How 3 Forms of Therapy Understand and Treat Anxiety

Anxiety is among the most common psychological complaints, and for good reason. Most psychodynamic theories see anxiety as a necessary feature of human nature, helping us avoid danger and seek security, and acting to motivate us to prepare for difficult situations and manage our lives with foresight. Anxiety becomes problematic when it leads to excessive vigilance and a host of symptoms that can interfere with our health and functioning, such as sleeplessness, stomach trouble, increased blood pressure, reduced immune function, anxious rumination, avoidance of necessary or desirable activities, and depression.

Anxiety encompasses a number of conditions, including phobias and PTSD, but since each of these has its own meanings and may require different approaches, here I’ll be addressing the more common, free-floating worry that is known diagnostically as generalized anxiety disorder (GAD.)

Choosing the Right Therapy for Anxiety

With so many kinds of therapy offering solutions for GAD, it can be hard to know which one to choose. When making that decision, consider that different therapies can have quite varied ideas about what anxiety is, what causes it, and what forms of treatment are best suited to manage, if not eradicate, it. Here, I introduce a few of the most common approaches and the similarities and differences between them. Keep in mind that no two practitioners are identical and that many will alter and integrate approaches to suit their unique styles.

Psychoanalytic and Psychodynamic Therapy

Psychoanalysis is a form of talk therapy that’s less structured than cognitive-behavioral therapy (CBT), one that emphasizes the relationship with the therapist as the context in which change can occur.

There’s a complex theoretical history underpinning psychodynamic work, starting with Freud and including many others who have revised or replaced Freudian concepts. Today, most psychotherapists engage in an open and reflective conversation with their patients, exploring patterns of behavior, thoughts, and emotions that shape their patients' lives, largely outside their conscious awareness or control. By helping people better understand the expectations, fantasies, and fears that drive them, and by creating a space for new and better experiences with an attentive, generous, and compassionate other, psychotherapists help their patients let go of those aspects of themselves that stand in the way of their fulfillment.

So what does psychodynamic theory have to say about anxiety?

Freud, the founder of talk therapy, famously defined anxiety as arising from a conflict between the id and ego, or between our impulses and conscious mind, shaped by practical or social forces that restrict our free expression. All that Freud and others after him have said about anxiety could fill a book, but it's possible to distill several prominent ideas that shape contemporary psychodynamic thinking on the subject.

First, anxiety is a fundamental human experience, tied to our early helplessness and dependence, and to the dangers of losing our protectors or experiencing hurt. Feelings of anxiety may be generated by internal or external causes—either by intolerable impulses in us or by fears generated by the environment. For later Freud and other influential theorists like Harry Stack Sullivan, avoidance of anxiety is what motivates our defenses (self-protective behaviors) and is crucial for understanding who we are and what we do.

Additionally, especially for contemporary psychotherapists, anxiety is viewed within the context of relationships: a stable, responsive, and loving caretaker is likely to reduce levels of anxiety in an infant, whereas a person raised by caretakers who are neglectful, erratic, or anxious themselves will likely develop anxiety as an adult.

Given this framework for understanding anxiety, a psychotherapist is likely to focus on exploring early relationship experiences along with past traumas to grasp the meaning of anxious behaviors in the present. Like CBT, a psychodynamic approach will look at the underlying thoughts and beliefs that give rise to the anxiety, but it will also ask where those thoughts and beliefs come from, and how they proved necessary for survival in their original context. Unlike cognitive-behavioral therapists, psychoanalysts are less likely to believe our thoughts or behaviors can be changed at will, in part because they’re integral to our sense of safety, and even identity. In fact, trying to change behaviors without adequate readiness can potentially increase anxiety. Psychotherapists believe that it’s only within the context of a therapeutic relationship that creates enough security, insight, and new positive experience, that anxiety begins to lessen, and the self-protective behaviors that sustain it can begin to lose their hold.

