Sunday, October 30, 2016

Exposure Therapy for Worries, Intrusive Thoughts, Ruminations, and Obsessions

Worries, ruminations, intrusive thoughts, and obsessional thoughts can be a terrible source of suffering.  If they are mild or infrequent, they can be part of a healthy, balanced life.  But when they are occurring frequently, they interfere with all of our activities.  They make it hard to enjoy anything.  A beautiful walk in the forest is interrupted by upsetting thoughts about daily stresses, or about painful events that happened long ago.  Attempts to work or study are interrupted constantly, preventing you from getting things done, and certainly preventing you from enjoying what you are doing.  If the intrusive thoughts have to do with past traumatic events, it is as if these terrible events are happening to you all over again.

In this post, I am exploring a challenging approach to this.  But I know that in many cases upsetting thoughts cause extreme pain and suffering, and therefore any therapeutic approach must be considered with very great care.  The approach I am proposing may not be right for you, unless you feel very well-prepared for work that could be difficult.   With any therapeutic approach, you must feel entirely in control of the therapeutic process.  You must never be pushed into any sort of therapy, even by a well-meaning therapist whom you trust entirely.  Sometimes the framework of therapy implies that you should be doing certain types of work.  Just coming to a therapy appointment can implicitly push you into engaging with certain therapeutic tasks, such as sharing a painful story about your past.  

But I believe it is of the greatest importance to be guided entirely by your own will, with any therapeutic task.   

Upsetting thoughts are problems in which an event is happening outside of your own will.  Past traumatic events also have happened against your will.  So it would be wrong to engage in a therapeutic effort, unless you are very clearly in agreement with it, and you are engaging in each step with the full force of your will and consent.

I am also aware that many therapeutic ideas can seem too focused on some particular "technique."  Sometimes we can focus too much on "technique" in such a way that we are distracted from the larger picture.  In the big picture, I believe that healing forces include gentle self-care, empathy, healthy lifestyle, and loving relationships.  So, regardless of whatever "techniques" you try, be careful to remember that the "big picture" factors are the most important of all.

But let's get started on looking at some "techniques," with these limitations in mind:

What strategies or techniques can help to manage anxious thoughts, worries, or ruminations?

The Problem with Relaxation Techniques

Most people, including therapists, focus on techniques to help calm the mind.  These could include relaxation or meditation techniques.  Most of us would also encourage healthy distraction techniques, such as trying to read a book, listen to music, "breathe," go for a walk, talk to a friend, have a bath, etc.  Many medication treatments also focus on relaxation.  Benzodiazepines, including lorazepam (Ativan), clonazepam (Clonopin), alprazolam (Xanax), or diazepam (Valium), often literally calm the mind, slow down racing thoughts, and reduce the distress caused by rumination or worry.

But the problem with these approaches is that they are primarily avoidance-based, rather than strength-based.

Analogously, if you are very fearful about swimming, it will absolutely relieve your anxiety if you distract yourself, meditate, read a book, or take a sedative, whenever you are close to a swimming pool--but, of course, these techniques will not help you to cure your anxiety!  The only cure must involve deliberately approaching the water, and gradually facing your fear!

In many cases, relaxation therapy (especially if it is the only approach used) can make underlying anxiety worse, because it consolidates the notion that the anxiety is intolerable and must be avoided.

Exposure-Based Techniques

Over the years, I have become more and more a fan of behavioural therapy ideas, for approaching a wide variety of psychological symptoms.  I believe that this approach is strength-based, and is similar to having a physical fitness regime, or a structured program of learning a new skill (such as speaking a new language, playing a new sport, enjoying a new hobby, or playing a new musical instrument).

To treat a phobia about swimming, it is easy to prescribe a behavioural therapy program.  The first step might be to just watch people swim, while you sit in the bleachers.  The next step could be sitting at the side of the pool, with your feet in the water.  Eventually you might walk in the shallow end of the pool.  This could build up to putting your head under the water, learning to float, etc.  Eventually, with practice, you could be swimming laps in the deep end (maybe with the help of a swim teacher).

But how could we devise a plan to treat anxious thoughts or ruminations, using this type of approach?

An idea I have been working with is to encourage patients to make a detailed record of anxious thoughts or ruminations.  Try to "catch" the thoughts verbatim -- as though you are taking dictation, or using quotation marks.  Then make an audio or video recording, of yourself reading these thoughts aloud, in a way which mimics as closely as possible the way in which the thoughts occur in your mind.    The recording then becomes something to practice listening to...the task is to sit calmly with your thoughts.  If anxiety comes as you listen, let it come.  Consider it a type of "workout" to face a difficult task.

As with other types of workouts, it is important to plan the duration and intensity so that it is challenging but not overwhelming.  It can't be too easy -- otherwise there would be no training or strengthening effect.  But it can't be too hard -- otherwise you could injure yourself, or just have an unpleasant experience that would discourage you from working out again.

