3 Ways to Manage Anxiety with Mindful CBT

When Julie came to me for therapy, she was very pregnant and very anxious about her health.

She was terrified that she would get cancer and die young, leaving her soon-to-be-born child and her three-year-old to grow up without a mom. Anxiety like Julie’s often develops when two things are true: 1) There’s an outcome we care about, such as being present for our kids, and 2) the outcome is uncertain, which is almost always the case for things that matter to us. Julie’s fears were especially pronounced because her own mom had died of cancer when Julie was in college.

For many weeks, Julie and I used research-based techniques to address her illness anxiety. Our work focused on three main approaches: tending to thoughts, facing fears, and focusing on what Julie could actually control. These techniques come from cognitive behavioral therapy, also known as CBT. As Julie discovered, integrating mindfulness into CBT provided more profound relief from anxiety.

1. Seeing Through the Stories

Julie worked on noticing the thoughts that contributed to her anxiety, such as the assumption that having a headache meant she must have a brain tumor. As we examined this type of thought together, Julie realized that her mind was making an inference that wasn’t true—since brain tumors can cause headaches, her headaches must be a sign of a tumor.

By considering the evidence more carefully, Julie understood that most headaches have more benign causes, which had been true for 100 percent of her headaches so far. These cognitive exercises helped her to recognize that her mind was terrifying her with stories that weren’t true. Through this process, she learned to take her thoughts less seriously.

But as helpful as this cognitive work was for Julie, it had one big limitation: The underlying premise behind challenging her thoughts was that she could be okay only if things worked out the way she wanted them to. Accordingly, the relief she found was fragile and persisted only as long as she believed she would stay healthy.

Julie found greater equanimity by questioning the deeply held assumptions on which her peace of mind was based. Was it true that she could know peace only if her health was good? Could she open herself to other experiences rather than cordon off certain possibilities as unacceptable? As Julie grew in her practice of mindful acceptance, she began to drop the conditions she had placed on her wellbeing. As a result, she found a deeper peace than she knew was available.

Ask yourself: Are there conditions you have placed on your peace of mind? For example, I can be okay only if this happens or doesn’t happen. What might it be like to let go of those preconditions and open to more of life?

2. Facing Fears

Julie had been avoiding all things related to cancer in order to avoid triggering her anxiety. But that avoidance actually reinforced her anxiety and played into her fears that even thinking the word “cancer” could cause her to get sick.

So Julie confronted her fears. For example, she read stories about moms who had developed cancer. She also repeatedly said and wrote “cancer” and related words. The exercises were hard while she did them, but over time her fear shrank. Mindful acceptance was a key part of these exposure exercises, helping Julie to accept the discomfort she felt as she faced her fears.

Julie also opened her mind to accept the uncertainty about her health that these exercises triggered. Rather than trying to convince herself that everything would work out fine, she practiced deliberately leaning into uncertainty. When she had a thought such as, “My cough means I have lung cancer,” she would respond by telling herself, “Maybe I do. And I’ll need to cope with it if it’s really cancer.”

Eventually Julie stopped feeling upset when she encountered the topic of cancer in her daily life because she had faced her fears on purpose and embraced the unknown.

Ask yourself: Are there certain things you’re avoiding due to anxiety? Consider whether the avoidance could be helping the anxiety to stick around. Are there small ways you could begin to face the things that trigger your anxiety?

3. Releasing a False Sense of Control

Mindfulness was a crucial element of the final part of Julie’s treatment: letting go of her efforts to control everything. For as long as she could remember, Julie had felt like her health was entirely up to her. That outsized sense of responsibility was a heavy burden and did not reflect reality. The truth was she didn’t have that kind of control because many factors contributed to her health, such as genetics.

Julie practiced mindful acceptance as she released ultimate power over her health. She began to focus instead on the limited but real control she did have, which amounted to living a healthy lifestyle.

Ask yourself: Are you assuming more responsibility and control in your life than you actually have? Consider letting go of control that was never yours.

These three approaches together helped Julie to feel much less anxious. She took a break from our treatment shortly before her baby was born and felt optimistic about managing her illness anxiety with the skills she had learned. But neither of us could have known that Julie’s biggest challenge was yet to come.

Finding True Freedom

A few weeks after her daughter’s birth, I got a call from Julie’s brother. “Julie’s in the hospital,” he told me. “She had a heart attack.” Julie had developed a rare postpartum complication that led to a major heart attack, and she nearly died. It was unclear whether she would see her children or husband again as the medical staff wheeled her into the operating room. Thankfully, the surgery was successful and she eventually made a full recovery.

When I met with Julie a few weeks later, she described being more at peace than ever. Her tranquility was apparent, as was her profound gratitude for all of life. Even pain felt like a gift, she told me, because it told her she was still alive. She still wanted to be in her kids’ lives for decades to come, but she no longer felt desperately attached to that desire.

Most of us will discover, as Julie did, that life continues beyond the horizon of our fears. With this awareness we can embrace all of our experience rather than just struggle against our worries and fears. By being fully present in our lives just as they are and opening to an uncertain future, we can connect to the deepest part of ourselves that witnesses all of our experience.

With this deeper connection, we’re no longer attached to ego-based judgments of what we want and don’t want: good or bad, gain or loss, fame or shame, safety or danger, life or death. There’s nothing left to fight against. We can meet life as it is and as we are. Love grows as our fear shrinks—love for self, for others, and for life in all its sadness and beauty.

Explore how mindfulness has the potential to aid the recovery process.