fear. The goal of cognitive behavioral therapy for anxiety is to identify and correct these negative thoughts and beliefs. The idea is that if you change the way you think, you can change the way you feel.
Thought challenging in CBT
Thought challenging—also known as cognitive restructuring—is a process in which you challenge the negative thinking patterns that contribute to your anxiety, replacing them with more positive, realistic thoughts. This involves three steps:
Identifying your negative thoughts. With anxiety disorders, situations are perceived as more dangerous than they really are. To someone with a germ phobia, for example, shaking another person’s hand can seem life threatening. Although you may easily see that this is an irrational fear, identifying your own irrational, scary thoughts can be very difficult. One strategy is to ask yourself what you were thinking when you started feeling anxious. Your therapist will help you with this step.
Challenging your negative thoughts. In the second step, your therapist will teach you how to evaluate your anxiety-provoking thoughts. This involves questioning the evidence for your frightening thoughts, analyzing unhelpful beliefs, and testing out the reality of negative predictions. Strategies for challenging negative thoughts include conducting experiments, weighing the pros and cons of worrying or avoiding the thing you fear, and determining the realistic chances that what you’re anxious about will actually happen.
Replacing negative thoughts with realistic thoughts. Once you’ve identified the irrational predictions and negative distortions in your anxious thoughts, you can replace them with new thoughts that are more accurate and positive. Your therapist may also help you come up with realistic, calming statements you can say to yourself when you’re facing or anticipating a situation that normally sends your anxiety levels soaring.
To understand how thought challenging works in cognitive behavioral therapy, consider the following example: Maria won’t take the subway because she’s afraid she’ll pass out, and then everyone will think she’s crazy. Her therapist has asked her to write down her negative thoughts, identify the errors—or cognitive distortions—in her thinking, and come up with a more rational interpretation. The results are below.
Challenging Negative Thoughts
Negative thought #1: What if I pass out on the subway?
Cognitive distortion: Predicting the worst
More realistic thought: I’ve never passed out before, so it’s unlikely that I will on the subway.
Negative thought #2: If I pass out, it will be terrible!
Cognitive distortion: Blowing things out of proportion
More realistic thought: If I faint, I’ll come to in a few moments. That’s not so terrible.
Negative thought #3: People will think I’m crazy.
Cognitive distortion: Jumping to conclusions
More realistic thought: People are more likely to be concerned if I’m okay.
Replacing negative thoughts with more realistic ones is easier said than done. Often, negative thoughts are part of a lifelong pattern of thinking. It takes practice to break the habit. That’s why cognitive behavioral therapy includes practicing on your own at home as well.
CBT may also include:
- Learning to recognize when you’re anxious and what that feels like in the body
- Learning coping skills and relaxation techniques to counteract anxiety and panic
- Confronting your fears (either in your imagination or in real life)
Exposure therapy for anxiety
Anxiety isn’t a pleasant sensation, so it’s only natural to avoid it if you can. One of the ways that people do this is by steering clear of the situations that make them anxious. If you have a fear of heights, you might drive three hours out of your way to avoid crossing a tall bridge. Or if the prospect of public speaking leaves your stomach in knots, you might skip your best friend’s wedding in order to avoid giving a toast. Aside from the inconvenience factor, the problem with avoiding your fears is that you never have the chance to overcome them. In fact, avoiding your fears often makes them stronger.
Exposure therapy, as the name suggests, exposes you to the situations or objects you fear. The idea is that through repeated exposures, you’ll feel an increasing sense of control over the situation and your anxiety will diminish. The exposure is done in one of two ways: Your therapist may ask you to imagine the scary situation, or you may confront it in real life. Exposure therapy may be used alone, or it may be conducted as part of cognitive behavioral therapy.
Rather than facing your biggest fear right away, which can be traumatizing, exposure therapy usually starts with a situation that’s only mildly threatening and works up from there. This step-by-step approach is called systematic desensitization. Systematic desensitization allows you to gradually challenge your fears, build confidence, and master skills for controlling panic.
