Proven CBT techniques to help anxiety

CBT (Cognitive Behavioural Therapy) focuses on managing problems by changing the way you behave and think. It is one of the most effective treatments for anxiety and depression. This could be by identifying and challenging unhelpful thinking patterns, surfacing damaging habits and developing coping strategies to problem-solve more efficiently, just to name a few.

I thought it would be an idea to document some of the knowledge from CBT that I have found helpful to understand and cope with anxiety.

The Anxiety Equation

You can guarantee this equation won’t end up on geeky pop-sci t-shirts but is essential to understand anxiety. The equation is as follows:

What the equation shows is anxiety occurs when you have an overestimation of the danger of a situation (this lift will break down) and an underestimation of your ability to cope (I can't get out and I’ll be stuck here forever and die).

The amount of anxiety is a balance between the two. Your lowest anxiety is when the numerator the lowest (it’s not going to be as bad as you expect) and denominator is the highest (you know you will cope).

If you’re an anxious person you may think you only overestimate the likelihood of something bad happening, which is very tough to overcome. What could be more helpful is instead of telling yourself ‘not to worry’ (if it was that easy…) to think ‘if the worst-case scenario happens, I will still cope’. This is changing the ‘What if?’ to ‘So what, if it does?’.

You’ve survived 100 % of your bad days, after all!

Thoughts, Feelings, Behaviours cycle

There is no reason to practice mindfulness, yoga, light a candle etc. if you don’t understand how they are going to help.

The thought, feelings, behaviour cycle encompasses the vicious cycle of anxiety and helps explain why some worries just keep coming back or are maintained for a long time, sometimes leading to a panic attack.

I’ve drawn up an example of this cycle. Note that the arrows are double-headed. There is no specific start or end to this, a cycle of anxiety can start from any of these positions.

Thoughts: These are commonly the trigger and can be down to negative attitudes and beliefs or just seemingly ‘out of the blue’. Thoughts can relate to either overestimating how bad an outcome will be or underestimating your ability to cope. They can be self-focused (‘I can’t do this what is wrong with me’) and commonly follow unhelpful thinking patterns. Some examples are:

Mind-Reading: Assuming we know what others are thinking - ‘Everyone will laugh at me’, ‘Everyone thinks I’m a failure’

Prediction: Believing we know what will happen in the future - ‘I will definitely mess up this interview and won’t get the job’

Catastrophising: Imagining and believing that the worst possible thing will happen - ‘If I drive too far, I’ll crash and die and no one will be there to help me’

Black and white thinking: Believing that an outcome can only be good or bad rather than anything in between - ‘If I don’t get over 90% in this exam I am a failure’

Shoulds and musts: Vocabulary such as ‘I should’ and ‘I must’ puts unnecessary pressure on oneself and demands unrealistic expectations - ‘My makeup must be perfect everyday, otherwise, people will think I am ugly’

Feelings: These are physical sensations caused by your body’s natural ‘fight or flight’ response such as: sweaty palms, racing heart, feeling dizzy, nausea etc. It could also be general feels of fear, dread, panic or depression.

One way of fueling the cycle is to focus far too much on these to the point where you’re making them worse. For example, interpreting heart palpitations (caused by a thought) as a heart attack and now you’ve got a whole new worry to worry about!

Behaviour: These vary on the person and situation and are a consequence of focusing on your thoughts or feelings. Safety behaviours can be looking for escape routes (e.g. toilets, fire exits). One natural one is complete avoidance of the situation in the future. You may also seek reassurance or look for evidence to fit your worries e.g. checking your partner’s phone if you’re anxious that they are cheating on you.

Safety behaviours may give a short term relief (believing you to think they work), but they don’t fix the initial problem and are therefore harmful in your progress in living an anxiety reduced/free life.

What we do affects how we think and feel. The behaviour reinforces thoughts and hence continues the cycle. Like a worry-go-round.

Beliefs About Worry

Some people believe that being an anxious person is actually good because you ‘care more’ and are ‘prepared’ for the worst. However, no one can ever truly prepare for everything and keeping up safety behaviours is just an illusion.

This can be summed up in an analogy one therapist told me. This is a bit wacky but stay with me here:

One day someone comes across a lady waving her arms wildly. They ask why she is doing that and she says 'I'm keeping the dragons away'. They say 'what dragons?' and she replies 'exactly'.

