Coping with anxiety a guide to cognitive therapy

• "What if I fail this exam? My career will be ruined before it starts. I feel so sick just thinking about it that I can't study. But I have to study or ...”

• “Every time I leave the house 1 feel sick, I think I'm going to collapse and have to go back home. I can't go anywhere unless someone is with me.”

• “When I have to talk to strangers I start to sweat and panic I feel trapped and can't think of anything to say.”

• “It sometimes feel very tense and uncomfortable, worrying about things that I've got to do the next day, or even the next month. I can't seem to get rid of these worrying thoughts no matter how hard I try.”

Such are the thoughts and emotions that sweep over those who suffer from anxiety and phobias. Since both anxiety and phobias are rooted in fear, they both indicate the dread of some type of danger or threat to ones well being. This sense of threat is manifested by a wide range of physical symptoms anxiety's body language which are distressing in themselves, rapid breathing, accelerating heart rate, dizziness, nausea, headache, sweating, dryness of mouth, tightening of the throat, pain in various sets of muscles, etc. When the state of anxiety is prolonged or chronic these frightening, uncontrollable symptoms may take the form of what seems to be a real disease or disability.

One of the most important facts for a severely anxious person to learn and recall to mind at critical moments is that the symptoms he is experiencing are not dangerous. The racing pulse or pounding heart, the dizziness or nausea, the desire to scream or cry or pound the table - none of these physical or emotional reactions indicate that the person is dangerously ill or going crazy. They are unpleasant. They are uncomfortable. But they can be tolerated until they go away. And they will go away.

The phobias cause intense anxiety, accompanied by its various physical and emotional symptoms, the phobic individual is reacting to a specific object or situation which can to some extent and without great inconvenience, be avoided. As long as the feared event, object or situation is not an integral part of the person's life, he can remain free from the anxiety effects of phobia.

For instance, someone who has an intense fear of flying can usually find ways of getting to places without going on an aeroplane. The anxiety sufferer however, cannot always pinpoint the source of his anxiety. And even if he can identify the cause, he cannot avoid encountering it; either the demands of his daily life force him to confront the feared circumstances, or he has so completely internalised his fear that the source of it is within himself. Sometimes it is necessary for a person to experience fear in order to acknowledge the threat of a real danger and prepare himself to meet it. A certain degree of anxiety may accompany such fear. But the person who suffers from excessive anxiety or phobic reactions is not responding to the realities of the situation. He may be anticipating a threat to his well being when there is little likelihood of it happening.

If he is facing a challenge of some sort an exam or a job interview, he will magnify the difficulties and dwell on the horrors of a negative outcome. At the same time he will underestimate, overlook or discount his own ability to cope with whatever he fears. In other words, he misinterprets and distorts reality so that he feels anxious about dangers which either do not exist or which he could cope with effectively if he were not so disabled by his own anxiety reactions. To make matters worse, when the severely anxious person becomes intensely aware of his own unpleasant physical and emotional reactions, he may begin to dread and fear the symptoms themselves even more than the situation that triggers them. The more upset he gets, the more exaggerated his symptoms become, and he is involved in a self-perpetuating spiral of increasingly intense emotional and physical suffering.

Since this form of anxiety is based on a misinterpretation of reality, research has revealed that certain thoughts and mental pictures automatically accompany the experience of anxiety. These AUTOMATIC THOUGHTS or cognitions, are usually focused on the future: “I won't be able to do the job”, “I'II lose control of myself and be humiliated” “I'll die from a heart attack”, “If I go to the party no-one will want to talk to me”.

The connection between these AUTOMATIC THOUGHTS and the experience of excessive anxiety, suggest to those people studying the problem that if the patient became aware of these thoughts and changed them to conform with reality, the anxiety would be very much less. Clinical experience with people who suffer from anxiety has shown that this method can be very effective. The approach is called COGNITIVE THERAPY.

