Photo by Karen Robinson/Panos
Cognitive behavioural therapy provides a toolbox of skills to help you manage anxiety and do what you want with your life
by Regine Galanti
Photo by Karen Robinson/Panos
is a clinical psychologist. She is the founder of the cognitive behavioural therapy practice Long Island Behavioral Psychology and the author of Anxiety Relief for Teens (2020). She lives in New York.
Edited by Christian Jarrett
Most people are afraid of something, whatever age they are. But the teenage years definitely have their fair share of challenges. Maybe you’re anxious about being judged in class, going off to college, getting good grades or being separated from the people you love. The list can go on and on because anxiety is a normal part of being human, especially in adolescence.
But though it can be uncomfortable, anxiety can actually be helpful. It’s what keeps us from jumping off buildings, or running in front of moving cars. It prompts us to focus on potential dangers and respond to them in a way that keeps us safe. This system works pretty well at protecting us most of the time – which is great, if and when you’re in actual danger. Anxiety becomes a problem if it raises the alarm when there isn’t really any actual danger around. In fact, you can think of problematic anxiety as being like a false or overly sensitive alarm – a smoke detector going off when there’s no fire.
As a clinical psychologist, I meet a lot of teenagers with anxiety. I emphasise to them that anxiety-free living might sound amazing, but it would in fact be dangerous because you’d miss out on cues that something is actually wrong. So instead, I use an approach called cognitive behavioural therapy (CBT) to help teens learn tools to manage their anxiety so that it doesn’t get in the way of their lives; in this Guide, I’m going to share some of these tools with you.
Before getting to the practical exercises, it helps to know a little about how your anxiety system works in terms of your thoughts, feelings and behaviour, which all contribute to the emotions you experience at any given time. Let’s look at these three components in the context of a tiger walking into the room you’re in right now. (Unlikely, I know, but bear with me!)
What you think
Your thoughts influence your emotions. So if, as the tiger starts getting closer, you think to yourself Hey, I love tigers, you probably won’t feel very anxious. If on the other hand you think Woah, that tiger wants to eat me for lunch, you’ll probably feel super-scared. In this way, thoughts are like sunglasses: you can change them or take them off, and the world will look different. Here’s a more realistic example: if you think to yourself If I fail this exam, I’ll never get into college, and my whole life will fall apart, you’ll probably feel anxious and hopeless before and during the exam. If instead, you had the thought It’s a good thing this exam is worth only 5 per cent of my grade. I can always recover any lost marks on the next exam, you probably wouldn’t feel so anxious.
What you feel (in your body)
Anxiety includes a physical reaction called the ‘fight or flight response’. When you feel anxious, your body kicks into high gear. The hormone adrenaline starts to flow, and a host of other things happen as well, such as your heart racing, your breathing speeding up and your pupils enlarging. This reaction gets your body ready to move away from danger, or fight the enemy if you can’t run (hence the name, ‘fight or flight’). You might also feel your muscles tense up, feel shaky, have headaches or nausea. This might feel natural or appropriate if you were running a marathon or fleeing a tiger that had just wandered into the room, but when you’re anxious in a more ordinary situation, you might find these bodily sensations not only unpleasant, but experience them as further ‘proof’ that something is wrong, even if it isn’t! Although these physical changes might feel dangerous, they’re harmless. It’s just your body’s natural way of trying to get you out of harm’s way.
What you do
This third part of anxiety involves how you behave in response to your thoughts and physical sensations. If you think That tiger wants to eat me, and you feel your heart pounding out of your chest, you’ll probably want to run away. It’s perfectly normal to try to escape situations that make you anxious. This is a great plan for actual danger, but it can become problematic in the context of false alarms. Avoidance not only causes practical problems, it often fuels more anxiety in the future.
These three parts of anxiety – your thoughts, your physical feelings, and your behaviours – impact on each other, and form an anxiety ‘cycle’. Anxious thoughts can bring on a physical response, which makes you want to run or avoid.
Here’s an example: imagine you feel anxious about parties. You have negative thoughts about them, such as I won’t have anyone to talk to, this makes you feel physically tense, maybe even nauseous, and you decide to stay at home in your room. If you turn down every invitation you ever receive, you’ll never learn that parties are nearly always harmless and they’re often fun. You won’t get any experience of socialising at parties and, the longer time goes on, the more daunting they might seem.
The good news is you can break this anxiety cycle by addressing any or all of the three components. For example, if you recognise your thoughts aren’t necessarily true (you might meet someone you really enjoy talking to), accept your feelings of anxiety and manage to go to some parties, you’ll soon learn that some are boring, some might be a little daunting (if you don’t know many people), but that they can be enjoyable too. Above all, you’ll learn that you’re stronger than you think you are – you’ll see that you can live with feeling a bit anxious.
Of course, all of that is easier said than done. Next, I’ll show you some practical techniques to help you address each of the three components of the anxiety cycle.