With exposure to recordings of anxiety thoughts, you can adjust the intensity in a number of ways (this is analogous to adjusting the weights in the gym).  Here are three ways to adjust the intensity or difficulty:
1) just turn the volume of the recording down.
2) listen to the recording for very short periods of time, and gradually increase the duration as tolerated.
3) listen to recordings of thoughts which are less upsetting.  As you feel able, you can introduce more difficult or challenging thoughts.  

There are various phenomena that can happen which reduce the effectiveness of this technique.  The mind has strong reflexes to manage anxiety using avoidance.  When dealing with worries or intrusive thoughts, it is very common to want to respond to these thoughts by trying to reason with them, reassure yourself, problem-solve, or distract yourself in various ways.  With this technique, it is important to simply let the thoughts come, let the ensuing anxiety happen, without trying trying to reassure, problem-solve, or distract.

I am not saying that problem-solving is unhealthy!  Of course, problem-solving and reassurance are very important!  But not if they occur during this type of exercise!  Analogously, if you are lifting weights in the gym, you could roll the weight upwards using a ramp, instead of lifting it directly!  This would be using clever problem-solving to bring the weight to a higher point!  But you would not get stronger if you used the ramp!  Or you could use a flotation device in the pool...this would be a good solution to help you float safely.  But it would not help you to swim better, or to master your anxiety of deep water!

Another type of technique used commonly for managing worrying and rumination is "thought stopping."  There has been some research supporting it.  This would appear to be an avoidant technique.  But according to one analysis, the reason that thought stopping can sometimes appear to work is because the exercise often first calls for people to deliberately induce anxious thoughts!  Only after a period of exposure to the anxious thoughts do people then use a thought-stopping technique.  At this point, often the thoughts which are "stopped" are not the anxious thoughts themselves, but rather the compulsive self-reassurances or problem-solving attempts.  Therefore the thought-stopping is actually favouring a better anxiety exposure exercise!

Summary of the Technique

1) make a detailed list of anxious thoughts, to replicate as closely as possible how they occur in your mind

2) make a recording, in which you read these thoughts out loud
3) listen to the recording, as a type of psychological "workout"
4) adjust the volume, duration, and content of the recordings, so that it is moderately difficult for you, but not overwhelming.  Aim for an experience of "mastery" just as you would when you are lifting weights successfully at the gym, or when you are doing some other type of exercise
5) While you are listening, you could attempt to do other tasks that you normally would like to do, such as studying.  But work hard not to engage in "avoidance" behaviours such as distraction, reassurance, or even relaxation techniques
6) You could aim for about 20 minutes at a time...but you might need to start with much shorter durations, such as a few seconds, if you are very sensitive.  Once again, it is like starting to do a new exercise such as may need to begin with running just a few steps, and then building up to longer distances as you get stronger.
7) After each exercise, you could then do some relaxation or other pleasant activities...just like soaking in the hot tub after a workout at the pool or gym...
8) Pay attention to how you feel in the next few days.  Just like workouts at the gym, you might feel "sore" in some ways.  Sometimes you might have more upsetting thoughts or nightmares, and feel worse.  If this is the case, you may need to make the next "workout" easier.
9) You may need to have a guide (such as a trusted therapist) to help you with this.  The role of the therapist, with respect to this technique, would be like a "personal trainer" at the gym--the therapist would be there to support you, encourage you, and help you with any problems along the way.
10) Sometimes a particular technique, such as this one,  may not be right for you.  If this is the case for you, remind yourself that it is not a sign of "failure."  It is just a sign that a different strategy is needed for now.  You might come back to a technique like this at a later time, or you may find other techniques that suit you better.

Is there still a role for Relaxation Techniques? 

To carry the fitness analogy further, I think most of us like to relax during part of our physical workouts.  Before or after our exercise, we might like to stretch, warm up, cool down, or relax in a hot-tub or sauna.  This could add to the enjoyment of the workout, and possibly even reduce the chance of injuries.

With an exposure-based anxiety management technique, perhaps some relaxation-oriented ideas could be used before or afterwards, in the same way.  It could help make your work a little bit more enjoyable, part of a pleasant routine.  It would just be important that your relaxation technique does not cause you to indulge in some kind of compulsive pattern that could contradict the work you were doing.

How other techniques already use this idea

In mindfulness-style meditation, the strategy is not to "empty your mind" or to prevent anxious thoughts.  The goal in mindfulness is acceptance and practicing attention without excessive reaction to sensations, feelings, or thoughts.   Worries or intrusive thoughts are viewed as clouds drifting through the sky of your consciousness, rather than attackers which need to be confronted.  Therefore, a person practicing mindfulness is also practicing being with the upsetting thoughts, rather than avoiding them.

In EMDR, various upsetting thoughts or memories can be contemplated while doing a physical activity.  In this way, arguably, the eye movements have a catalytic role to allow exposure practice to occur in a framework which feels therapeutic and well-boundaried.  A weakness in this technique, and possibly a reason that EMDR may work better with some therapists or clients than others, is that the eye movement activity could in some cases be an excessive distraction, and therefore dilute the effectiveness of the other therapeutic work.  But I think that provided this potential problem could be addressed, EMDR techniques could help a client and therapist adjust the intensity of a therapeutic session, analogous to adjusting the difficulty of a physical workout.

