Cognitive-Behavioral Therapy is used all around the world to help people with many different problems like anxiety, depression, anger, relationship problems, substance use, accomplishing goals, and motivation.
We created a video to help people understand fundamental CBT tools and ideas to improve their lives.
Lots of people struggle with identifying their thinking. Some insist that they are “just anxious” and they have no worries creating this anxiety. While it may be the case that some health conditions can produce an anxiety like response, CBT suggests that the vast majority of the time there are thoughts or beliefs creating our emotions and there are some tools we can use to help identify them.
This is a fundamental technique in CBT. Our feelings are excellent clues into what we are thinking. Also, since we frequently misuse the word “feel” in English, sometimes our “feelings” are actually thoughts in disguise. For example, woman struggling with guilt about parenting insisted she couldn’t identify her thoughts when she felt guilty. When describing the situation in therapy she claimed “I just feel like a bad Mom.” This was immensely helpful because she had been confusing her feelings with her thoughts. She felt guilty and she thought “I’m a bad mom.”
Even when we are not confusing thoughts and feelings, our emotions give us hints about our thinking. As described above, when we are anxious we are usually worried about something, when we are depressed we are usually thinking negative thoughts about ourselves, the world, or our futures, and when we are angry we are usually thinking about what “should” happen or how someone “should” behave. Sadness tends to be about loss, guilt about judgments about our own behavior, and embarrassment tends to be created by assumptions about how others might judge us.
You can improve your skills of identifying your thoughts by checking-in with yourself next time you have a feeling. So next time you feel anxious ask yourself “what am I worrying about?”
The first technique is very simple, but usually can be effective for most people. This technique involves carrying a small notebook, a piece of paper, or a cue card with you (and a pen) and writing down any automatic thoughts you have when you feel anxious, depressed, angry, etc. You can also use worksheets to help with this process. Here are some hints for writing down automatic thoughts:
Although this one can seem silly, it can be one of the most effective skills for identifying thinking. Simple think of a time when you were feeling depressed, anxious, angry, etc. Then draw a stick person in that situation. Here’s an example of a stick-person getting anxious when they saw a snake when he was on a hike with his stick-girlfriend:
Then simply guess or imagine what the stick-person might have been telling himself in this situation to create his anxiety.
Usually, what we imagine the stick person might have been thinking is precisely what we were telling ourselves in this situation.
Other techniques to become more aware of our thinking include meditation and free association. These techniques encourage us to be mindful or our thoughts in the present moment.
Once we can identify our thoughts, we can then use cognitive-restructuring techniques to change the way we feel and/or behave.
Daniel Kahneman won the Nobel Prize in 2002 for the work he, and fellow psychologist Amos Tversky, began in 1974 when they and published their article “Judgment under Uncertainty: Heuristics and Biases” in the esteemed academic journal Science (Vol 185. Pp. 1124-1131). Tversky and Kahneman sought to understand how humans made decisions in uncertain situations. This work suggests people use a series of mental processes to make decisions and the underlying machinery of these mental processes tends to make predictable errors. Their findings have profound implications for our understanding of mental health.
Anxiety is the product of perceiving a threat to something we value. In the simplest terms, when we believe there is a bear (a threat) in the bush near us (something we value) our body gets ready to run/fight/or freeze (anxiety). This simple formula can take far more advanced forms because we can value other things besides our own physical health and threats can take many forms beside that of a bear. While threats and things we value can take many forms, our bodies only have a small number of responses. These responses are run, fight, or freeze and we interpret our bodies getting ready to do these things as anxiety. For example, public speaking is perceived to be a threat to our goal of being perceived as competent and confident, taking a test poses a threat to our hopes of completing a class with a particular grade, and running out of gas threatens our goal of getting where we want on time. Our bodies will get ready to deal with all of these threats in the same ways – by making us anxious.
If we accept this formula as an explanation for why we get anxious, this leads to another reasonable question: How do we decide how much of a threat something is? Tversky and Kahneman provide us with an answer but first let’s consider some other questions:
To answer these questions our minds could use a number of different strategies. Our minds could list every known English word that is 3 or more letters, then compare how many begin with K and how many have K as the third letter. Even if we used this exhaustive and thorough strategy, our answers would be imperfect because we do not know every English word so we would be guessing based on the words we do know. As for the questions about heart attacks and honesty, we would never truly know the exact values because we are not omniscient and honesty is not something you can quantifiably measure. However, most people do not find it difficult to come up with answers to all of these questions. In fact, people tend to come up with answers extremely quickly.
When we are asked questions like these, our minds take the question we have been asked then quickly replace this very difficult question with a simpler question like “How easily can I remember or imagine something like this?”
If you are like most people, when asked the question about the letter K, you tried to think of words that begin with the letter K or had K as the third letter. If you could easily recall words beginning with K, but had greater difficulty thinking of words with K as the third letter, you concluded there must be more words beginning with K. Words with K tend to be easier to recall and most people assume there are more words beginning with K, even though there are more words with K as the third letter in English. Instead of being able to provide the true likelihood of heart attacks, our mind replaces this question with something like “How easily can you remember or imagine a middle aged man having a heart attack?” Then finally, you likely replaced the question about honesty with “How easily can I remember situations in which I was honest and dishonest?” It is not about how many memories we have being honest or dishonest, we form our judgments on the availability of those memories. Memories we can easily recall are said to be more available to our conscious minds than memories that are difficult to recall.
