About two millennia ago, suspected for his role in a plot when he was likely innocent, the ancient Roman philosopher known as Seneca, was targeted by the empire’s ruling class and marked for death. As things quickly slipped out of his favor, a thought occurred to him: “What’s the worst that can happen?”
His way of coming to terms with the inevitable might have some merit. Today, there is a growing body of research literature suggesting that an exercise in the spirit of Seneca- —permitting the anxious brain to reflect and create a tangible vision of what its worst fears would look like if allowed to come to fruition —is in fact one of the most evidence-based methods of anxiety therapy. This particular exercise is known in the scientific community as imaginal exposure, affording the patient an opportunity to “face the thing you’re most afraid of” by invoking it mentally, according to Dr. Regine Galanti, who is the founder of Long Island Behavioral Psychology. As a licensed clinical psychologist, Galanti routinely incorporates the use of imaginal exposure into her therapy.
As a subset of cognitive behavioral therapy (CBT), imaginal exposure relies on simple logic. Just as anxiety is created in your head, it can also be squashed in your head. And even though the most effective anxiety treatment is administered by a mental health professional over a long period of time, a growing brigade of psychologists are finding ways to help people attempt imaginal exposure in their own homes, on their own terms.
In the two thousand years before imaginal exposure would earn its reputation as one of science’s most durable remedies for anxiety, dozens of ancient Greek and Roman philosophers shared a similar intuition about the theoretical value of worry.
In the year 64 A.D., Seneca wrote to his friend Lucillus: “There are more things likely to frighten us than there are to crush us. We suffer more often in imagination than in reality. What I advise you to do is, not to be unhappy before the crisis comes, since it may be that the dangers before which you paled as if they were threatening you, will never come upon you.”
Dr. Marc Antoine Crocq, a psychiatrist at Centre Hospitalier Universitaire in eastern France, proposes that it was their worldview that informed their religious beliefs“They believed in a god (Zeus or Jupiter) who was rather distant and not interested in the daily life of humans,” says Crocq, who has researched the topic. “So they tried to understand the world and human functioning with a more materialist scientific approach.”
The conclusion these philosophers came to, according to Crocq, is that “pathological anxiety is a mental representation”— coming from the same mental construct as thought. Consequently, they felt it was something that we could confront ourselves.
Dr. Stefan Hofmann, who is a professor of psychology and the director of the Psychotherapy & Emotion Research Laboratory at Boston University, set out to prove this with empirical data. As with Crocq, he has looked into the ancient historical roots of this theory. In his work, he references the ancient Greek philosopher, Epictetus, of the school of Stoicism and famously wrote: “Men are not moved by things, but the view they take of them.”
Epictetus and his contemporaries believed in the development of self-control as the road to virtue, the only way to avoid being overcome with destructive emotions. As Hofmann explains, “The idea [behind that quote] is that we are always engaging with our environment to make sense of it, and so it really matters how we perceive things. Anxiety itself is a healthy, adaptive response to an environmental threat, but sometimes, those perceptions are maladaptive, if they’re not actually putting you in danger.” Think of how easily we tend to fear unknown things like snakes, spiders, or even being thrust into a new social situation where we can’t quite read the room. “Sometimes we respond with emotional distress in situations where it doesn’t make sense to feel emotional distress.”
Getting to the root of these maladaptive perceptions is central to CBT and why Hofmann got into it in the first place, a profession he has described as “toning down the intensity of the emotional states” that accompany anxiety, in order to help the individual feel better. When Dr. Aaron Beck, who passed away earlier this month, first proposed this approach back in the 1960s, he had an interest in helping people to realize the disconnect between their thoughts and the reality of the situation they faced.
While every practicing therapist might vary in their ways of administering CBT, the element of imaginal exposure—targeting the primary source of the thoughts that cause anxiety and then replacing them with healthier thought patterns tends to be a common ground between practicing therapists and their patients.
In the five decades since Beck coined his practice, CBT has regularly been hailed as one of the more effective means for managing anxiety over the long term. Hofmann authored what is one of the most widely cited literature reviews on the efficacy of the practice. By the same token, imaginal exposure, just the sliver of CBT older than the therapy itself, has been linked to a large swath of mental health gains, improving things like a reduction in both worry and negative emotion, improving the classic symptoms of depression and even those associated with post-traumatic stress disorder and also increasing an individual’s ability to engage in activities they once dreaded.
Unfortunately, not everyone is able to enjoy access to professionally-administered cognitive therapy. A single study of 2,300 psychotherapists throughout the U.S. revealed that just 69% of them used CBT when it came to treating anxiety and depression – in some instances, just prescribing meds. Of course, another issue is the lack of access. One Census Bureau survey reveals that over one-third of Americans reside in areas that lack mental health professionals. This problem has actually gotten worse just over the last year. When the COVID-19 pandemic set off record rates of anxiety across the country, it also caused a shortage in the number of therapists who were available to talk to patients. The good news, however, is that even without professional supervision, help could still be on the way. According to psychologist Dr. Regine Galanti, there are a number of basic CBT-informed techniques that anyone can apply in their own lives.
Before encouraging people to actively confront their worry, Galanti starts with a simple question: why is it there in the first place?
“People don’t often stop and think about what it is that they’re afraid of, or even that they’re afraid at all,” she says when it comes to our anxieties. One patient might be afraid of cats or dogs, for example, and avoids them as a result, but may not necessarily know what’s driving that fear.
Once she has helped her patients to identify what provokes their fears, Galanti then helps them to validate the emotion—without working to downplay it or reassure the patient that their fears are misplaced. “We think naturally when someone’s anxious to say, ‘Oh, don’t worry, it’s gonna be okay,’ but anxiety is not logical,” she says. “Often when we feel anxiety coming on, we do everything we can to get away from it, but we’re rarely successful, since we don’t follow it through to its logical conclusion. So these little worries just pile up, and you never actually give it the time and space to see what happens when it is there.”
In the case of her patient who was afraid of dogs, Galanti took an approach that to some might have appeared counterintuitive: inviting her patient to meet and spend time with a dog, allowing her to face the fear when she approached it. This was successful, according to Galanti – but not all of her patient’s fears are as concrete. How, for example, might one deal with the death of a loved one and the mixed feelings that come with it, using the modeling approach? “It’s about learning to handle uncertainty that we don’t know what’s going to happen,” she says. “But how can we orient ourselves to the present to say it’s not happening now?”
This piece of advice was particularly invaluable in the earliest days of the COVID-19 pandemic, when uncertainty about the future multiplied in just a short period of time – among people who did not always have these feelings of uncertainty before. When the pandemic hit, Galanti publicly suggested that people should set apart 15 minutes of their day as personal “worry time.”
“Anxious thoughts tend to take over your thinking, and it ends up being a game of whack-a-mole—when you knock one down, another pops up,” says Galanti. “So this strategy focuses on not postponing your worries, [instead] setting up a time where you can worry all you want.”
In this strategy, Galanti encourages her patients to write down whatever it is that brings them anxiety, and then have them select a certain time slot in their day—typically not before bedtime—to reflect on those worries. One advantage of this exercise is it gives the individual some control over their concerns without fringing on their productivity. “The reason why this works is that it sets boundaries, so when a worry comes up at 9 a.m., you can say, ‘Hey, not now, your time is coming.’”
She says that it’s rare for people to make use of the full 15-minute time frame to worry, but what it does do is allow the patients to add some perspective to their own episodes of anxiety. “Sometimes when you hit your worry list, you might find that the thing that bugged you at 9 a.m. that you thought would be the end of the world is actually not bugging you anymore at all.”