In conventional CBT, the initial phase of paying attention to upsetting thoughts, and recording them, is already a type of "exposure."  The act of writing something down can often require a strong act of will, and carry powerful symbolic value.  But a problem with cognitive therapy can sometimes be that the thought records become distractions, foster rumination, or lead to excessive debate or intellectual argument about thoughts.  

In psychodynamic styles of therapy, the experience of freely discussing painful thoughts and memories also involves exposure to the strong emotions associated with them.  Sometimes, in this style, the therapist's quiet presence is not directly "reassuring."  Rather, the therapist has a quiet role of facilitating exploration without a need for direct reassurance or problem-solving.  But a problem with psychodynamic styles has to do with its passivity--there is a lot of focus on exploration and "interpretation" but often not enough focus on strength and practical, immediate, active mastery of symptoms.   The preoccupation, in psychodynamic therapies, of searching for remote causation of symptoms, can distract clients or patients from working on strategies to master their anxiety in the present moment.  


For many people, intrusive thoughts are occurring so frequently and intensely that it is hard to recommend deliberate exposure to even more upsetting thoughts.  It would be like recommending a demanding physical workout to someone who is exhausted or injured from a grueling daily routine of hard labour.    In these situations, it may be important to look at other techniques, including more of a focus on relaxation, or on medication, to help reach a state of calm restfulness, before beginning an exposure-based strategy.

If there is a history of psychosis or mania, then there would have to be a lot of caution about using this type of technique.  But I would not rule it out entirely...there is more and more evidence about CBT-style ideas being useful in managing psychosis.

If negative thoughts are part of a volatile pattern leading to dangerous behaviours, including suicide attempts, self-injury, destructive bouts of anger, or severe dissociation, then very great care would have to be taken to make sure that this type of technique was used in an especially slow, cautious manner if at all.  There might have to be some preparatory steps to make sure that the situation was safe and stable enough to proceed.  This is again similar to recommending a physical exercise routine to someone:  it is important to make sure that a person does not have joint problems, heart disease, etc. which could make the exercise dangerous.

In some types of depression, a person can feel self-destructive.  With this technique, excessive exposure to the content of upsetting thoughts could be self-injurious.  Self-destructive behaviour would need to be addressed first, in order to allow a technique such as this one to be safe and helpful.  
One of the most important things, with any type of therapy, but especially with a process such as this, is to frequently emphasize that it is completely up to the client or patient to engage with the technique or not.  The therapist must never push this.  The client must feel completely free to stop the technique at any time, without any concern that the therapist would somehow be disappointed or disapproving.

The Role of Medication

A goal of medications is usually to reduce anxiety directly.  But I think it is important to think of effective medication as a "catalyst" rather than a direct "cure."   Medication may reduce the severity of the underlying problem, so that other types of therapeutic work could take place more effectively. The effect of medication could be analogous to reducing the weights in the gym, or to using a flotation device to help you practice kicking in the swimming pool.    Without medication, sometimes the symptoms could be so severe that it is much more difficult or painful to do the therapeutic work.  It would be like going to a gym where the only barbells available had 200 pounds or more on them!

Some medication can also theoretically improve sleep or restfulness, and therefore allow you to do better and more enjoyable therapeutic work the next day, when you will feel more rested.  In other cases, medication could help with energy, allowing you to become more actively involved in all therapeutic tasks.  

Another dynamic in PTSD can be that uncomfortable experience is too quickly assimilated--perhaps via the amygdala--into a strong, aversive "emotional memory."  Past trauma, in combination with inherited factors, can make this type of neural pathway hypersensitive.  Arguably, some medications, including beta-blockers and other adrenergic antagonists,  could reduce the intensity of this reflex.   This would be analogous to a person with arthritis using an anti-inflammatory medication before doing physical exercise--the medication would allow the exercise to occur more comfortably, and with a lower chance of injury.     But I have to admit that it can be hard to find medications that are consistently helpful for this type of problem...I do think it is good to have an open mind about trying different approaches.


Upsetting thoughts can be a difficult problem, but I encourage patient, gentle persistence in a search for relief.  Remember the big picture, of patient, gentle self-care, healthy lifestyle, and nurturing loving relationships.

I do invite you to consider the possibility of finding ways to approach upsetting thoughts in a way which seems paradoxical--by finding a way to face them directly, and to practice having the thoughts rather than practicing ways to get rid of them.  This practice is not meant to be masochistic, but rather is meant to build a strength inside of you, so that the bully-like emotional effect of upsetting thoughts is gradually weakened as your strength improves.


There are not enough research studies done regarding approaches to rumination, primary obsessions, and other intrusive thoughts...but a similar exposure-based idea is described by  Salkovskis & Westbrook (1989).  I will look for other articles to expand my list of references later.

Salkovskis, P. M., & Westbrook, D. (1989). Behaviour therapy and obsessional ruminations: can failure be turned into success?. Behaviour research and therapy27(2), 149-160.

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