exposure

Understanding the Origins of those Negative Predictions and Judgments

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tversky and kahneman

 

Amos Tversky (left) and Daniel Kahnement (right)

 

Daniel Kahneman won the Nobel Prize in 2002 for the work he, and fellow psychologist Amos Tversky, began in 1974 when they and published their article “Judgment under Uncertainty: Heuristics and Biases” in the esteemed academic journal Science (Vol 185. Pp. 1124-1131). Tversky and Kahneman sought to understand how humans made decisions in uncertain situations. This work suggests people use a series of mental processes to make decisions and the underlying machinery of these mental processes tends to make predictable errors. Their findings have profound implications for our understanding of mental health.

Anxiety 101 – a Review

Anxiety is the product of perceiving a threat to something we value. In the simplest terms, when we believe there is a bear (a threat) in the bush near us (something we value) our body gets ready to run/fight/or freeze (anxiety). This simple formula can take far more advanced forms because we can value other things besides our own physical health and threats can take many forms beside that of a bear. While threats and things we value can take many forms, our bodies only have a small number of responses. These responses are run, fight, or freeze and we interpret our bodies getting ready to do these things as anxiety. For example, public speaking is perceived to be a threat to our goal of being perceived as competent and confident, taking a test poses a threat to our hopes of completing a class with a particular grade, and running out of gas threatens our goal of getting where we want on time. Our bodies will get ready to deal with all of these threats in the same ways – by making us anxious.

An Available Heuristic

If we accept this formula as an explanation for why we get anxious, this leads to another reasonable question: How do we decide how much of a threat something is? Tversky and Kahneman provide us with an answer but first let’s consider some other questions:

  • When considering all of the words in the English language, which are three or more letters, are there more words with the letter K as the first letter, or more words with the letter K as the third letter?
  • What percentage of middle aged men will have a heart attack?
  • How honest are you?

To answer these questions our minds could use a number of different strategies. Our minds could list every known English word that is 3 or more letters, then compare how many begin with K and how many have K as the third letter. Even if we used this exhaustive and thorough strategy, our answers would be imperfect because we do not know every English word so we would be guessing based on the words we do know. As for the questions about heart attacks and honesty, we would never truly know the exact values because we are not omniscient and honesty is not something you can quantifiably measure. However, most people do not find it difficult to come up with answers to all of these questions. In fact, people tend to come up with answers extremely quickly.

When we are asked questions like these, our minds take the question we have been asked then quickly replace this very difficult question with a simpler question like “How easily can I remember or imagine something like this?”

If you are like most people, when asked the question about the letter K, you tried to think of words that begin with the letter K or had K as the third letter. If you could easily recall words beginning with K, but had greater difficulty thinking of words with K as the third letter, you concluded there must be more words beginning with K. Words with K tend to be easier to recall and most people assume there are more words beginning with K, even though there are more words with K as the third letter in English. Instead of being able to provide the true likelihood of heart attacks, our mind replaces this question with something like “How easily can you remember or imagine a middle aged man having a heart attack?” Then finally, you likely replaced the question about honesty with “How easily can I remember situations in which I was honest and dishonest?” It is not about how many memories we have being honest or dishonest, we form our judgments on the availability of those memories. Memories we can easily recall are said to be more available to our conscious minds than memories that are difficult to recall.

This mental “trick” is called the “availability heuristic.” As Tversky and Kahneman explain in their 1974 article, “There are situations in which people assess the frequency of a class or the probability of an event by the ease with which instances or occurrences can be brought to mind” (p. 1127). In other words, we believe something to be more likely if memories or fantasies of similar situations are “available” to our conscious mind. Most of the time the availability heuristic serves us pretty well. If something frequently happens in our life (the sun comes up every morning), one can assume it is likely for it to happen again without many costs being associated with this prediction. This allows us to avoid living in a constant state of uncertainty, predict what is likely to happen in the future, and plan accordingly. Unfortunately, the availability heuristic can be biased and sometimes this can have serious adverse consequences.