CBT psychologists teach that you can manage your anxiety by disrupting that cycle of thoughts, physical feelings and behaviours. There are effective, research-based strategies for changing each piece of the cycle. Before we get to the specifics, some general advice:
Question your anxious thoughts
The way you respond to a situation often begins with your thoughts and, if they’re emotionally laden, they will often get stuck in your mind. For example: if I think to myself Hey, that car is blue, or There’s that kid from school, I’ll probably pay no more attention to those thoughts. They just come and go. But if I have a thought such as That blue car wants to run me over, or if in a class I think I’m sure I’ll make a fool out of myself and he’ll tell everyone I know, then these thoughts will consume my attention and I’ll probably start feeling really scared and anxious. Whether these kinds of thoughts are true or not, they usually feel uncomfortable. You can change your thoughts, but actually the first step is to notice them. Sometimes, anxiety-laden thoughts creep in without you even being aware of it. So, the next time you feel anxious, grab a notebook and ask yourself: what am I thinking? Write it down. That will set you up to treat your thoughts more critically. Here are two strategies:
Reality-check your thoughts: it’s normal to have thoughts that cause you anxiety, but just because you get worried doesn’t make these thoughts true. Remember, thoughts are not facts. Ask yourself: where is the evidence that my thought is true? For example, you might have the thought that you’re going to bomb the soccer team try-outs and definitely won’t get picked. But what’s the proof for and against this thought? How do you generally do in soccer practice? Another way to use this technique is to ask yourself what advice a friend would give you if you expressed your thought.
Separate yourself from your thoughts: another strategy to manage your anxiety is to create space between yourself and your thoughts. By distancing yourself from your thoughts, you take the intensity out of them and help yourself appraise them more objectively. Here’s one simple way: say you’re having anxious thoughts about being judged harshly by your friends; pause, and tell yourself: I’m having the thought that my friends will judge me and not want to be friends with me. This allows you to see thoughts for what they are: thoughts, not facts. They have only the power that you give to them. By creating distance between yourself and your thoughts, or questioning their truth, you will learn that thoughts – even negative ones – don’t have to make you anxious.
Calm the physical sensations
When your body feels anxious, it responds with the fight or flight reaction. You might not even notice your muscles tensing, or your breathing speeding up when you get anxious, so another important step in managing anxiety is noticing how it’s making you feel physically. The next time you feel anxious, ask yourself: what’s going on in my body right now? Am I dizzy? Is my heart pumping? Are my shoulders so tense that they’re up at my ears? If the answer to any of these questions is yes, then use some of the following strategies to change that physical reaction.
Abdominal breathing: deep breathing, from your belly (technically, a muscle called your diaphragm) rather than your chest is an effective relaxation and coping tool. This is a good strategy to use when you first notice yourself feeling a bit anxious. It will help you to cope with the negative emotions and reduce the intensity of your anxiety. It’s best used preventatively, before you’re in full-blown anxiety mode. A good time might be before bed, when you’re winding down for the day. Here’s how it works:
Colour breathing: this tool is similar to abdominal breathing, but adds a visualisation. Choose two colours: one that you find relaxing or calming, and another that you associate with tension or just don’t like. For me, blue is calming, and yellow is tense because it reminds me of caution tape.
The Colour Game: for this strategy, rather than focus on directly changing your anxious body sensations, you can redirect your attention to something else for a bit, and see what happens to your physical reactions over time. Spoiler: your bodily sensations will definitely fade if you give them enough time. One of my favourite strategies for redirecting your attention in this way is an exercise I like to call the Colour Game:
Breathing and re-directing your attention (a mindfulness technique) are excellent tools to help you change the physical sensations of anxiety or refocus yourself away from them, but they aren’t the only strategies. You can also work on changing your response to your anxiety by confronting your fears.
Confront your fears
When you avoid things that make you anxious (but that are not actually dangerous), you make your anxiety worse in the long run. Here’s an example:
Joe has a big school assignment due next week, but he’s not sure how to go about it. He feels anxious about failing, so blows it off, and watches Netflix instead. The next night, when he thinks about starting the assignment, he is again unsure of what to do first. He starts getting anxious, and thinks back to last night and what he did to get rid of his anxiety: Netflix. If he does the same thing again, he’ll have even less time to complete his project and will face the same problem night after night. So even though avoiding starting his work made his anxiety go away in the moment, it will make things much more difficult for his future self if he keeps running away from the challenge. Moreover, it will leave him with no experience at actually tackling his anxiety in a manner that allows him to get his work done.
Trying to run away from your anxiety, or to avoid any situation that you fear will trigger anxiety, will ultimately backfire, and you’ll end up experiencing more anxiety. That’s because the more you avoid, the less of a chance you get to see what would happen if you faced the thing that makes you anxious and, like Joe, the less chance you’ll get to learn how to cope. Avoidance also tends to store up practical problems for the future if important activities get left undone.