Cognitive-Behavioral Therapy

Based on the work of Allen Beck and Albert Ellis, CBT combines cognitive therapy and behavior therapy into a structured, time-limited approach. Cognitive therapy focuses on the automatic thoughts that underlie our behavior, while a more behavioral approach focuses on changing the behaviors that contribute to the disorder.

So what does CBT have to say about anxiety?

The principle idea behind a cognitive approach is that thoughts, beliefs, and attitudes, often automatic and unquestioned, directly influence our behavior. This is a belief also present in psychodynamic approaches, but CBT focuses on this fact more exclusively, with less attention to the causes of these thoughts, or the relational context for them. CBT places greater emphasis on how to challenge and alter our thinking in the present, with practical tools and learned skills.

Anxiety is among the conditions that CBT was designed to treat, and its approach is to examine the beliefs that underlie our anxious feelings: for instance, "When I go to parties, people find me boring," or "Whenever I go out on a limb, I embarrass myself." Such negative beliefs are said to be the result of cognitive distortions, and a few common mechanisms of distortion are typical of anxious patients, such as emotional thinking—"If I feel like they think I’m boring, it must be true"—and catastrophizing—"If I go out on a limb, I’ll fail and look like a fool."

To help identify cognitive distortions and negative thoughts, CBT practitioners may suggest journaling or other exercises. Another method often used to manage anxiety is the Worst Case/Best Case/Most Likely Case Scenario technique, where patients imagine an anxiety-arousing situation to gain a more realistic picture of likely outcomes. Mindfulness and muscle relaxation exercises are also frequently employed with anxious patients, as are behavioral strategies. A CBT practitioner may encourage patients to engage in previously avoided stressful activities and may use a technique known in exposure therapy as systematic desensitization. Assisted by relaxation exercises, patients are gradually exposed to objects or situations that arouse their anxieties.

In deciding whether or not to engage in exposure therapy, it’s important to consider that there have been some ethical concerns over patients’ experiencing distress or even retraumatization. From a psychodynamic perspective, this danger is largely due to the fact that exposure therapy treats symptoms in isolation without considering what function they provide the individual. If underlying causes aren’t addressed, symptoms might reappear, or other symptoms or psychiatric issues could emerge. That said, if performed by a well-trained and sensitive practitioner, there is evidence that exposure therapies can prove effective, especially in treating more targeted anxieties.[1]

As different as the two treatments are, a recent study has found that both CBT and psychotherapy were equally, and substantially, effective in treating anxiety.[2]

Dialectical Behavior Therapy

For people seeking an intense and immersive approach, dialectical behavior therapy could be the right choice. DBT, developed by Marsha Linehan, is a form of CBT originally designed to treat borderline personality disorder. Today, the treatment is applied more broadly, including for those suffering from anxiety disorders.

Like CBT, DBT is skills-based and time-limited, but it incorporates teachings in mindfulness derived from Zen practices, balancing the desire for change with the need for acceptance. There are four main components of DBT: Mindfulness, Distress Tolerance, Emotional Regulation, and Interpersonal Effectiveness.

So what does DBT have to say about anxiety?

In dealing with anxious patients, DBT practitioners use mindfulness techniques to help them focus on the present, rather than worry about things to come. Distress tolerance can help an anxious person accept difficult situations, rather than ruminate over the desire to change them, and emotional regulation can help them manage or tolerate the uncomfortable emotions that emerge. Interpersonal effectiveness skills are designed to help patients improve communication, create useful boundaries, assert needs, and build trust in their relationships. Since emotionally fraught and avoidant ways of relating are often present in those with anxiety, this is an important step in altering patterns that perpetuate the problem.

Whether or not DBT is right for you may depend on whether you favor a treatment that takes longer and offers ongoing support, or one that involves a short-term but intensive time commitment. Typical DBT treatments involve weekly individual therapy sessions, longer group skills training sessions, homework assignments, and sometimes additional coaching. Though there is less research on DBT as a treatment for anxiety, DBT has been proven effective for PTSD, and some studies suggest it is effective for GAD as well.[3]

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