The availability heuristic is disproportionately influenced by recent and emotionally salient situations. Following a traumatic experience, people are far more likely to overestimate the probability of a similar traumatic event happening which artificially inflates our perceptions of how threatening a situation is, which in-turn unnecessarily increases anxiety and distress. Following a car accident, you will likely overestimate the likelihood of being in another car accident, which increases anxiety while driving. Following 9/11, many of us felt a new anxiety we did not previously experience while getting on air planes, not because flying was anymore dangerous (flying had probably never been safer than after 9/11) but because memories and fantasies of planes being high jacked were far more available.

Mental Process Underlying Mental Health Challenges

We determine which situations are threatening not by assessing the true threat level, but by assessing how easily we can remember or imagine similar situations ending-up poorly. Panic disorder can manifest in a number of ways, everyone is different, but people with panic disorder tend to worry that bodily sensations (heart arrhythmias, increased heart rates, accelerated breathing, dizziness, sweating, etc.) are evidence of a serious catastrophe (heart attack, stoke, going insane, etc.) which escalates anxiety resulting in panic attacks. Once we’ve had a single panic attack, the memory of this experience can be particularly available because panic attacks are so emotionally distressing. If we have had a panic attack in a store, we might later wonder about the possibility of having a panic attack in another store like Walmart. This question about the probability of having a panic attack in that particular Walmart at that particular time is replaced with “How easily can I imagine having a heart attack in Walmart?” If the answer is “very easily” then, we will assume the likelihood of having a panic attack in Walmart is high and we will likely avoid Walmart to avoid having another panic attack.

In obsessive-compulsive disorder (speaking of true OCD not the “OCD” people claim to have when they have strong preferences for cleanliness or organization), people can grossly overestimate the likelihood of someone breaking into their home and murdering their family because this specific fantasy can be incredibly distressing. When a fantasy is emotionally distressing, it is more available to consciousness, and this availability inflates perceptions of likelihood. Put simply, because the obsession is so upsetting, people will think it is likely, and they will act compulsively to reduce the probability of the feared event occurring.

In addition to anxiety disorders, the availability heuristic also plays a role in the development and maintenance of other mental health challenges. People with eating disorders often worry that people will judge them negatively if they were “fat.” They sometimes have vivid fantasies of being publically ridiculed or rejected for having what most people would consider to be an average or even below average weight. The maintenance of an eating disorder is riddled with availability heuristic errors. Often people will be able to easily imagine people judging them for being “fat” because they themselves frequently judge other people as fat and they take this as evidence suggesting other people have similar thoughts. The memory of their own judgments will be available because they are so frequent and this will inflate their perception about the likelihood of other people being judgmental like themselves. There are often historical traumas in childhood in which the person with the eating disorder was indeed bullied, mocked, and/or criticized, sometimes by close loved ones. While memories of this abuse are no longer recent, they may be incredibly available because of their emotional salience. They may also judge themselves as inadequate because they can easily recall examples of “beautiful” celebrities which inflates their perception of the regularity of these “beautiful” people.

When we are depressed, we will often have negative automatic thoughts about ourselves like “I’m a failure” or “I’m a loser.” Our minds will form these judgments by seeing which memories are most available, so if we can easily recall examples of “failures” or “losing”, we will be more likely to make judgments consistent with these memories. Since we tend to feel negative emotions more intensely than positive emotions, memories involving failure and loss may be easier to recall, and so these memories bias the availability heuristic and negatively distort our judgments.

Help is Available

The availability heuristic seems to be at the heart of many mental health challenges and this has some interesting implications for the treatment of mental illness. The availability heuristic is biased by recent and emotionally evoking memories and being aware of these biases allows us to think critically about the assumptions we make. In his 2011 book “Thinking, Fast and Slow” Daniel Kahneman explains “Resisting this large collection of potential availability biases is possible, but tiresome. You must make the effort to reconsider your impressions and intuitions by asking such questions as, ‘Is our belief that thefts by teenagers are a major problem due to a few recent instances in our neighborhood?’ or ‘could it be that I feel no need to get a flu shot because none of my acquaintances got the flu last year?’ Maintaining one’s vigilance against biases is a chore – but the change to avoid a costly mistake is sometimes worth the effort” (p. 131). This method of monitoring and thinking critically about our assumptions is identical to the cognitive restructuring interventions used in Cognitive-Behavioral Therapy.

