Everyone experiences anxiety – it is built into our brains as part of the fight-or-flight stress response. Most of the time, people know exactly why they are feeling anxious: starting a new job, moving to a new city, driving for the first time after a car accident. Other times, anxiety shows up out of the blue. And for those who experience chronic anxiety, it is easy to get caught in a trap of asking, “Why?”  As mental health clinicians, it’s our job to help them find the answer – sort of.

There are many things that can contribute to anxiety but at the end of the day, knowing what caused the feeling is not necessarily helpful. Considering how the brain is wired, we may never uncover the truth behind the “what” or the “why.” For instance, a patient may experience a panic attack without thinking about anything in particular. Yes, something triggers the attack, but it could be a subconscious emotional memory, such as a subtle smell, that turns on the anxiety alarm.

Not only can it be nearly impossible to identify exactly what causes a client’s anxiety but we cannot change what caused it in the first place.  Therefore, it is important to encourage clients to not get “stuck in the Why’s” – which can perpetuate their anxiety.

Instead, we can help them understand how anxiety is maintained – that is, why their anxiety sticks around versus why it showed up.

How to Help Clients Break the Anxiety Cycle

Below are a few clinical pearls I’ve picked up over the years on helping clients – no matter the age – to become masters over their anxiety. It starts with breaking the cycle that maintains anxiety. I ask my clients to avoid the following anxiety-driving behaviors.

Avoid Anxiety-Driving Behaviors, including:

  • Talking about anxiety excessively. Anxiety loves taking center stage. Therefore, talking about it too much gives it importance and credibility. When clients do this, they are often just spinning their wheels, so to speak, and making their anxiety worse – especially when asking too many of those “why” questions.
  • Seeking reassurance. Clients with anxiety often seek reassurance to make them feel better (eg, continuously seeking confirmation from a doctor that they are not going to have a heart attack). But this behavior reinforces the anxiety and creates a dependency on others to feel better. Even if reassurance makes a person feel better in the moment, the anxiety will be back, creating a cycle and/or leading to compulsive behavior. I have seen many clients develop OCD develop through constant reassurance seeking.
  • Seeking certainty. Anxiety also wants certainty and predictability. Therefore, people with anxiety may try to control everything to make themselves feel better. However, we never know what curveball life is going to throw at us. If we are not flexible, we will crash hard as soon as things do not go the way we planned. Like reassurance, I tell my clients that seeking control reinforces anxiety because we are giving anxiety exactly what it wants, which only makes it stronger and can lead to compulsive behaviors. Perhaps ironically, anxiety loves when we have someone breathing down our necks, constantly commenting on or correcting our work. This behavior makes us believe we are not successful enough or good enough to make our own decisions.
  • Blaming genetics. When a client blames family history or talks about anxiety as a chemical imbalance in the brain, they create a belief that there is nothing they can personally do about it other than taking medication. This belief can be damaging, especially when there is actually something that can be done. Blaming genetics also creates a sense of permanence, which can lead to hopelessness.
  • Accommodating anxiety. I often share with my clients another word for accommodate: enable. Humans often provide accommodations to support people with a particular difficulty. However, in the anxiety world, accommodations give anxiety exactly what it wants, which makes it stronger. For instance, a person with anxiety may choose to record a presentation in advance rather than present in person. Others may have a glass of wine before going to a party to “take the edge off,” purposefully run a few minutes late to avoid being the first one to show up at a meeting, wear a scarf around our neck so others do not see them turn red when talking, or bring a cellphone everywhere they go – just in case. Although accommodations may provide situational relief, their repeated use can sneak up until the realization hits, how did we become so dependent?
  • Safety behaviors. A lot of the accommodations people make for anxiety are safety behaviors – things aimed at preventing disaster and/or escaping from worry. But safety behaviors teach us that we are not safe and, so, we continue to be afraid. Obviously, there are important safety behaviors we do need to follow, especially in the age of COVID. But when the behaviors become excessive (especially when there is no real danger), we are creating distorted perceptions of safety as well as unhealthy, unhelpful, coping habits.

