“How strange it is. We have these deep terrible lingering fears about ourselves and the people we love. Yet we walk around, talk to people, eat and drink. We manage to function. The feelings are deep and real. Shouldn’t they paralyze us? How is it we can survive them, at least for a little while? We drive a car, we teach a class. How is it no one sees how deeply afraid we were, last night, this morning? Is it something we all hide from each other, by mutual consent? Or do we share the same secret without knowing it? Wear the same disguise?”
— Don DeLillo, White Noise (1985)
Anxiety takes different forms. For some people it is constant worry that moves from one thing to the next. For others it is panic attacks, trouble sleeping, physical tension, or a sense of dread with no clear object. Whatever form it takes, most people respond by avoiding whatever sets it off. Avoidance brings relief in the moment, but over time it teaches us that the danger was real, and the anxiety spreads to more of life.
Most clients want some practical relief for symptoms right away. Some have a sense that worry is one of the oldest things about them and want to understand where it comes from. Both are reasonable places to start, and treatment usually involves some of each.
Cognitive Behavioral Therapy
CBT starts from the premise that how we think about situations determines how we feel and react. Anxious thinking runs in predictable directions: focusing on negative scenarios, overestimating how likely a bad outcome is, overestimating how bad it would be, and underestimating our ability to handle it. These thoughts happen quickly, and often all we notice is the fear they leave behind.
Often cognitive behavioral work on anxiety is concrete and present-focused. You learn to notice the predictions your mind is making, weigh them against the evidence, and over time adjust your behavior to better match the real risks and rewards. The goal is not to eliminate anxiety entirely, but to have anxiety in proportion to reality, and a life that is not organized around avoiding it.
Psychodynamic Therapy
Sometimes the things we consciously worry about are stand-ins for deeper unresolved tensions. Psychodynamic treatment interprets anxiety as a signal, often of a subconscious conflict between what we feel is acceptable to express and things that may even be unthinkable — anger at someone we depend on, a need or desire we were ashamed of, or a conflict we have been effectively avoiding. The worry can serve a purpose, keeping something more threatening out of awareness. People who struggle with perfectionism or people-pleasing often recognize this pattern.
Psychodynamic treatment is slower and more relational than CBT, and often develops over time. Rather than targeting anxious thoughts directly, we work on developing insight into the conflicts underneath them, and trace them back to early experiences where you learned what to expect from the world and what role you were to play in it. When those conflicts are better understood, the anxiety has less work to do.
If your anxiety is connected to traumatic experiences, as it often is, see trauma and PTSD treatment.