What would convince you to face anxiety?

February 22, 2019 11:43 AM

What are the most compelling and succinct explanations you've heard for why coping with anxiety by avoiding the things that make you anxious is a bad idea, and why facing the things that make you anxious is a good idea? What would it take to convince you that anxiety goes away when you confront it, and the things that make you anxious will eventually no longer make you anxious if you face them repeatedly?

I'm a researcher who studies trauma/PTSD and a clinician who treats PTSD and other anxiety disorders. It's pretty universally agreed among those who study anxiety/PTSD, and is a fundamental assumption of cognitive behavioral therapy, that avoiding things that make you feel anxious maintains anxiety. Avoidance works well in the short term to make anxious feelings fo away, but doesn't change that the thing that makes you anxious still makes you anxious. Cognitive behavioral therapies for anxiety (especially the ones that focus more on the "behavioral" part) work by getting people to confront the things that make them anxious and stick with the thing until the anxiety goes down. This is called "exposure." People who aren't pathologically anxious tend to do this naturally.

So the main problem here is that avoidance works in the short term but maintains anxiety in the long term. Avoidance coping is also a problem because:
1) unless they're 100% successful at avoiding everything that makes them anxious, the person will still have to feel anxious whenever they are confronted by one of those things
2) to avoid most things that make them anxious, they may have to give up doing things they cared about or that are important to their goals, and they may resort to using illicit drugs or alcohol to suppress their anxiety
3) the person never discovers for themselves that they can handle the things that make them anxious or feeling anxious itself, so they may see themselves as less capable or strong than they actually are

It's not a problem to explain this to therapy clients, because you can talk back and forth about it. They're often skeptical that anxiety goes down when you confront the thing that makes you anxious, but they test it out for themselves when they try exposure, and they nearly always find that their anxiety goes down and the thing that was a trigger before becomes less of a trigger. So they prove it to themselves.

BUT. I'm increasingly called upon to explain this in a soundbite to reporters. They often come to me with questions like, "how can people with PTSD prevent being triggered" or "how can people relax when they are triggered." What are some ways that I can gently challenge the premise (that anxiety and things that make you anxious are bad things that should be avoided) BRIEFLY without sounding patronizing or blaming people for the anxiety they feel? What would convince YOU?

Please avoid debating the premise of whether exposure is a good thing.

posted by quiet coyote to Society & Culture (23 answers total)

"An anxious person's brain has somehow gotten wired to associate more danger with something than generally exists. It then very reasonably tries to get them to avoid that thing for the person's own good. When they are able to experience that thing in a controlled, safe way, they are helping their brain to learn that it's not as dangerous as they thought."
posted by praemunire at 11:54 AM on February 22, 2019 [3 favorites]

Jon Kabat-Zinn, who has written a great deal on Mindfulness Based Stress Reduction technique has a quote I like that is very succinct but would take a little unpacking, although it gets the idea right:

"You cannot stop the waves, but you can learn how to surf" - therapy helps teach folks with PTSD to surf. Surfing here is a metaphor for skillful navigation past an onslaught of emotion.

Other quotes I've used to remind MYSELF to face my fears: "Whatever it is, it's already here" (also from Kabat-Zinn) - basically, the thing I'm most afraid of is fear, not the thing.
posted by Dressed to Kill at 11:56 AM on February 22, 2019 [14 favorites]

"Science has proven what parents have known for generations, that the fastest way to stop feeling scared of the boogeyman under the bed is to actually look under the bed."
posted by slidell at 11:57 AM on February 22, 2019 [5 favorites]

What works for me is that I've been burned so badly so many times in my life that I finally am more anxious about letting my anxieties control me than I am about whatever I was anxious about in the first place. I now see anxiety as a sign that I should charge in and do the thing before the anxiety snowballs and destroys my entire life yet again.

It works about half the time.

Anxiety is fucking hard.
posted by Anticipation Of A New Lover's Arrival, The at 11:57 AM on February 22, 2019 [15 favorites]

As a trauma survivor who tends toward the anxious, for 43 years of my life I always prepared for everything to go wrong. Then, my therapist asked me to also start preparing for what would happen if everything goes right.

So much WHOA
posted by wellred at 12:04 PM on February 22, 2019 [12 favorites]

The thing about exposure therapy is that it's controlled, to some extent. You start by facing the smallest, easiest version of what triggers anxiety and then gradually move up to bigger triggers.