Sample Case: I worked with a healthy college student (with no family history of heart problems) who was terrified of having a heart attack. To prevent that from happening, he wore a heart rate monitor and sat down anytime his heart rate reached 120. By engaging in this safety behavior, he incorrectly believed that the reason he has not had a heart attack yet was because he always sat down before that could happen. Every time he sat down, he concluded that he saved himself from a heart attack, thereby strengthening the belief that sitting down is the only way to avoid a heart attack.

  • Justifying worries. Sometimes clients might come up with reasons that sound good to justify their worries. For example, a lot of people say worrying helps with problem-solving. They believe that, if they think through the situation over and over, it will help them prepare for whatever ends up happening. As we know, however, we can never fully prepare for any situation. There are always curveballs. Worrying is the opposite of problem-solving and can cause more problems. Others believe that worries help prevent anything bad from happening. For example, if I worry about whether all the locks are locked in the house, then no one will break in. But we can never make ourselves feel better, which leads to compulsive behaviors.
  • Trying to “get rid” of anxiety. As soon as someone focuses on getting rid of, or even reducing, anxiety, they reinforce the belief that anxiety is bad, it must be fixed, and there is something wrong. But this idea perpetuates worries about anxiety and causes them to interpret that the inevitable and normal anxiety humans are meant to experience is a sign of failure.

Unfortunately, futility sinks in, leading some to feel hopeless. I have heard from so many clients who have given up because they have “tried everything,” and “nothing has worked,” and they are “still anxious.” And then, they regress.

This, too, is why habituation should never be the goal of exposure therapy. If the focus is always on feeling better, then clients will have a hard time coping in situations when anxiety is strong and beat themselves up when it does not go away.

  • Staying at the Bottom of Fear Hierarchies. Although they are widely used in psychotherapy, fear hierarchies can sometimes maintain anxiety. When we encourage clients to start small and address the easier worries first (ie, the fears at the bottom of the ladder), we reinforce the belief that the scarier things are too big and should be worried about. Moreover, we ingrain the belief that they cannot handle those bigger worries.
  • Thinking “happy.” Sometimes, people try to force themselves to think happy, positive thoughts while suppressing anxious thoughts. Reinforce with clients that anxiety is a normal feeling – our brain is built to be anxious to keep us safe. We want, for instance, to feel anxious when crossing a highly trafficked road to ensure our safety. We want our heart to beat fast when we walk into an interview because our body is giving us the energy we need to do our best. And, when stressed, the brain’s release of neuropeptide Y and DHEA helps to reduce anxiety while promoting our resilience, and even brain growth. (Bonus: And, as clinicians know, when stressed, our body also releases oxytocin, which helps us to connect with others, resulting in boosted confidence and motivation). As soon as we try to get rid of that feeling, however, our brain clings on to it.

Sample Technique: I give my clients this example: Try not think of your left hand, whatever you do, do not think of your left hand. Most likely, I tell them, they have not thought about their left hand all day (or ever) until I told them not to.

  • The rush. Rushing reinforces anxiety. Unfortunately, many people rush to get their kids off to school and themselves ready for work, which creates stress and anxiety. When we rush, our body goes into a panicked state. We might use high-pitched voices or make anxiety-provoking comments about being late and what is going to happen when we are late.
  •  Technology. Unfortunately, technology can be a major trap for people with anxiety for many reasons. For starters, a lot of images on various programs, including social media and games, can raise the body’s stress response. Technology also gives the illusion of certainty – another anxiety trap. Instead of seeking reassurance from others, many people will turn to the internet to check the weather, physical symptoms, or probabilities of certain situations occurring. I have clients who check the weather every few minutes, just to be sure that there are no tornado warnings through the day (even though they live in a place that has never had a tornado).

Simply put, I use the above tactics to teach my clients that, as humans, we simply cannot “stop being anxious.” As part of this counseling, I let them know that they can, however, create new pathways in their brains to compete with the old ones.

Part of this approach is exposure therapy. To effectively manage anxiety and redirect brain pathways, people need to experience anxiety on purpose to learn that anxiety is safe and the feelings that come with it are temporary. Our clients need to know that they can handle whatever situation they are faced with.

Below are clinical strategies for helping clients to manage and maintain anxiety disorders.

How Clients Can Master Anxiety by Engaging with It

Once a client understands that anxiety is an inevitable part of being human, we can help them learn how to tolerate and cope with anxiety better.

