Reading · Inside the Curious Mind

If you’ve ever been told to “talk it out,” you’ve heard the standard prescription for anxiety: sit down, unpack your worries, analyze them. For decades, that’s been the gold standard.

Still, when it comes to anxiety, talking it out can sometimes keep people stuck.

As a psychiatrist and neuroscientist who’s spent years watching anxious minds (including my own), I’ve started to see that traditional psychotherapy, especially the kind that centers on talking about worry, may not fit how anxiety actually works in the brain. The problem isn’t therapy itself. Ironically, it’s that the process of talking and analyzing often runs against the way anxiety keeps itself alive.

To be clear, psychotherapy helps a lot of people. For depression, trauma, and relationship struggles, it can be really helpful. For anxiety, especially generalized anxiety disorder (GAD), the results are less consistent.

A recent JAMA Psychiatry meta-analysis found that several psychotherapies, traditional CBT, “third wave” cognitive approaches (eg. Acceptance and Commitment Therapy), and relaxation, beat treatment-as-usual (TAU). TAU is basically whatever someone is already doing. Importantly, FIVE treatments, including psychodynamic psychotherapy, supportive psychotherapy, and cognitive restructuring were no better than TAU. In other words, it didn’t make a difference if someone with GAD would have gone to that type of therapy or saved their time and money for other things.

With the three treatments that were better than not going to therapy, another study showed that average remission rates for traditional CBT only hover around 50 percent. In other words, half of people still feel anxious after months of therapy.

That’s not half bad, as the saying goes. But, half also isn’t great.

Flip a coin to see if you are in the category that benefits. Does this make you worry a little? It has certainly kept me up at night, wondering what is missing in how we approach treating anxiety. To see what, it helps to look at how anxiety actually works.

Generalized Anxiety Disorder is fundamentally different from other anxiety disorders. No specific trauma causes it. No particular situation triggers it. In fact, it often triggers itself: my patients wake up feeling anxious for no particular reason, and then worry all day only to (try to) go to sleep and repeat the process the next day.

With GAD, what you see is chronic, uncontrollable worry that becomes self-perpetuating. The clinical challenge isn’t figuring out where it came from, but instead interrupting the ongoing process that keeps it going.

GAD is maintained by a learning mechanism in your brain. Specifically, negative reinforcement (one of the most powerful learning processes we have).

Think about how worry actually works. You’re sitting at home, and your mind starts spinning about something bad that might happen. Maybe it’s your job, your health, your relationships. The worry feels productive, like you’re preparing yourself, preventing disaster, at least doing something about the problem.

Then the feared outcome doesn’t happen. And here’s where your brain learns the wrong lesson: “See? The worry helped. It either prevented the bad thing or prepared me for it.” That moment of relief when the catastrophe doesn’t strike? That’s negative reinforcement in action. Your brain just got rewarded for worrying.

By the time someone comes to see me, they’ve often reinforced this cycle thousands of times. The worry has become automatic, habitual. It’s their brain’s go-to strategy for dealing with uncertainty.

But there’s a deeper mechanism at play. I’ve written about this in previous articles (see anxiety = habit), but here’s the skinny: research by Tom Borkovec and colleagues several decades ago revealed something crucial about worry: it’s not a passive symptom. It’s an active avoidance strategy.

People with GAD aren’t just anxious. They’re using worry to avoid something that feels even worse. When researchers ask GAD patients what they’re doing when they worry, they often say they’re trying not to think about “even more emotional things.” They’re using worry (which lives mostly in their heads as verbal, linguistic thought) to distract themselves from deeper, more visceral feelings of distress.

Think of it as an avoidance hierarchy. At the bottom is the sharp, somatic, gut-level feeling of vulnerability or dread. That can feel pretty unbearable. So instead, the person retreats into worry, which is uncomfortable, sure, but feels safer and more controllable than the raw emotional experience underneath.

There’s even a more refined model that adds to the picture called the Contrast Avoidance Model. It suggests that GAD patients are uniquely afraid of sudden negative emotional shifts. They don’t want to feel okay one moment and then get hit with bad news the next; that emotional whiplash feels dangerous. So they maintain a constant low level of negative affect through worry. They’re pre-loading the distress, staying perpetually braced, because it feels safer than being caught off guard.

This is why simply understanding where your anxiety comes from doesn’t fix it. The behavior is tied to a perceived survival function. Your brain thinks worry is keeping you safe.Not only is it not keeping you safe, it is making it harder for you to think and plan, let alone live a normal life.

