Kathleen Kawamura, PhD Clinical Psychologist
Kathleen Kawamura, PhDClinical Psychologist

Cognitive Behavioral Therapy (CBT)

The section on Understanding Anxiety describes the three components of anxiety as being the thoughts, feelings, and behaviors that contribute to the experience of anxiety. Cognitive behavioral therapy addresses each of these components via education, cognitive skills training (thoughts), somatic management skills (feelings), and behavioral strategies (behaviors).


EDUCATION regarding the causes and treatments for anxiety can provide peace of mind, a sense of control, and motivation for treatment. There should be no mystery or complexity in the explanations and treatment. This is why I provide detailed information about anxiety on this website and more in therapy. By knowing what is happening in your brain and body, catastrophic worries about anxiety can decrease, and you will be better able to tolerate the uncomfortable and distressing feelings associated with anxiety and will be able to reconsider avoidance behaviors that maintain anxiety. Truly, knowledge is power when it comes to anxiety management.


COGNITIVE SKILLS TRAINING involves identifying thoughts that increase anxiety through the practice of self-monitoring. Becoming aware of the thoughts that contribute to anxiety and seeing where they might have come from can itself diffuse some of the anxiety and can also help you see ways in which certain thoughts contribute to the experience of anxiety. Once the anxious thoughts are identified, it may be easier to see ways in which the thoughts may be exaggerated, catastrophic, unhelpful, or biased. Learning to identify patterns of thinking that occur when anxious can help keep the anxious response in check. The primary goal of this stage is to Observe and Learn.


It is important to remember that these thoughts are not necessarily wrong or bad, but rather, the brain is rigidly fixated on thinking in a way that is meant to keep you safe from imminent danger. This way of thinking may have been adaptive in the past, may have been learned from childhood, or as in OCD may seem as if it is neurological in nature. When you consider how they developed, the thoughts often make sense. The problem is that if anxious thoughts continue even after the situation is safe, a false alarm will continue to sound, keeping your mind and body in a state of anxious arousal. This emergency mode that was once life-saving in dangerous situations becomes an obstacle for day-to-day living. 


Developing a flexible thinking style that allows you to evaluate your situation and consider other perspectives is a skill that is developed over time. Therapy can help you identify alternative, less anxiety provoking, perspectives. Alternative perspectives do not have to be overly positive. In fact, they are more effective if they are 100% believable and 100% possible. The goal here is to Observe and Wait. By learning to sit with the thoughts, without immediately reacting, you will be able to implement strategies that can help you consider other possibilities. There are various strategies used in therapy to help with cognitive skills training.


For example, if you are overwhelmed by worries before a presentation, saying to yourself, “I won't make any mistakes and everybody will love my speech,” may not be as effective in reducing your anxiety as, “That is my anxious voice speaking. I tend to think of unlikely, worst case scenarios when I'm anxious. I've been like that since I was a kid, but I don't have to continue to be that way. I’ll try my best, see how it goes, and hopefully some people will enjoy my presentation. If not, I’ll be upset but will handle it and will learn something from the situation.” Better but believeable thoughts tend to be much more detailed, but eventually with practice, all that self-talk can be condensed into, "Try my best." 


The best way to rewire the circuitry in the brain is to practice sitting with your thoughts and consciously deciding to consider other interpretations to strengthen those pathways. The thoughts we are used to thinking occur automatically and habitually, as if there is a pathway tread into the grooves of our brain. To pull your mind out of this frequently used pathway and to develop new pathways, or new perspectives, can take some effort at first but with practice can become more natural and automatic.


BEHAVIORAL STRATEGIES include exposing yourself to situations that induce anxiety in a controlled manner thus allowing you to challenge your fears and develop confidence in your coping skills. If anxiety is the problem, why would you put yourself in situations that make you anxious? The reason is that anxiety is not necessarily the problem. Avoidance is the problem.


By avoiding or escaping situations that make you anxious (which is a reasonable reaction to fear and discomfort), you can find yourself missing out on meaningful life experiences. You also lose the opportunity to have a new experience, to teach your brain and your body that you are safe and that you are capable, and to change neural connections. Avoidance and escape preserve the wiring in your brain that leads to anxious responding.


