Introduction to Concepts, Terms, and Tools

The most important function our brains perform in addition to keeping lungs breathing and hearts beating is to protect us. Anxiety and fear (fight or flight) are self-protective responses to a physical or psychological threat. In this mind-body experience, our whole physical being goes on a state of alert. We usually discriminate between fear and anxiety even though the emotional and physiological experiences have a lot in common. Fear occurs when there is an actual physical threat. Anxiety may relate more to anticipated threats than immediate.

In high anxiety, heart rate increases, respiration rate goes up, palms can feel sweaty, and the mouth can go dry. Some people feel like they must be having a heart attack. The discomfort associated with anxiety can range from minimal symptoms to mild, moderate, or severe. If you haven't lived with an anxiety disorder, you can still be sympathetic. As a human being you've experienced some level of anxiety from time to time. It may have been mild, like when you forgot to study for that midterm exam. Perhaps you felt butterflies in the pit of your stomach, you had difficulty falling asleep because of worry, your palms became sweaty, or your heart rate increased.

If you were driving on a dark stretch of road at night and suddenly, in your rearview mirror, you saw the flashing blue lights of a police cruiser, you would probably experience quite a surge of adrenaline! You may feel a sudden hot flush, pounding heart, dry mouth, and sweaty palms. Now imagine feeling those same sensations from out of nowhere and for no apparent reason, and you know how a panic attack feels. In panic disorder, that feeling comes unexpectedly, sometimes repeated at random intervals. The shock and discomfort of high anxiety will cause a person to avoid situations where they fear having a panic attack. In extreme cases, people with panic disorder don't dare venture outside their homes.

Working with people suffering from anxiety or distressing emotions provides some of the most gratifying experiences for clinicians. By teaching some useful tools, counselors get to see a real, long-lasting transformation with successful treatment. Moderate to severe anxiety can cause people extreme difficulty in completing everyday tasks. Concentration, decision-making, coping with everyday stress, and the ability to relax or fall asleep may be impaired. This can begin a downward spiral of physical and mental fatigue, leading to a loss of interest in daily activities and even depression.

Depression, like anxiety, could also be adaptive in helping a person withdraw from situations in order to recover from stress or take the time to solve or reflect on difficult problems. However, in today’s social environments marked by chronic stress and isolation, it can trap an individual in a cycle of withdrawal, overthinking, and impaired functioning, making it difficult to break out of the cycle and giving our conscious and nonconscious brain the experience we need to function well.

Fortunately, people with anxiety disorders and other disorders treated with CBT can significantly reduce anxiety and depression, a change in the brain that continues after therapy ends. Medications such as selective serotonin reuptake inhibitors (SSRIs) may also ameliorate some of the uncomfortable physical symptoms of anxiety and depression, enabling sufferers to function better as long as they continue taking medication. Most people prefer not to take medication, or to take as little medication as necessary. If they can learn to cope with or reduce negative emotions through their own effort, that is their preference.

Anxiety and depression can be evoked by many factors, none of which are elective. People don’t choose to have these reactions. Sometimes extreme events such as war, sexual and physical abuse, traumatic loss of a loved one or associate, natural disasters, or even drug use and medications may precipitate anxiety or other mental disorders. Names for some of these anxiety disorders include post-traumatic stress disorder (PTSD), panic disorder, major depressive disorder, and acute stress disorder. Sometimes, people may be genetically predisposed to anxiety or depression. However, people can develop mental disorders such as obsessive-compulsive disorder, depression, social phobia (social anxiety), specific phobia, separation anxiety, or generalized anxiety disorder without any obvious family history.

Intrusive thoughts, flashbacks (memories of traumatic events), guilty feelings, and even shame make people with these disorders hide their inner turmoil from others, and they often fail to get the help that they need. If their disorder significantly interferes with their ability to function, it may come to their physician’s attention, or they may seek a consultation with a counselor. Being given a diagnosis often brings great relief and the recognition that there is a pathway to improved mental health.

They often ask, “What are my chances of getting better?” With OCD, which is one of the most difficult disorders to treat, studies indicate a 75% probability of significant improvement through CBT. Research also shows that only 20% of individuals who receive cognitive therapy suffer from acute and post-traumatic stress symptoms after six months, as compared to 67% who only receive supportive counseling. Other studies looking at PTSD and generalized anxiety disorder (GAD) indicate that when exposure therapy (purposely subjecting oneself to an anxiety-provoking situation) is included as a part of CBT for approximately sixteen to twenty sessions, a 50% reduction of symptoms may be achieved. The efficacy of CBT is also well documented for the treatment of panic disorder. Research reveals that by week six of treatment, approximately 76% of compliant individuals see a reduction in panic symptoms and by eleven weeks may be ready to reduce or end therapy. Medication and relaxation procedures used to treat panic disorder, when compared to cognitive behavioral therapy over a three-month period, have not been found to be as successful for panic disorder. However, recent studies have revealed that after only three months of cognitive therapy (the equivalent of eleven to twelve weeks), a significant reduction of panic symptoms is evident. With social and other specific phobias, even Internet-delivered CBT has shown an approximate 65% improvement rate, and that is with minimal therapist contact. Individuals with separation anxiety have also reported improvement with the use of both family-based and individual-based cognitive approaches.