Let’s use the example of traditional insight-oriented psychotherapy, which runs into trouble with GAD.

The foundation of insight therapy (whether psychodynamic or other exploratory approaches) is that if you understand the unconscious patterns and historical causes of your symptoms, you’ll be able to change them. You talk about your childhood, your relationships, your recurring patterns. You gain insight into why you are the way you are.

The problem? Gaining intellectual understanding (insight) doesn’t automatically give you the capacity to tolerate intense, present-moment emotional discomfort. And for GAD, that’s exactly what’s required.

Remember, GAD is maintained by avoidance. To break an avoidance behavior, you need to learn how to tolerate the uncomfortable feeling of anxiety, and relate to it differently.

What often happens instead? The GAD patient sits in the therapist’s office and does what they always do. Based on what I’ve seen over the past decades, here’s how this tends to go: They retreat into their head. They intellectualize. They analyze. They tell elaborate stories about their worry. They stay as far as possible away from their direct, embodied experience, because going there is uncomfortable. And if the therapist is trained to explore and validate and help the patient gain insight, they go along with this process.

The problem is that this extended verbal processing can function as a sophisticated form of the same avoidance the patient uses outside of therapy. The patient feels like they’re doing something productive (and they are, in terms of self-understanding), but they’re not actually confronting the visceral experience they’re avoiding. Worse, the therapeutic relationship (the caring, supportive presence of the therapist) can actually reinforce this cognitive retreat.

Ethan Kross, a researcher who studies what he calls “chatter” (that repetitive stream of anxious negative thoughts), has shown that when someone deeply describes a difficult experience to a caring listener, it can actually fuel the negative emotions rather than resolve them. He calls this “co-rumination”: you’re both tossing fresh logs onto the fire of an already burning internal monologue.

The therapeutic alliance feels supportive, and that’s valuable. But if all you’re doing is revisiting and rehashing the worry without learning concrete skills to interrupt it, you’re essentially practicing the problem. You’re getting better at the very thing that’s keeping you stuck.

Yikes.

We now know what works for GAD. The most effective treatments (enhanced Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, mindfulness-based approaches) all share a common feature: they directly target the avoidance mechanism. They teach you skills to tolerate internal distress and actively interrupt the reinforcement loop.

Enhanced CBT doesn’t just challenge the content of your worried thoughts (though it does that too). It targets the process of worry itself—the generalized verbal thinking style, the cognitive biases that maintain it.

Acceptance and Commitment Therapy (ACT) takes a different angle but hits the same target. Instead of trying to change the thoughts, ACT teaches you to change your relationship with them. You learn to observe anxious thoughts without getting fused with them, to tolerate uncomfortable feelings without needing to fix them or make them go away. Research shows that increases in psychological flexibility, which is a fancy term for the ability to experience discomfort while still taking meaningful action, predict recovery from GAD, even when the frequency of worries doesn’t change much.

Let me translate this into the reward-based learning framework I use in my lab and clinic. Anxiety is a habit loop: trigger (uncertainty, stress) → behavior (worry) → reward (temporary relief from deeper distress). Like any habit, it’s maintained because the reward is immediate and the costs come later.

To break it, you need to update the reward value of the old behavior and find something that’s more rewarding than the habit you’re trying to change.

This is where mindfulness practices come in. Techniques like RAIN (Recognize, Allow, Investigate, Nurture with self-compassion) teach you to pause between the trigger and the automatic reaction. You learn to recognize the urge to worry, get curious about what anxiety actually feels like in your body (not what you think about it, but the raw sensations), and discover that you can tolerate it without needing to do anything about it.

When you bring awareness to the actual experience of anxiety (the tightness in your chest, the buzzing in your stomach, the contraction in your throat), you update the reward value in real time. You learn that the discomfort is tolerable. The sky doesn’t fall. And curiosity itself becomes rewarding, more rewarding than the temporary relief of worry.

My lab has studied this. We’ve found that when people get curious about cravings and urges instead of fighting them or giving in to them, they can decouple the trigger from the behavior. We’ve shown this works for smoking cessation (five times better than the current gold standard), for emotional eating (40% reduction in craving-related eating), and for anxiety, where we found a 67% reduction in symptoms in people with GAD.

The key here is that people are shifting from thinking and talking (and worrying) about their anxiety to learning skills that target the specific mechanism maintaining the disorder.

So why doesn’t everyone take one of these evidence-based (and theoretically aligned) approaches?