This mental “trick” is called the “availability heuristic.” As Tversky and Kahneman explain in their 1974 article, “There are situations in which people assess the frequency of a class or the probability of an event by the ease with which instances or occurrences can be brought to mind” (p. 1127). In other words, we believe something to be more likely if memories or fantasies of similar situations are “available” to our conscious mind. Most of the time the availability heuristic serves us pretty well. If something frequently happens in our life (the sun comes up every morning), one can assume it is likely for it to happen again without many costs being associated with this prediction. This allows us to avoid living in a constant state of uncertainty, predict what is likely to happen in the future, and plan accordingly. Unfortunately, the availability heuristic can be biased and sometimes this can have serious adverse consequences.
The availability heuristic is disproportionately influenced by recent and emotionally salient situations. Following a traumatic experience, people are far more likely to overestimate the probability of a similar traumatic event happening which artificially inflates our perceptions of how threatening a situation is, which in-turn unnecessarily increases anxiety and distress. Following a car accident, you will likely overestimate the likelihood of being in another car accident, which increases anxiety while driving. Following 9/11, many of us felt a new anxiety we did not previously experience while getting on air planes, not because flying was anymore dangerous (flying had probably never been safer than after 9/11) but because memories and fantasies of planes being high jacked were far more available.
We determine which situations are threatening not by assessing the true threat level, but by assessing how easily we can remember or imagine similar situations ending-up poorly. Panic disorder can manifest in a number of ways, everyone is different, but people with panic disorder tend to worry that bodily sensations (heart arrhythmias, increased heart rates, accelerated breathing, dizziness, sweating, etc.) are evidence of a serious catastrophe (heart attack, stoke, going insane, etc.) which escalates anxiety resulting in panic attacks. Once we’ve had a single panic attack, the memory of this experience can be particularly available because panic attacks are so emotionally distressing. If we have had a panic attack in a store, we might later wonder about the possibility of having a panic attack in another store like Walmart. This question about the probability of having a panic attack in that particular Walmart at that particular time is replaced with “How easily can I imagine having a heart attack in Walmart?” If the answer is “very easily” then, we will assume the likelihood of having a panic attack in Walmart is high and we will likely avoid Walmart to avoid having another panic attack.
In obsessive-compulsive disorder (speaking of true OCD not the “OCD” people claim to have when they have strong preferences for cleanliness or organization), people can grossly overestimate the likelihood of someone breaking into their home and murdering their family because this specific fantasy can be incredibly distressing. When a fantasy is emotionally distressing, it is more available to consciousness, and this availability inflates perceptions of likelihood. Put simply, because the obsession is so upsetting, people will think it is likely, and they will act compulsively to reduce the probability of the feared event occurring.
In addition to anxiety disorders, the availability heuristic also plays a role in the development and maintenance of other mental health challenges. People with eating disorders often worry that people will judge them negatively if they were “fat.” They sometimes have vivid fantasies of being publically ridiculed or rejected for having what most people would consider to be an average or even below average weight. The maintenance of an eating disorder is riddled with availability heuristic errors. Often people will be able to easily imagine people judging them for being “fat” because they themselves frequently judge other people as fat and they take this as evidence suggesting other people have similar thoughts. The memory of their own judgments will be available because they are so frequent and this will inflate their perception about the likelihood of other people being judgmental like themselves. There are often historical traumas in childhood in which the person with the eating disorder was indeed bullied, mocked, and/or criticized, sometimes by close loved ones. While memories of this abuse are no longer recent, they may be incredibly available because of their emotional salience. They may also judge themselves as inadequate because they can easily recall examples of “beautiful” celebrities which inflates their perception of the regularity of these “beautiful” people.
When we are depressed, we will often have negative automatic thoughts about ourselves like “I’m a failure” or “I’m a loser.” Our minds will form these judgments by seeing which memories are most available, so if we can easily recall examples of “failures” or “losing”, we will be more likely to make judgments consistent with these memories. Since we tend to feel negative emotions more intensely than positive emotions, memories involving failure and loss may be easier to recall, and so these memories bias the availability heuristic and negatively distort our judgments.
The availability heuristic seems to be at the heart of many mental health challenges and this has some interesting implications for the treatment of mental illness. The availability heuristic is biased by recent and emotionally evoking memories and being aware of these biases allows us to think critically about the assumptions we make. In his 2011 book “Thinking, Fast and Slow” Daniel Kahneman explains “Resisting this large collection of potential availability biases is possible, but tiresome. You must make the effort to reconsider your impressions and intuitions by asking such questions as, ‘Is our belief that thefts by teenagers are a major problem due to a few recent instances in our neighborhood?’ or ‘could it be that I feel no need to get a flu shot because none of my acquaintances got the flu last year?’ Maintaining one’s vigilance against biases is a chore – but the change to avoid a costly mistake is sometimes worth the effort” (p. 131). This method of monitoring and thinking critically about our assumptions is identical to the cognitive restructuring interventions used in Cognitive-Behavioral Therapy.