What this lady will never know is that there are no dragons even if she stopped waved her arms i.e. stopped her safety behaviour.

There are a few things that could happen:

1. There are no dragons, ever (sad, would be pretty cool though)
2. The dragons could still arrive but they're actually really friendly! (Why can’t they be?)
3. She realises they're not as scary as she thought they would be (Fair play)

This analogy proves that safety behaviours are illuding you to think they work and you need to prove to yourself that your worst case scenario won't happen (or atleast, less frequently) even if you don't use them. This could save tons of time preparing up your battle gear for the worst.

Delay the Worry Technique

This is particularly useful when you’re worrying about things in the future, out of your control or that you cannot attend to immediately.

When you catch your worrying interfering with your daily life (i.e. at work, before sleeping), postpone the worry to a particular day, time and duration (preferably not before bed) where you won’t be distracted. As soon as other worries pop up, postpone them to the same worry time.

The reason being by having a specified time you are still going to address the worry (and not just pushing it away for it to pop up again later) but just not right now. What you’ll find is, you either forget about your worry time (the worries were clearly not that important) or you get to the worry time and at least your anxiety hasn't interfered with another task (and hence reducing worry from not focusing on those tasks)

Five-Finger Breathing Technique

I got this breathing technique from Dr. Rangan Chatterjee’s ‘Feel Better, Live More’ podcast (highly recommend). I like this one because you can guide yourself without any animations and can be done subtly (sometimes I do this on the bus or under the table at a restaurant).

Using your index fingers of your dominant hand, trace up and down along the edge of the fingers of your other hand slowly. When you’re moving up the fingers, inhale, and moving down, exhale. Overall, you will have done 10, slow, deep breaths.

The guide of your fingers, just like those inhaling and exhaling animations, really forces you to slow your breathing. When you’re in a panicked state, it may take a few cycles of this to work but having something to follow is incredibly effective. Here's a video demonstration.

5, 4, 3, 2, 1 Grounding Technique

This is another popular technique for situations when you feel anxious but can’t necessarily escape (e.g. on a packed train, in a waiting room). When you feel extremely anxious your mind starts to wander, and spiral (think the anxiety cycle). Grounding is a coping strategy to reconnect with the present and separate yourself from distressing thoughts or feelings.

For this exercise, pay close attention to your breathing and make sure you have slow and deep breaths to maintain a sense of calm. Then go through the following steps:

5: Acknowledge 5 things you can see (a small pencil, a crack on the wall…)

4: Acknowledge 4 things you can touch around you (your jeans, your glasses...)

3: Acknowledge 3 things you can hear (the car engine, your laptop whirring…)

2: Acknowledge 2 things you can smell (perfume, paint...)

1: Acknowledge 1 thing you can taste (toothpaste, imagining a cold creamy ice cream…)

Don’t worry about remembering the order. The most important thing is you really engage all your senses into your surroundings. Sometimes, I even forget what made me anxious in the first place after doing this, or notice a cute puppy on the bus that was right next to me the whole time (aww).

Your Thoughts Cannot Harm You

Although this list is by no means exhaustive, I want to end on a note about thoughts. It is a lot easier to acknowledge them as just thoughts rather than push them away (which is why 'don't worry about it!' is more harm than good). If I said 'don’t think about a pink elephant' - what are you thinking about? Exactly!

Thoughts are not real and have no real power over you unless you let them. They will come and go and only you can give them power by how much you focus on one. If you have a negative thought, as we all do, the difference between giving it attention is the reason you spiral into anxiety or not. The focus can produce new thoughts, or feelings, to which you might start noticing things which become worse as a result (e.g. focusing on a small pain in your stomach thinking it's a tumour when it's slight indigestion and then noticing more aches and pains which suddenly appear all over). Acknowledging this could help stop some anxiety spiralling and nip the thought, feeling, behaviour cycle in the bud.

CBT is about 'what you think and do affects the way you feel'. It's the reason I finished university and have kept a stable job despite mental health issues. I hope these understandings of anxiety and techniques can help you too.

If you live in England and would like think CBT therapy could help you, the 'How to Find a CBT therapist' section on the NHS website can guide you to the relevant service for therapists in your area.