Two Ways to Make CBT Work More Effectively for Anxiety

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It’s likely you’ve heard of CBT, one of the most widely used types of treatment for anxiety, and many other conditions. It’s called an evidence-based therapy as it’s been shown in numerous rigorous studies to work—to make people less anxious. CBT is a sophisticated treatment approach with many important components. It’s often delivered in a setting with a trained therapist, although there are several good books that can often help you learn the skills on your own (listed in references). In this post, I’m going to show you two ways to make CBT work more effectively, especially in managing anxiety issues.

Simplify the Anxiety-Management Technique

One of the standard pieces of a CBT protocol is to identify your “irrational” thoughts, label them according to what cognitive distortion they contain, and then refute the thought with an alternative, more realistic thought. Here’s an example:

Kevin has been in the workforce awhile, but he wants to go back to college to finish his Bachelor’s degree. He didn’t take college seriously when he was young and dropped out, but now he sees how completing his degree will help him advance in his career. His therapist has him keep a thought diary (or thought log), and one of his entries goes like this:

“If I enroll in college full-time, I’m going to flunk out my first semester, and I won’t be able to come back to this job. Then I’ll run out of money. I’ll have to move back in with my parents, and I’ll be so ashamed I’ll just want to lay down and die.”

After writing out his thoughts, he goes through a long list of cognitive distortions that his therapist gave him. Are his thoughts an example of Emotional Reasoning? Catastrophizing? Or maybe they’d be better categorized as Black-and-White Thinking? Kevin can’t decide, and he spins his wheels trying to determine the correct cognitive distortion to write down in his log. He ends up getting frustrated, criticizing himself (“Why can’t I get this?”), and gives up before he gets to the next step in the process.

What could Kevin do instead? Instead of going through a long list of cognitive distortions, he could simply ask himself:

Is this thought useful or not useful?

Or he could try a variant:

Is this thought helpful or not helpful?

This was a much easier approach for Kevin. He didn’t have to memorize or keep a list of cognitive distortions in front of him. All he had to do was notice when his mind was spinning out of control (or look at his thought log), and ask himself, “Hmmm… is this line of thinking useful?” That was very do-able for Kevin, and he was much less frustrated.

Another form of this approach: You can turn this into a mindfulness practice, sometimes called “noting practice”. As you notice thoughts arise, either during a specified time of practice or more informally throughout your day, simply label your thoughts “helpful” or “not helpful” (or useful/not useful; decide which works best for you).

Now to be clear, there can be value in learning the different flavors of cognitive distortions, but one suggestion is to do this when you are NOT anxious. (Here's a comprehensive list from popular blogger Alice Boyes.) When you are already in an anxiety spiral, it can be difficult to concentrate. Having a shorter, simpler version such as what I just described may be just what you need.

Make the Anxiety-Management Technique “Better but Believable”

Another way to make CBT more effective is to make alternative thoughts "better but believable", a phrase coined by psychologist Jennifer Abel (2010). I’ll describe what this means below, but first, let’s look at an example.

Janine is a mother who tends to worry a lot about her child’s safety. Her son, Tommy, has known how to ride a bike for several months. Her husband taught him and he has assured her Tommy has mastered the skill and is conscientious about safety, including wearing his helmet. Tommy asks her one day, “Can I ride my bike with my friends?” Janine’s first thought is, “What if he gets hurt?” Now, let’s imagine that Janine has enough insight to recognize this as a worry thought, and she tries to tell herself instead, “I’m sure he’ll be fine.”

Is this helpful? No. Why is this not helpful? Because it’s not believable, or true. Tommy could fall off his bike and skin his knee. Unfortunately, there’s even a chance he could have a more serious accident.

At this point, a common technique in CBT would be to have Janine rate the probability that something bad will occur: How likely is it that Tommy will get hurt riding his bike today? And then, you'd go one step further asking her to rate how awful it would be if he, in fact, did get hurt riding his bike? Typically, people are asked to rate their answers to these questions in terms of percentages. For example, Janine might have said, “I think there’s a 5% chance that Tommy will fall off his bike today.” Sometimes this can take up a good chunk in a session, having the client rate the probability of something bad happening, and then rate how severe it would be, should the event occur.

I’ve found that people do well with this when they have a therapist guiding them through the process, but find it cumbersome to do at home, especially if they’re in the middle of a worry-producing episode.

To circumvent this problem, Dr. Abel, mentioned above, uses a catchy phrase that she teaches to her clients. She has people come up with an alternative thought that is “better but believable.” For example, Janine’s first alternative thought after worrying about her son’s safety was, “I’m sure he’ll be fine.” To make it better but believable she could say, “There’s a good chance he’ll be fine today.” It's believable because it still acknowledges that there is always some uncertainty in life. Ironically, acknowledging that there is some uncertainty allows Janine's mind to calm down a bit. Abel notes that the characteristics of good B3s are that they are simple, effective, catchy and pragmatic.

Anxiety Essential Reads

The Hallmarks of High-Functioning Anxiety

How Long Do Panic Attacks Last?

The next time you find your anxiety rising, remember to:

1. Simplify: Ask yourself, is this thought helpful or not helpful? And

2. Try a B3: Come up with an alternative thought that is better but believable.

I hope you’ll let me know how this goes for you.