In addition to cognitive restructuring, exposure based therapies may also be used to combat the biases of the availability heuristic. It’s no surprise that people tend to avoid anxiety provoking situations. As Dr. David Burns explains in his book When Panic Attacks:

Most people who are anxious avoid the things they fear, so they never experience enlightenment or relief. If you’re afraid of heights, you’ll avoid high places because they make you feel dizzy and anxious. If you’re shy, you’ll avoid people, because you feel so insecure and inadequate. The avoidance fuels your fears, and your anxiety mushrooms. If you want to be cured, you’ll have to face the thing you fear the most. There are no exceptions to this rule. (Pp. 252-253)

Imagine a person who has a panic attack on an elevator. Following this experience, when the person’s mind attempts to calculate how dangerous a particular elevator is, it will not be calculating the true risk of taking the elevator because this is truly unknowable for every elevator in the world at any given time. It’s not like their mind will know there is a 1.2496% chance something goes wrong if they get in that elevator right now and remain in it for 28 seconds. Instead, they will replace the question, “How dangerous is this elevator?” with “how easily can I recall having an uncomfortable emotional experience in situations similar to what I imagine it is like to be in that elevator?” The memory of their last panic attack in the elevator will be very available because it is so emotionally evoking, even if it is not recent, and so the person will conclude getting on the elevator will be very dangerous. However, if the person decides to go into the elevator, even though they feel anxious, there is very little chance anything will go wrong. They will likely feel anxious and perhaps even have another panic attack, but after a few minutes this anxiety will dissipate. If they stay until their anxiety is gone, they may even feel pride and excitement about their achievement. Let’s say they repeat this exposure exercise 5 or even 10 times. The next time they wonder about how dangerous it is to get on an elevator, the memories of taking the elevator with nothing bad happening will be far more available and they will conclude the elevator is likely safe.

I recommend combining both of these cognitive and behavioral (exposure) approaches. Be mindful of how and why your mind is making the predictions and judgments it is making, but also go and have positive experiences to replace the negative memories creating these predictions and judgments. As you change your assumptions, predictions, and judgments through cognitive restructuring and exposure, you’ll experience serious emotional changes.

To be thorough, lets consider an example in which a person is depressed. As mentioned above, people who are depressed frequently experience negative judgments and predictions. We can fight depression by identifying and thinking critically about these judgments and predictions. So when we tell ourselves things like “I really can’t do anything right” we notice these thoughts and write them down, or record them in some way. Writing down our thoughts is a great way of distancing ourselves from what we are thinking. Then we think critically about these thoughts by simply asking some questions like “What memories is my mind accessing when I think I can’t do anything right? Are there other examples of me doing things reasonably well that my availability heuristic is ignoring? I put my pants on today correctly, is that not an example of doing “anything” right? So if I have done somethings right, like putting on pants, what do I really mean when I think I can’t do anything right? Do I mean that I have some regrets and if so, how do I know I have more regrets than other people? Even I have done more regretful things, what can I do about it? What is the value to ruminating on these regrets?” So this is one example of a cognitive restructuring technique called Socratic Questioning.

To combine our cognitive restructuring with a behavioral technique to combat the biases of the availability heuristic, we might create a list of things we could do to have the experience of doing something right. To make this list we might ask, what are some things you would be proud to do? Things like hike a mountain, read a book, volunteer, get a job, take a class, or clean up a local park. Then the depressed person would go and do these things, even if they don’t feel motivated to do so (action comes first, motivation comes later). The person would take photos of how they did and this would serve as evidence to dispute future thoughts about not doing anything right. Combining both these cognitive and behavioral approaches will help the person to become less depressed over time by combating the availability heuristic’s biases for emotionally evoking and recent memories.

 Summary

To summarize, the availability heuristic is a mental process we use to make predictions and judgments. While it frequently helps us make complex decisions effectively, it is also biased to overemphasize recent and emotionally salient memories and fantasies. Unfortunately, these biases can create and maintain challenges like anxiety and depression. Cognitive restructuring and exposure techniques can help us challenge the underlying thinking which contributes to these problems.

