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Unravelling Anxiety with Cognitive Behavioural Therapy: An Occupational Therapy Perspective


Anxiety disorders are among the most common mental health problems affecting approximately one in 10 Canadians (Health Canada, 2009). Anxiety can disrupt various aspects of daily life, including sleep, focus, and social interactions. Fortunately, occupational therapy provides robust tools to address these challenges. This post will guide you through the fundamentals of anxiety disorders, the principles of occupational therapy, and the science-backed strategies occupational therapists use to improve daily functioning for those with anxiety.


"Anxiety is a thin stream of fear trickling through the mind. If encouraged, it cuts a channel into which all other thoughts are drained." - Arthur Somers Roche

Man sitting in waiting room of therapist office

Introduction to Anxiety and Occupational Therapy


Anxiety disorders are a group of mental health conditions characterized by excessive and persistent feelings of fear, worry, or nervousness that interfere with a person's daily life. These disorders are relatively common and can affect people of all ages, backgrounds, and walks of life. There are various types of anxiety disorders, and while each has its unique features, they all share the common thread of excessive anxiety that negatively impacts one's well-being.



Some of the most common anxiety disorders include:

  1. Generalized Anxiety Disorder (GAD): GAD is marked by chronic, excessive worry about various aspects of life, such as work, relationships, or health. Individuals with GAD often struggle to control their anxiety, even when they realize their concerns are unwarranted.

  2. Panic Disorder: This disorder is characterized by sudden, intense episodes of fear known as panic attacks. These attacks can cause physical symptoms such as a racing heart, shortness of breath, and dizziness, often leading individuals to believe they are experiencing a heart attack or other life-threatening situation.

  3. Social Anxiety Disorder: Also known as social phobia, this disorder involves an overwhelming fear of social situations, often driven by a fear of being judged or embarrassed in front of others. People with a social anxiety disorder may avoid social events or struggle with everyday activities such as work or school.

  4. Specific Phobias: A specific phobia is an intense fear of a particular object or situation, such as heights, enclosed spaces, or certain animals. These fears are often irrational and can lead to avoidance of the feared object or situation, causing significant distress.

(Anxiety Disorders, n.d.)



Understanding Occupational Therapy


Occupational therapy is a holistic healthcare profession focused on helping individuals of all ages participate in everyday activities or "occupations" that they find meaningful and purposeful. Occupational therapists work with people of all ages with physical, mental, or developmental challenges to help them improve their ability to perform daily tasks, increase their independence, and enhance their overall quality of life.


Group therapy for anxiety. People sitting around in a circle talking about their thoughts.


In the context of working with individuals who have anxiety disorders, occupational therapists play a crucial role by addressing the impact of anxiety on a person's daily functioning. Let’s look at some examples of how anxiety might manifest in day-to-day life and ways an occupational therapist may help.


Social withdrawal: People with anxiety, particularly social anxiety disorder, may withdraw from social situations or avoid engaging with others due to fear of embarrassment or judgment. This can result in feelings of isolation and may limit opportunities for personal or professional growth. Some treatment interventions might include:

  • Social skills training: Teaching clients effective communication techniques, assertiveness, and active listening to improve their social interactions.

  • Role-playing and rehearsal: Practicing social situations through role-playing scenarios to help clients become more comfortable and confident in navigating real-life interactions.

  • Graded exposure therapy: Gradually exposing clients to increasingly challenging social situations while providing support and guidance to help them build confidence and reduce anxiety.



Difficulty concentrating: Excessive worry and anxious thoughts can make it challenging for individuals to focus on tasks, potentially affecting their work or school performance. Some treatment interventions might include:

  • Time management and organization: Teach clients to prioritize tasks, break them down into smaller steps, and create schedules to better manage their time and reduce stress.

  • Mindfulness practices: Guiding clients through mindfulness exercises that promote present-moment awareness can help improve concentration and reduce anxious thoughts.

  • Environmental modifications: Recommending changes to the client's workspace or study area to minimize distractions and create a more conducive environment for focused work.

Sleep disturbances: Occupational therapists can help clients establish healthy sleep habits and routines to improve sleep quality. Some treatment interventions might include:

  • Sleep hygiene education: Teach clients about the importance of a consistent sleep schedule, creating a relaxing bedtime routine, and maintaining an optimal sleep environment.