Things get even more frustrating now. I’ve just spent several hundred words explaining why you need evidence-based CBT or ACT instead of traditional talk therapy. But there’s a massive gap between knowing what works and actually getting it.

Let’s talk about cost first. A CBT session typically runs between $100 and $250 out of pocket in most of the U.S., with prices higher in major cities. If you have insurance, you might pay a copay of $20-$50 per session using an in-network provider, but many therapists don’t accept insurance at all. (Why? Because insurance companies can restrict treatment plans, limit the number of sessions, or require a diagnosis that not everyone is comfortable receiving. The very system designed to make treatment affordable can end up limiting access to the treatment you actually need. Thank the insurance industry for this monetary-forward instead of mental health-forward model.)

You can probably do the math yourself: Even at the lower end (let’s say $100 per session), you’re looking at $1,200-$1,500 just for the first three months of therapy. With insurance and a favorable copay, you might cut that to $240-$300. And that’s for only 3 months. And don’t forget, only 50% of people show significant benefit here.

Let’s say you can afford it. Now you need to actually find a therapist. I’m sorry to sound cynical, but good luck.

Over half (56%) of psychologists surveyed in 2023 reported having no openings for new patients. Among those who keep waitlists, average wait times were three months or longer, and nearly 40% said their waitlist had grown in the past year. Three months. That’s three months of continuing to reinforce your anxiety habit loop, three months of suffering, three months where, according to research, longer waits are associated with greater drop-out and disengagement once intervention begins.

The situation is even worse in rural areas. Seventy percent of rural counties don’t have a psychiatrist. Transportation becomes a major barrier when mental health providers are scarce and you have to drive an hour or more just to get to an appointment. Some areas report even more dire statistics. In Maine, preliminary survey results from 2024 showed clients waiting an average of 32 weeks (more than half a year) for mental health counseling services. Yes you read that correctly. More than HALF a YEAR.

Okay, so you’ve somehow found a therapist who says they do CBT, you can afford it, and they have an opening. Now you’re playing another lottery: will they actually deliver high-quality, evidence-based treatment?

This is where the gap between clinical trials and real-world practice becomes critical. Clinical trials of CBT use therapists who are extensively trained, closely supervised, and whose adherence to the treatment protocol is regularly monitored. In contrast, real-world therapists may experience “therapist drift:” the tendency to only partially adhere to established empirically supported practices.

This is important because therapist adherence to concrete CBT techniques predicts patient improvement and symptom change. If your therapist isn’t actually implementing the core components of CBT, you’re not getting the treatment that showed those impressive results in the research studies.

You often can’t tell the difference. A therapist can call what they’re doing “CBT” while spending most of the session in supportive conversation that looks a lot more like traditional talk therapy. Unless you know what to look for, you won’t know you’re not getting the real thing until months have passed without improvement.

I’m not telling you this to be discouraging. I’m telling you because it’s real, often not talked about, and pretending these barriers don’t exist doesn’t help anyone.

So what does all of this mean if you have GAD?

First: your brain isn’t broken. It learned a strategy (worry) that seemed protective at the time. That strategy is now causing more problems than it solves, but your brain keeps using it because of how reinforcement learning works.

Second: insight alone won’t fix this. Understanding why you’re anxious is interesting, and it might help in some ways. But it won’t give you the skills to tolerate distress or interrupt the habit loop. In fact, if therapy keeps you “in your head,” it might be inadvertently reinforcing the avoidance.

Third: you need skills training, not just support. The most effective GAD treatment teaches you to recognize when you’re using worry as avoidance, to get out of your head and into your body (where primary emotions actually live), to tolerate uncomfortable feelings without needing to fix them, to observe thoughts without getting fused with them, and to take meaningful action even when you feel anxious.

This has nothing to do with positive thinking or trying to convince yourself everything will be okay. You’re changing the underlying learning process. You’re teaching your brain that safety doesn’t come from worry; it comes from your capacity to handle whatever shows up.

[A note to therapists:] If you’re a therapist reading this, I’m not saying insight is worthless or that the therapeutic relationship doesn’t matter. Both can be valuable.

But if you’re treating GAD, watch for verbal processing that functions as a safety behavior. If your patient spends the entire session in intellectual analysis, gently redirect them to the somatic, emotional experience underneath. Remember that co-rumination, even in a supportive therapeutic context, can reinforce the problem. I don’t need to tell you that what we all signed up for isn’t just to help the patient feel heard, it’s to help them develop the skills to interrupt the cycle. And most importantly: exposure to emotional discomfort is necessary. One of the big and often uncomfortable tasks of therapists (especially those who haven’t nailed distress tolerance themselves) is to learn to stay with uncomfortable feelings in session, not just talk about them. Distress tolerance is where the real growth happens (for both patients and therapists).