In the following anecdote you may recognise the way in which anxious persons thoughts destroy his ability to function adequately. A lonely young man wants to ask a girl for a date, but every time he has the opportunity to do so the anxious thoughts rise up and he avoids asking her. The 'automatic thoughts' he has are; “She'll thing I'm stupid to be so nervous. She'll turn me down and I'll look pathetic. I'll have failed yet again”.

How would Cognitive therapy help someone whose anxious thoughts and imaginings interfered with their ability to lead the kind of life that is rewarding to them?

Firstly, by helping you to recognise the kind of errors of reasoning in your thinking that cause you to be upset. Secondly, by helping you to correct these errors and substitute more reasonable and rational ones that will not result in excessive anxiety, and debilitating ways of looking at the world (what are called UNDERLYING ASSUMPTIONS) may make you vulnerable to thinking in anxiety provoking ways.

During treatment, your therapist will help you to learn how to challenge your irrational, automatic thoughts and to change maladaptive underlying assumptions. There are a variety of ways of doing this, and your therapist will help you to find the particular ways that helps you best. This can be a slow and at times painful process, and will involve you taking some risks in 'testing out' your beliefs and ideas to determine how realistic they are. However, the rewards of learning how to control your anxiety will almost certainly compensate more than adequately for the hard work that may be involved. As you gradually eliminate the distortions and inaccuracies in your own thinking you will develop an increasing confidence in your ability to handle situations in your life that previously caused you a lot of difficulty.

The first step is to recognise your own AUTOMATIC THOUGHTS whenever you feel anxious. In order to help you recognise them, keep these characteristics in mind. These thoughts just seem to come out of nowhere, and flash through your mind without you really being aware of them.They seem very plausible and believable to you at the time you are experiencing them. In fact you tend to accept them as perfectly reasonable way of thinking in the circumstances, just as you might readily accept the truth of a realistic thought like "The phone is ringing, I must answer it". These thoughts are however, quite unreasonable and irrational as you will realise when you learn to challenge them with reason and facts. Automatic thoughts are the kind of thoughts that most people would find depressing or anxiety-provoking if they believed them.

The second step is to learn how to challenge automatic thoughts with mason and fact about how the world really is. A good way of doing this is to consider all the various thoughts that you might have had instead of the automatic ones. When you do this you will begin to realise that the way you thought about the situation was only one of a number of different interpretations. (IT IS VERY IMPORTANT TO REMEMBER THAT THERE ARE ALWAYS LOTS OF DIFFERENT WAYS OF LOOKING AT THE SAME SITUATION) Once you do this you will start to see that the automatic thoughts that caused you to be anxious or upset contained THINKING ERRORS. These errors tend to fall into the following categories:—

• ALL OR NOTHING THINKING: Seeing things in black or white rather than in shades of grey (e.g. you're either a total success or a total failure).

• OVER GENERALISING: Imagining that one bad experience in a situation means that you will always have a bad experience in such situations; leg, thinking that you will always be anxious in social situations just because you were extremely anxious at a party you went to recently)

• CATASTROPHISING: Assuming that the worst possible thing is bound to happen in a situation you find difficult leg, after an argument with your boss, assuming that you will lose your job, have to sell your house, and won't ever be able work again)

• CATASTROPHISING: Assuming that the worst possible thing is bound to happen in a situation you find difficult leg, after an argument with your boss, assuming that you will lose your job, have to sell your house, and won't ever be able work again)

• IGNORING THE POSITIVE: Overlooking positive experiences and positive aspects of a situation because they'don't count' for some reason. Dwelling exclusively on the negative qualities and personal failings after you have been turned down for a job.