So, when faced with a question like "how can people with PTSD avoid being triggered?" I would answer, "Actually, as part of treatment, people with PTSD gradually expose themselves to triggers and learn that they will be okay even when a trigger occurs. Over time, their reactions to triggering stimuli dissipate."
posted by tuesdayschild at 12:09 PM on February 22, 2019 [2 favorites]

"The only way out is through" helps me face my anxieties more deliberately.
posted by slidell at 12:32 PM on February 22, 2019 [3 favorites]

The only way to avoid triggers is to isolate yourself completely and that isn't a nice life. The trick is to pay attention to how your anxiety is affecting your life; sometimes family and friends can help you see the full affect of avoidance.

Also, you already know how avoiding anxiety feels. If you're interested in following evidence-based treatment, it involves facing your anxieties.
posted by Gor-ella at 1:22 PM on February 22, 2019 [1 favorite]

I would emphasize the importance of the therapeutic relationship over the importance of exposure.

The specifics of your research is important to clinicians and patients- because they've already established the therapeutic relationship. They have a professional monitoring their progress, and knowing just how far to push their exposure in a safe way to get that benefit.

But I'm reading these answers, and I'm imagining all the people who don't seek help. I was one of those people for a long time. I did face a lot of my anxieties because I couldn't have a life otherwise. But facing those anxieties would push me into dissociative episodes, which is just as debilitating as a sheltered life. I needed help. Not a to-do list.

Take care to make sure your interviews are not used to avoid getting help. Instead it's to let people know that there is help out there. Giving them insight into what that help can look like makes it feel less scary or stigmatizing. But just saying "exposure to your triggers will make it better" is dangerous to say without contextualizing it within a therapeutic relationship.
posted by politikitty at 1:44 PM on February 22, 2019 [9 favorites]

I came here to say “the only way out is through” and also “what we resist, persists” both of which I use a lot!
posted by ukdanae at 1:45 PM on February 22, 2019 [3 favorites]

They often come to me with questions like, "how can people with PTSD prevent being triggered" or "how can people relax when they are triggered." What are some ways that I can gently challenge the premise (that anxiety and things that make you anxious are bad things that should be avoided)

that isn't a premise of those questions as you represent them here. If I follow your line of reasoning correctly, it is not feasible or desirable to avoid triggers altogether, but one goal of therapy for PTSD is to achieve a state where one is no longer easily and uncontrollably triggered. so, the soundbite answer to A, "how can people with PTSD prevent being triggered," might be: by engaging in structured exposure therapy, guided by a professional, in a controlled and safe setting, a technique with a demonstrated track record of success. With, if you can, the added note that nonprofessionals who deliberately confront traumatized people with disturbing material don't help and do harm.

the answer to B, "how can people relax when they are triggered," I don't know the answer to, but you presumably do. There is no pernicious premise underlying that question. If your answer is that people cannot relax in such a situation unless and until they have been through a course of some particular therapy, say that. if there are certain basic steps that lay people -- and people without the means to access professional therapy but who nonetheless follow the news -- can take on their own, without training, to help manage the effects, say that.
posted by queenofbithynia at 2:05 PM on February 22, 2019 [6 favorites]

It has to reach the point where the effect on your life of avoiding [thing] doesn't seem worth it. I am very afraid of flying but dragged myself onto a plane last year and am going to try to do so again this year because I now live very far from most of the people and things that mean much to me, and it is also good for my relationship if I have a bit more ability to travel as most of the world does, so I did it. It wasn't fun and I'm not really looking forward to the next trip, but it's a relief to know that I can do it if I need to. I have missed some events and opportunities in my life that are some cause for regret because I hadn't gotten to the point where I could quite convince myself to do the thing I was most afraid of.
posted by Smearcase at 2:12 PM on February 22, 2019 [1 favorite]

Aaaaand that was me answering the question as I read it before noticing there was stuff beneath the fold. Please ignore, as I don't think I've answered your question very well.
posted by Smearcase at 2:14 PM on February 22, 2019

In terms of a media-friendly soundbite aimed at someone who is reading and might benefit from your research: If you take the time and do the work to prepare yourself for situations that are going to happen eventually, then it's easier even when it's unexpected.
posted by epersonae at 2:38 PM on February 22, 2019

Response by poster: Just to clarify, the idea is that it is GOOD to experience anxiety in the moment because that reduces long-term anxiety. Suggesting that relaxing to make that anxiety go away is desirable is missing the point- which is that anxiety has to be experienced **without pushing it away** to get anxiety to go away long-term. I find that it's hard to communicate that nuance to people in a succinct way.
posted by quiet coyote at 2:41 PM on February 22, 2019

What would convince YOU?