 

Postscript

I’ve been studying the work of Tversky and Kahneman for several months now, beginning with the Michael Lewis book “The Undoing Project” which tells the amazing story of how they changed the world of psychology, economics, health care, finance, marketing, and so many more fields. Judgment under Uncertainty: Heuristics and Biases is a brilliant 7-page article that can be found for free – click here. Daniel Kahneman’s book Thinking, Fast and Slow is a fantastic insight into our minds and how they work.

The Core of Therapy for Anxiety

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Exposure Therapy and Behavioral Experiments

Cognitive Behavioral Therapy is the most validated form of therapy for anxiety disorders. In a huge review of studies exploring the effectiveness of CBT, the researchers found “The efficacy of CBT for anxiety disorders was consistently strong” (click here for a link to a free copy of this study). In another comprehensive review of studies exploring CBT for generalized anxiety, the authors concluded “when compared to waiting list control groups, these treatments have large effects on worrying, anxiety and depression, regardless of whether effects were measured with self-report measures or with clinician-rated instruments” (click here for a copy of this study). Many people would prefer their anxiety just went away but research suggests few people who do nothing, reduce their anxiety. As the studies above suggest, one of the things people can do to reduce their anxiety is cognitive-behavioral therapy and at the core of CBT for anxiety is exposure therapy and behavioral experiments.

Exposure therapy:

Simply put, exposure therapy involves exposing the client to their feared situations in a gradual, repeated, and prolonged manner until the client becomes desensitized. For example, if a client is terrified of public speaking they may work with their therapist to create a list of anxiety provoking situations (speaking in class, watching videos about public speaking, taking a class on public speaking, imagining speaking in public, speaking in a meeting at work, talking to a cashier at a store, doing a speech at Toastmasters, etc.). The client then ranks these situations from least anxiety provoking to most anxiety provoking, this is called an anxiety hierarchy. Then starting with a situation that does evoke some anxiety but is not overwhelming, the client would repeatedly expose themselves to these situations, over and over, until they become desensitized to this situation. A useful example of this most people can relate to is learning to swim as children. Many children are afraid or at least tentative about the water, but their parents encourage them to become more comfortable over time, often enrolling them in swim classes. As the child is gradually exposed to the water over time, they become less afraid. Alternatively, the children that are terrified of the water, and refuse to ever go in the water continue fear the water.

*For more information about exposure therapy see my article “Overcoming Anxiety and Avoidance” by clicking here, or download our free anxiety workbook by clicking here.

Behavioral experiments:

Behavioral experiments can take a number of different forms. Similar to exposure therapy, the client and therapist may work together to create a list of anxiety provoking situations. Then the client and therapist will work together to identify the client’s fears about what could go wrong in these situations. Often these fears are exaggerated and extreme but the client sees them as perfectly reasonable. So then we create a little experiment in which the client enters the feared situation and observes to see if their fears come true. Then the client runs the experiment several times in an attempt to gather more information. Once the client has run the experiment several times, they reconvene with the therapist to discuss what they have learned about their fears and their abilities to cope.

For example, perhaps one of the situations on the client’s anxiety hierarchy is saying “no” to other people. Perhaps the fear in this situation is something like “If I say no to my mother when she asks me to do something, she will call me selfish, the rest of my family will hate me, and I won’t be able to handle that.” So then the client and therapist run an experiment in which the client talks with their mother, explains they are trying to be more assertive and wants to work on saying “no” sometimes. Then the next time their mother asks them to give them a ride to the store, the client explains they cannot help that day due to other commitments, then observes what happens. In this situation, the client’s mother may very well call the client “selfish” and their family may complain, but the client also learns they can survive being called selfish and occasionally listening to complaints. Or perhaps the client’s mother understands the client has other commitments and they schedule a plan in which the client gives their mother a ride another time, or the client’s mother finds another way to the store. See the below table for an example how I would write-up a behavioral experiment assignment with a client.

