Anxiety disorders are the most commonly diagnosed psychiatric disorder in the United States. Approximately 40 million adults suffer from anxiety severe enough to negatively affect their lives. In addition, about 13 percent of American children and adolescents are affected by anxiety disorders each year. The impact can be debilitating, as people who suffer anxiety are often unable to have normal social interactions, leave their homes or go to stores, school or work. According to the Anxiety Disorders Association of America (www.adaa.org), anxiety disorders cost the U.S. more than 42 billion dollars a year, about a third of the country’s total mental health bill.
In a 2002 article in the journal “Dialogues in Clinical Neuroscience,” Thierry Steimer, Ph.D. explains that anxiety serves the very necessary function of warning us of danger or threat and spurring us to protect or remove ourselves from that danger. According to Aaron T. Beck, MD and David A. Clark, Ph.D. in their 2010 book “Cognitive Therapy of Anxiety Disorders,” though, there is considerable empirical evidence that those with excessive anxiety hold beliefs that lead them to perceive danger when there isn’t any and think that they don’t have the ability to tolerate anxious feelings. Beck and Clark also report that excessive attempts to stay safe and avoid situations perceived as threatening can get in the way of functioning effectively in the world. While it is natural to avoid what makes us anxious, doing so reinforces our belief that we can’t handle what we are avoiding and places significant limits on our social and vocational functioning.
Anxiety takes many forms; people can suffer from separation anxiety, social phobia, obsessive compulsive disorder, generalized anxiety disorder, panic attacks, agoraphobia and post-traumatic stress disorder. Along with the worried thinking associated with anxiety disorders, many sufferers also struggle with physical symptoms such as sweaty palms and rapid heartbeat, and behavioral symptoms such as avoiding going to a crowded mall or checking many times to see if the stove is turned off.
The good news is that anxiety disorders are very treatable. Yet only about a third of those who have an anxiety disorder get help. Cognitive behavioral therapy, or CBT, is considered the gold standard for the treatment of anxiety disorders, and is a well-researched, highly effective, and lasting treatment. A large number of peer-reviewed, controlled studies have demonstrated that CBT alone can greatly reduce anxiety symptoms. In some cases, however, CBT with medication produces the best treatment outcomes.
So what is CBT? According to Jesse H. Wright, MD and his co-authors in “Learning Cognitive Therapy,” CBT is based on ideas about the role of cognition in controlling human behavior that have been traced to writers from ancient times to the present. CBT emphasizes that thoughts, feelings, and behaviors all influence each other. CBT is a very collaborative approach where the therapist and the client together develop therapy goals that often involve identifying and changing maladaptive thinking patterns and core beliefs, coping with feelings of anxiety more effectively, and facing situations or experiences rather than avoiding them.
In 2008, the Jewish Board of Family and Children’s Services (JBFCS) launched a program to train all of its approximately 400 mental health professionals in cognitive-behavioral therapy. So far, many of the psychologists, social workers, art therapists, and case workers from JBFCS’s community mental health clinics, adolescent specialty clinics, and programs for the chronically mentally ill have received intensive training in CBT. To ensure that all JBFCS clients have access to a therapist competent in CBT, staff at all levels participate in training. First, directors and supervisors receive training, individual supervision, and group supervision on CBT. Next, their staff members receive training. Learning by doing is encouraged, and all are asked to treat a client with a CBT approach and receive case-based supervision. The results are promising. Many clinicians have found that their clients respond positively and rather quickly to CBT. Below are some case examples. All names have been changed to protect privacy.
Anita, a married mother in her 40’s, was diagnosed with panic attacks after repeated visits to the emergency room for what she believed were symptoms of a dangerous gastrointestinal disease or food allergies. In response to these attacks, she had been limiting herself to a few “safe” foods. Her therapist at one of JBFCS’s community counseling centers in Brooklyn educated Anita about the nature of panic attacks and informed her of research findings about effective interventions. Anita agreed to collaborate on a CBT treatment that would include psychoeducation to help her better understand her condition, relaxation training, gradual exposure to a wider range of foods, and modification of her beliefs about her fears and worries.
Anita worked hard in therapy, following up on “homework” assignments between therapy sessions, and reading David Carbonell’s The Panic Attack Workbook, which her therapist had recommended. She learned and practiced relaxation techniques such as deep breathing, muscle relaxation, and “safe place” imagery, and discovered that with active use she could calm herself. This provided some quick relief while increasing her confidence that her problem was not medical, and that she could overcome it. In another assignment, she developed a list of foods she was afraid to eat, and rated them from the least to the most anxiety-producing. She introduced the least frightening foods, one at a time. Her instructions were to use relaxation exercises if she felt anxious, and to keep eating the same food until she could eat it without experiencing anxiety. She became more aware of the way she thought about herself and her problems, and how this affected her feelings. Her therapist helped her identify, examine, evaluate, and modify her thoughts when they were unrealistic, and develop more accurate, balanced, and useful alternatives. Anita told her therapist that she no longer fears having panic attacks because she knows how to change her experience by modifying her thinking and using coping skills.