In addition to cognitive restructuring, exposure based therapies may also be used to combat the biases of the availability heuristic. It’s no surprise that people tend to avoid anxiety provoking situations. As Dr. David Burns explains in his book When Panic Attacks:
Most people who are anxious avoid the things they fear, so they never experience enlightenment or relief. If you’re afraid of heights, you’ll avoid high places because they make you feel dizzy and anxious. If you’re shy, you’ll avoid people, because you feel so insecure and inadequate. The avoidance fuels your fears, and your anxiety mushrooms. If you want to be cured, you’ll have to face the thing you fear the most. There are no exceptions to this rule. (Pp. 252-253)
Imagine a person who has a panic attack on an elevator. Following this experience, when the person’s mind attempts to calculate how dangerous a particular elevator is, it will not be calculating the true risk of taking the elevator because this is truly unknowable for every elevator in the world at any given time. It’s not like their mind will know there is a 1.2496% chance something goes wrong if they get in that elevator right now and remain in it for 28 seconds. Instead, they will replace the question, “How dangerous is this elevator?” with “how easily can I recall having an uncomfortable emotional experience in situations similar to what I imagine it is like to be in that elevator?” The memory of their last panic attack in the elevator will be very available because it is so emotionally evoking, even if it is not recent, and so the person will conclude getting on the elevator will be very dangerous. However, if the person decides to go into the elevator, even though they feel anxious, there is very little chance anything will go wrong. They will likely feel anxious and perhaps even have another panic attack, but after a few minutes this anxiety will dissipate. If they stay until their anxiety is gone, they may even feel pride and excitement about their achievement. Let’s say they repeat this exposure exercise 5 or even 10 times. The next time they wonder about how dangerous it is to get on an elevator, the memories of taking the elevator with nothing bad happening will be far more available and they will conclude the elevator is likely safe.
I recommend combining both of these cognitive and behavioral (exposure) approaches. Be mindful of how and why your mind is making the predictions and judgments it is making, but also go and have positive experiences to replace the negative memories creating these predictions and judgments. As you change your assumptions, predictions, and judgments through cognitive restructuring and exposure, you’ll experience serious emotional changes.
To be thorough, lets consider an example in which a person is depressed. As mentioned above, people who are depressed frequently experience negative judgments and predictions. We can fight depression by identifying and thinking critically about these judgments and predictions. So when we tell ourselves things like “I really can’t do anything right” we notice these thoughts and write them down, or record them in some way. Writing down our thoughts is a great way of distancing ourselves from what we are thinking. Then we think critically about these thoughts by simply asking some questions like “What memories is my mind accessing when I think I can’t do anything right? Are there other examples of me doing things reasonably well that my availability heuristic is ignoring? I put my pants on today correctly, is that not an example of doing “anything” right? So if I have done somethings right, like putting on pants, what do I really mean when I think I can’t do anything right? Do I mean that I have some regrets and if so, how do I know I have more regrets than other people? Even I have done more regretful things, what can I do about it? What is the value to ruminating on these regrets?” So this is one example of a cognitive restructuring technique called Socratic Questioning.
To combine our cognitive restructuring with a behavioral technique to combat the biases of the availability heuristic, we might create a list of things we could do to have the experience of doing something right. To make this list we might ask, what are some things you would be proud to do? Things like hike a mountain, read a book, volunteer, get a job, take a class, or clean up a local park. Then the depressed person would go and do these things, even if they don’t feel motivated to do so (action comes first, motivation comes later). The person would take photos of how they did and this would serve as evidence to dispute future thoughts about not doing anything right. Combining both these cognitive and behavioral approaches will help the person to become less depressed over time by combating the availability heuristic’s biases for emotionally evoking and recent memories.
To summarize, the availability heuristic is a mental process we use to make predictions and judgments. While it frequently helps us make complex decisions effectively, it is also biased to overemphasize recent and emotionally salient memories and fantasies. Unfortunately, these biases can create and maintain challenges like anxiety and depression. Cognitive restructuring and exposure techniques can help us challenge the underlying thinking which contributes to these problems.
Postscript
I’ve been studying the work of Tversky and Kahneman for several months now, beginning with the Michael Lewis book “The Undoing Project” which tells the amazing story of how they changed the world of psychology, economics, health care, finance, marketing, and so many more fields. Judgment under Uncertainty: Heuristics and Biases is a brilliant 7-page article that can be found for free – click here. Daniel Kahneman’s book Thinking, Fast and Slow is a fantastic insight into our minds and how they work.
Cognitive Behavioral Therapy is the most validated form of therapy for anxiety disorders. In a huge review of studies exploring the effectiveness of CBT, the researchers found “The efficacy of CBT for anxiety disorders was consistently strong” (click here for a link to a free copy of this study). In another comprehensive review of studies exploring CBT for generalized anxiety, the authors concluded “when compared to waiting list control groups, these treatments have large effects on worrying, anxiety and depression, regardless of whether effects were measured with self-report measures or with clinician-rated instruments” (click here for a copy of this study). Many people would prefer their anxiety just went away but research suggests few people who do nothing, reduce their anxiety. As the studies above suggest, one of the things people can do to reduce their anxiety is cognitive-behavioral therapy and at the core of CBT for anxiety is exposure therapy and behavioral experiments.
Simply put, exposure therapy involves exposing the client to their feared situations in a gradual, repeated, and prolonged manner until the client becomes desensitized. For example, if a client is terrified of public speaking they may work with their therapist to create a list of anxiety provoking situations (speaking in class, watching videos about public speaking, taking a class on public speaking, imagining speaking in public, speaking in a meeting at work, talking to a cashier at a store, doing a speech at Toastmasters, etc.). The client then ranks these situations from least anxiety provoking to most anxiety provoking, this is called an anxiety hierarchy. Then starting with a situation that does evoke some anxiety but is not overwhelming, the client would repeatedly expose themselves to these situations, over and over, until they become desensitized to this situation. A useful example of this most people can relate to is learning to swim as children. Many children are afraid or at least tentative about the water, but their parents encourage them to become more comfortable over time, often enrolling them in swim classes. As the child is gradually exposed to the water over time, they become less afraid. Alternatively, the children that are terrified of the water, and refuse to ever go in the water continue fear the water.
