CBT for Anxiety

Anxiety has a myriad causes, but clinically can be divided into three pictures:

A. Isolated panic attacks [such as specific phobias],
B. Panic with in-between background anxiety [such as social phobia], and
C. Constant background anxiety [such as worry].
Working with the last two is more complex, but this is often the form of Christian worries about sin, purification and hell.

Simple Panic

In the first case, the person is fine in-between and the panic attacks are in response to well-defined stimuli. These people can be helped by even an inexperienced CBT therapist using a simple CBT model. They are great training cases over just a handful of sessions. There are a number of models available such as the 'hot-cross-bun' model [1] and the Five Areas Approach [2], both of which are based upon the psychological underpinning model 'Clark's Model of Panic' where the key aspect is the 'interpretation of physical sensations as catastrophic'. That is, 'I feel funny' becomes 'I feel as though I am going to die' becomes 'I AM going to die!' and then panic ensues.

Complex Panic

In the other two cases, the situation is more complex. Where there is significant anxiety between panic attacks, this suggests that there is an ongoing pathology even when away from the stimulus. This might take the form of scanning for threats, compulsions to reduce risk or reassurance seeking to name but a few. This type of process is present in Social Phobia, Hypochondriasis/Health Anxiety, PTSD and OCD. In this short article, I cannot cover the models of each of these disorders, but list some top tips below. However, I must recommend that you equip yourself with a core text on CBT for Anxiety Disorders (such as the one by Adrian Wells [3]), which has a chapter on each disorder. I first learnt how to do CBT by being one page ahead of the client in this book!

Core principles for working with Anxiety

A. Get the temperature of the session right - it cannot be an academic discussion, but cannot be full-blown panic. Try to ensure that there is an element of stimulus and anxiety in the session (armpits should be sweaty!), and reflect to the person how their anxiety changes in session as thoughts and behaviours are challenged.
B. Watch out for subtle safety behaviours, as it is these that keep the anxiety level up between panic attacks. Panic attacks will result in escape or avoidance safety behaviours, but it is the little things like carrying a water bottle ('for my dry mouth...') that will stop the person from fully learning that their physical sensations are just physical sensations rather than the sign of impending doom. If you do not tackle these, the person will remain with a background anxiety and will relapse.

Social Phobia

A. Watch out for contamination of the social environment by the person - wearing extra clothes so sweaty armpits don't show, looking just away from direct eye-to-eye contact, drinking water before speaking. These behaviours are perceived to reduce social risk but actually make them more likely to be thought of as 'odd' by another person
B. Beware of alcohol use. This may happen before a social encounter to give 'Dutch courage', or be used later in the evening to help them switch off before bed as people with social phobia often get stuck doing a 'post-mortem' of the day ('did I do OK, did anyone notice?').

Hypochondriasis/Health Anxiety

A. The person will be seeking reassurance from medical tests and opinions. As a potential expert, your opinion as to the risk of a particular situation may be sought. Never offer it, instead use this as an opportunity for good therapy using Socratic questioning.
B. Make good use of in-session behavioural experiments, for example hyperventilating (both of you) to prove that all that happens is you feel nauseated and no one has a heart attack. There is a great book on Behavioural Experiments [4] in the footnotes, with examples for each disorder.

Post-traumatic Stress Disorder

A. Go out and about doing behavioural experiments in the feared locations. They will often be near your office, or substitutes may be found. However, be aware of genuine risk or assault if you are in a dodgy part of town, so you can usefully explore with the client just how much of their anxiety is appropriate and how much is not. A survey of friends and family may be a good way to do this. This re- calibrates their threat-ometer!
B. Watch out for secondary depression. PTSD sufferers can often have a completely healthy background with good self esteem and no risk factors. When they cannot 'snap out of it' like they have done before, they may process this by having thoughts like 'I must be weak/useless/no good' and this is the start of depression. You still treat the PTSD first, but this needs acknowledging in the formulation.

Obsessive Compulsive Disorder

A. The issue here is not about the obsessions and compulsions, which are obvious and the person knows they are irrational. Instead, look for the deeper fears about the power to harm others or have power over others. This might sound odd, but ask anyone with OCD what their deepest fear is... This is why OCD is so hard to treat - the presumed costs to them are huge. Read up about 'insurance policy' analogies.
B. Ask about internal compulsions such as counting and saying prayers as well as the obvious ones like washing and checking. These are harder to treat, but the same principles apply. You may need to make a loop tape of counting or prayers to over-expose them and habituate the response.

Background Worry

In these situations, there is rarely a panic attack, but then there is rarely peace. Examples are the worry process in generalised anxiety disorder and the rumination process in chronic depression or dysthymia. The key here is not to get drawn into exactly what it is the person is worried about or ruminating on as, no sooner than you have helped them deal with this, that it is replaced with another problem. They are expert brainstormers - the more they think, the more things they find! Instead, you have to get them to commit to get away from the individual worries or concerns and instead focus on the form/style of thinking being exhibited and see that as the problem.

There are two main schools of thought. The Wells book mentioned below talks about 'meta-worry', or 'types I and II worry', and I find this unnecessarily complex. It is the one chapter in that book I would not recommend. Instead, I would suggest reading something by Mark Freeston such as Overcoming Worry [5] . This helps the person see that they oscillate between worrying too much (which they know makes them feel bad, but they feel they have to because they have over-inflated positive beliefs about the power of worry to solve problems] and trying not to worry at all [because as they start worrying to much, they panic about the possible outcomes and 'avoid' them by 'trying not to worry'). 'Trying not to worry' is actually one of the subtle behaviours I mentioned above, and is joined here by other subtle internal behaviours like distraction. As above, these safety behaviours need to be challenged and the person exposed to over-worrying to see that it really makes you feel bad but nothing happens. Likewise, they need to learn to act on decisions rather than worrying about them, and a graded hierarchy can be set up like any other exposure

Christian Application

In previous articles for Accord last year, I have covered some Christian applications of CBT. It is worth reading the second of those two articles. To recap a few points, CBT techniques for OCD can be used in a person with a purification ritual or fear of hell, and Christians are great worriers but can be helped by the model for worry above.

Should Christian Counsellors get involved with complex anxiety disorders? By all means! Not only will working with such cases really sharpen your CBT skills in a way that struggling through a case of depression sometimes cannot, but there is a great need for therapists for these problems. Anxiety disorders lie at the root of much depression, as they make the person drop out of the things that could have given them life like hobbies, jobs and church. Also, if we do not understand the more complex anxiety disorders, we run the risk of making the problems worse by providing reassurance, not picking up subtle safety behaviours and joining the person in their stuckness. Finally, if the person does need to see a psychologist, your informed involvement in the case will be a great witness and a chance for networking with your local NHS hospital.

1. Mind over Mood, Greenberger and Padesky
2. The Five Areas Approach, Dr Chris Williams, www.fiveareas.com and www.livinglifetothefull.com
3. Cognitive Therapy of Anxiety Disoder, Adrian Wells. John Wiley and Sons, Chichester.
4. Oxford Guide to Behavioural Experiments in Cognitive Therapy, Bennett-Levy. Oxford University Press
5. Overcoming Worry, Kevin Mears and Mark Freeston, [a self help book part of the popular 'overcoming' series]. Robinson

Rob Waller, 25/01/2009

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