What Keeps Anxiety Going

25th August 2021

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What keeps anxiety going?

Last year, I worked with a young man who I will call Josh. Josh was 15 years old and he had a long-standing, extreme fear of dogs.

This fear impacted on his ability to walk to school, to visit the homes of friends’ and relatives and to visit parks, beaches and the countryside. Josh’s belief was that he was highly likely to be approached, chased and potentially hurt by a dog. In the safety of the therapy room, he predicted that there was a 25% likelihood of this happening. However, during a session where we ventured outside the building, his prediction of being hurt by a dog increased to 40%. When we walked up the street towards a park popular with dog walkers, the prediction jumped to 85%.

Josh was over-estimating the chances of being hurt by a dog. But he also believed that he wouldn’t cope if a dog did actually approach him. When we were in the therapy room, Josh believed he had a 60% chance of being capable of responding well if in the close vicinity of dogs. However, this coping confidence dropped to 30% when we left the building and to 10% when approaching the park. At this level, he was noticeably anxious. He was able to share his anxious thoughts and describe a vivid image he had of a large, young and energized dog off the lead, bounding towards him. He visualized running away with the dog chasing him and jumping up and biting him. In this image Josh had no control, he was being hurt and felt powerless to do anything. He wasn’t able to access any resources or coping strengths that he believed he could make use of in such a situation. These reactions and images are typical of anxiety. What do they tell us about why anxiety persists and why the anxiety doesn’t naturally go away over time?

The closer Josh got to the source of his anxiety (i.e. dogs), the more he over-estimated danger and the more he under-estimated his coping ability. Dr Christine Padesky and Dr Kathleen Mooney, co-founders of the Centre for Cognitive Therapy in California, and two of the leading CBT experts in the world, developed a simple anxiety equation to explain why this is the case:

Diagram to show anxiety

Once someone develops an anxiety disorder, anxious thoughts and images serve to exaggerate the danger and at the same time, convince the individual that they’re not able to cope. The greater the danger seems and the less a young person believes they’re able to cope with it, the more anxious they will become. It then becomes a natural response to avoid the situations that make them anxious. The more Josh avoided dogs, the less confidence he had in coping being around dogs. The less confidence he had in his ability to cope, the more dogs seemed dangerous to him.

Anxiety creates a vicious cycle in which dangers get bigger and bigger in the young person’s mind and their coping confidence gets smaller and smaller. This is why anxiety persists, even though dangers don’t often occur. It took a few weeks of persuasion by his parents for Josh to agree that his fear of dogs had overtaken him and that he needed help. At first, he didn’t realise that seeking help was itself a courageous thing to do. Over 10 sessions of CBT treatment, he worked through a systematic programme of gradual exposure to dogs. He discovered that not only was he over-estimating danger, but that he coped much better than expected when dogs did approach him. By the end of his treatment, although Josh acknowledged that he would never be a “dog person” he achieved his goal of stroking a young, large dog off its lead and his anxiety no longer impacted on his day to day life. He was able to pass dogs on his way to school, visit friends’ houses and enjoy walks on the beach during a family holiday.

In CBT, we treat anxiety disorders by reducing a young person’s over-estimation of danger and risk, or by increasing their estimation of coping and resources. Depending on the anxiety disorder, it may be more helpful to focus on one or the other, or like in Josh’s case, both.

If you have been suffering from persistent anxiety, then over the next week you may want to try the following:

You may be surprised what you discover!

25th August 2021