Kathleen Kawamura, PhD Clinical Psychologist
Kathleen Kawamura, PhDClinical Psychologist 

Cognitive Behavioral Therapy (CBT) for Anxiety

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 for anxiety and stress addresses each of these components via: 

  • Education
  • Cognitive skills training (thoughts)
  • Behavioral strategies (behaviors)
  • Somatic management skills (physical feelings)




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.




Identifying Anxiety Igniting Thoughts


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 understanding where they might have come from can itself diffuse some of the anxiety.


Once the anxious thoughts are identified, it may be easier to see ways in which certain patterns of thinking contribute to the anxious response. In addition, you may be able to identify beliefs about yourself, others, the world, and the future that also contribute to anxiety. Beliefs about anxiety and the worry process can contribute to additional anxiety.


Understanding the Thoughts


It is important to remember that these thoughts, patterns of thinking, and beliefs are not necessarily wrong or bad, but rather, the brain is rigidly fixated on thinking in habitual patterns. Certain thinking styles may have been adaptive in the past, may have been learned from childhood, or as in OCD may seem biological or neurological in nature. 


Understanding how your thoughts, patterns of thinking, and beliefs came to be can help put them into perspective so that you can better step outside of them without automatically reacting to them as the only truth. When you consider how they developed, the thoughts often make sense.


With anxiety, certain thinking styles may have developed as a way of keeping you safe from danger. The problem is that if anxious thoughts continue even after a 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 meant to be life-saving in dangerous situations can then become an obstacle in living a full and meaningful life. 


Considering Multiple Perspectives


Therapy can help you identify alternative, less anxiety provoking, perspectives. It is not that the original perspective is wrong or bad, but rather, it may not be the only perspective and may not be the most helpful perspective. The goal is to allow for more flexibility of thinking so that alternative perspectives can also be considered.


Alternative perspectives are not meant to be overly positive or provide reassurance bur rather they are meant to make the case that there may be other ways of looking at the situation. This can open up your mind to other potential outcomes that your anxious thinking may not be considering.


Developing a flexible thinking style that allows you to evaluate your situation and consider other perspectives is a skill that is developed with time and practice. There are various strategies used in therapy to help with cognitive skills training.


Practicing a New Way


The best way to rewire the circuitry in the brain is to practice sitting with your thoughts, validating those original thoughts and feelings, and then consciously choosing to consider other interpretations. This can be difficult as 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 and strengthen new pathways, or new perspectives, requires consistent effort and practice. Again, the goal is not to abolish old ways of thinking, but rather to allow for multiple perspectives and interpretations - flexibility of thinking.




Avoiding Anxiety


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.


Approaching Anxiety


On the other hand, with exposures, you will be able to learn that after an initial surge of anxiety, the anxiety 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 exposures 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 to inhibit or override old 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 refer to strategies that are used to help calm general physiological arousal. 




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. 




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. 




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.


Breathing Retraining


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 strategy is not effective, remember that these are skills that need 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, setting your mind to examine your thoughts, and settling into a relaxing pose may be able to encourage an automatic relaxation response in your body.


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