I know this is harder to do when you’re seeing 30+ patients a week, when insurance is breathing down your neck about session limits, when you didn’t get training in these specific protocols. The system makes it hard to do excellent work. But understanding the mechanism—that GAD is maintained by negative reinforcement of avoidance—can help you recognize when you’re inadvertently enabling that avoidance, even with the best intentions.

If you’re struggling with chronic worry and traditional therapy hasn’t helped, it’s not your fault. The approach may simply be mismatched to the problem. And if you’re struggling to access any therapy at all, that’s not your fault either—it’s a systemic failure.

If you can access face-to-face therapy, look for therapists trained in evidence-based treatments for GAD (enhanced CBT, ACT, or mindfulness-based approaches). Ask explicitly whether the treatment will include skills training (not just insight or exploration), exposure to uncomfortable emotions (not just talking about them), homework and between-session practice, and concrete techniques to interrupt worry cycles. Ask about their training and supervision in these specific approaches. Don’t be shy about this; it’s your time and money.

If you can’t access or afford traditional therapy, consider digital therapeutics and app-based interventions that teach the same principles. Look for programs based on evidence-based approaches that specifically target anxiety as a habit loop. These aren’t perfect substitutes for skilled human guidance, but they can teach you the core skills you need. Consider group therapy if available (it’s usually more affordable and for GAD can be as effective as individual therapy). The connection with others struggling with similar issues can itself be therapeutic.

Regardless of your path, remember: anxiety is a habit. Like any habit, it can be unlearned. But you need the right tools for the job—tools that target the mechanism, not just the symptoms.

The goal isn’t to never feel anxious. Stop being afraid of your anxiety, stop feeding it with avoidance, and start living your life even when uncertainty is present.

The future is always uncertain. No amount of worry will change that. But you can change how you respond to uncertainty. And that changes everything.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

REFERENCES

Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 77–108). Guilford Press.

Brewer, J. A., Roy, A. H., (2021) “Can approaching anxiety like a habit lead to novel treatments?” American Journal of Lifestyle Medicine 15(5).

Gao, M., Roy, A., Deluty, A., Sharkey, K. M., Hoge, E. A., Liu, T., Brewer, J. A., (2022), “Targeting anxiety to improve sleep disturbance: a randomized clinical trial of app-based mindfulness training.” Psychosomatic Medicine 10-1097.

Kross, E. (2021). Chatter: The voice in our head, why it matters, and how to harness it. Crown.

Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting the contrast avoidance model. Behavior Therapy, 42(3), 375–390. https://doi.org/10.1016/j.beth.2010.10.006

Papola, D., Gastaldon, C., Ostuzzi, G., Tedeschi, F., Purgato, M., & Barbui, C. (2024). Comparative efficacy and acceptability of psychotherapies for generalized anxiety disorder: A systematic review and network meta-analysis. JAMA Psychiatry. Advance online publication. https://doi.org/10.1001/jamapsychiatry.2024.

Roy, A. H., Hoge, E. A., Abrante, P., Druker, S., Liu, T., Brewer, J. A., (2021) “Clinical efficacy and psychological mechanisms of an app-based digital therapeutic for generalized anxiety disorder.” JMIR 23(12):e26987.

Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical Psychology Review, 61, 1–8.

Stone, L. B., & Hankin, B. L. (2011). Correlates of co-rumination among children and adolescents: The role of emotional clarity, cognitive style, and friendship quality. Journal of Abnormal Child Psychology, 39(6), 921–933. https://doi.org/10.1007/s10802-011-9514-9

Association of American Medical Colleges. (2023). Exploring barriers to mental health care in the U.S. https://www.aamc.org/about-us/mission-areas/health-care/exploring-barriers-mental-health-care-us

Directions Counseling. (2023). How much does CBT cost? https://www.directionscounseling.com/how-much-does-cbt-cost/

Penn Center for Cognitive Therapy. (2024). Fees and insurance information. https://www.med.upenn.edu/cct/fees.html

Verywell Mind. (2024). How much does therapy cost? https://www.verywellmind.com/cost-of-therapy-survey-5271327

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Why psychotherapy may not be the best way to treat anxiety

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