In this chapter you will expand your list of feared situations and explore your safety behaviors, including your unique pattern of avoidance. By the end of the chapter you will have a detailed inventory of the people, places, things, situations, and experiences you fear and tend to avoid. You will use this inventory in subsequent chapters, so take your time in this chapter and do the exercises thoroughly.
Get started by transferring your feared situations from the previous chapter to the first column of the worksheet on the following page. (A downloadable version of this worksheet is available at http://www.newharbinger.com/34749.) List all the situations you can think of, including experiences, people, places, things, and even internal experiences such as worrisome thoughts and panicky sensations—everything you fear.
In the second column, rate your SUDS (Subjective Units of Distress) from 0 to 100, where 0 would be no anxiety and 100 would be maximum anxiety possible.
Leave the third column blank for now.
| Feared situation | SUDS
0–100 |
Safety behaviors |
|---|---|---|
Eileen loved horseback riding, but after a fall from her horse she became fearful about riding. Here is her list of feared situations and SUDS ratings.
Eileen’s Exposure Inventory Worksheet
| Feared situation | SUDS
0–100 |
Safety behaviors |
|---|---|---|
|
Cantering in small corral |
60 |
|
|
Riding Meadow Loop Trail |
75 |
|
|
Visiting horse in stable |
30 |
|
|
Remembering/thinking about the fall |
50 |
|
|
Talking about the fall |
45 |
|
|
Galloping |
85 |
|
|
Riding High Ridge Trail |
90 |
|
|
Walking horse in corral |
35 |
|
Eileen’s feared situations were all related to a particular trauma, the fall from her horse. Depending on the type of anxiety you experience, your list of feared situations might be much more varied.
The next column you will complete on your inventory will be the typical safety behaviors you use in response to your feared situations.
What are safety behaviors? We’re all hardwired to protect ourselves from dangerous situations. When we experience threat, we’ll act quickly and go to great lengths to feel safe. If you were in an unlit parking garage and you heard footsteps behind you, it’s likely that you’d move fast to get to the safety of your car. In addition to seeking safety in response to a physically threatening situation, you’ll find yourself seeking safety to alleviate the anxiety you experience when you worry about something. Safety behaviors are chosen actions that are carried out to protect you from the emotion of fear, and the catastrophes you worry about.
Safety behaviors are compelling because they provide immediate benefits. They reduce the feeling of danger in the short term. For example, if you have OCD, an invitation to dine out may trigger worries about being exposed to germs from the seats and the crowd, the bacteria in the food that’s served, and the germs in the public restrooms. If you decline the invitation, thereby avoiding the restaurant and all of the perceived threats that come with it, you’ll feel better immediately. If you decide to go, you might take precautions (safety behaviors)—bring antibacterial wipes, wear gloves for the bathroom door, and eat only salad. With these safety behaviors you’re alleviating anxiety about contamination, but creating a far greater difficulty. Your fear of germs will continue and perhaps worsen because you haven’t done anything to directly decrease the fear itself.
There are two types of safety behaviors: avoidant and approach. With avoidant safety behaviors, you are avoiding, delaying, or escaping the fear. This coping behavior is very appealing because you get an immediate decrease in your level of anxiety. With approach safety behaviors, you engage in the anxiety-provoking situation, but you use strategies that will prevent or minimize your feared outcomes. Both types of safety behaviors make you feel better in the short term. So what’s the problem with them?
The problem with using safety behaviors is that you never learn anything. You never learn whether your feared situation or experience will really cause you harm. You never learn to tolerate uncertainty. And you never learn to trust your judgment. So the next time the same threat appears, you suffer the same anxiety, push it away with the same safety behavior, and so on indefinitely. You live in a recursive loop where anxiety tends to become more frequent and intense, not less. The following sequence shows how safety behaviors maintain and often worsen anxiety:
Specific threat creates uncertainty about safety
↓
Worry (thinking about catastrophic things that could happen, in hopes of reducing uncertainty)
↓
Anxiety/fear increases the longer you worry
↓
Safety behaviors help you avoid or reduce the threat
↓
Anxiety temporarily reduces
↓
No learning takes place—you don’t learn to tolerate uncertainty or learn that the threat won’t hurt you
↓
Specific threat reappears
↓
Sequence repeats
Here are some common safety behaviors to consider as you fill in your list:
Take your time filling in column 2. Identify the safety behaviors you use when encountering each of your feared situations and experiences. What exactly do you do to cope with the anxiety these experiences trigger? How do you get away from or diminish your fear?