BE

Another type of behavioral experiment involves the client identifying what they suspect other people believe then conducting a survey to assess the accuracy of the client’s assumptions. For example, the client may believe that people believe that women over a particular weight are “unattractive.” Clients may start by simply ask some trusted friends or family about this assumption. They may take photos of themselves or others to friends or family and ask people about their impressions about the people in the photos. In this example, the client ideally learns that attractiveness is not directly related to something as arbitrary and simplistic as weight.

How it works:

In my experience, exposure therapy and behavioral experiments have been immensely helpful for clients. Clients usually report dramatic shifts in their anxiety in only a short period of time. In CBT we assume the client becomes less anxious in situations they are exposed to because they learn that their initial assumptions about the dangerousness of the situation is exaggerated and their beliefs about their abilities to cope with the danger posed by those situations is minimized. In other words, their cognitions change. After exposing themselves to a variety of different situations, the client learns they have a habit of exaggerating danger and minimizing their abilities to cope, and so they become less anxious in other situations they have not exposed themselves too.

For example if you are anxious about travelling but you muster the courage to go to Mexico, you might learn that Mexico isn’t as dangerous as you expected. Then if you go to Germany you might learn that Mexico and Germany are safe. Then if you go to India you might learn that Mexico, Germany, and India can be travelled to safely. Then you might learn that travelling in general can be done safely, not only to those countries you have been to in the past.

Challenges:

One challenge in using exposure and behavioral experiments is explaining the importance of actually facing fears to the client. Some clients have spent decades avoiding situations that make them anxious and the thought of deliberately exposing themselves to these situations is terrifying. People tend to want to avoid situations that make them anxious. Unfortunately, it is this very avoidance which perpetuates the anxiety indefinitely.

Another barrier to effective exposure and behavioral experiments is called “safety behaviors.” Safety behaviors can sometimes resemble the compulsions of someone who struggles with OCD. Safety behaviors are unnecessary, excessive, or unhelpful activities or strategies people use in anxiety provoking situations to protect them from “something going wrong.” When the client is anxious about going to a new restaurant they may excessively research the restaurant online to create a plan to prevent something “bad” from happening. In this example the excessive research is the safety behavior the client uses to keep themselves “safe.” Then when they go to the new restaurant and nothing “bad” happens they convince themselves it is because they researched prior to going. In this situation, the client has not learned that they can safely go to a variety of different restaurants, but instead they have learned they can go to a restaurant when they excessively research it in advance. Other examples include holding glasses very tightly when you’re afraid of spilling, distracting yourself with your phone when afraid of standing in lines, and never disagreeing with people when you are afraid of conflict. Research suggests it is imperative safety behaviors are identified so the client can either avoid using them or gradually reduce the use of safety behaviors over time.

Sometimes a client’s anxiety is about situations to which they cannot be exposed. For example, the client might be terrified of earth quakes, someone dying, their son being in a car accident, getting fired, or being homeless. When the client cannot be directly exposed to their feared situations, we have got to get creative. We can watch videos of these situations, we can do research, we can read stories, we can write then recite our own stories in which the client is exposed to these situations, etc. This is based on the idea that thinking about the feared situation can actually desensitize the client. Some of these interventions are called “imaginal exposure.”

Conclusions:

Research suggests CBT is an effective treatment for anxiety disorders. Exposure therapy and behavioral experiments are core elements of CBT for anxiety. By facing fears the client learns their feared situations are not as catastrophic as originally predicted and their ability to cope is better than expected.

 

Overcoming Anxiety and Avoidance

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Although this will likely reduce the number of “likes” I get for this post, I believe it is important to begin with some honesty. Overcoming anxiety is hard work. Most people want a simple and easy answer that can make all of their suffering go away. However, for every complicated and messy problem there are many simple and easy answers that are ineffective. For example, in Canada the use of antidepressants increased over 450% between 1981 and 2000, but the demand for mental health services has never been higher. This post is not an “8 easy steps to being less anxious” kind of post, it is more of a “if you work really hard, stay determined despite set-backs, and keep an open-mind about trying new things you may be able to make some real improvements to your life” kind of post.

