CBT for Generalized Anxiety

How Can CBT help with Generalized Anxiety and Worry?

We all worry. We worry about our relationships, our finances, our diets, and many other things. In our high-stress and fast-changing world, there is a lot to worry about!

However, for some people worry becomes impairing. I have clients who describe themselves as "addicted to worry." Many of them find it difficult to fall asleep at night. When they do sleep, they are often plagued by troubling dreams and wake up feeling exhausted. Some report a great deal of muscle tension or digestive difficulties.

Researchers have found that chronic worry is often accompanied by feelings of being on edge, poor concentration, irritability, tension, and sleep difficulty. These symptoms can sometimes grind a person's life to a halt.

Therapy can help with these issues. In cognitive-behavioral therapy, we use a variety of methods to help with worry, generalized anxiety, and related symptoms such as insomnia. Let me describe a few of these below.

Worry as a Problem-Solving Habit

If you take a close look at the process of worry, you may find that it involves a great deal of "rumination." In other words, when you worry, you retread the same mental ground over and over. You might think about one scenario after another — perhaps in somewhat extensive detail.

This problem-analysis can actually be a helpful skill if you're using it to prepare for action. But paradoxically, chronic worry often replaces action. We can become stuck in our ruminations. We just cover the same mental and emotional ground again and again.

People who chronically worry have often developed the habit of using worry to respond to challenging situations. However, chronic worry doesn't really solve problems! This is one of the most important ideas we build on in cognitive therapy.

Analyzing (or worrying about) a problem may help prepare you for action — but at some point, you need to convert the energy behind worry to productive steps. These steps might include movement toward resolving the problem, or they might simply focus on self-care. The energy needs to be directed in positive directions.

Shining a Spotlight

As support for this shift, I often find it helpful to first "shine a spotlight" on the process of worry and anxiety. One helpful approach that we use in cognitive therapy is called the "downward arrow" technique — a strategy developed by Dr. David Burns.

In the downward arrow technique, we bring the content of worry out onto center-stage, and take a close look at it. We clarify the various levels of fears and concerns that are fueling the worry. This can sometimes be enormously revealing.

As an example of this, let's take a young man named Mark. Mark is a recent college graduate who is working in his first job. Mark has been feeling "keyed-up" almost all the time. He's also experiencing a great deal of trouble falling asleep. Throughout the day, he finds himself worried about one thing after another.

We would begin the downward-arrow approach by asking Mark to write out one of his specific worries. Usually, just about any of them will do! Mark chooses the following:

    "I'm worried that my upcoming report for work is not going to be up to my boss's standards. I'm worried that I won't do a good enough job."

Now, that sounds like a fairly normal worry. Most of us worry about things like that. However, because Mark is finding himself somewhat overwhelmed by worry, we'll ask him to take another step.

I might say to Mark, "OK, let's imagine that that scenario actually happens. Let's imagine that you don't do a good enough job on your report, and your boss tells you it's not up to her standards. Tell me what you're worried will happen next."

Mark might say:

"Well, if that happens, then I'll probably get a reprimand and a bad review."

"OK," I say to Mark, "and what will happen then?"

"I might be passed over for a raise. I might even lose my job!"

"And then?"

"Then I'll have a really hard time finding another job with that black mark on my resume."

"And then?"

"Then everyone will see what a complete failure I am! They'll realize that I'm a fake and I really don't know what I'm doing in my life!"

We would probably stop there, because Mark has uncovered some core negative beliefs about himself — beliefs that might be fueling a great deal of the worry. After we've mapped out this worry cycle, we would work to counter (or address) each level in the downward-arrow technique.

For example, starting at the bottom: Is Mark really a "complete failure"? (I doubt it — in fact, he's probably quite successful at many things.) Is he a "fake"? (He sounds pretty honest to me!) Does he "not know what he's doing in his life"? (Perhaps... We could begin to clarify things, if so.)

Moving up a level: Will Mark have a hard time finding another job if he loses his current job? (It's possible, but it's unlikely that a single bad job experience will hold him back. If he is concerned about future job-searches, we can begin to discuss approaches that might help. We can also discuss methods of structuring a resume to soften job transitions.)

And so on. As you can see, in this approach we (1) clarify various elements of the worry-cycle, and (2) then begin to shift both thoughts and actions to reduce the worry associated with each level.

I've included a worksheet for the first part of this approach in my resources section. It is called "Shining a Spotlight on Worries and Fears."

Letting the Mind Wind Down

Another extremely important step in the reduction of chronic worry is to set aside time each day (preferably multiple times each day) to let the mind "wind down."

Our minds are extremely active — they often run on autopilot all day, and then they run all through the night in our dreams as well. Sleep alone often does not allow the mind to rest. Because of this, it's important to consciously set aside rest times.

Hundreds of years ago, this wasn't as important. Most people practiced farming, fishing, hunting, and gathering — activities that allowed for a great deal of quiet time. The mind would have hours each day to rest.

In our current society, however, that's not the case! We often move from fast-paced home life to faster-paced work life to highly-stimulating leisure activities. Often, generalized anxiety and worry stem from an overloaded mental and emotional system.

This is why it's essential to form a habit of taking "rest times" throughout the day. In therapy, I often work with my clients to find relaxation and rest techniques that they can use in a non-disruptive way. Even a few brief "wind-down" periods several times a day can help the mind to "re-boot." As with other cognitive-behavioral therapy approaches, developing this new habit takes practice!

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