Here is Eileen’s inventory with her safety behaviors added:
| Feared situation | SUDS
0–100 |
Safety behaviors |
|---|---|---|
|
Cantering in small corral |
60 |
Holding saddle horn the whole time |
|
Riding Meadow Loop Trail |
75 |
Procrastinating/avoiding riding, or riding with instructor |
|
Visiting horse in stable |
30 |
Procrastinating, or constantly saying “Good boy!” |
|
Remembering/thinking about the fall |
50 |
Distracting myself with my iPhone |
|
Talking about the fall |
45 |
Distracting by changing subject |
|
Galloping |
85 |
Avoiding, thinking I can ride later with instructor |
|
Riding High Ridge Trail |
90 |
Avoiding, thinking I can ride later with instructor |
|
Walking horse in corral |
35 |
Constant reassurance seeking with riding instructor |
There are three kinds of avoidant safety behaviors that people use in an attempt to control anxiety: situational, cognitive, and sensation or interoceptive avoidance. As you read the descriptions below, put a check mark next to the type(s) of avoidance you’ve used. It’s not unusual for people to use all three, so don’t be discouraged if that’s the case. This program will help you no matter what forms of avoidance you use.
Situational avoidance. This is the most common type of avoidance. You stay away from activities, places, people, and things that tend to trigger your anxiety. For example, when Scott was a child, a dog bit his hand when he tried to pet it. Scott remained fearful of dogs. As an adult, he would not attend any functions at the homes of friends who owned a dog, and he avoided parks and other outdoor venues that allowed dogs. In the short term, Scott was able to avoid the feelings that got triggered when he was near a dog, but in the long term he missed out on experiences with friends and loved ones.
Cognitive avoidance. This type of avoidance is specific to what takes place in your mind. You expend great effort to get rid of distressing thoughts or disturbing memories by making conscious attempts to suppress them. This might involve replacing them with more pleasant or distracting content such as fantasies, daydreams, mantras, prayers, or other thought rituals. Or you might try suppressing distressing thoughts with drugs, alcohol, high-risk behaviors, binge eating, self-harm, and so on. For example, Ellen struggled to push away memories of molestation by a neighbor when she was nine. When the memories came up, she drank, picked fights with her boyfriend, binged on reality TV and ice cream, and made covert plans to move out of state. She also avoided sexual experiences that reminded her of the molestation. Despite her efforts at suppression, memories of the trauma still came up, alongside feelings of being somehow bad and wrong. Not only did Ellen’s cognitive avoidance not work to avoid anxiety, but it also resulted in a drinking problem, loss of her relationship, social withdrawal, and depression—a feeling that she was failing at life.
Sensation/interoceptive avoidance. With sensation or interoceptive avoidance, your efforts are focused on avoiding internal sensations such as feeling hot, feeling tired, labored breathing, or rapid heartbeat. You may even avoid pleasant sensations, such as sexual excitement or excitement about an event, because they feel similar to anxiety sensations. For example, Juan had a panic attack on a gridlocked freeway where there had been a major accident. During the panic he felt dizzy, hot, and shaky, had palpitations, and felt “totally out of it.” Since that time, he fears and vigilantly watches for any of these sensations. He tries desperately to stop or block them, avoiding places where they might occur. As a consequence, Juan is now avoiding all exercise so he won’t get heart palpitations or overheated or too excited. He doesn’t watch sports, go to concerts, hike, or go on outings with friends. What’s worse, if Juan even anticipates the possibility of panic, he begins to feel dizzy and “out of it”—which often triggers a full-blown attack.
After focusing on the types of avoidance, you might find that you can break some items on your inventory down into more components. For example, a fear of crowded places might include the following items:
Or a fear of germs might include:
Go back to your inventory and expand any of the feared situations or safety behaviors that could use more detail.
When Eileen considered the three types of avoidance, she realized that she used cognitive avoidance any time she even thought about riding on the higher trails. And she drilled down into her real fears to realize that what caused her the most distress was the possibility of experiencing again the physical sensations of panic that she felt when her horse threw her on a steep trail. So she added items 9 and 10 to her inventory:
| Feared situation | SUDS
0–100 |
Safety behaviors |
|---|---|---|
|
Cantering in small corral |
60 |
Holding saddle horn the whole time |
|
Riding Meadow Loop Trail |
75 |
Procrastinating/avoiding riding, or riding with instructor |
|
Visiting horse in stable |
30 |
Procrastinating, or constantly saying “Good boy!” |
|
Remembering/thinking about the fall |
50 |
Distracting myself with my iPhone |
|
Talking about the fall |
45 |
Distracting by changing subject |
|
Galloping |
85 |
Avoiding, thinking I can ride later with instructor |
|
Riding High Ridge Trail |
90 |
Avoiding, thinking I can ride later with instructor |
|
Walking horse in corral |
35 |
Constant reassurance seeking with riding instructor |
|
Thinking about riding difficult trails |
45 |
Distracting with iPhone |
|
Panicky physical sensation of not being in control when horse thrusts up on steep trails |
100 |
Avoiding, thinking I can ride later with instructor |
In the next chapter you will work on motivation, exploring why it is worth it to you to use exposure and the other techniques in this book to solve your anxiety problems.