Facing a fear of flying
Step 1: Look at photos of planes.
Step 2: Watch a video of a plane in flight.
Step 3: Watch real planes take off.
Step 4: Book a plane ticket.
Step 5: Pack for your flight.
Step 6: Drive to the airport.
Step 7: Check in for your flight.
Step 8: Wait for boarding.
Step 9: Get on the plane.
Step 10: Take the flight.
Systematic desensitization involves three parts:
Learning relaxation skills. First, your therapist will teach you a relaxation technique, such as progressive muscle relaxation or deep breathing. You’ll practice in therapy and on your own at home. Once you start confronting your fears, you’ll use this relaxation technique to reduce your physical anxiety response (such as trembling and hyperventilating) and encourage relaxation.
Creating a step-by-step list. Next, you’ll create a list of 10 to 20 scary situations that progress toward your final goal. For example, if you final goal is to overcome your fear of flying, you might start by looking at photos of planes and end with taking an actual flight. Each step should be as specific as possible, with a clear, measurable objective.
Working through the steps. Under the guidance of your therapist, you’ll then begin to work through the list. The goal is to stay in each scary situation until your fears subside. That way, you’ll learn that the feelings won’t hurt you and they do go away. Every time the anxiety gets too intense, you will switch to the relaxation technique you learned. Once you’re relaxed again, you can turn your attention back to the situation. In this way, you will work through the steps until you’re able to complete each one without feeling overly distressed.
Complementary therapies for anxiety disorders
As you explore your anxiety disorder in therapy, you may also want to experiment with complementary therapies designed to bring your overall stress levels down and help you achieve emotional balance.
Exercise – Exercise is a natural stress buster and anxiety reliever. Research shows that as little as 30 minutes of exercise three to five times a week can provide significant anxiety relief. To achieve the maximum benefit, aim for at least an hour of aerobic exercise on most days.
Relaxation techniques – When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, controlled breathing, and visualization can reduce anxiety and increase feelings of relaxation and emotional well-being.
Biofeedback – Using sensors that measure specific physiological functions—such as heart rate, breathing, and muscle tension—biofeedback teaches you to recognize the body’s anxiety response and learn how to control them using relaxation techniques.
Hypnosis – Hypnosis is sometimes used in combination with cognitive-behavioral therapy for anxiety. While you’re in a state of deep relaxation, the hypnotherapist uses different therapeutic techniques to help you face your fears and look at them in new ways.
Making anxiety therapy work for you
There is no quick fix for anxiety. Overcoming an anxiety disorder takes time and commitment. Therapy involves facing your fears rather than avoiding them, so sometimes you’ll feel worse before you get better. The important thing is to stick with treatment and follow your therapist’s advice. If you’re feeling discouraged with the pace of recovery, remember that therapy for anxiety is very effective in the long run. You’ll reap the benefits if you see it through.
You can also support your own anxiety therapy by making positive choices. Everything from your activity level to your social life affects anxiety. Set the stage for success by making a conscious decision to promote relaxation, vitality, and a positive mental outlook in your everyday life.
Learn about anxiety. In order to overcome anxiety, it’s important to understand the problem. That’s where education comes in. Education alone won’t cure an anxiety disorder, but it will help you get the most out of therapy.
Cultivate your connections with other people. Loneliness and isolation set the stage for anxiety. Decrease your vulnerability by reaching out to others. Make it a point to see friends; join a self-help or support group; share your worries and concerns with a trusted loved one.
Adopt healthy lifestyle habits. Physical activity relieves tension and anxiety, so make time for regular exercise. Don’t use alcohol and drugs to cope with your symptoms, and try to avoid stimulants such as caffeine and nicotine, which can make anxiety worse.
Reduce stress in your life. Examine your life for stress, and look for ways to minimize it. Avoid people who make you anxious, say no to extra responsibilities, and make time for fun and relaxation in your daily schedule.