I live with anxiety that I work on with the help of a great therapist and occasional medication. I think the part that's useful to include is that facing your anxieties in a supported/supportive environment is part of it. So you're not just like "Hey people with anxiety/PTSD have to get right back out there and face their fears" but "Hey people with anxiety/PTSD can, over time, learn to manage and face their fears in a supportive environment." I think the understanding that it can take time, along with it can require help are useful parts to try to include, even in a short sound byte. One of the things that helped me in terms of the "not all anxiety is bad" is the idea that it's trying to tell me something, even if it's just some stupid thing from my childhood that I KNOW ALREADY. So I learn to listen, somewhat, and sit with it instead of the anxiety itself making me feel like I have to do something. You sit with it. You listen to it. Maybe it has a message that's important. Probably it has a message that was important and that isn't anymore. Understanding that time aspect of it can also be useful.
posted by jessamyn at 4:04 PM on February 22, 2019 [5 favorites]

Your ability to do stuff mentally is like your ability to do stuff physically. Some people don't need to really think about physical exercise, either. But if you're naturally inclined not to do stuff, for whatever reason, then the less you do, the less you're able to do. I do happen to have the brain equivalent of a bad back, but if I never get off the sofa again, it will only get worse.

On the other hand, it's an incredibly dumb idea to go sign up for a triathlon when you know you just busted your knee and it isn't fully healed. You have to find the appropriate levels of things to engage with as you get better.

I find generally that people "get" physical health issues much more easily. Especially the idea that some things provoke pain for some people and not others, but that sometimes mild discomfort is healthy. But--mild. If something is horrifically painful, in either case, you need to back off and find something more suited to your current ability level.
posted by Sequence at 4:17 PM on February 22, 2019 [8 favorites]

Mod note: A couple deleted; if you disagree with the premise, it's okay to skip the question, which is pretty specifically about how to present the given set of information to reporters.
posted by Eyebrows McGee (staff) at 4:33 PM on February 22, 2019

I am glad you’re considering how to frame an issue like this to reporters, it’s a tricky subject to sum up succinctly and it’s good you’re thinking about the soundbite nature of your quote, as that will affect what people do with it. Something worth considering, especially as this question is specifically about media interviews, is what a layperson will take away from your quote, out of context. It’s not clear whether you specifically are addressing only PTSD, or if you want to make a broader statement about anxiety disorders in general, but either way it’s important to consider what the general public will do with your quote.

If you frame it as ‘anxiety is good, and should not be avoided’ or ‘triggers are helpful, and it’s best not to avoid them’, many people will interpret that as free license to harrass and abuse people with anxiety disorders by intentionally triggering them. Obviously, a layperson reading your interview soundbite is not a trained medical professional working closely with a patient on their PTSD, and there is an enormous difference between carefully conducting exposure therapy in a clinical environment and some random person intentionally triggering someone with PTSD.

Unless these reporters and quotes are only being circulated within a therapy-centric professional publication, average people will be reading your quote and some will likely use it as a justification for harming anxious people. I mention this because I have explicitly seen this happen multiple times, and I am very sure it’s not at all what the experts had intended at the time they were quoted.

Because I have seen soundbites used to justify harm for this exact issue, I strongly recommend being specific in your wording, to emphasize that dealing with PTSD triggers is something best explored in a therapeutic setting and not something anyone should attempt on another unconsenting human ‘for their own good’. This is something that happens quite a bit with anxious people, and it does serious long-lasting psychological damage, so I do hope you’ll consider the effect your word choice will have when proceeding with this venture.
posted by suri at 4:43 PM on February 22, 2019 [14 favorites]

there is also a great difference between triggers that are innocuous in and of themselves and triggers that are harmful to everyone, even if they are only triggering, strictly speaking, to traumatized people. supposing a person X who was assaulted in a room with yellow walls, a trigger of type A might be, I don't know, yellow walls. a trigger of type B might be strangers laughing and joking about how funny it is when people in person X's demographic are assaulted.