  • Relaxation techniques: Guiding clients in progressive muscle relaxation, deep breathing exercises, or mindfulness meditation to help calm the mind and body before sleep.

  • Activity scheduling: Helping clients create a balanced daily routine that includes regular physical activity, exposure to natural light, and limited screen time before bed.


Woman laying in bed, wide awake. It is 3 in the morning and she is having trouble sleeping due to anxiety.


The Science Behind Cognitive-Behavioral Strategies



Cognitive Behavioral Therapy (CBT) explores how our thoughts, feelings, and actions are interconnected. It recognizes that our perceptions influence our experiences and that by changing negative thoughts and attitudes, we can better control our emotional and behavioural responses. (“What Is Cognitive Behavioral Therapy?” 2017). CBT is a multi-step process that generally might go as follows:


1. Identification of Negative Thoughts: The first step in CBT involves recognizing the negative thought patterns that are contributing to anxiety. These might include catastrophizing (believing the worst will always happen), overgeneralizing (believing that one negative experience means all similar experiences will be negative), or personalizing (believing that you are the cause of adverse events).




2. Challenge Negative Thoughts: Once these thought patterns have been identified, the next step is to challenge them. This might involve asking questions like, "Is this thought based on fact?" or "Is there another way to look at this situation?" The therapist will guide the person to understand that these negative thoughts are often irrational or overblown.


3. Replace Negative Thoughts: After challenging the negative thoughts, the individual then learns to replace them with more realistic, balanced thoughts. For instance, the person might replace the thought, "I'm going to embarrass myself at the party" with "I might feel a bit nervous at the party, but that's okay. Not everyone is constantly judging me."


"The greatest weapon against stress is our ability to choose one thought over another." - William James

4. Behavioral Techniques: Alongside cognitive strategies, CBT also involves changing behaviours that contribute to anxiety. One common technique is 'exposure therapy,' where the individual is gradually and repeatedly exposed to the anxiety-provoking situation until it no longer causes the same level of fear.


Image of an occupational therapist discussing CBT with a client.

If you want to learn more about CBT, you can check out our other post called "Cognitive Behavioural Therapy: Techniques, Principles, and Application." Just click or tap the link or on the image to access it.





Transforming Anxiety with CBT


For a more comprehensive understanding of the CBT process outlined above, let's look at a practical example using a case study and how CBT can help people with anxiety disorders.


A Case Study of Samantha


Samantha, a young woman in her late twenties, has always loved music. However, she's developed a significant fear of attending concerts due to her social anxiety. Her fear is rooted in a recurring thought: "If I go to the concert, I'll have a panic attack, and everyone will notice and judge me." This thought triggers such intense anxiety that Samantha avoids concerts altogether, thus missing out on experiences she'd otherwise enjoy.


Samantha begins working with an occupational therapist who uses a CBT approach. The therapist's primary goal is to help Samantha challenge her negative thoughts and eventually change her behaviours related to concerts.


Identification of Negative Thoughts:


The first step in Samantha's therapeutic journey with the occupational therapist involves identifying and understanding her negative thought patterns, a crucial aspect of CBT. The focal point of this process is the thought, "If I go to the concert, I'll have a panic attack, and everyone will notice and judge me."


Person standing on pavement looking at their feet trying to decide which direction to turn.

This thought illustrates Samantha's tendency to 'catastrophize,' a term used in psychology to describe the habit of always expecting the worst possible outcome. Catastrophizing is considered a cognitive distortion, a way the mind convinces us of something that isn't necessarily true. The negativity of this thought comes from Samantha's assumption that her worst fears will undoubtedly happen. She isn't just worried about possibly feeling uncomfortable or anxious at the concert; she's utterly convinced that she will experience a panic attack—a highly distressing event.


By identifying this thought as a significant source of her anxiety, the occupational therapist can help Samantha recognize her tendency to catastrophize, which is the first step towards challenging and changing this unhelpful thought pattern.



