Being AWARE of Anxiety

Cognitive Therapy and Emotional Acceptance

Therefore when some terrifying sound, either from heaven or from a falling building or as a sudden announcement of some danger, or anything else of that kind occurs, even the mind of a wise man must necessarily be disturbed, must shrink and feel alarm... — Epictetus, Fragment

In recent decades, there’s been a revolution in the way cognitive-behavioural psychotherapists treat emotional disorders. A “third wave” of evidence-based therapies evolved that focus more on mindfulness of thoughts and acceptance of unpleasant feelings, rather than disputing our beliefs in order to change our emotions.

This change emerged from a growing body of research, which converged on the finding that people with severe anxiety and depression already tend to be trying too hard to think their way out of their problems and struggling too much to control their feelings.

The Stoic philosophy, which originally inspired cognitive therapy, had also endorsed a similar acceptance of unpleasant emotions, although this is often forgotten today.

Acceptance of uncomfortable emotions had already been taught by many earlier forms of psychotherapy, e.g., the Gestalt therapy of Fritz Perls and others, which developed in the 1950s. Indeed, even the original forms of behaviour therapy and cognitive therapy had, sometimes, taught emotional acceptance.

In his revised manual for the evidence-based treatment of anxiety disorders, Aaron T. Beck, one of the pioneers of cognitive therapy, clearly states that his objective is not to teach people how to “control their anxiety”.

Instead cognitive therapy focuses on helping individuals develop a more “accepting attitude” toward anxiety rather than a “combative (i.e., controlling) attitude.” When thoughts like “I can’t let these anxious feelings continue” are replaced with “I can allow myself to feel anxious because I know I’m exaggerating the threat and danger,” then the intensity and persistence of anxiety are greatly diminished. — Clark & Beck, 2010, p. 195

The Stoic philosophy, which originally inspired cognitive therapy, had also endorsed a similar acceptance of unpleasant emotions, although this is often forgotten today. When people today speak of “being stoic” (lower-case) they typically mean “having a stiff upper-lip”, i.e., suppressing or concealing unpleasant and painful emotions. Several modern research studies have shown that this is often an unhealthy way of coping, though. Lower-case stoicism actually does the opposite of what people are hoping. It tends to make us more emotionally vulnerable. The stiff upper-lip is really a sign, in most cases, not of psychological strength and resilience but of weakness. In contrast, ancient Stoic philosophy led to cognitive therapy, and modern evidence-based protocols for psychological resilience training, which many studies have shown to be healthy and effective.

Indeed, the Stoics make a very nuanced distinction between aspects of emotion that are involuntary and those that are voluntary. We should accept the former, as natural and inevitable, but take greater responsibility for the latter. When we’re caught in a threatening situation, they said, like being in a ship during a storm at sea, even a seasoned sailor will often turn pale and tremble, if his life is in imminent danger. We shouldn’t struggle against those feelings or view them as bad. However, we don’t need to make things worse either by worrying or ruminating about events afterwards, or complaining excessively about them.

Beck and his colleagues introduced the convenient acronym “AWARE” in their earlier treatment manual for anxiety disorders, Beck, Emery, & Greenberg, Anxiety Disorders & Phobias: A Cognitive Perspective (2005). I’ve taught it to hundreds, perhaps thousands, of therapy clients and students over the years. It’s a very simple tool for remembering healthy ways to cope with anxiety, and it can also be used to cope with other feelings such as anger or sadness.

Being AWARE

The letters of the word AWARE were used by Beck to stand for: Accept, Watch, Act, Repeat, and Expect.

• Accept your feelings as harmless and allow them to come and go naturally.

• Watch your thoughts from a detached perspective, as if observing someone else thinking them.

• Act in accord with your values, not your feelings.

• Repeat this process as often as possible.

• Expect realistic progress.

Accept your anxious feelings, or other unpleasant feelings as natural, transient and harmless. Allow yourself to feel them without becoming annoyed or frustrated with yourself. Literally, say “hello” in your mind to the thoughts and feelings and welcome them instead of putting up a fight. Accept the discomfort and think of it as being fairly normal. Acknowledge the fact that these feelings exist, and adopt a very patient attitude toward change, letting them come and go freely without struggle.

Watch your anxious thoughts from a detached perspective. Observe yourself non-judgmentally, without strongly evaluating your thoughts or feelings as bad, or yourself as flawed for having them. Just imagine you’re observing your them from a distance, without placing too much importance on them or buying into them too much. You are not your thoughts or your feelings; rather you’re the person watching them. Think of these internal experiences as transient things, like clouds passing across the sky, instead of becoming absorbed in them.

Act as normal despite your feelings, or, even better, act in accord with your core values. Behave as if you’ve already overcome your fears, and decouple your actions from your feelings. If you wait for your feelings to change before you change your behaviour, you’ll potentially be stuck forever. Reverse your avoidance behaviour and gradually face your fears in steps and stages, dropping any unnecessary signs of anxiety such as gripping objects for safety or averting your gaze from people. Approach what you fear, where possible, rather than avoiding it, and patiently remain in the situation, until you get used to the feelings.

Repeat as much as possible. Keep getting back in the saddle. Keep accepting your anxiety, watching it from a detached perspective, and acting as if you’re better until it becomes second nature and your feelings change. Also, consider repeatedly reviewing mental imagery of upsetting events while distancing from thoughts and accepting feelings. Be persistent, don’t give up, and eventually your anxiety should abate naturally.

Expect realistic improvement. Be hopeful, confident, and optimistic but don’t rush things. Be realistic about the possibility of encountering setbacks but also see them as temporary and surmountable. Approach them as opportunities to improve your coping skills. Expect that anxiety may return, because it’s human nature. However, you can also expect to learn better ways of coping and experience more improvements as long as you keep persevering.

To begin with, adopting this mind-set might take some effort. You’ll need to keep reminding yourself to do it. However, it soon becomes easier and will evolve into a habit, something you’ll find yourself doing automatically. It takes a lot of fuel to get a locomotive steam engine going, I’m told, but a lot less fuel to keep it moving once it’s started rolling. It sometimes takes a lot of motivation to begin learning new thinking habits but it takes less and less effort with each attempt — the main thing is to take the first step and get the process started. So why don’t you begin right now and see what happens if you put the AWARE strategy into practice as often as possible over the next few days or weeks?