ideally, person X will one day get to a point where trigger A causes them no anxiety, no flashbacks, no troubles. but getting to that same point for trigger type B would be a sign of a different sort of mental injury, not only for person X but for anybody.

you may say: popular perceptions are confused; few people are triggered in the strict sense by something so literal. that is probably true, but few is not none. and what a reporter has in mind when they ask you about "triggers" is quite likely to be type B rather than type A.

this really is important. while I do not question the value of exposure therapy for objectively neutral phobias and triggers, the kind of stimulus that gets a "trigger warning" in public discourse is generally the kind of thing that is at best a low-level irritant or micro-aggression (so-called) and at worst a piece of verbal abuse or hate speech that as one isolated specimen can be tolerated and overcome, but as an accumulating avalanche of similar input is itself a cause of anxiety. as in, verbal expressions of e.g. intense misogyny are just the right blend of frequent and rare to be always expected and always a shock. there is a way to deliberately become totally blase and immune to their impact, and that way is injurious to the human personality. when a person is anxious about this kind of thing, the ideal treatment outcome is not so straightforward as when she is anxious about, I don't know, elevators.

what I am saying is that with certain triggers, ones often identified as triggers in non-specialist writing, exposure therapy and self-harm are one and the same thing. prolonged exposure to toxic substances is bad for you. you might not think it necessary to say this -- you know you're not going to teach a client to stop being anxious about poisoning by having her eat poisonous things until she doesn't mind them anymore, you don't need to say it, it's obvious. but in the realm of words and situations that are both irrationally frightening and genuinely bad for you, it is not so obvious and does need to be said.
posted by queenofbithynia at 5:51 PM on February 22, 2019 [8 favorites]

I generally go with something like: Avoiding triggering things makes you feel better, which reinforces your anxiety about that thing because your brain learns that avoiding that thing is the only way to feel better. By facing the triggering thing in a safe, supportive environment, however, you start to learn that you have the strength to cope with your anxiety, which, over time, decreases your anxiety overall because you're no longer frightened to encounter the thing.

I have also said things like: You want to be working at juuuuuust outside the edge of your comfort zone, because that allows you to start expanding your comfort zone. If you go too far outside your comfort zone, you'll scare yourself and retreat, which will reduce your comfort zone. So work on doing or facing the things that are uncomfortable but not debilitating, and then expanding from there.
posted by lazuli at 8:50 PM on February 22, 2019 [3 favorites]

Fear is easy to learn. Put a rat in a cage, play a tone before giving it an electric shock, and soon the rat associates the tone with pain and fears the tone. That fear response does not go away on its own; it must be actively unlearned. Play the tone, don't shock the rat, and eventually the association goes away.

And so it is with people: If talking on the phone gives you anxiety, avoiding the phone will not make the anxiety go away. It is only by repeatedly calling people and having it go well that you unlearn the fear response.

And that is what we do: We expose the patient to their anxiety trigger in a controlled way, ensuring that there is not a negative outcome. Eventually, they become comfortable with, or least more capable of dealing with, the thing that once made them afraid.
posted by JDHarper at 9:01 AM on February 23, 2019 [1 favorite]

Response by poster: All great ideas. I love the metaphors, and am reminded that I've used physical therapy metaphors with patients- when something is injured, you have to move it in particular ways, and often they're ways that hurt, but lying in bed can make things worse even though it feels better.

I was secretly hoping that there would be some soundbite that would make clear that 1) exposure MUST be consensual/within the control of the person (both morally and for it to work) and 2) exposure is only to meant to be to things that are OBJECTIVELY SAFE. But I will be sure to say those things explicitly given your feedback.

Most people have symptoms of PTSD after a life-threatening or sexual trauma, and it only becomes official "PTSD" once the symptoms don't go away. People whose symptoms go away tend to do "exposures" naturally, on their own. So I do think that there is room for people to do this safely without the assistance of a therapist if they can really get the concept of it. The vast majority of therapists don't offer exposure or other evidence-based treatments for PTSD, and it feels like maybe if I can just explain it well enough to people, more people who can't access treatment could recover. The alternative is that people will suffer with PTSD for their whole lives, losing time, money, and relationships, and potentially dying by suicide.
posted by quiet coyote at 12:32 PM on February 23, 2019 [1 favorite]