*For more information about exposure therapy see my article “Overcoming Anxiety and Avoidance” by clicking here, or download our free anxiety workbook by clicking here.
Behavioral experiments can take a number of different forms. Similar to exposure therapy, the client and therapist may work together to create a list of anxiety provoking situations. Then the client and therapist will work together to identify the client’s fears about what could go wrong in these situations. Often these fears are exaggerated and extreme but the client sees them as perfectly reasonable. So then we create a little experiment in which the client enters the feared situation and observes to see if their fears come true. Then the client runs the experiment several times in an attempt to gather more information. Once the client has run the experiment several times, they reconvene with the therapist to discuss what they have learned about their fears and their abilities to cope.
For example, perhaps one of the situations on the client’s anxiety hierarchy is saying “no” to other people. Perhaps the fear in this situation is something like “If I say no to my mother when she asks me to do something, she will call me selfish, the rest of my family will hate me, and I won’t be able to handle that.” So then the client and therapist run an experiment in which the client talks with their mother, explains they are trying to be more assertive and wants to work on saying “no” sometimes. Then the next time their mother asks them to give them a ride to the store, the client explains they cannot help that day due to other commitments, then observes what happens. In this situation, the client’s mother may very well call the client “selfish” and their family may complain, but the client also learns they can survive being called selfish and occasionally listening to complaints. Or perhaps the client’s mother understands the client has other commitments and they schedule a plan in which the client gives their mother a ride another time, or the client’s mother finds another way to the store. See the below table for an example how I would write-up a behavioral experiment assignment with a client.
Another type of behavioral experiment involves the client identifying what they suspect other people believe then conducting a survey to assess the accuracy of the client’s assumptions. For example, the client may believe that people believe that women over a particular weight are “unattractive.” Clients may start by simply ask some trusted friends or family about this assumption. They may take photos of themselves or others to friends or family and ask people about their impressions about the people in the photos. In this example, the client ideally learns that attractiveness is not directly related to something as arbitrary and simplistic as weight.
In my experience, exposure therapy and behavioral experiments have been immensely helpful for clients. Clients usually report dramatic shifts in their anxiety in only a short period of time. In CBT we assume the client becomes less anxious in situations they are exposed to because they learn that their initial assumptions about the dangerousness of the situation is exaggerated and their beliefs about their abilities to cope with the danger posed by those situations is minimized. In other words, their cognitions change. After exposing themselves to a variety of different situations, the client learns they have a habit of exaggerating danger and minimizing their abilities to cope, and so they become less anxious in other situations they have not exposed themselves too.
For example if you are anxious about travelling but you muster the courage to go to Mexico, you might learn that Mexico isn’t as dangerous as you expected. Then if you go to Germany you might learn that Mexico and Germany are safe. Then if you go to India you might learn that Mexico, Germany, and India can be travelled to safely. Then you might learn that travelling in general can be done safely, not only to those countries you have been to in the past.
One challenge in using exposure and behavioral experiments is explaining the importance of actually facing fears to the client. Some clients have spent decades avoiding situations that make them anxious and the thought of deliberately exposing themselves to these situations is terrifying. People tend to want to avoid situations that make them anxious. Unfortunately, it is this very avoidance which perpetuates the anxiety indefinitely.
Another barrier to effective exposure and behavioral experiments is called “safety behaviors.” Safety behaviors can sometimes resemble the compulsions of someone who struggles with OCD. Safety behaviors are unnecessary, excessive, or unhelpful activities or strategies people use in anxiety provoking situations to protect them from “something going wrong.” When the client is anxious about going to a new restaurant they may excessively research the restaurant online to create a plan to prevent something “bad” from happening. In this example the excessive research is the safety behavior the client uses to keep themselves “safe.” Then when they go to the new restaurant and nothing “bad” happens they convince themselves it is because they researched prior to going. In this situation, the client has not learned that they can safely go to a variety of different restaurants, but instead they have learned they can go to a restaurant when they excessively research it in advance. Other examples include holding glasses very tightly when you’re afraid of spilling, distracting yourself with your phone when afraid of standing in lines, and never disagreeing with people when you are afraid of conflict. Research suggests it is imperative safety behaviors are identified so the client can either avoid using them or gradually reduce the use of safety behaviors over time.
Sometimes a client’s anxiety is about situations to which they cannot be exposed. For example, the client might be terrified of earth quakes, someone dying, their son being in a car accident, getting fired, or being homeless. When the client cannot be directly exposed to their feared situations, we have got to get creative. We can watch videos of these situations, we can do research, we can read stories, we can write then recite our own stories in which the client is exposed to these situations, etc. This is based on the idea that thinking about the feared situation can actually desensitize the client. Some of these interventions are called “imaginal exposure.”
Research suggests CBT is an effective treatment for anxiety disorders. Exposure therapy and behavioral experiments are core elements of CBT for anxiety. By facing fears the client learns their feared situations are not as catastrophic as originally predicted and their ability to cope is better than expected.
The AWARE strategy can be used to reduce our distress we feel when we become anxious. The five steps of this strategy are:
Anyone that has tried to wrestle anxiety into non-existence can tell you this is not an effective long-term strategy. Fighting with anxiety is like holding a beach ball under water – the harder we push it down, the stronger it wants to pop back up. So our first step to reducing our anxiety is to first accept the anxiety, even though it is uncomfortable. Do not judge the anxiety as good or bad, instead simply acknowledge the physical sensations that you feel in your body.
