What the Stoic literature doesn’t make clear, though, is that the feared situation must be experienced for considerably longer than normal for anxiety to properly habituate. In fact, if exposure is terminated too soon, the technique may actually backfire and increase anxiety and sensitization to the feared situation. So it’s important to compare what the Stoics recommend to what we know from clinical research using similar techniques.
Exposure therapy works best when the anxiety-provoking trigger is physically present, like the cats in our example above. Therapists call this in vivo, or “real-world,” exposure. However, anxiety also habituates almost as reliably, in most cases, when the threat is merely imagined, something known as in vitro, or “imaginal,” exposure. The Stoics realized that exposure to imagined events can lead to emotional habituation in this way, allowing anxiety to abate naturally. Their recommendation to regularly picture catastrophic events, which we’ve called the premeditation of adversity, is essentially a form of imaginal exposure therapy. Aesop’s fable “The Fox and the Lion” shows that people have long grasped this phenomenon, but it’s still quite remarkable to discover a philosophical therapy employing it over two thousand years before it was rediscovered by modern behavior therapists.
However, in the case of imaginal exposure, maintaining the image for long enough requires considerable patience and concentration, especially when practiced as a form of self-help without the aid of a therapist. Many people find that it helps to imagine the anxiety-provoking situation as if it were a short movie clip, or sequence of events, with a beginning, middle, and end, lasting roughly a minute or so. They can then replay the same scene repeatedly, in their mind’s eye, for five to fifteen minutes or even longer. For example, someone who is anxious about losing their job might visualize being called into their boss’s office, told that they’re being sacked or made redundant, and later clearing their desk and leaving, etc. They’d picture this as a short movie, perhaps repeatedly on a loop. As noted, the actual amount of time required varies, but anxiety should have reduced to at least half its initial level before ending the exercise. The most common reason for failure is that people terminate these sorts of exposure exercises before their emotions have had enough time to habituate. It takes patience, in other words.
Therapists will often ask their clients to rate their discomfort or anxiety level while picturing a scene on a scale from zero to ten, or as a percentage. Clients then re-rate their anxiety every few minutes during repeated imaginal exposure until it has sufficiently reduced. For example, the cat phobic might patiently visualize stroking a cat over and over, until their anxiety reduces from 80 percent to at least 40 percent or even lower if possible (where 100 percent would be the most severe anxiety they could imagine feeling and 0 percent would be no anxiety at all). Nota bene: It’s important to emphasize that any technique that involves imagining upsetting scenes should be approached with caution by individuals who suffer from mental health problems or those vulnerable to being emotionally overwhelmed, such as sufferers of panic attacks. When doing this alone, don’t pick an image that’s going to be too much for you to handle, such as a traumatic memory of sexual assault, for instance—that’s where the support of a qualified psychotherapist may be necessary. Nevertheless, most people are capable of safely confronting ordinary fears and worries in their imagination. SPONTANEOUS PSYCHOLOGICAL CHANGE
Emotional habituation is the most important process to take place during imaginal exposure, such as the premeditation of adversity. However, we can activate a surprising number of other beneficial psychological processes when we patiently and repeatedly picture stressful events. Therapy clients who are asked to mentally review emotional situations in this way may exhibit one or more of the following changes:
1. Emotional habituation, as described above, where anxiety or other feelings naturally wear off over time and become blunted through exposure to the feared situation.
2. Emotional acceptance, where we gradually reduce our struggle against unpleasant feelings such as pain or anxiety, come to view them with greater indifference, and learn to live with them—something that, paradoxically, often greatly alleviates emotional distress.
3. Cognitive distancing, where we increasingly view thoughts and beliefs with detachment: we begin to notice that it’s not things themselves that upset us but our judgments about them.
4. Decatastrophizing, where we gradually reappraise our judgments about the severity of a situation, of how awful it seems, downgrading it by going from “What if this happens? How will I cope?” to “So what if this happens? It’s not the end of the world.”
5. Reality testing, where we reappraise our assumptions about a situation to make them progressively more realistic and objective; for example, reevaluating the probability of the worst-case scenario or that something bad will even happen at all.
6. Problem-solving, where repeatedly reviewing an event leads us to creatively figure out a solution to some problem facing us—perhaps like Marcus and his generals’ paradoxical idea of deliberately marching their legionaries into a Sarmatian ambush in order to spring a trap on the enemy.
7. Behavioral rehearsal, where our perception of our ability to cope improves as we practice, in our mind’s eye, employing skills and coping strategies in an increasingly refined manner—for example, mentally rehearsing assertive ways to deal with unfair criticism until we’re more confident about doing so in reality. This can take the form of modeling the behavior of others whose way of coping we admire and want to emulate—we imagine how they would act and then picture ourselves doing something similar.
I’ve found that informing patients that other people often experience these sorts of changes is helpful because it can make the same processes more noticeable in their own mind and more likely to happen spontaneously. Of course, it’s also possible to deliberately utilize these psychological mechanisms by employing various psychological techniques. For instance, in addition to the premeditation of adversity, Marcus refers to the repeated use of two particularly important Stoic exercises that resemble cognitive distancing and decatastrophizing in modern psychotherapy. We’ve mentioned these already, and now we’re ready to consider their use in relation to worry and anxiety. THE INNER CITADEL
Although Marcus says little about anxiety explicitly, he often talks about the kind of peace that Stoicism offers, and his words obviously have implications for the Stoic therapy of anxiety. During his early reign, after the death of Antoninus, he took trips to his holiday villas in Italy to get a break from the worries of the Parthian War and running the empire. We can see from his letters to Fronto that he was wrestling with the whole idea of taking time away from work, feeling instead that it was his duty to attend to state business even though his friends advised him that retreats were necessary for his health.