Anxiety and Avoidance

Anxiety is a normal reaction to perceived threats. However, when we have a tendency to focus on threatening situations, the problems in our lives, we are fueling excessive amount of anxiety. One way we attempt to reduce the amount of anxiety we experience is by avoiding challenging situations. However, avoidance prevents us from overcoming our fears. Furthermore, as we avoid more and more things, our lives become more and more restricted.

For example, if you had social anxiety and were terrified of 1talking to authority figures, you would likely experience anticipatory anxiety before you spoke to people of authority, then when you did have to talk to someone of authority (exposing yourself to the feared situation) your anxiety would likely spike. Then when you avoid the situation by promptly leaving, your anxiety will naturally go down. Unfortunately, when we cope with anxiety by avoiding challenging situations we cannot challenge our assumptions that the situation is dangerous, we cannot challenge our assumptions that we cannot handle the stressful situation, nor can we learn how to handle the situation more effectively. So then the next time we exposure ourselves to the stressful situation we experience a similar amount of anxiety.

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Overcoming anxiety can be accomplished a number of ways. However, research strongly suggests that one of the most effective strategies for overcoming anxiety is something called “exposure therapy.” Exposure therapy rests on the premise that if we can expose ourselves to our anxiety provoking situations in a certain way, we can learn: the situation isn’t as dangerous as we assume, we can handle the challenging situation, and we can practice skills to better handle similar situations in the future.

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Exposure therapy

  • Begin by creating a list of situations you avoid
  • Rate how much anxiety you suspect you will experience in each of these situations on a scale from 0-100
  • Select a situation that will provoke a small amount of anxiety – set yourself up for success
  • Create a plan to expose yourself to this situation –when? Where?
  • Expose yourself to the situation
  • When you are in the situation try and pay attention to what is going on around you as opposed to what is happening in your body or distracting yourself (looking at your phone, talking to a friend, reading a book, etc.)
  • Stay in the situation until your anxiety has diminished, do not just leave when you feel some anxiety
  • After your anxiety has gone down, ask yourself what you have learned about how dangerous the situation was, what you have learned about your ability to cope (did you survive?), and some skills you could practice to handle the situation more competently in the future
  • If you notice yourself going over and over the situation in your mind, distract yourself by doing something engaging
  • When you are able, expose yourself to the same situation again and again until you do not feel very much anxiety at all in that situation
  • Once you have completed the first anxiety provoking situation, move on to another situation on your list of anxiety provoking situations and repeat this process

By exposing ourselves to anxiety provoking situations appropriately, we are able to reduce the amount of anxiety experienced when we face similar situations in the future.

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Some notes about exposure therapy:

Exposure therapy can be immensely effective for anxiety created by many different situations. Personally, I have seen clients make radical changes in only a small number of sessions when they are committed to their exposure plan. However, it is important to remember than some situations are actually dangerous and we are not always exaggerating the danger in our minds. Therefore, I do not encourage people to behave recklessly, for example standing in a busy highway, going down dark alleys at night, or committing any crimes. Also, this article only describes one type of exposure therapy, something called “in vivo” exposure therapy and this type of exposure therapy cannot be used to overcome some anxiety provoking situations. Obviously, we cannot expose ourselves to our fear of our own death (at least not more than once), to fears of loved ones dying, or to fears of natural disasters. For these types of hypothetical fears, we may need to practice something called “imaginal exposure” which is not described in this article.

Some notes for therapists:

Many clients struggle with creating the motivation to engage with exposure therapy. When we are distressed we often resort to coping mechanisms that are familiar to us, even if they are not helpful. It can be useful to go slow with clients and discuss the costs and benefits of avoidance. Encourage the client to consider what their life may be like if they continue to avoid anxiety provoking situations indefinitely and/or consider the opportunities their avoidance may have already cost them. Remember, it is not our job to convince the client to do anything. Instead we are there to help them make informed decisions. If the client chooses to continue to avoid, while knowing the consequences of this decision, that is their choice and that should be respected.

Processing what the client has learned from exposing themselves is just as important as collaborating with the client to design the exposure activity. “what did you learn from exposing yourself to this situation?”, “what did you learn about your ability to cope with the situation?”, “what did you learn about your anxiety in general?” “what did you learn about your fears?” – Questions like these can be very helpful.