Pay attention to your thoughts and physical sensations in a non-judgemental manner. You can rate your anxiety on a scale from 0-100, then watch it ebb and flow.
Continue to live your life despite the anxiety. Slow down if you have to, but stay in the situation and keep doing what you are doing. Continue to breath slowly. If you run from the situation your anxiety will go down, but your fear will go up. If you stay, both your anxiety and your fear will go down eventually.
Continue to accept, watch, and act until the anxiety dissipates. This will reduce your fear and you will learn to cope with your anxiety for future situations.
When we struggle with anxiety, we often catastrophize (predict a catastrophe will occur). We can challenge these catastrophized automatic thoughts by expecting positive outcomes. Expect some anxiety but also expect that you will be able to handle it and it will go down eventually.
The AWARE strategy comes from one of the most influential therapists in history Dr. Aaron Beck, one of the founding fathers of CBT. He details this strategy in greater detail in his 15th edition of “Anxiety Disorders and Phobias: A cognitive perspective.” Click here for a video of Aaron Beck and the Dalai Lama.
Personally, I have found the AWARE model helpful in both my own life, and in the lives of my clients. It combines the non-judgemental acceptance of the present moment of mindfulness approaches with the deliberate continuing to remain in the anxiety provoking situations of exposure therapy. When I was in school I would become anxious prior to having to give class presentations. I would sweat through my shirt and my body would shake uncontrollably. By accepting my anxiety and repeatedly giving presentations, I was able to reduce my anxiety over time. Now I routinely teach classes in front of dozens of students with only minimal anxiety. When we stop fearing our anxiety and avoiding anxiety provoking situations we can learn to trust ourselves and the world a little bit more.
Admittedly, it took me a long time to learn to listen to my fear. My earliest memory is from when I was three years old. My Mother, Father, little brother and I went to play in a local river. I did not recognize the danger and I fell into the water. I remember feeling helpless and confused and then my father saved me. Although I’m sure there were previous times, this was the first time I remember meeting fear.
As a man, I met fear on the top of a mountain with the whole universe watching. He greeted me as an old friend and embraced me with genuine warmth.
“What would my life be without you?” I asked.
“Why ask me that my son? Have I not protected you and guided you through all of the horrors in the dark?” he asked.
“I’ll admit there have been times when you have saved me from suffering and almost certain death, but I’ve noticed the times I have truly lived were the times I had the courage to ignore your warnings. When I have wanted to love, you warned me about humiliation and rejection. When I aspired to more, you took the air from my lungs and warned me about losing what I’ve got. And when I prepared to rest you made me uncomfortable and gave me fantasies about failure and suffering. But when I ignored you, I loved with my whole heart, I worked with passion, and I rested enjoying the present.” I explained.
Fear smiled with knowing sadness and replied “Even I am conflicted in this messy existence. I did indeed warn you of humiliation, rejection, loss, failure, and suffering. But, in those times of action and acceptance, I also spurred you forward with an even greater fear – a fear of dying without living.”
As a child I had to learn to listen to my fear. As an adult, I suspect I must learn when it should be ignored.
Anxiety is a normal reaction to perceiving a threat. When we believe something important to us (our lives, our jobs, our families, etc.) is threatened, our bodies prepare us to deal with this threat. Our muscles tense, our heart beats faster, our breathing may get rapid and shallow, etc. these are the physical symptoms of anxiety.
There is a lot of research suggesting people who struggle with excessive anxiety have difficulties tolerating uncertainty. In other words they struggle with not knowing what might happen. “Worrying” is attempting to anticipate threats that may occur in the future – trying to figure out what might happen. People tend to believe that if they can just predict everything that could go wrong, they can plan and problem solve, and then they will be safe. However, our brains easily confuse real threats with imagine threats. For example, if you were extremely afraid of spiders, seeing photos of spiders, seeing videos of spiders, or just thinking about spiders might be enough to trigger anxiety – even if you know the spider in the photo is not actually in
the room with you. This is important because when you are worrying, you are thinking about “something bad” that could happen, and your brain gets confused and thinks the “something bad” is actually happening right now. So your brain tells your body to get ready to deal with the “something bad” right now, and as described above, we call these preparations “anxiety.” As advanced as our brains are, its responses to “something bad” happening can be overly simplistic. It doesn’t matter if the “something bad” is someone saying something mean to us or having to run away from a tiger in the bush, our brain and bodies tend to react in the same way (fight/run away/freeze). So the more we worry (think about what could go wrong/perceive a threat) the more your brain tells your body to get ready to deal with what could go wrong by becoming “anxious.”
Researchers Dugas and Robichaud identify five beliefs that keep people stuck in a cycle of excessive worrying. If we believe these things, we are encouraged to worry as much as possible. These beliefs are:
1) “Worrying helps find solutions to problems.” While recognizing the problem is one part of problem solving, it is no longer helpful when we start worrying about problems with a low probability of occurring. For example, if you are going camping it makes sense to recognize that it could rain (anticipate a problem with a reasonable probability of occurring) and plan accordingly by bringing a tarp. However, it is less helpful to plan for a satellite falling from orbit and landing on your campsite. This sounds ridiculous but we often do we worry about all the things that could go wrong as opposed to what is likely to happen.
2) “Worrying helps motivate me to get things done.” Similar to the previous rationalization for worrying, perhaps some worrying does help motivate you. It makes sense to remember you have a test coming up in a couple of weeks, so you can start studying for the test. However, when we excessively worry we can often get overwhelmed by anxiety. If we are worrying about our test in a couple of weeks, about the bus maybe being late, about our partners not actually loving us, about what we are going to get our mother for her birthday, about the assignment due next month, etc. we may experience too much anxiety and being distracting ourselves, procrastinating, using substances to calm down, or use another unhelpful coping mechanism.
