Some 2,000 years ago, in the throes of a targeted chase to his death, a Roman philosopher named Seneca had a thought: “what’s the worst that can happen?”
Today, a growing body of research finds that a Seneca-inspired exercise—inviting the worried brain to literally envision its worst fears realized—is one of the most evidence-based treatments for anxiety. In scientific terms, that exercise is called imaginal exposure, or “facing the thing you’re most afraid of” by summoning it in your mind, says Dr. Regine Galanti, the founder of Long Island Behavioral Psychology, and a licensed clinical psychologist who regularly integrates imaginal exposure into her therapy.
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Imagical exposure, a subset cognitive behavioral therapy (CBT) focuses on simple logic. You can squash anxiety in your own head just as it is possible to create it in your brain. Although a professional in mental health can provide the best treatment for anxiety, it is not always possible to treat your symptoms over time. A growing number of psychologists have found ways to assist people with imaginal exposure from their homes.
Two thousand years before imaginal exposure would be proven one of science’s strongest anxiety treatments, dozens of Greek and Roman philosophers had the same intuition about the theoretical value of putting worry in perspective.
In a letter to his friend Lucilius, around 64 A.D., Seneca wrote: “There are more things likely to frighten us than there are to crush us. It is more common to suffer in our imaginations than it is in real life. 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.”
Marc Antoine Crocq is a psychiatrist at Centre Hospitalier Universitaire, eastern France. He says their worldview was influenced by 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 philosophers’ conclusion, Crocq says, was that “pathological anxiety is a mental representation”—and therefore, something that humans can address themselves.
Dr. Steffan Hoffman, a professor of psychology and director of the Psychotherapy & Emotion Research Laboratory at Boston University, has proven this empirically and, like Crocq, has studied the theory’s deep historical roots. He references the ancient Greek philosopher, Epictetus, who wrote: “Men are not moved by things, but the view they take of them.”
As Hoffman explains, “The idea [behind that quote]The truth is that our perceptions of the environment are constantly changing. 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.” He points to the way people commonly fear spiders or snakes, or even social situations. “Sometimes we respond with emotional distress in situations where it doesn’t make sense to feel emotional distress.”
Correcting those maladaptive perceptions, Hoffman says, is at the heart of CBT, a practice he describes as “toning down the intensity of the emotional states” that follow anxiety, in order to feel better. The approach was developed by Dr. Aaron Beck in 1960, when he wanted to help people see how thoughts can be disconnected from reality.
And though each therapist may differ in precisely how they administer CBT, the elements of imaginal exposure—confronting the source of anxiety-provoking thoughts, and developing healthier thought patterns around them—is a common entry point.
CBT has been long considered the most effective treatment for anxiety management. Hoffman ran one of the most cited literature reviews about its effectiveness. Imagineal exposure, a small slice of CBT that is Seneca-inspired, has been associated with many mental health improvements, including lower worry levels and negative emotions, better symptoms of depression, post-traumatic stress disorder, and greater ability to participate in once-dangerous activities.
Still, not all people have access to professionally-administered cognitive therapy. Only 69% of the 2,300 American psychotherapists used CBT in treating depression and anxiety. And then there’s the problem of access: one Census Bureau survey indicates that more than one-third of Americans live in areas lacking mental health professionals. This problem has gotten worse over the last year. The pandemic caused unprecedented anxiety levels and led to shortages of therapists. There are many options to help you. Psychologist Dr. Regine Gallanti says that even without the supervision of professionals, there are easy CBT-informed methods anyone can use on their own.
Galanti begins by asking the question “Why does it exist?”
“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, describing a patient who’s scared of dogs and, as a result, avoids them.
After identifying the cause of someone’s fear, Galanti focuses on validating the emotion—not diminishing it or reassuring the patient. “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.”
Let’s take, for instance, the woman who was afraid of dogs. Galanti tried something surprising: she invited Galanti to take the woman out for a walk with her dog. This allowed Galanti to confront the fear head-on. That worked well, Galanti says, but what about when people’s fears—like the death of a loved one—aren’t as plainly testable? “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 was especially true during the first days of the pandemic when there was uncertainty and high levels of anxiety. Galanti recommended that people set aside fifteen minutes for worry.
“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,” she says. “So this strategy focuses on not postponing your worries, [instead] setting up a time where you can worry all you want.”
Through this strategy, Galanti encourages people to jot down whatever is causing them anxiety, and then to pick a dedicated time—ideally not before bed—to revisit those concerns. “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.’”
Although people don’t use all 15 minutes of their allocated worry time, it can help to put anxiety in perspective. ”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.”