When six-year-old Alicia first came to one of JBFCS’s community counseling centers in the Bronx, she made no eye contact, constantly clung to her mother and refused to speak. She was terrified of men, had difficulty falling asleep and sleeping alone, and became extremely distressed when her mother dropped her off at school or left her with trusted family members. Though Alicia had signs of other disorders, the main problem appeared to be separation anxiety. Alicia’s excessive distress when separated from a major attachment figure, reluctance to go to school because of fear of separation, and reluctance to go to sleep without being near a major attachment figure clearly met the criteria for separation anxiety disorder.
Alicia’s therapist worked with both Alicia and her mother. Cognitive-behavioral therapists often use modified play therapy techniques to help children express their thoughts and feelings and learn new behavioral skills. Using play and artwork, Alicia’s therapist helped Alicia learn to identify and modify her anxious thoughts about being away from her mother. The therapist provided psychoeducation for Alicia’s mother about separation anxiety disorder, about how creating structure can reduce anxiety, and about how learning to sleep on her own would reinforce Alicia’s self-soothing skills. The therapist also taught Alicia’s mother to use behavioral charting as a tool to reward behaviors that moved Alicia toward her goals.
Alicia now looks forward to going to school every day and no longer cries. She is able to fall asleep at bedtime and sleeps most of the night alone in her bed. When her mother leaves home, Alicia shows minimal distress. She told her therapist that she no longer worries when away from her mother.
JBFCS’s continuing day treatment program in Brooklyn provides day treatment services for clients diagnosed with severe and persistent mental illnesses. Some have co-morbid anxiety disorders, and most struggle with significant symptoms of anxiety that interfere with their mood, relationships, and activities. Staff members find group CBT interventions to be useful for many of their clients.
In group sessions, clients learn to use breathing exercises, progressive muscle relaxation, visualization, and aerobic exercise for reducing their anxiety and coping with stress. As members identify specific stressors, together they practice their problem-solving skills and generate possible responses. Social anxiety and interpersonal problems are targeted by having members identify, discuss, and role play social skills for meeting people, reading social cues, starting conversations, making friends, and coping with conflicts and rejection.
In a number of groups, clients identify individualized coping strategies. In group, members quickly realize how many of their struggles and solutions are shared. They also note their differences and learn to respect their own individuality in tailoring self-help interventions to their own needs, personalities, cultures, and circumstances.
Groups also become a living social laboratory that allows members to test out some of the thoughts and perceptions connected to their anxiety, and to get feedback. One member often felt overwhelmed and anxious because of his perception that he was alone and disliked. When group members responded by spontaneously sharing how much they like and care for him, he was able to take in their support, see himself and his relationships more accurately and positively, and notice an improvement in the way he felt.
JBFCS clinicians have found that CBT has been very effective in helping clients of all ages better manage their anxiety and function more effectively. As the case studies indicate, CBT can be used in individual and group therapy and in several different treatment settings. JBFCS plans to continue to build its capacity to provide the most effective evidence-based CBT treatments for anxiety and other disorders.
Thanks to the dedicated therapists and case associates who contributed to this article: Katie McCaskie, LMSW; Tzipporah Wisansky, LCSW; Dana Barth, LMSW; Abigail Bryskin, LCSW; Cristina Caroli, LMSW; Manuel Olavarria, LMSW; Malik Wright, CA; and Natalie Zvyagina, CA.
Martha Spital, LCSW-R is a Certified Affiliate, The Academy of Cognitive Therapy. Ms. Spital is an Administrative Supervisor at the JBFCS J. W. Beatman Counseling Center and a Master Trainer in the Cognitive-Behavioral Therapy Training Program at the Martha K. Selig Educational Institute. Ms. Spital also maintains a private practice, where she specializes in treating anxiety disorders.
Sararivka Liberman, LCSW-R, has been a psychotherapist for over 26 years, and has run short-term CBT groups since 2002. For the past 19 years, she has provided supervision and training to mental health professionals in community settings. She currently serves as the Administrative Supervisor at the Boro Park Clinic of JBFCS, and is a Master CBT Trainer for the Martha K. Selig Educational Institute. She maintains a private practice for adults in Brooklyn.
Susan Trachtenberg Paula, Ph.D. is a psychologist and director of the cognitive-behavioral training program at JBFCS’s Martha K. Selig Educational Institute. She specializes in CBT for children and evidence-based trauma treatments for children and adults.