On the other hand, with exposures, you will be able to learn that after an initial surge of anxiety, the anxiey will plateau and eventually decrease on its own. Multiple exposures will also help you build up a tolerance to the physical sensations associated with anxiety which will then lead to a reduction in anxiety levels over time. Exposures can also help you learn coping skills on how to manage anxiety without resorting to avoidance or safety behaviors and will allow you to challenge, through direct experience, negative predications about what might happen in your feared situations. It seems that logic only goes so far in changing how our brains react to anxiety provoking situations. In the end, exposures may be able to teach you (your brain, your amygdala) that the sensations and the situations are not dangerous by breaking the connection between the feared situation and the anxiety response as new learning occurs.


For exposure to be effective, a moderate level of anxiety needs to be experienced. It may be that the neural circuits need to be activated for real change to occur in the part of the brain that reacts to fear (the amygdala). Also, minimal anxiety will provide a minimal learning experience whereas too much anxiety can overwhelm the system. A moderate amount of anxiety means that the brain circuits are activated and ready for new learning experiences. It becomes an opportunity for new learning.


Prior to any exposure strategy, it is important that you become well versed in the education regarding anxiety and the cognitive interventions mentioned above so that you are not adding fuel to the fire with anxiety igniting thoughts. It is also essential that you have learned and practiced some coping thoughts to help you through anxiety provoking situations. Various strategies are used in therapy to identify feared situations and help you prepare to reintroduce these situations into your life in a safe and controlled manner.


  • SOMATIC MANAGEMENT SKILLS refers to strategies that are used to help calm general physiological arousal. 


Sleep - The benefits of adequate sleep and regular exercise cannot be emphasized enough as they are critical in reducing activation of the amygdala and the sympathetic nervous system. Without adequate sleep and exercise, the mind and body become unstable and vulnerable to anxiety. Extended, uninterrupted sleep seems to be most important in reducing anxious activation. 

The Cognitive Behavioral Treatment for Insomnia (CBT-I) has been shown to be highly effective in the treatment of insomnia. Those with insomnia may need more than basic sleep hygiene recommendations to help them recover sleep skills that they may have lost. CBT-I involves techniques to help you recalibrate your internal clock, reestablish your bed as a sleep cue, increase your sleep drive, and challenge anxiety provoking thoughts that disrupt sleep. 


Exercise - Regarding exercise, 20 minutes of aerobic activity may be sufficient in reducing anxious activation. By exercising, you are engaging in the fight or flight response (at least the flight part), thereby releasing the energy that is being built up in your body for that very purpose. Exercise has also been known to be involved in the release of endorphins, which are neurotransmitters in our body that trigger positive feelings in our mind and body. Regular exercise may also decrease the sensitivity of the anxiety response in general. 


Aerobic exercise has been found to be related to increases in the levels of glutamate and GABA in the brain. GABA is an inhibitory neurotransmitter that dampens the anxiety response and levels of glutamate, whether low or high and depending on which part of the brain, has been associated with anxiety and depression. The findings are preliminary and the mechanisms still not thoroughly understood, but the finding that exercise is associated with changes in the brain is promising. 


Relaxation – There are a variety of relaxation exercises that have been developed to manage anxiety by slowing our breathing, relaxing our muscles, and calming our mind. Relaxation exercises can involve tensing and releasing muscles, visualization, meditation, yoga, or breathing exercises. The goal is to find the relaxation exercise that works best for you, and the only way to make that decision is to try various relaxation exercises.


Because of the relationship between breathing and anxiety, many treatments for anxiety disorders involve breathing retraining. Breathing retraining refers to teaching clients how to breathe from their diaphragm, or from their bellies, vs their chest. Breathing retraining also involves learning how to slow the breath cycle to about 6 breaths per minute, or 10-second breaths. Often, this can be done by imagining breathing through the nose (smelling the flowers) and then breathing out through pursed lips (blowing out the candles) and imagining that you are breathing into your belly, filling up a balloon that expands and pushes up your belly.


Before you decide a certain exercise is not effective, remember that relaxation is a skill that needs to be developed. Our brains are like a muscle that needs to be trained, and just as in physical exercise, the more you do it, the better you become at it. Eventually, just closing your eyes and settling into a relaxing pose can automatically trigger a relaxation response in your body.


Click here for a thorough description of the most effective relaxation strategies for anxiety.