I want a self-help book that addresses all my different worries and is based on scientific evidence; I want to be able to use it by myself, but also for it to be useful for my husband and children, who have suffered with me and who want to help.
Ana, 54
I’m so confused. I feel anxious so much of the time, and I can’t work out what’s wrong with me. My friend said she thought I had social anxiety, but my GP said it was generalized anxiety disorder. How can I get help if I don’t even know what’s wrong with me? I feel like I’ve got bits of everything.
Tom, 23
There are lots of books on overcoming anxiety, and many of them are based on cognitive behavioural therapy. So, why write another? The reason is that the other books either tend to talk about anxiety in general, or else they talk about overcoming a very specific form of anxiety such as social anxiety or panic disorder. In this book we provide a general account of anxiety and the means to overcome it, as well as specific guidance on strategies for overcoming particular forms of anxiety.
We are committed to the idea that all therapies need strong scientific support to back up their ideas about treatment. We can have interesting ideas and theories about which treatments are best, but unless we have good evidence to show that they work, we are really just making it up!
In research carried out on anxiety, all the strong scientific support for treatments comes from studies into specific forms of the disorder, not anxiety in general. We can apply the same general principles of cognitive behavioural therapy to any psychological problem, but this is not quite the same as having tailor-made CBT approaches for specific anxiety problems. Only the tailor-made approach has real evidence to support it.
Even with a tailor-made approach, there is a further problem: people usually have more than one anxiety problem at a time. According to one large study, 29 per cent of people have problems with anxiety at some point of their lives – this is more than one in four of us (Kessler et al, 2005). In addition, if we do have problems with anxiety, 40–80 per cent of us will have more than one type. This means that we need to tackle each problem with the ‘disorder-specific’ approach that has been shown to work. There is a great deal of similarity and overlap between these individual approaches, but there are also key differences in the way that they fit the approach to the problem. Unified or ‘transdiagnostic’ approaches to the treatment of emotional problems are currently being developed (e.g. by David Barlow and colleagues) which offer the potential to address multiple anxiety problems simultaneously. Such approaches are relatively new, however, and not yet sufficiently developed to form a self-help programme.
What’s the answer? We decided that what was needed was a self-help book which does two things. Firstly, it should explain the ideas and the techniques that are common to the CBT treatment of all forms of anxiety disorder and, secondly, it should describe the tailor-made treatments for the different disorders in separate chapters. In this way, the similarities between the different approaches would be described for people with more than one anxiety problem at the same time as describing the specific treatments that have been found to work for the particular problem.
We also felt that almost all the existing books are written either for someone with the problem, or for therapists. Although there is a great deal of overlap in their content, they are often pitched to different readerships, written as separate books using slightly different language.
We wanted to produce a book that could be used both by people who are experiencing anxiety problems and those who are supporting their efforts to recover – friends, family members and therapists. In this way, people could be sure that they were all talking the same language and sharing a common understanding, rather than reading separate books that might explain problems in slightly different ways.
In addition, because we are committed only to treatments with a sound evidence base, we wanted the people who have actually developed and researched the specific CBT approaches for the specific anxiety problems to write the chapters in this book, and we were very pleased that everyone we asked agreed to this! This means the chapters on specific anxiety problems are written by international experts, and the treatments are in fact those that are recommended by the National Institute of Health and Clinical Excellence (www.nice.org.uk), who provide treatment guidelines to health professionals.
We have given a brief treatment programme for each disorder, and each chapter should give you all the basics you need, but for readers who would like more detail we have also included recommendations for further reading. You will only have to read and follow the specific chapters that are relevant to you, so you’ll be able to skip many of them.
Almost everyone has experienced anxiety at some time in their lives, and to do so is not only natural, but probably quite sensible, too. In some sense the feeling of anxiety is like a signal to us that we need to take action. If we are walking alone down a dark street and start to feel anxious, we might think, ‘This is getting spooky – I think I’ll nip into the pub and call a cab’, so we will be doing something to get ourselves somewhere safe. If we have an exam coming up, we are likely to start feeling anxious. We might think, ‘It’s no use; I can’t pretend it’s not happening – I’ve got to revise or I’ll totally mess up.’ Once again, anxiety can guide us to behave in a way that is in our best interests. Not only will anxiety help to guide what we should be doing, but sometimes it will help to make us better at it, too. It can make us stronger or faster if we need to respond physically, for example if we are in physical danger and need to run away. The text box on ‘Fight or Flight’ on pages 5–6 outlines our body’s natural response to anxiety.
However, no doubt you know all too well that anxiety can also become unhelpful. It can become unhelpful in two different ways. First, anxiety does not help if we become anxious in situations where there is really no danger or threat. Examples of this are being frightened that a house spider will jump out of the bath at us (spiders won’t do this), or being scared that people are laughing at us when they are not, or thinking that we’re dying of a heart attack when we are not. In these examples people feel anxious because they think that something bad is going to happen, even when it is not.
The second way in which anxiety becomes unhelpful is when there is some kind of real threat to you, but the amount of anxiety you feel is out of proportion to the reality of the situation. As in the example earlier, it is natural to feel anxious if we have an exam coming up, but for some people the anxiety can become so overwhelming that instead of motivating us to revise, it completely interferes with our ability to concentrate, or we get so frightened at the thought of failing that we avoid even thinking about the exam. For another example, many people don’t like being in crowds, but if we are so frightened of getting caught in a crowd that we can’t leave the home, then anxiety is clearly having a serious impact on our life.