Challenging Negative Thoughts:


The role of the occupational therapist at this stage is pivotal. Once Samantha is aware of her negative thoughts, she must confront and challenge them. This process involves dissecting her thought and questioning their factual basis to see if they are logical to her situation.


The therapist may pose thought-provoking questions such as, "How many times have you noticed others having a panic attack at a concert?" and "Even if you were uncomfortable, do you believe everyone would be focused on you?" and "Is it possible that people at the concert would be more understanding or less judgmental than you're imagining?” These questions are meant to stimulate Samantha's analytical thinking and encourage her to examine her fears from a different perspective.


The reason behind challenging these negative thoughts is to help Samantha differentiate between her fears and objective reality. Often, anxiety disorders are linked to patterns of thought that overestimate danger and underestimate one's ability to cope. This perception of excessive risk and insufficient coping tends to foster avoidance behaviours, which in turn reinforces Samantha’s anxiety.


By challenging these thoughts, the therapist encourages Samantha to examine the evidence for and against her fearful predictions. The therapist gently guides her to understand that her apprehensions about attending a concert might not be as grounded in reality as she believes. This process of challenge and rationalization acts as a bridge toward changing her thoughts and avoidance behaviour.


Replacing Negative Thoughts:


Once the negative thoughts have been challenged, the next crucial step in CBT is to replace them with more balanced and realistic thoughts. This stage aims to alter the cognitive schema - the mental framework influencing our interpretation of situations. Samantha might replace her original thought with, "I might feel anxious at the concert, but it doesn't mean I'll have a panic attack. Even if I feel uncomfortable, people are usually too engaged in the concert to notice me."


"You don't have to control your thoughts. You just have to stop letting them control you." - Dan Millman

The purpose of replacing negative thoughts is twofold. Firstly, it helps Samantha change her perspective and reinterpret the situation in a less threatening way. This adjustment helps her reduce her anxiety levels and approach the concert with a more confident outlook. Secondly, by fostering positive and realistic thought patterns, Samantha is better equipped to cope with future anxiety-inducing situations. Over time, these new thought patterns can start to override the old, negative ones, leading to a lasting change in Samantha's mindset.


Sticky note on a cork board posted with saying "same old thing equals same old results"


The shift from negative to positive thoughts is not about denying the possibility of discomfort or difficulty. It's about acknowledging that while she may feel anxious at the concert, this anxiety does not necessarily translate into the worst-case scenario she initially envisioned. Replacing negative thoughts emphasizes Samantha's ability to cope with the situation, which can be empowering, boosting her self-confidence and reinforcing her belief in her own resilience. Over time, as Samantha becomes more proficient in this cognitive restructuring process, she may find it easier to manage her anxiety and engage in other activities that she previously avoided.



Behaviour Change:


With a more positive perspective and the ability to challenge her own negative thoughts, Samantha is now ready to work on the behavioural aspect of her anxiety. This is where Samantha takes the insights from cognitive restructuring and applies them in real-life scenarios, initiating tangible changes in her actions and reactions. When Samantha approaches the concert situation with new thoughts, like "I might feel anxious, but people are usually too engaged in the concert to notice me," her anxiety's hold on her actions begins to loosen. This altered perspective makes it easier for her to engage in behaviours she'd previously avoided due to fear.


In Samantha's case, her occupational therapist helps her devise specific coping strategies for attending a concert. These strategies are not just about managing her immediate anxiety symptoms but also about building her resilience in the long run. The therapist may teach Samantha techniques like mindfulness, deep breathing exercises or progressive muscle relaxation, which can help manage her anxiety in the moment. The therapist also suggests a gradual exposure approach, which is a standard treatment in CBT for anxiety disorders. This involves attending a smaller, more intimate concert first to acclimate to the environment before tackling larger, more crowded ones. This stepwise exposure helps Samantha build confidence in handling anxiety-inducing situations. The therapist also recommends Samantha consider bringing along a supportive friend who understands her anxiety. Having a trusted person there for reassurance can provide an additional layer of comfort and security.



3 dice with the letter CBT written on them


Over time, and with consistent application of these strategies, Samantha learns to manage her social anxiety better. She slowly changes her cognitive distortions and avoidance behaviours related to concerts. It takes time and practice, but eventually, Samantha starts to feel less anxious about attending concerts. This transformative journey of behaviour change helps Samantha partake in experiences she enjoys without being held back by her anxiety.


