Cognitive Behavioural Therapy

Cognitive-Behavioural Therapy is a form of treatment that has repeatedly been shown to be among the most effective in reducing or eliminating anxiety and depressive disorders. The Cognitive-Behavioural Therapy provided at the FEAR Clinic involves three components that are critical to overcoming anxiety/depression:

  • Education
  • Thought Challenging
  • Emotional Exposure and Response Prevention

4.1 Education

“You can’t fix what you don’t understand.” This adage is completely true when it comes to anxiety and depressive disorders. This is why it is essential for treatment to have a good educational component that explains what the disorders are all about and how they are treated. Education itself won’t get rid of anxiety or depression - it’s not quite that powerful - but it makes the other techniques work. Education serves several purposes:

  • reduces stigma
  • lets clients know they are not alone
  • provides hope
  • helps you understand what the treatment will involve
  • gives solid reasons for why clients need to do things like emotional exposure, response prevention, and thought challenging.

4.2 Thought Challenging

Our minds are wonderful things. They take in massive amounts of information about the world, try to make sense of the information based on our past experiences, beliefs, and biases, and then create an appropriate emotional state based on the information. Usually our minds are accurate in interpreting the information and selecting the appropriate emotional response, but not always. Consider a scary movie. We are not in any real danger while watching the movie, but emotionally we respond as if we were in danger. 
With anxiety and depression, this type of mismatch is happening. With anxiety, the mind interprets something as dangerous or threatening when in fact it is either not dangerous or not nearly as dangerous as the person believes. When the mind interprets something as dangerous or threatening, it creates the emotional response of fear/anxiety. Similarly, with depression, the mind interprets things as more negative or hopeless than they actually are. When the mind interprets something as negative or hopeless, it creates the emotional response of sadness/depression. Thought challenging is a process of systematically and logically challenging these thoughts, helping the client learn to re-evaluate the actual amount of danger, threat, negativity, or hope.

4.3 Emotional Exposure and Response Prevention

Education sets the stage and thought challenging is very useful, but emotional exposure is the magic bullet for treating anxiety and depression. It is the most powerful component of treatment, a critical element. Unfortunately, it is by definition the most difficult part of treatment. As the name suggests, emotional exposure involves exposing yourself to things that cause negative moods or anxiety to rise. Depending on the specific emotional difficulties, this may involve social interactions, activity schedules, confronting certain animals or objects such as heights or germs, situations such as talking to authority figures, body sensations such as racing heart or shortness of breath, thoughts such as worries or memories. There are several explanations for how emotional exposure therapy works.

  1. The first way that emotional exposure works is through habituation. The more often we are exposed to something, be it good, bad, or otherwise, the less of an emotional reaction we will have to it. We get used to things; that’s just human nature. The key is to push through without withdrawing, avoiding, or doing things to make it feel better or easier.
  2. Second, emotional exposure works by giving clients new, correct information to contradict what they expected to happen. Whether this is learning that “I expected [dangerous outcome] to happen, but it didn’t” or “I expected this to [be overwhelming, be a failure] but it wasn’t that bad”. The more we learn this, the more our minds shift from expecting the worst to having more realistic expectations.

Our therapists understand that this usually is difficult, which is why we don’t expect (or want) our clients to tackle the harder things first. Instead we start with something that will be only mildly to moderately difficult. Once our client has success in overcoming that emotional exposure, we move to something slightly harder and so forth. Very often, a therapist and client will sit down before undertaking exposure to create a “Hierarchy of Emotional Exposures”, which is an ordered list of things that cause different amounts of negative moods or anxiety, as well as the different variations that make them more or less emotionally difficult. This hierarchy then serves as a roadmap for treatment.

Anxiety and depression also often lead to a tendency to engage in actions to minimise the negative mood or anxiety symptoms. This can involve giving up or not even trying, or avoiding certain things, emotions, situations, activities or thoughts. It can involve escaping from things when they come up unexpectedly. It can involve doing, saying, or thinking things that make you feel safer or better. It can involve carrying something with you. These safety behaviours all share the common purpose of making you feel safer or better. And they all have to go. Emotional exposure helps you learn that something is not as negative, dangerous, or threatening as you expected. If you use safety behaviours in emotional exposures, you give your emotions an escape hatch. Instead of learning “the thing didn’t happen because this isn’t as negative as I expected”, safety behaviours cause your mind to say “the bad thing did not happen because I did _______. If I hadn’t, the bad thing would have happened”.

*Much of this material is adapted from an article published by Dr. Norton for the Anxiety Disorders Association of Manitoba*