University of HoustonDepartment of Psychology
University of Houston


Cognitive Behavioral Therapy

Cognitive-Behavioral Therapy is a form of treatment that has repeatedly been shown to be among the most effective in reducing or eliminating Anxiety Disorders. The cognitive-behavioral therapy provided at the Anxiety Disorder Clinic involves three components that are critical to overcoming anxiety:

  • Education
  • Thought Challenging
  • Exposure and Response Prevention



“You can’t fix what you don’t understand.” This adage is completely true when it comes to anxiety disorders. This is why it is essential for treatment to have a good educational component that explains anxiety is all about and how it is treated. Education itself won’t get rid of an anxiety disorder - it’s not quite that powerful - but it makes the other techniques work. Education serves several purposes:

  • reduces stigma
  • letting clients know they are not alone
  • providing hope
  • providing correct information about danger and threat
  • helping you understand what the treatment will involve
  • give solid reasons for why they need to do things like exposure and thought challenging.

Many years back, a famous psychologist named Jerome Frank recognized that all forms of therapy must have certain features to be effective. One of these is providing the client with a rationale for how treatment will work. Education does this.

Thought Challenging

Our minds are wonderful things. They take in massive amounts of information about the world, try to make sense of the information based on our past experiences, beliefs, and biases, and then create an appropriate emotional state based on the information. Usually our minds are accurate in interpreting the information and selecting the appropriate emotional response, but not always. Consider a scary movie. We are not in any real danger while watching the movie, but emotionally we respond as if we were in danger. Likewise, I can recall many times where I was in some danger but did not realize it - and therefore did not respond fearfully.

With anxiety disorders, this type of mismatch is happening. The mind interprets something as dangerous or threatening, when in fact it is either not dangerous or not nearly as dangerous as the person believes. When the mind interprets something as dangerous or threatening, it creates the emotional response of fear/anxiety. Thought challenging is a process of systematically and logically challenging the danger thoughts, helping the client learn to re-evaluate the actual amount of danger or threat.

Thought challenging is really a three-step process:

  1. The first step involves identifying these danger thoughts that flash into the mind. Psychologists call these “automatic thoughts” because they seem to come to mind immediately when a person encounters something he or she fears. One good strategy is to immediately ask oneself “what was I thinking?” as soon as you notice your anxiety increase.
  2. Once someone becomes good at identifying their automatic thoughts, we then focus on trying to teach them to challenge the logic of that thought through a variety of methods. Most commonly we have clients ask themselves various questions designed to challenge the accuracy of a thought.
  3. Finally, when the inaccurate thought has been broken apart and shown to be inaccurate, we replace it with a thought that is a more accurate reflection of the actual amount of danger, if any.

Exposure and Response Prevention

Education sets the stage, relaxation feels great, thought challenging is very useful, but exposure is the magic bullet for treating anxiety. It is the most powerful component of treatment. In fact the U.S. Surgeon General recently agreed that “a critical element of therapy is to increase exposure to the stimuli or situations that provoke anxiety”. Unfortunately, it is by definition the most anxiety provoking part of treatment. As the name suggests, exposure involves exposing yourself to things that cause your anxiety to rise. Depending on the specific fears, this may involve certain animals or objects such as heights or germs, certain situations such as talking to authority figures, certain body sensations such as racing heart or shortness of breath, certain thoughts such as worries or memories. There are several explanations for how exposure therapy works.

  1. First, much of what we learn in life comes from things being paired together, such as public speaking and having people laugh at you or seeing a dog and getting bitten. Much of what we unlearn, on the other hand, comes from un-pairing two things. With anxiety disorders, this means un-pairing the fear trigger (e.g., public speaking) from the expected outcome (people laughing).
  2. The second way that exposure works is through habituation. The more often we are exposed to something, be it good, bad, or otherwise, the less of an emotional reaction we will have. We get used to things; that’s just human nature.
  3. Finally, exposure works by giving the people new correct information about the things they thought were threatening. This is the “A-hah... it wasn’t as dangerous as I expected” principle.

Our therapists understand that this usually is very scary, which is why we don’t expect (or want) our clients to tackle the scariest things first. Instead we start with something that will cause only mild to moderate anxiety. Once our client has success in overcoming their fear to that situation, we move to something slightly harder and so forth. Very often, a therapist and client will sit down before doing exposure to create a “Hierarchy of Fears”, which is an ordered list of things that cause different amounts of anxiety, as well as the different variations that make them more or less anxiety provoking. This hierarchy then serves as a roadmap for treatment.

Anxiety disorders all involve the tendency to engage in preventative or defensive actions to protect oneself. This can involve trying to avoid certain things, situations, activities or even thoughts. It can involve escaping from things when they come up unexpectedly. It can involve doing, saying, or thinking things that make you feel safer. It can involve carrying something with you. These safety behaviors all share the common purpose of making you feel safer. And they all have to go. Exposure helps you learn that something is not as dangerous or threatening as you expected. If you use safety behaviors in exposure, you give the anxiety an escape hatch. Instead of learning “the bad thing didn’t happen because this isn’t as dangerous as I expected”, safety behaviors cause your mind to say “the bad thing did not happen because I did _______. If I hadn’t, the bad thing would have happened”.

* Much of this material is adapted from an article published by Dr. Norton for the Anxiety Disorders Association of Manitoba

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