Understand that the Brain Can Be Retrained

I often counsel my clients on neuroplasticity, helping them to understand that they can rewire their nervous response system to be less trigger-happy or, rather, less sensitive to triggers. I share how no amount of talking (despite our psychotherapy sessions) will ever change those pathways. We can only change brain pathways by learning through experience that they can handle whatever challenge, stress, or anxiety-provoking situation comes their way.

Create an Anxiety Trigger List, Test It

We start by creating a list of anxiety triggers – see an example below. (Note that “triggers” are not on the list of things to avoid above; we want our clients to face their triggers). This list is not to be used as a fear hierarchy or fear ladder; instead, this list is used as a map. People can choose to go in any random direction they want. The stronger anxiety occurs when they face the trigger, and when this happens, the quicker the worried brain will learn that it is safe. For each trigger, it is imperative to identify any safety behaviors to ensure they are not being used during exposure.

Using this sample, I like to have clients predict how anxiety-provoking, stressful, scary, or awful they think the trigger is going to be. Afterward, we talk about how awful it was. Even if it was as awful or worse than they predicted, I then add another column – did they survive the trigger experience? So even if their anxiety went from a 5 to an 8 on a 0-10 scale (with 10 being the worst possible experience), they learn that they can handle something as high as an 8.

Table I: Sample Anxiety Trigger List Using Fear of Snakes and Client Response to Feelings of Anxiety.

Antecedents (Triggers to Anxiety) Predicted Awfulness (before trigger exposure, 0-10)

Actual Awfulness

(client fills in after trigger exposure, 0-10) 

Seeing a picture of a snake 5 TBD
Standing in front of a caged snake 7 TBD
Seeing someone holding a snake 6 TBD
Opening the snake cage 8 TBD
Snake slithering on the ground in front of me 9 TBD
Touching a snake 9 TBD
Holding a snake 10 TBD

Then, the accuracy of worries needs to be tested by facing them head-on – without any old coping strategies. So, if a client must check and double-check the locks every night before they go to bed, I ask them to stop doing that.

When clients face their fears, it is important to realize that the goal is not to make sure the feeling of anxiety is reduced. Remember the trap above: if a person focuses on reducing anxiety, they may end up feeling like they failed, which worsens anxiety. Instead, clients need to focus on ensuring that their beliefs about how awful the situation is going to be are contradicted.

Learn to Accept Discomfort and See Anxiety as a Protector

Specifically, I talk with clients about how:

  1. The discomfort that comes with anxiety is normal, not dangerous. Anxiety exists to protect ourselves. So yes, we might feel chest pain as the blood rushes as fast as it can to our major muscles but that does not mean we are having a heart attack. Why would the body do something harmful if it is meant to protect us? It does not make sense. (On a side note, if the body is revved up, full of energy, and ready to go, I tell my clients to use that energy and stress is to do something active!). The bottom line: they can handle whatever uncomfortable feelings that come up. With practice, they will not need to avoid them anymore.
  2. They must activate the worried part of their brain (ie, get anxious) to teach it that the probability of the worst-case scenario happening is low. And, if it does end up happening, they can handle it.

Relinquish Control and Maintain Anxiety through Daily Practice

Participating in an exposure therapy session with a mental health professional once a week is not going to create change very quickly. As clinicians, we want to make sure we are promoting a lifestyle focus to exposure in which we encourage clients to lean into anxiety, fear, uncertainty versus trying to resist, control, or escape these experiences.

For example, I tell my clients to view anxiety-provoking experiences as lucky breaks that strengthen their brave brain. I remind them often that every choice they make regarding whether to confront or avoid something that worries them is important. Every time they choose to confront a situation without avoidance or safety behaviors helps them to become less fearful in the long run. Alternatively, each time a decision is made to avoid an experience, they are strengthening their fear.

I encourage daily self-guided exposure practices. This may include repeating what they did in session or practicing something new, such as asking someone out on a date or offering their opinion in a classroom or work meeting. The focus should be on getting them invested with committed action – that is, commitment to continuing this work on their own. A commitment is not a promise or hope but a choice to live without anxiety getting in the way.

Last Updated: Apr 9, 2021