To change your anxious behaviours, think about what you do when you confront the things you fear: do you stick with it and stay in the anxiety-provoking situation, or do everything you can do avoid it? Of course, it might depend on the intensity of your anxiety. One way to get a sense of this is to rate your anxiety on a scale of 1-10, with 1 being total comfort and 10 being the most anxious that you can possibly be. For instance, if you’re afraid of speaking in public, speaking to a small group of friends and family might provoke medium anxiety, and you might label it a 6, whereas speaking in front of a large crowd on an unfamiliar topic might be a 10. These scores will be useful for the next exercise, which involves systematically facing the things that make you anxious.
Graded exposure: anxiety might feel dangerous, but it’s actually harmless. By doing the things that you fear, and staying in those difficult situations, you might notice that they’re not as scary as you initially thought they would be (but you hadn’t noticed before, because you avoided these scenarios in the past). You might also notice that you’re able to handle these situations better than you’d expect, even if they’re difficult. This method, called ‘exposure’, allows you to see what happens, and check if your fear actually does come true. This strategy can be a bit uncomfortable (that’s what anxiety does!) but it works. Here’s how to use it:
By working hard to face your fears, in a step-by-step way, you have the chance to learn that you can handle them, and that they’re not as difficult as you might have thought. This powerful strategy can show you that, when you stay in an anxiety-provoking situation (without avoiding!) you often feel less anxious in the end.
Being a teenager is hard! It’s a life stage that comes with a lot of expectations. Your school demands increase dramatically, and often get harder. Your social life is also tricky – from navigating friend groups to romantic relationships. And to top it off, it’s a phase of life where you’re getting more and more independent. You might be travelling by yourself for the first time, spending periods home alone or, later, moving out of your parents’ house, living with friends and managing your own finances. All of these stressors are normal. But for someone struggling with anxiety, those emotions can add another weight to an already challenging time.
In my experience, the most effective way to manage anxiety is by using exposure-based strategies, and learning to face your fears. These exposure techniques will work for more than just a specific fear, such as a fear of dogs or asking questions in class. Confronting your fears could also be a really helpful tool in many of the teenage ‘firsts’ that you’re probably encountering – such as first dates, first college classes, anything. What I really like about exposure is that it works even if you can’t face your fear in the real world right now. For example, if you’re anxious about dating, but you don’t have the opportunity to go out with anyone right now, there are a few ways to tackle that situation. You could use exposure as described above: take your fear and break it down by taking steps, such as going on a pretend date with a friend, letting a friend set you up on a date or, later, joining a dating app.
If you don’t think you’re quite ready for the real-world practice yet, or you can’t get the practice you need, you can use a technique called imaginal exposure. Pick a specific goal, break it down into steps, and then do each step. The difference lies in the way that you face your feared scenario. Instead of facing things in the real world, imagine what it would be like to have this fear happen. Often, it helps to write it down using as much detail as possible. What would you see? Feel? Taste? Touch? Bring in all your senses, almost like a creative writing assignment. After you finish writing out this scenario, read it to yourself, repeatedly. Spend 10-15 minutes a day reading this script, and notice what happens to your anxiety. Your anxiety might go up at first, it might stay the same, or it might decrease. The more you stick with it, the more you will learn that you can.
Remember, the purpose of this strategy is to face your fear, so it’s natural to feel anxious while doing so. If you’re afraid of going on dates, imagine everything that might go wrong. Will you say the wrong thing? How will the other person react? Often, when we worry, we don’t actually think of these worst-case scenarios, because our anxiety is so good at avoiding them. By thinking about such scenarios, on purpose, in detail, it often helps you realise that you can, in fact, handle thinking about scary things.
One of the most important messages I can leave you with is that you’re definitely not alone. Anxiety can have a big impact on your life, but there are also effective treatments that can help. A positive step is to find the people who can help you get the support you need to succeed – and reading this Guide was a fantastic move in the right direction. If you need extra help, I strongly recommend finding a therapist who can direct you in using these and similar skills. Cognitive behavioural therapy is effective for all types of anxiety, so I recommend looking for a therapist who specialises in CBT and can be your guide.
My book Anxiety Relief for Teens: Essential CBT Skills and Mindfulness Practices to Overcome Anxiety and Stress (2020) will help you learn more about CBT tips for anxiety, including going into more detail about the strategies I outlined in this Guide.
The YouTube channel The Psych Show from the US psychologist Ali Mattu is full of short videos that teach effective techniques to manage anxiety and other symptoms you might face.
Another recommended YouTube channel is DBT-RU (which stands for the Dialectical Behavior Therapy Clinic at Rutgers University in New Jersey). It has quick animations (five minutes or less) on coping skills, and is a great resource to learn some practical strategies – fast.
The MindShift app, created by Anxiety Canada, is teen-friendly and uses CBT techniques to help you change your thinking and behaviours.
The Smiling Mind app provides a free source of mindfulness techniques to help you calm the physical sensations of anxiety.
The book Mindfulness for Teen Anxiety: A Workbook for Overcoming Anxiety at Home, at School, and Everywhere Else (2014) by the US psychologist Christopher Willard is a great handbook for learning more about mindfulness, specifically for teens.