Therapy for Anxiety: What Works and What to Ask For

Therapy for anxiety is not one thing, and which kind you get changes what actually happens in the room. Cognitive behavioural therapy has the strongest evidence, it is structured, it is shorter than most people expect, and it will ask you to do things between sessions that you would rather not do.

That last part is not a side effect of the treatment. It is the treatment, and knowing that in advance is the difference between finishing a course and concluding that therapy does not work for you.

What kind of therapy works best for anxiety

Cognitive behavioural therapy has the strongest evidence base across the anxiety disorders, and the effect is moderate rather than dramatic. A meta-analysis of 41 randomised placebo-controlled trials, covering 2,843 people with generalised anxiety, panic disorder, social anxiety, obsessive compulsive disorder or post-traumatic stress disorder, found a moderate effect of CBT on the symptoms of the target disorder and smaller effects on other anxiety symptoms, depression and quality of life. [carpenter-2018-cbt-anxiety]

Two things about that number are worth holding on to. It is measured against a placebo rather than a waiting list, which is a much harder comparison and the reason the effect looks smaller than the figures quoted in most articles. And a moderate average means a meaningful number of people did not improve, which is information you deserve before you start rather than after.

Guidelines follow this. For generalised anxiety and panic disorder, a structured psychological intervention based on CBT principles is the recommended psychological treatment. [nice-cg113-anxiety-therapy]

Why the uncomfortable part is the part that works

Anxiety is maintained by avoidance, so a treatment that never asks you to approach anything cannot correct it. The prediction driving an anxiety disorder is that some situation will be unbearable or dangerous. Every time you avoid it, or get through it using a precaution, the prediction survives untested, and it quietly gets stronger.

What CBT does is arrange for that prediction to be tested under conditions where it can actually be disproved. This is why the homework matters more than the conversation, and why a course that consists entirely of discussing how the week went is unlikely to move anything.

Feeling heard is not worthless, and a therapist you cannot talk to is a bad therapist regardless of method. The point is that it is not sufficient on its own for an anxiety disorder, and a course built entirely around it will usually leave the avoidance exactly where it was.

What the different therapies actually involve

The names are not interchangeable, and knowing roughly what each one does makes the choice yours rather than the waiting list’s.

• CBT identifies the specific predictions you make, then tests them through planned tasks between sessions. Structured, time-limited, homework-based. This is the default to ask for.
• Exposure-based work is often a component of CBT rather than a separate thing, and it dominates where the anxiety attaches to a specific situation.
• Acceptance and commitment therapy works on your relationship to anxious thoughts rather than on their content, and asks what you would be doing if anxiety were not deciding. Reasonable where CBT has been tried, or where the anxiety is diffuse.
• Counselling is supportive rather than protocol-driven. Genuinely useful for a difficult period in your life, and not the same as treatment for an anxiety disorder.
• Psychodynamic therapy works on patterns and their origins over a longer course. Its evidence base for anxiety specifically is thinner than CBT’s.

Our guide to how to deal with anxiety covers what to do while you wait, and the anxiety hub sets out what the condition is and how it differs from ordinary worry.

Therapy or medication

Both work, and this is one of the few places in mental health where a meta-analysis has compared them directly. Pooled across anxiety disorders, psychological therapy and medication both produce meaningful improvement, and the combination is a reasonable option where symptoms are severe. [bandelow-2015-anxiety-efficacy]

The practical differences matter more than the average effect sizes. Medication generally acts sooner and asks less of you week to week. Therapy asks considerably more and its gains tend to hold up better once it stops. Availability is often what actually decides: where a course of therapy is a year away, starting medication is not a compromise, and it does not prevent therapy later.

When to seek help

Speak to a doctor or a therapist if anxiety has been getting in the way of work, sleep or relationships for more than a couple of weeks and your own efforts are not shifting it. That threshold is deliberately set at interference rather than at intensity, because how bad anxiety feels is a poor guide to whether it needs treating.

Go sooner if you are avoiding things you need to do, if you are drinking or using something to manage the feeling, or if panic attacks have started. Ask for cognitive behavioural therapy by name, say what you have stopped doing, and ask how many sessions the course runs to.

The practical side of that, which is where most people stall, is covered separately: our guide to finding a therapist explains what the licence letters actually mean, what a session costs, and why contacting eight clinicians rather than two is the change that most reliably gets somebody seen.

Go urgently if you have thoughts of harming yourself.

How MyFreud can help

Whether anxiety tracks events or arrives on its own is the question a first appointment turns on, and it is very hard to reconstruct from memory. MyFreud gives you daily mood tracking that shows the pattern across weeks, so you arrive with a record rather than an impression.

Download MyFreud and start today: App Store or Google Play.