March 02, 2011

Just Don't Think About It

Last time, I described exposure therapy and how it can be used to successfully treat most common fears and phobias. But what if what you fear and avoid isn’t dogs, flying, or heights? What if you’re scared of and avoid your thoughts?

Some people get overwhelmed by worries—What if I can’t pay my rent next month? What if this lump is breast cancer? What if I marry the wrong person and one day get divorced?—and cope by pushing them out of their heads. Cognitive avoidance is the equivalent of putting your hands over your ears and singing “LA LA LALALA!” in order to not hear your scary thoughts. It’s things like distracting yourself with another activity, thinking about something pleasant instead, and avoiding places, people and situations that remind you of your worries.

The problem with cognitive avoidance is that it doesn’t work. Distracting yourself from worries provides short-term relief, but a) the relief you feel when you successfully avoid your thought reinforces the idea that the thought is scary and that you can’t deal with it, and b) thought suppression doesn’t work and your worry will come back. In the same way that crossing the street every time a dog approaches maintains and reinforces a dog phobia, avoidance of worries prolongs and reinforces worry.

The cure for cognitive avoidance is cognitive exposure. Cognitive exposure rests on the principle of habituation, that is, that with enough exposure to a feared stimulus, anxiety always fades naturally. In this case, the feared stimulus is your worry. Cognitive exposure requires you to choose one of your worries and compose a short text describing the worst-case scenario. You have to include all the thoughts and images that you associate with the worry, especially the most disturbing ones; you have to describe the situation in the present, as if it were happening right now, leaving out any reassurances or distractions. In other words, write out your worst nightmare in the simplest, scariest way. 

The exposure part is to interact with the scenario by listening to a recording of yourself reading it out loud. You have to close your eyes, vividly imagine yourself in the situation, and allow your anxiety to mount. Prolonged and repeated exposure (e.g., 45 minutes every day for a week) to your scenario will decrease your anxiety to the point that you’ll eventually be able to hold the worry in your mind without becoming overwhelmed or having to distract yourself.

NB: Cognitive exposure is primarily indicated to help with hypothetical worries (e.g., What if I get divorced one day?) whereas real and current worries (e.g., What if this lump is cancerous?) are managed through problem solving. However, I think that cognitive exposure can be used for both types of concerns. It’s true that if you have a lump (real and current problem), you need to see a doctor; however, if you’re too anxious to even think about the lump, let alone make an appointment, cognitive exposure can help you calm your fear enough to be able to begin the problem solving process.


  1. 45 minutes of exposure seems like a long time!

  2. So is this why writing journal entries (or blogs, say) is thought to be effective in dealing with your life worries?

    And yah, how is one supposed to commmit 45 minutes (out of maybe 3-4 hours of free time a day) to something that we perceive as being scary and horrible? That sounds not so fun.