Whichever way anxiety is unhelpful to us, the reason that it does not help is that instead of protecting us, it imprisons us. It stops us from doing what we would like to do, and living our life the way we wish. If you are reading this book, then you will almost certainly have experienced this for yourself. If you recognize that this has been happening, the book is for you!
The aim of this book is to help you overcome your anxiety so that you can go freely about your daily life doing what you wish without being unduly scared. We hope that the first part of the book – the common ideas and techniques of CBT – will help you understand more about anxiety and cognitive behavioural therapy. Given that the different CBT treatments for anxiety problems all have a common structure and style, we hope we are being efficient by describing these common features so that they don’t have to be repeated in the second part of this book. Part 2 provides you with an understanding of what keeps different forms of anxiety going, and will give you the tools to change so that your anxiety comes down to acceptable levels. The goal is not to live an anxiety-free life – for one thing, nobody ever does; and for another, anxiety can be useful in that it prepares us for real danger – but to live your life with acceptable levels of anxiety in a rich and full way.
Getting help: We know from studies that many people get most from self-help books if they have help and support from a therapist or therapy assistant as they work through them. If you do not have a therapist, then you may want to try to get a friend or family member to help you with the book, to read it along with you and support you as you try to make changes. For this reason we have added ‘Tips for supporters’ throughout the text. These come from our experience of supervising therapists, and from the feedback we’ve received from family members of the people we have treated. Don’t worry if you don’t have support; just try to be as objective as possible as you read through the book, and try to be your own therapist – just apply the tips to yourself.
Making a commitment: If you want to make real changes in your life then it will not be enough to simply read the book. You will need to really commit yourself to doing the tasks and exercises in the specific chapters. Otherwise it is rather like exercise – reading about going jogging doesn’t make us any fitter!
Understanding common factors: The good news is that you do not have to read the whole book, though it would be sensible to read Part 1 on common ideas and techniques before moving on to the chapters that are relevant to your particular problem in Part 2.
Identifying your problem: It may be that you don’t know which chapters are relevant for you, or think all of them could apply. Each chapter opens with some information about the nature of the specific problem being considered, which should help you decide how relevant it is to you. Don’t try to decide if that’s the only one for you – just see if the problems they are describing would be good for you to try to tackle. You might find that you need to work through more than one chapter in Part 2. If so, then you should find that the skills you’ve learned from the first one make it easier to work through the next one.
If more than one chapter is relevant to you, there are two ways to decide which chapter to start with. The first is to start with the problems that are causing you the most difficulties in your life – perhaps you feel that if this was sorted out, your day might be a lot easier for you. Alternatively, you could start with something that you think might be reasonably easy to tackle – that way you will start to see changes quickly and hopefully your confidence will grow. If you have a supporter working with you, you can discuss together where to start, but there’s no golden rule – as long as you start somewhere then you will have begun to overcome your problems.
Although this book is about self-help through CBT, you may be wondering whether medication would be able to help you. If you would like to know more about this, then your General Practitioner (GP) will be able to advise. The medications that are most useful for anxiety can be obtained by prescription from your GP, but not bought over the counter from the pharmacist.
Medication can be useful on its own, but also in conjunction with CBT. Taking medication may make it easier for you to use this book, or to benefit from further help from a therapist, so you don’t need to think of it as an either CBT or medication decision.
We have included below links to the guidance on anxiety disorders that is produced by NICE – the National Institute for Health and Clinical Excellence. NICE reviews all the available evidence about treatments for physical and mental health conditions, and produces guidance about which treatments should be offered. This covers both psychological and drug treatments – you will see that CBT features heavily. The numbers at the end of the address relate to the most recent version of the guidance for that disorder.
In relation to the anxiety disorders covered in this book, NICE has produced guidance for those shown below. In each case we give the disorder and the web link to the guidance. At the time of writing, NICE had not yet produced guidance for social anxiety (due out in May 2013) or for health anxiety or specific phobias, but if you would like to explore the use of medication for these problems then your GP will be able to assist you.
For generalized anxiety disorder and panic disorder:
For obsessive compulsive disorder:
For post-traumatic stress disorder:
Finally, we have included a chapter on post-traumatic stress disorder (PTSD), the anxiety that overwhelms people when they have been through a highly traumatic event. While research has shown that self-help works for other forms of anxiety, to date it does not support the use of a self-help book without a therapist for people who have PTSD. The chapter on PTSD is therefore not designed to be used as a self-help manual but to provide you with information on effective cognitive behavioural therapy for this problem and how to access it.
• It is difficult to change. Be ‘empathic but firm’ when helping someone. That is, show them that you really do understand how difficult it is for them to confront their anxieties and deal with them differently, but don’t let the difficulties stand in the way of making changes.
• Make sure that the person you are supporting is ready to commit themselves to change, and you are committed to helping them. People tend to have a ‘right time’ to take on challanges like this – a kind of window of opportunity when they are in the right frame of mind. You can help to motivate your ‘supportee’ by pointing out all the benefits of change to them, but, most importantly, you can help them decide whether this is the right time to change.