I’ve treated a lot of people in my clinical practice who were dealing with overwhelming anxiety. For some, it was pervasive worry about nearly everything or fear of embarrassing themselves while giving a speech. For others, it was the nagging doubt of obsessive-compulsive disorder (OCD), or the terror of panic.
I specialize in cognitive-behavioral therapy (CBT), and the core of this approach is identifying and challenging problematic thoughts. The things our minds tell us can have powerful effects on our feelings and actions, and when anxiety is high, we’ll usually find predictable habits of thought related to danger.
Often these thoughts overestimated the probability of danger. Panic-related thoughts, for example, might tell us that we’ll drive off a bridge if we have a panic attack while driving across it. Social anxiety thoughts could tell us that everyone is going to think poorly of us if we blush.
These thoughts can drive up our anxiety, as we anticipate the worst. In classic CBT we work to pinpoint what we’re telling ourselves, and then we examine the evidence to see how accurate the thoughts are. With the bridge example, we might ask how many times we’ve panicked on bridges (probably many), and approximately how many of those times we’ve driven our car over the edge (the answer is always zero).
Anxious thoughts also tend to overestimate the severity of bad things that could happen. If we’re afraid of blushing, our minds might tell us it will be terrible if we do. As we examine that belief, we’ll find that most people actually don’t think badly of us when we blush—and there’s even some evidence showing positive reactions to others’ blushing.
We would take a similar approach when we’re worried about being a few minutes late for work. If our thoughts tell us it’s going to be a catastrophe, we could walk back that thought and take a more realistic view of the likely cost. In reality, it probably won’t be as big a deal as we fear.
Limitations of Arguing with Our Thoughts
Challenging unhelpful and inaccurate thoughts can be a useful way to reduce anxiety. However, it has its limitations. Early in my training, many of the people I was working with found little benefit from arguing with their anxious thoughts. No matter how low the probability of what they were afraid of, there was always the possibility that it could happen. Even if the likelihood was almost zero, it wasn’t exactly zero, so there was still a chance.
And even though the feared outcome had never happened in all the hundreds of times the person had worried about it, the mind would always treat the next time as different. There’s always a first time, our minds like to remind us.
The limitations of traditional CBT led me to mindfulness- and acceptance-based approaches, and to the work of Dr. Steven C. Hayes, creator of Acceptance and Commitment Therapy (ACT). I recently spoke with Hayes on the Think Act Be podcast and explored with him the pros and cons of a cognitive-based approach to anxiety—and why acceptance can be so powerful.
What Do You Mean “Accept”?
ACT is part of the “third wave” of CBT (after behavior therapy and cognitive therapy), and yet it’s radically different in many ways from more traditional CBT. ACT emphasizes opening to our experience, rather than pushing away the parts we don’t like (like anxiety). And instead of arguing with our thoughts, we forge a different relationship with them—one based on acceptance, while we choose actions that are in line with our values.
If we’re going to give a talk for work, for example, we might notice that we’re having anxious thoughts about how it will go. Rather than disputing the thoughts and trying to change them, we’ll allow them to be there while we focus our energy on what we can control, like preparing for the talk as best we can.
But many people—myself included—balk at the word “accept.” What does it mean to accept our thoughts? If we’re worried about doing a bad job, do we accept that we’ll do a bad job? “Acceptance is a tricky word,” said Hayes. “It comes from a Latin root—ceptere—that means ‘to receive,’ as if to receive a gift.”
So with an ACT approach we “actively, willingly receive” our thoughts, said Hayes, as well as “our emotions, memories, and histories.” Through this acceptance, we also avoid the potential pitfalls of arguing with thoughts.
Dangers of Arguing with Thoughts
Our negative thoughts rarely go away for good, even if we’ve convinced ourselves that they don’t make sense. When I used to go on long bike rides, I worried every time, thinking this would be the ride where I had a serious accident. If we make our goal to rid our minds of anxious thoughts like “I’m going to get hit by a car,” we’ll have to monitor for whether the thoughts are still there. So we’ll be asking ourselves, consciously or unconsciously, “Is it gone yet? Is it gone yet?” said Hayes. “And every time you ask that question, the answer is no—because you’ve just recalled that thought.”
What’s more, we’ll also strengthen neural connections to thoughts about what we’re afraid might happen. “Now you have a new pathway to the negative thought,” said Hayes, making it even more likely that the thought will intrude on our awareness in the future.
