Cognitive Behavioral Therapy is basically a collection of techniques that are effective for anxiety.

There are three main techniques: Relaxation Training (different forms of self-guided meditation), Thought Restructuring (a type of journaling where you practice talking back to thoughts on paper and then start doing it in your head), and Gradual Exposures (ways of confronting anxiety in such a way that your brain burns through it).

If you think of anxiety as being an enemy that comes up and messes with you periodically, there are three styles of fighting against that enemy: the Yoga Style, the Logic Style, and the Berserker Style.

The Yoga Style

The Yoga Style of fighting against negative thoughts or feelings is to push them away by focusing on a distraction. American-style distractions would be things like focusing on work, TV, exercise, or reading a book. More Buddhist forms of distraction would be things like focusing on your body, your breathing, or a mantra. This idea comes to western culture mainly through India - the idea of detaching from thoughts and feelings by putting your mind elsewhere.

The Logic Style of fighting against negative thoughts is to engage them by using logic and reason. This idea comes to western culture mainly through Greece - the idea that you can use logic and reason to manage all of your emotions.

The problem with the Yoga Style and the Logic Style is that they are notorious for working really well for mild and moderate anxiety, but then not working at all when you are really anxious. That’s because when you are really anxious, you can’t even focus on a distraction; and when you are really anxious, you can try talking back to the thoughts, but it just doesn’t seem believable in the moment. That’s where the Berserker Style comes in (AKA Gradual Exposures/Cathartic Techniques).

The Berserkers were a tribe of Nordic warriors in the Middle Ages related to the Vikings. They used to go into battle just wearing a bear skin and holding a sword. This is back when people used to wear armor, so these guys were basically out of their minds, but their deal was that they wouldn’t stop fighting unless they were killed - they just wouldn’t stop. So, they became the most feared warriors of the Middle Ages, because if you were a Berserker and you were about to attack a village, the people in the village would be like, “Holy &%#@! This person is coming that I literally have to kill them in order to make them stop!” It’s pretty intimidating. So, from then on, the kings of the Middle Ages designated their best troops as being their Berserker troops, and that’s where the word “berserk” comes from in the English language.

The Berserker Style of fighting against negative thoughts is, instead of talking back to them or pushing them away, once example of a Berserker technique would be to repeat your thoughts over and over again on purpose. For example, you might repeat “I’ll never get better” over and over in your head, while trying to feel bad about it. What you’re basically saying to the thought is, “Screw you. I’m going to keep doing this until either I die or you die, but one of us is going to die right now.” The great thing is that no thought can kill you. If you just stay on one sentence, it always starts to sound like a chant, or a song, or a mantra; and, if you do it long enough, your brain eventually starts talking back to the thought or you get distracted and start thinking about something else. You can use the same technique to focus on physical pain, panic symptoms, sadness, or anger. The feelings get more intense at first, but then your mind starts to wander. You can also use the same technique to expand your life by doing things just a little bit outside your comfort zone (such as leaving the house more often, reaching out to friends, and being more assertive). You would do things just a little outside your comfort zone, but over and over again until they are inside your comfort zone.

While not usually included in Cognitive Behavioral Therapy, I often also teach my patients Assertiveness as well (i.e. a technique I call a "Mind Bomb"). This is for three reasons: 1. Anxious people often have difficulty being assertiveness. 2. A lack of assertiveness often leads to anxiety (due to feeling victimized or harassed). and 3. Assertiveness often ends up being one of my patients’ favorite techniques.

Teaching all of these techniques usually takes five to seven sessions. So, after five to seven sessions, my patients usually know whether or not it's working. If it is working, then we keep meeting, but for shorter sessions, and we start to spread them out. If it’s working, then we focus on medications and/or I recommend a therapist who does a different type of therapy (such as EMRD, general talk therapy, couples therapy, or ISTDP).

Deciding which CBT techniques to use in a particular situation depends mainly on how responsive you are to each technique. The vast majority of the time, however, the following sequence seems to work well: When anxious, first try the Yoga Style and the Logic Style (because they are quicker). If those doesn’t work, then switch to the Berserker Style (because that usually ends up being the strongest and most reliable). When angry, try Cathartic Letters first, and then Assertiveness once you've figured out what's bothering you.

Although self-help is not the same as one-on-one treatment, I'd still like to provide you with the timing of how I teach these techniques to patients. Hopefully, this will help give you enough time to practice each technique, before moving on to the next one.

• Week 1 : Yoga Style (11-Muscle Relaxation, Smiling/Nodding)

• Week 2 : Yoga Style (Permission Breath Counting, Sensation Focusing)

• Week 3 : Logic Style (Dysfunctional Thought Records)

• Week 4 : Berserker Style (Sentence Exposures, "I Feel It" Exposures)

• Week 5 : Berserker Style (Sadness Exposures, Anger Exposures, Cathartic Letters, Real-Life Exposures)

• Week 6: Assertiveness ("Mind Bombs")

• Week 7: Emotion Validation, Neapolitan Assertiveness

Of note, if a patient feels strongly that a particular style will help them best, then I’ll usually start with that instead. For example, patients sometimes prefer to start with the Logic Style or the Berserker Style. In my experience, a patient’s gut feeling about what will work almost always ends up being right, so I find it best to start with what they feel most drawn to.