These changes appear to make long-lasting differences in brain and behavioral functioning. For those who may be encouraged to do the challenging work of bearing the anxiety of exposure and response prevention and the work of cognitive restructuring, there is ample evidence of changes occurring in the brain as a result of CBT. Brain studies involving cerebral blood flow and the medial prefrontal cortex during anticipatory anxiety have shown reductions in blood flow while performing a variety of cognitive tasks (e.g., writing). Reduced blood flow indicates lower anxiety levels. The research shows that the practice of tasks such as anticipating a shock to the fingers actually decreases blood flow in the brain and lowers anxiety levels. In studies of social phobia, panic disorder, and post-traumatic stress, researchers have found that using emotional regulation techniques like those taught in CBT produces greater cognitive-control responses (i.e., right dorsolateral prefrontal cortex) in patients. For those suffering from PTSD, researchers have found a reciprocal relationship between blood flow in the medial prefrontal cortex and amygdala function in neutral and traumatic activity. Symptom severity was noted to decrease in the medial frontal cortex for both male veterans and female nurse veterans diagnosed with PTSD.

So, the good news is that people can manage, reduce, or eliminate the interference of anxiety and other mental health issues in their lives, just like others manage, reduce, or eliminate the interference of diabetes, coronary artery disease, or some other physical ailment. People can benefit from counseling, coaching, education, and behavior change in dealing with mental health, just as they have learned to manage their physical health.

Clinically, we ask our clients to describe the intensity of their anxiety in subjective units of discomfort (SUD), ranging on a scale from one to ten. A rating of one is almost no discomfort, and a ten represents the equivalent feeling of facing a bear alone in the woods. Minimal levels of anxiety may be dismissed quite easily for people without anxiety disorders (SUDs of one to three), but for those with anxiety disorders, even minimal symptoms can escalate into intense feelings (SUDs of seven to ten). This may lead to a perpetual state of worry and exhaustion at times.

Writing has many benefits, and it is important to understand them to help motivate you to do the homework. Even when I wrote the word “homework” just now, I felt a little twinge of anxiety. Homework is often associated with something many people don't want to do–it could be difficult, and they would honestly rather be doing something fun. While some people enjoy writing, others are hesitant to write or “do homework” for one reason or another. Remember, this is not a school assignment about a subject that you are not interested in or won't really use in your practical life. These writing exercises are specifically about helping you develop skills and awareness you can use in daily life, to help YOU. It will not be graded or critiqued for grammar and spelling!

If your first thought is, “I don't like to write,” please see the benefits above and, well, how can I say this nicely? Write anyway. Here's a bit more encouragement.

In this workbook, you will often be invited to write your responses by hand. This is not because handwriting is “magic,” and it is not because typing is wrong. Writing by hand simply adds one more layer of participation: your eyes, hand, body, attention, and words are working together. Research suggests that handwriting activates broader brain networks involved in movement, sensory feedback, attention, and memory than typing does (Van der Weel & Van der Meer, 2024; Marano et al., 2025).

For fear and trauma work, that slower pace can be useful. Handwriting may help you stay with the material long enough to notice what shows up, rather than rushing past it. It may also support deeper processing of words and meaning, since studies have found stronger learning-related brain responses after handwriting compared with keyboard typing (Kake et al., 2021).

At the same time, the most important part is not perfect handwriting. The important part is willingness, honesty, and repetition. Written exposure and expressive writing approaches have been shown to help many people reduce trauma-related symptoms, even when writing is delivered in different formats, including paper, electronic, or remote formats (Werner et al., 2021; Sloan & Marx, 2024). If handwriting is painful, inaccessible, or becomes a distraction, typing is a reasonable alternative. The goal is not to write beautifully. The goal is to face what fear has taught you to avoid, one sentence at a time.

One of the things we learn in counseling and psychotherapy is that we can't change what we don't monitor. Clients who benefit the most from CBT take notes, do homework, and get into the habit of writing their thoughts, feelings, triggers for anxiety, plans, and goals, on paper or on a computer. They learn to be open and honest about their experiences and collaborate in treatment. Overcoming anxiety requires hard work. To help you get into the swing of writing and becoming aware of your anxiety, triggers, and reactions, I suggest you begin with the same exercise I did when I worked with Dr. Gorbis (see Preface).