There are also research studies showing that a focus on challenging thoughts, compared to other components of CBT, doesn’t necessarily lead to better treatment outcomes, including for depression, generalized anxiety, and posttraumatic stress disorder (PTSD). For these reasons, Hayes urges caution when using a style of CBT in which we aim to “detect, challenge, dispute, and change” our unhelpful thoughts.
However, this is not to say that our mental habits are irrelevant. “Thought does matter,” said Hayes, “and thinking differently is important.” He recommends what he calls a “safe version” of cognitive therapy, which focuses on the “detect” part of the sequence above.
Like many of my fellow CBT therapists, I’ve shifted away from a lot of explicit pushing back on thoughts and trying to adopt more accurate ones. Instead, we work on noticing when the mind is telling us stories. If a friend isn’t answering our texts, for example, the mind might tell us, “They’re annoyed with you.” Rather than accepting that thought as unfiltered truth, we recognize it as one possible explanation among many.
Most of the time, just noticing that we’re having a thought helps us to think more flexibly, and to entertain different possibilities. In this example, we might realize that they could just be busy, or have their phone off. Knowing their silence isn’t necessarily personal can make us feel a lot less distressed.
If you’ve tried disputing your thoughts, you probably found that sometimes it works. “You can kind of get away with it,” said Hayes—“but you’re walking on the edge of a cliff psychologically.” I’ve experienced that cliff with my own patients when thoughts became the enemy and getting rid of them the goal. I experienced it myself when I thought I needed to stop my anxious thinking about my bike rides. As Hayes noted above, trying to get rid of thoughts usually backfires, and paradoxically strengthens the very thoughts we’re trying to stop thinking.
How to Get Started
Imagine you were anxious about an upcoming event, like giving a toast at a wedding. What might an ACT-based approach to dealing with that anxiety look like?
1. Back Up and Notice
“The first step is distancing,” said Hayes, “so you can see the thought.” Distancing happens through identifying thoughts as thoughts. We might notice that the mind says, “Your toast is going to be really dull.” That’s a story about how things could go. It might be true, and it might not be. And simply knowing it’s one story among many can do us a lot of good.
“You’re backing up and noticing your thoughts,” said Hayes, “and that’s already way helpful. You’re changing your relationship to the thoughts.” I generally ask a person to write down the thoughts, to provide additional perspective on them—getting them out of our heads where we can see them at an actual physical distance.
Just realizing we’re having thoughts, as opposed to observing objective reality, gives us more choice in how we react to the products of our minds. If my toast is definitely going to be dull, maybe I shouldn’t even waste time preparing for it. But if a dull toast is one possible outcome among many, then maybe I have a say in how it actually turns out.
2. Think More Flexibly
Next, Hayes recommends that we notice other thoughts we’re having, especially ones that are useful. For example, we might also have the thought, “I can give a decent toast when I take the time to prepare.” Or maybe, “My toasts in the past have gone pretty well.” And we might think, “I really admire my sister, and I want to communicate that admiration in my toast.”
We don’t have to force ourselves to believe that our negative thoughts are wrong. Rather than trying to police our anxious thoughts and escort them from the building, we allow them to be one of many temporary occupants in our heads. And then we focus our attention on what’s actually important to us.
3. Focus on What You Value
When anxiety is riding roughshod over us, it’s like we’ve handed the wheel of our lives over to our anxious thoughts. We’re allowing anxiety to determine what gets our energy and attention, and which activities we approach or avoid. A more traditional CBT approach would be to open the car door and try to kick the anxious thoughts to the curb. With ACT, we take back control of the wheel, and we let the anxious thoughts do what they want. If they hop off at some point, fine. And it’s okay if they choose to come along for the ride. (I’ve adapted a classic ACT metaphor here.) My anxious thoughts logged hundreds of cycling miles with me, though I was always a lot less anxious while riding than when thinking about riding.
Thankfully we don’t have to change our thinking in order to live a life that’s in line with our values. Even within traditional CBT, we often focus on changing behavior even before we’ve directly addressed problematic thoughts. “The deep meta-message of CBT is that you can behave differently, even in the presence of these thoughts,” said Hayes. “And that’s very helpful.”
We can have fears about giving a crummy toast and then prepare and deliver a beautiful tear-jerker. We can be afraid of having a panic attack in an important meeting, and still show up for the meeting. We can worry about our kids’ safety, and yet emphasize love with them rather than our fear. We can let thoughts be thoughts, and let our passions live through our actions.
The full conversation with Dr. Steven C. Hayes is available here: Ep. 108—You Want to Feel All of It.
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Hayes, S. C. (2020). A liberated mind: How to pivot toward what matters. New York: Avery.