A Quick Look at Mindfulness


Mindfulness-based occupational therapy is a type of therapy that integrates principles and practices of mindfulness into occupational therapy sessions. The focus of this approach in the context of anxiety disorders is to boost an individual's self-awareness and capacity to manage emotions. Being in the present moment, attentively acknowledging thoughts, feelings, and physical sensations can help individuals better understand their needs and learn strategies to cope with stress and anxiety.


A cup of tea, with a napkin beside it. The napkin has writing on it and says "mind full or mindful"

The beauty of mindfulness is its ability to effect change on a physiological level. There's a growing body of evidence to show its benefits, with studies pointing out that mindfulness exercises can positively impact brain function. This is thought to be related to its effect on the body's stress response system. When a person engages in mindfulness practice, it stimulates the parasympathetic nervous system, which is responsible for calming the body down after stress.



In the context of anxiety CBT, mindfulness can significantly change the way people perceive and react to their thoughts and emotions. Recall our case study about Samantha. Let's say Samantha has bought a ticket to a concert and is starting to feel anxious about attending. The day of the concert, she might wake up with thoughts like, "What if I have a panic attack? What if everyone notices?" These are anticipatory thoughts that amplify her anxiety. Instead of getting caught up in these thoughts or trying to suppress them, Samantha can acknowledge them without judgment – a crucial part of mindfulness. She might say to herself, "I'm noticing that I'm having the thought of having a panic attack at the concert."


Next, Samantha can bring her focus to the present moment. She can do a quick mindfulness exercise, such as focusing on her breath or the sensation of her feet touching the ground. This helps ground her in the present, shifting her focus away from her worries about the concert. As the day progresses, whenever those anxious thoughts pop up, Samantha can again observe them without judgment and return to the present moment. Mindfulness complements the work Samantha is doing in CBT with her occupational therapist.

ocean scene with rocks piled on top in the foreground and wave crashing onto the beach in the background


If you want to learn more about mindfulness and some of the techniques used in therapy sessions, you can check out our other post called "Finding Calm in the Chaos: Mindfulness and Occupational Therapy."



Concluding Remarks


Anxiety disorders, widespread in today's society, often have a significant impact on a person's daily functioning, affecting everything from sleep to concentration and social interactions. Occupational therapists, armed with an array of tools and techniques, play a pivotal role in assisting individuals in managing their symptoms and improving their overall quality of life.



Online Resouces for People with Anxiety


  1. Anxiety and Depression Association of America (ADAA): This organization provides a wealth of resources for individuals struggling with anxiety, including information on understanding anxiety, treatment options, finding a therapist, and support groups. They also offer webinars and blog posts on various aspects of anxiety. Website: https://adaa.org

  2. National Institute of Mental Health (NIMH): The NIMH provides detailed information on the types of anxiety disorders, symptoms, risk factors, and treatments. It's a great resource for anyone looking to understand more about their condition. Website: https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

  3. Mind: A UK-based organization, Mind provides information and support on a variety of mental health issues, including anxiety. Their resources include guides to support and services, real-life stories, and tips for everyday living. Website: https://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/

  4. The Mighty: An online community created to empower and connect people facing health challenges and disabilities. The Anxiety section provides personal stories, articles, and discussions about living with anxiety. Website: https://themighty.com/anxiety/

  5. Headspace: This is a well-known mobile app offering guided meditations. While it is not exclusively for anxiety, many users have found its resources helpful for managing anxiety and stress. The app offers a free trial, after which there's a subscription fee. Website: https://www.headspace.com

  6. Calm: Similar to Headspace, Calm is a mindfulness app offering meditations, sleep stories, and calming music. It has sections dedicated to anxiety management. It also operates on a subscription model after a free trial. Website: https://www.calm.com


These resources can provide valuable support and information for people dealing with anxiety. However, they should not replace professional help. If you or someone you know is struggling with anxiety, it's important to reach out to a healthcare provider.


"Man is not worried by real problems so much as by his imagined anxieties about real problems." - Epictetus

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