3) ‘Worrying prepares me for uncomfortable emotions.” This belief reflects the idea that if we worry about something bad happening, we will be less disappointed, sad, or guilty should that bad thing happen. Unfortunately, this belief will keep us locked in an endless pattern of worrying “just in case.”
4) “Worrying can prevent bad things from happening.” Some people believe that if they just worry enough, “magical thinking” will prevent what we are worried about from happening. If this were true, then we would become stuck in an endless cycle of worrying about all the bad things that could happen.
5) “Worrying is a positive part of my personality.” This is when we believe that worrying shows we are caring, loving, or conscientious. However, worrying too much can actually annoy and frustrate the people in your life, and push them away. Furthermore, there are many ways we can be caring, loving, and conscienti
ous without worrying.
A major theme within these beliefs is the idea that worrying will somehow prevent or reduce our pain and suffering. In other words, people think that if they can just anticipate all the problems, they can create some kind of plan, which “fixes” the “problem”, which will protect us from the pain and suffering we would experience if the problem were to occur. For example, if I worry about my kid using drugs, I can create a plan to talk to them about drug use, so I can avoid the pain and suffering I would experience if my kid were to use drugs.
However, when we anticipate problems, our mind tells our body to prepare to deal with problems, it tells our body to become anxious. Most people find anxiety painful and describe it as suffering. So ironically, by anticipating problems, to avoid pain and suffering, we are actually creating our own pain and suffering.
Many people want to spend a lot of time anticipating the bad things that could happen in their lives (worrying) but don’t want the anxiety. However, our brains are not wired for this and by choosing to worry, we are indirectly choosing to have anxiety.
Worrying can be helpful in some situations but we want to limit our worrying because excessive worrying will lead to excessive anxiety. For example, it can be helpful to anticipate and prepare for:
a) Things with a reasonable probability of happening,
b) Things we can reasonably do something about now or in the immediate future,
c) Things that would pose a legitimate threat to our health, safety, or goals.
If a situation meets all three of these criteria, it might be worth your worrying. For example, people often worry about public speaking. If we know we have to give a presentation in class, there is a reasonable probability we will have to speak in public. Perhaps a large portion of your grade is dependent on how you do in your presentation, so it may be important to you to do well, in which case it would be prudent to prepare thoroughly. By anticipating this challenge, we can prepare by doing our research and practicing our presentation thoroughly. If we are thinking about the challenges we may face while giving our presentation during a study session scheduled to work on your presentation, this would be helpful. However, worrying about giving your presentation is no longer helpful when you are lying in bed at 3 am wanting to sleep, because these is nothing you could reasonably do at that time and focusing on the presentation is interfering with your other important life goals (like getting a good night’s sleep). Worrying about being laughed out of the classroom and losing all your friends because you did poorly on a presentation isn’t helpful because, in my opinion, it doesn’t have a reasonable probability of occurring. It is also important to put the consequences of giving an imperfect presentation into perspective. While you might not get the grade you want, you will likely be physically fine – no one will chop your hand off for doing poorly.
This is a very old and complicated question with several different answers. For moderate to severe levels of anxiety medication can help, but medications can have side effects. Taking medication can also be relatively easy, you simply take some pills throughout your day. Other ways to reduce anxiety typically take more work, but they also have some benefits medication does not. In therapy, I usually start by recommending daily exercise, getting 8-9 hours of sleep per night, and eating a balanced diet. While people may not see the connection between these habits and their anxiety, research strongly suggests each of these interventions. These habits also come with a wide array of other benefits as well. Healthy living habits serve as the foundation upon which we can build wellness.
Then there are a number of mental exercises people can practice to reduce worrying and anxiety. One of which is called mindfulness which can be described as practicing non-judgmental awareness and acceptance of the present moment. This is when you pay attention to what is happening right now, in the room where you are, in your body, and in your mind. Then we accept the thoughts, feelings, sensations, and images in the present moment without judgement. So maybe you check-in with your body and notice some sadness, and instead of trying to get rid of the sadness because it is “bad” you accept the sadness without judging it as either good or bad. This can help reduce anxiety because when we are paying attention to the present moment, we cannot be attempting to anticipate the “bad things” that could happen in the future. As we continue to practice directing our attention to the present, this gets easier and we actually change the way our brains work.
The cognitive-behavioral therapy (CBT) approach to reducing anxiety includes changing patterns of thinking and behaving which maintain anxiety. We question the beliefs that maintain our worrying, our unhelpful ways of dealing with problems, the beliefs about our vulnerability to “bad things happening”, and our ability to cope with challenges. We largely do this through a series of activities designed to challenge unhelpful beliefs. For example, a person anxious about being in a public place will create a series of exposure exercises in which they expose themselves to their feared situations so they learn that their fear is irrational and that they can cope with being in public places. CBT is direct, short-term, and it can take a willingness to take some “risks.” There is a lot of research supporting CBT as a front-line treatment for anxiety. In my experience, CBT is most effective when the feared situation is concrete and specific. CBT can be offered in individual therapy, group therapy, self-help books, and online.
