Cognitive behavioural therapy for anxiety: understanding your own thoughts

You want to speak during a meeting. Before you raise your hand, a thought appears: “I will lose my train of thought, and everyone will think I am incompetent.” You feel tense and stay silent.

This fictional example raises a question that matters in cognitive behavioural therapy: what happens between a situation and our response to it? Recognising a feared prediction can be a first step towards having more choice in how we respond.

What is cognitive behavioural therapy?

Cognitive behavioural therapy, or CBT, examines how thoughts, feelings and behaviour interact. For anxiety, it can help people examine distressing appraisals and approach situations they have been avoiding. The UK's National Institute for Health and Care Excellence includes CBT among treatment options for generalised anxiety disorder and panic disorder. [1]

For you, this means that both your interpretation of a situation and your response to it can be explored in therapy. You do not have to justify feeling anxious.

A feared outcome is not yet an observed event

Return to the meeting. “I will lose my train of thought” is a prediction. “Everyone will think I am incompetent” adds another assumption: you believe you already know how others will respond.

For the person in our example, the situation and its interpretation might be separated like this:

• Observation: “I am in a meeting and want to make a suggestion.”

• Prediction: “I will embarrass myself.”

• Feelings and physical responses: anxiety, tension, warmth in the face.

• Behaviour: staying silent even though the suggestion seems important.

The anxiety is genuinely felt. Whether the prediction will come true is still an open question. Therapy offers a place to explore that question together. [1]

One possible question in this example is: “What do I know about this meeting, and what am I afraid might happen?” There may have been difficult experiences before. Perhaps earlier contributions were also received constructively. Both can inform the appraisal.

Noticing thoughts and taking a step back

“I will embarrass myself” can be rephrased as: “I notice that I am having the thought that I might embarrass myself.”

This illustrates decentering: experiencing thoughts as mental events rather than identifying fully with them. A small study following group CBT for social anxiety found that increases in decentering were associated with improvement on most outcome measures. This suggests a possible mechanism of change; it does not establish that observing thoughts alone treats an anxiety disorder. [3]

For the person in our example, this sentence could be an invitation to pause: “This fear is here. How do I want to respond to it?” There is no need to force a feeling of calm.

A short thought record exercise

A thought record is a common CBT exercise for examining a specific situation and the appraisals connected with it in writing. These questions are adapted from the NHS thought record. [2]

• Situation: What happened?

• Feelings: What did I feel?

• Thought: What feared prediction went through my mind?

• Supporting evidence: What observations support it?

• Contrary evidence: What observations count against it?

• Alternative: What more balanced appraisal fits the information?

• Afterwards: How do I feel now? [2]

A completed example might look like this:

“In the meeting I wanted to ask a question. I feared it would sound stupid. Supporting evidence: I do not know the topic well yet. Contrary evidence: other people also asked questions, and nobody has been put down for doing so. A more balanced appraisal might be: my question shows that I want to understand something. I cannot know what everyone thinks. I could also cope with a brief or critical response.”

The example deliberately does not promise a particular outcome. The person might feel a little more confident, or their anxiety might initially stay much the same. An honest entry could also read: “I understand my fear better now, but I still feel tense.”

Why new experiences matter too

Avoidance can bring short-term relief while maintaining fears over time. Behavioural approaches therefore include gradually approaching feared situations that are actually safe. This creates opportunities to compare predictions with experience. [4]

In our example, a step planned with a therapist might be to ask one short question during a manageable meeting. Afterwards, the person would compare: “What did I expect? What did I actually observe? What is still unclear?”

One possible learning goal would be to contribute despite feeling tense. The level of difficulty and approach should fit the person. Professional support is appropriate when anxiety is pronounced. [1, 4]

What research says about effectiveness

A 2018 meta-analysis by Carpenter and colleagues included 41 randomised trials involving 2,835 participants with anxiety and related disorders. Compared with psychological or pill placebo conditions, CBT showed an average moderate advantage for symptoms of the disorder being treated. [5]

A network meta-analysis by Papola and colleagues, published in 2024, examined 65 randomised trials involving 5,048 adults with generalised anxiety disorder. CBT was associated with lower anxiety symptoms than treatment as usual, including at follow-up three to twelve months after treatment ended. Certainty of evidence for the short-term comparison was rated moderate. [6]

These findings concern complete treatments. They do not establish the effectiveness of a single sentence, one writing exercise or a particular app. Average improvements also cannot predict how any one person will respond to therapy.

Something you can try

If the meeting example feels familiar, you could begin with one specific question: “What prediction is my mind making right now?” Choose a manageable situation to write about and approach your entry as a curious investigation. You do not need a perfectly worded alternative thought.

If anxiety substantially restricts your daily life, consider speaking with a qualified mental health professional or doctor. They can help assess which treatment fits your situation. This article provides information and does not replace individual assessment or therapy.

Sources and further reading

[1] NICE. Generalised anxiety disorder and panic disorder in adults: management (CG113). Recommendations and patient information. https://www.nice.org.uk/guidance/cg113 https://www.nice.org.uk/guidance/cg113/ifp/chapter/what-treatments-should-i-be-offered-for-gad

[2] NHS, Every Mind Matters. Thought record. A guide to using a thought record. https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/self-help-cbt-techniques/thought-record/

[3] Hayes-Skelton, S. A., & Lee, C. S. (2018). Changes in Decentering Across Cognitive Behavioral Group Therapy for Social Anxiety Disorder. Behavior Therapy, 49(5), 809–822. https://doi.org/10.1016/j.beth.2018.01.005

[4] NHS, Every Mind Matters. Facing your fears. Information about avoidance and gradual exposure. https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/self-help-cbt-techniques/facing-your-fears/

[5] Carpenter, J. K., et al. (2018). Cognitive Behavioral Therapy for Anxiety and Related Disorders: A Meta-Analysis of Randomized Placebo-Controlled Trials. Depression and Anxiety, 35(6), 502–514. https://doi.org/10.1002/da.22728

[6] Papola, D., et al. (2024). Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials. JAMA Psychiatry, 81(3), 250–259. https://doi.org/10.1001/jamapsychiatry.2023.3971

Sources checked on 11 October 2026.