• JUMPING TO CONCLUSIONS: Coming to a quite arbitrary conclusion about something in the absence of any definite facts to justify this, leg, deciding that your new neighbour doesn't like you just because she turned down your invitation to go to the supermarket with her)

• 'SHOULD' STATEMENTS: This refers to automatic thoughts that cause excessive anxiety or guilt because they inappropriately contain the words 'should' or 'must' or 'always' or 'never'. People generally have such thoughts when they try to live by personal rules and standards that may in fact be excessively rigid and over demanding and have no real application to normal, everyday life, leg, I must always look my best or people won't like me)

Once you have learnt to identify your automatic thoughts and the thinking errors they contain, the third step to practice is substituting RATIONAL RESPONSES for the automatic thoughts. Thus, instead of automatically responding to situations with a series of negative, anxiety-provoking thoughts, you will gradually' learn to respond to situations in a more reasonable way. For example, you will begin to realise that the experience of acute anxiety is always limited in time and that you can learn to control anxiety by not over reacting to symptoms. You will also learn to test out your anxious thoughts and beliefs about what might happen to you in certain situations, by conducting PERSONAL EXPERIMENTS. It very often happens that pople are not as anxious as they imagined they would be in certain situations. Remember that in nearly all anxiety-provoking situations, there are what we call RESCUE FACTORS, these are things that make the feared consequences of being anxious tolerable, unlikely to happen, limited in time, etc. When you have practised going through the first three steps and learnt how to control your anxiety symptoms in your everyday life, the fourth step is to modify any UNDERLYING ASSUMPTIONS you may have that make you vulnerable to being anxious.. These are a little more difficult to explain than automatic thoughts; they refer to the characteristic ways in which you tend to look at the world and think about yourself. For example, anxious people very often have excessive needs for love and approval from other people or beliefs that always being very successful at work is of vital importance to being a worthwhile person. They may have expectations of life that are very unlikely to be satisfied or perhaps excessive feelings of responsibility for other people. As therapy progresses you will begin to learn about the kind of beliefs and assumptions that you have that make you vulnerable to further episodes of anxiety in the future. Once these are identified you can work with your therapist to try and change them so that you are less likely to experience any recurrence of anxious thoughts and feelings.

The following statements are examples of maladaptive underlying assumptions:

• In order to be happy I have to be successful in everything I do

• I must be liked by people at all times

• If I make a mistake it means I am incompetent

• I can't live without being loved

• If somebody disagrees with me it means he doesn't like me

• My value as a person mainly depends on what others think of me.

1. This type of therapy works best when there is a close working relationship between you and your therapist. This relationship should be collaborative one in which you both work together as a team. It should be an open relationship in which you feel comfortable talking about any doubts or anxieties you may have about your progress your personal life, or the way in which your therapist behaves.

2. Throughout therapy you will be given HOMEWORK to do between therapy sessions. This is very important part of Cognitive Therapy and it is important that you understand both what you have to do, and why. It will almost certainly be useful to have a notebook and pen handy during therapy sessions so that you can take notes of anything that you need to remember.

3. During the first few sessions of therapy, as part of the general assessment of your problems and present circumstances, it will be useful to set specific TREATMENT GOALS. Setting goals gives impetus to the process of treatment. If you have in your mind a clear picture of how you would like to change and what you imagine your life could be like if you were free of anxiety, you will know what you are working toward. So share your ideas with your therapist so that he can help you reach your goal.In addition to the steps in Cognitive Therapy outlined above, there may well be other therapeutic techniques and approaches that you can use to learn how to control your anxiety, or to put yourself in situations that you have been afraid of, or to learn more effective ways of behaving in social situations.For example, your therapist may help you learn to relax, or how to approach fearful situations using a method called 'graded exposure', of how to become more assertive usingrole-play techniques. It is not always clear at the start of treatment which approach is likely to be most beneficial to you, and finding the right approach may involve some degree of trial and error.

This booklet has hopefully given you some idea of what is involved in Cognitive Therapy. Remember that the purpose of this type of treatment is to teach you skills that you can carry on using once therapy has ended. Learning to be confident about overcoming anxiety symptoms may take a while. It is something you will probably need to work at on your own whenever you come across situations in life that are stressful or problematic in some way. No ones life is ever completely free of anxiety or depression, the important goal is to free yourself of excessive anxiety that inhibits your ability to enjoy life and realise your potential. Learning how to do this is never a smooth, straight forward process you are bound to have some ups and downs and occasional setbacks. The important thing is that with hard work and practice you will gradually become more and more confident about doing things without anxiety that you had previously thought were out of reach.