This question is an overgeneralization – there is no way anyone could try “everything.” Instead, it is likely that you have tried several or many things in the past and have not gotten the desired results. However, there are many different medications, many different activities that promote wellness (yoga, joining a sports team, trying a new hobby, finding a new job, journaling, etc.), and many different kinds of therapy. Even among cognitive-behavioral therapists there is a lot of variation in how therapists actually practice. If we are trying to find a reason to give up (“I’ve tried everything”), this might mean we don’t actually want to put the work in to make changes, and that is okay. There may be a time in your life when you are more ready, willing, and able to try something new. If that time comes, hopefully this article has given you some ideas you could try.
People with anxiety and panic frequently tell themselves “I must do perfectly well” then ask themselves some version of “will I do perfectly well” and the answer is always “no.” After they have avoided the task, or tried and failed to meet their hopes, they then become depressed because they tell themselves they did not do as well as they “should” have done. These are some of the claims made by one of the most influential contributors to counselling psychology in history, Albert Ellis. (See here)
While, I’m not bold enough to claim that perfectionism is the core of mental illness, the majority of my clients report high levels of perfectionism. There does seem to be a real connection between anxiety, depression, and perfectionism. Therefore, this article delves into some modern research on perfectionism, how to know if you might practice unhelpful perfectionism, and what you can do if you are a perfectionist, to live a more satisfied life.
According to research, there are two dimensions to perfectionism: perfectionistic concerns and perfectionistic strivings.
While these two dimensions are related, they are not the same thing and you can have one without high levels of the other. In other words, you can have high personal standards and work to meet those standards, without over-focusing on mistakes, excessively doubting your performance, or being very concerned about what other people may think. Research shows people who report high levels of perfectionistic concerns also typically report lower life satisfaction, neuroticism, low self-esteem, negative affect, anxiety, depression, and suicidal ideation. While people who report high levels of perfectionistic strivings, without high levels of perfectionistic concerns, report higher levels of conscientiousness, positive affect (they are generally happier), endurance, and academic performance (Stoeber & Otto, 2006).
When working with clients, I often hear rationalizations like “my perfectionism motivates me to work harder” or “I have to be a perfectionist or something really bad might happen.” The research described above does suggest that there are a number of benefits to having high personal standards and working hard to achieve those standards. However, when we are overly focused on making mistakes, doubting our actions, and focusing on what others think, we lose the positive benefits of our perfectionism. For the remainder of this article, I’ll refer to being overly concerned about mistakes, doubting ourselves, and being focused on how others might evaluate our performance (perfectionistic concerns) as “unhelpful perfectionism.”
Interestingly, unhelpful perfectionism is a recipe for low life satisfaction regardless of how well we actually do. In a study from Pennsylvania State University, 273 students reported engaging in unhelpful perfectionism led to less satisfaction with grades, regardless of how well they did (Grzegorek, Slaney, Franze, & Rice, 2004). In other words, even if they met their high personal standards, they were still unsatisfied if they were overly focused on making concerns, doubting their actions, and focusing on what others think.
How to know if you might practice unhelpful perfectionism
People that practice unhelpful perfectionism might claim:
These are items from two measures of perfectionism, the Frost Multidimensional Perfectionism Scale (Frost et al., 1990) and the Multidimensional Perfectionism Scale (Hewitt & Flett, 2004) and they reflect concern about mistakes, doubts about actions, and concern about other people’s evaluations. Beliefs and behaviors like these tend to interfere with a person being satisfied in life.
In 2011, two researchers from the University of Kent, Joachim Stober and Dirk P. Janssen, wanted to better understand the relationship between perfectionism, how people typically coped with stresses in their lives, and the amount of satisfaction they generally felt at the end of the day. They found people reporting high levels of unhelpful perfectionism seemed to cope with stressors in their lives in similar ways, and these coping mechanisms were contributing to lower satisfaction. People who reported a lot of unhelpful perfectionism reported typically trying to cope with stresses by criticizing themselves or blaming themselves for the “bad things” that happen to them. Unsurprisingly, self-criticism was associated with diminished satisfaction.
Alternatively, people who reported high levels of unhelpful perfectionism reported more satisfaction when they used a coping mechanism “positive reframing” (aka “positive reinterpretation”). These people attempted to cope with challenges by “trying to see it in a different light, to make it seem more positive” or “looking for something good in what is happening” (Carver, 1997).
Two other ways of trying to cope with perceived failures were related to high levels of satisfaction, acceptance (“accepting the reality of the fact that it has happened”) and humor (“making fun of the situation”). Although, these coping mechanisms seemed to be less effective for people reporting high levels of unhelpful perfectionism.
Positive reframing has been explored in great detail in a multitude of studies over the last 30 years. Back in 1984 Lazarus and Folkam explained that positive reframing allowed people to manage their distress when challenged so they could continue with effective problem solving. This combination of positive reframing and actively trying to deal with stressors in an effective way can be an incredibly useful way to handle challenging situations in life.
We can have high personal standards and work hard to achieve these standards without over-focusing on our mistakes, excessively doubting your performance, or being very concerned about what other people may think. Indeed having high personal standards is associated with better life satisfaction. However, when we engage in unhelpful perfectionism it leads to reduced life satisfaction, neuroticism, low self-esteem, negative affect, anxiety, depression, and suicidal ideation.
Examples of unhelpful perfectionism include claiming things like:
However, even if we engage in unhelpful perfectionism we can experience greater satisfaction in life, by attempting to cope with challenges by seeing challenges as opportunities, focusing on what we learned from challenging experiences, and looking for something good in what has happened. By thinking about problems in this proactive way, we are better able to engage in effective problem solving.
Although this will likely reduce the number of “likes” I get for this post, I believe it is important to begin with some honesty. Overcoming anxiety is hard work. Most people want a simple and easy answer that can make all of their suffering go away. However, for every complicated and messy problem there are many simple and easy answers that are ineffective. For example, in Canada the use of antidepressants increased over 450% between 1981 and 2000, but the demand for mental health services has never been higher. This post is not an “8 easy steps to being less anxious” kind of post, it is more of a “if you work really hard, stay determined despite set-backs, and keep an open-mind about trying new things you may be able to make some real improvements to your life” kind of post.
Anxiety is a normal reaction to perceived threats. However, when we have a tendency to focus on threatening situations, the problems in our lives, we are fueling excessive amount of anxiety. One way we attempt to reduce the amount of anxiety we experience is by avoiding challenging situations. However, avoidance prevents us from overcoming our fears. Furthermore, as we avoid more and more things, our lives become more and more restricted.
For example, if you had social anxiety and were terrified of 
talking to authority figures, you would likely experience anticipatory anxiety before you spoke to people of authority, then when you did have to talk to someone of authority (exposing yourself to the feared situation) your anxiety would likely spike. Then when you avoid the situation by promptly leaving, your anxiety will naturally go down. Unfortunately, when we cope with anxiety by avoiding challenging situations we cannot challenge our assumptions that the situation is dangerous, we cannot challenge our assumptions that we cannot handle the stressful situation, nor can we learn how to handle the situation more effectively. So then the next time we exposure ourselves to the stressful situation we experience a similar amount of anxiety.
Overcoming anxiety can be accomplished a number of ways. However, research strongly suggests that one of the most effective strategies for overcoming anxiety is something called “exposure therapy.” Exposure therapy rests on the premise that if we can expose ourselves to our anxiety provoking situations in a certain way, we can learn: the situation isn’t as dangerous as we assume, we can handle the challenging situation, and we can practice skills to better handle similar situations in the future.
Exposure therapy
By exposing ourselves to anxiety provoking situations appropriately, we are able to reduce the amount of anxiety experienced when we face similar situations in the future.
Some notes about exposure therapy:
Exposure therapy can be immensely effective for anxiety created by many different situations. Personally, I have seen clients make radical changes in only a small number of sessions when they are committed to their exposure plan. However, it is important to remember than some situations are actually dangerous and we are not always exaggerating the danger in our minds. Therefore, I do not encourage people to behave recklessly, for example standing in a busy highway, going down dark alleys at night, or committing any crimes. Also, this article only describes one type of exposure therapy, something called “in vivo” exposure therapy and this type of exposure therapy cannot be used to overcome some anxiety provoking situations. Obviously, we cannot expose ourselves to our fear of our own death (at least not more than once), to fears of loved ones dying, or to fears of natural disasters. For these types of hypothetical fears, we may need to practice something called “imaginal exposure” which is not described in this article.
Some notes for therapists:
Many clients struggle with creating the motivation to engage with exposure therapy. When we are distressed we often resort to coping mechanisms that are familiar to us, even if they are not helpful. It can be useful to go slow with clients and discuss the costs and benefits of avoidance. Encourage the client to consider what their life may be like if they continue to avoid anxiety provoking situations indefinitely and/or consider the opportunities their avoidance may have already cost them. Remember, it is not our job to convince the client to do anything. Instead we are there to help them make informed decisions. If the client chooses to continue to avoid, while knowing the consequences of this decision, that is their choice and that should be respected.
Processing what the client has learned from exposing themselves is just as important as collaborating with the client to design the exposure activity. “what did you learn from exposing yourself to this situation?”, “what did you learn about your ability to cope with the situation?”, “what did you learn about your anxiety in general?” “what did you learn about your fears?” – Questions like these can be very helpful.
There are two workbooks you can now access in our “self-help” section for free.
The Making Changes workbook can help you learn about Cognitive Behavioral Therapy principles and how to apply them to your life. It can help you improve your living habits, set goals, and change your thinking.
The new Anxiety workbook can teach you about anxiety, skills to manage anxiety, and steps you can take to reduce your anxiety over time. Here is an portion from that workbook:
SUMMARY
· Anxiety is a normal human response to perceived danger.
· The more we worry, the more we are thinking about potential dangers, this then triggers the anxiety response.
· We can practice skills like box breathing, 5-4-3-2-1 sensory grounding, and progress muscle relaxation to cope with extreme anxiety.
· Cognitive behavioral therapy can help use reduce our anxiety.
· Our thoughts cause our emotions and behaviors, not situations. Therefore, our anxiety is being created by the story in our head, not the situation we are in.
· When we experience excessive anxiety we are usually engaging in unhelpful thinking styles.
· CBT teaches us to recognize our unhelpful thinking and then dispute irrational thoughts, replacing them with more helpful thoughts.
· Excessive worry fuels excessive anxiety. Sometimes we believe excessive worry can be a good thing, but these beliefs maintain worry.
· When we believe (1) “problems are threatening”, (2) “I can’t handle problems effectively”, and (3) “problems will turn out badly regardless of what I do” we are preventing effective problem solving. We can solve this by recognizing problems as a normal part of life and seeing the opportunities presented by our problems.
· A problem solving model can be used to help us effectively cope with challenges we can reasonably do something about.
· Graded exposure can be used to decrease the amount of anxiety we experience in situations. Graded exposure is a process by which we practice exposing ourselves to anxiety provoking situations, practicing and developing our skills, and gradually learning situations are not as threatening as our minds make them.
· We can improve our abilities to cope with stressors by maintaining a healthy self-care plan which includes diet, exercise, sleep, relaxation, work , socializing, thinking helpful thoughts, and goal setting.
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