Bryan Caplan  

Exposure Therapy: When Probabilities Fail

Read it and Weep... Status Competition...
In chapter 4 of Selfish Reasons to Have More Kids, I show that - objectively speaking - kids today are safer than ever.  And I'm far from the first social scientist to point out the public's systematically biased beliefs about risk - try Aaron Wildavsky, Kip Viscusi, Cass Sunstein, or Levitt & Dubner.  One fact that we quants tend to overlook, unfortunately, is that many people still feel extremely afraid even after they accept the facts.  This doesn't mean that correcting misconceptions is useless - many people's fear does respond to facts.  But it does leave a tough question: What can we do for everyone else?

I'm pleased to report that an effective supplement to objective risk analysis exists.  It's called exposure therapy.  Psychologists use it to help people with severe anxiety problems - people who have nothing to fear but fear itself.  The best source I've found is the Handbook of Exposure Therapies.  Intuitively, the idea is to get people to "face their fears."  From the introductory chapter: "Exposure therapy... involves deliberate and planned exposure to a feared stimulus, or representation of the stimulus, until the intensity of the person's distress recedes..."   The basic steps:

1. Choose to vividly experience a disturbing but tolerable fear.  Depending on the fear, this means either first-hand experience (e.g. spiders), or detailed imagination (e.g. the kidnapping of your child).  "Regardless of the way exposure therapy is conducted, clients are encouraged to confront their fears in the present-tense.  For example, a client recounting a traumatic event in exposure therapy is encouraged to describe the event as if it were being relived."

2. Continue doing #1 until the experience or imagination has become less frightening.

3. Move on to more intense anxieties and repeat.

The Handbook also reviews clinical evidence on exposure therapy vs. other talk therapies vs. drugs vs. nothing vs. combinations of the above.  The contributors to this volume are obviously sympathetic to exposure therapy, but their survey of the evidence is still impressive.  In almost every case, they conclude that exposure therapy plus X is no better than - and often worse than - exposure therapy alone.  The zero or negative marginal benefit of drugs is awfully Hansonian:
With respect to short-run efficacy, a number of studies suggest that [some drugs] may enhance the effects of exposure-based CBT [cognitive-behavioral therapy].  However, an approximately equal number of clinical trials provide no support for this conclusion, and a meta-analysis of this literature indicates that combined treatment is no more effective than CBT alone... On the other hand, clinical trials have consistently failed to support an advantage of combined treatment when long-term outcomes are considered.  In fact, the two largest and most well-designed trials of combined treatments provide unambiguous evidence that pharmacotherapy... interferes with the durability of exposure-based CBT.
Does this mean that teaching probabilities is a waste of time?  Not at all.  Many people's anxiety does respond to objective information.  But even if your anxiety is more stubborn, it's still good to learn about probabilities.  If the sky really is falling, you should run for cover.  But if the sky isn't falling, the best way to feel better is to sit down under the open sky and face your fear.

P.S. How can a Szaszian take this stuff seriously?  Easily.  Szasz would deny that anxiety disorders are a "disease."  But he'd surely admit that extreme fear of minor risks is a "problem in living" - and there's nothing anti-Szaszian about carefully comparing different strategies for overcoming such problems.

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COMMENTS (10 to date)
Scott Wentland writes:

This is interesting. But there could be a more rational explanation for at least some of the behavior of parents today. Perhaps one reason why parents nowadays have more fear for the safety of their children is because it costs more to "face their fear" and watch their kids more.

The two-parent working household has become more common over time, making child supervision more expensive (e.g. a higher opportunity cost for stay-at-home moms), some parents tend to go overboard with safety measures to compensate for less time spent watching their own kids.

I don't think this explains all behavior (like the ever-more sophisticated car seat and other safety measures), but it's worth thinking about.

John Jenkins writes:

As a self-identified Szaszian, how can you give any credence to any alleged psychological therapy?

You can give it the fancy name of "exposure therapy," but isn't it really just experimenting? To borrow your phrase, if you walk outside and the sky isn't falling, that's inconsistent with your belief. Unless you choose to be irrational, you have to modify your belief. But, if you're going to choose to be irrational, then all of the contrary evidence in the world is useless so this "therapy" won't work.

Mike Rulle writes:

"1.Choose to vividly experience a disturbing but tolerable fear. Depending on the fear, this means either first-hand experience (e.g. spiders), or detailed imagination (e.g. the kidnapping of your child)......."

"3. Move on to more intense anxieties and repeat"

Uhhh......more intense than "the kidnapping of your child"?

pjsw writes:

Thank you, Bryan, for bringing such an important and effective technique to your readers' attention.

However, as someone who has undergone a good deal of exposure-based CBT for OCD-related anxiety, I'm afraid you may have inadvertently downplayed the difficulty of the process for patients.

Steps 1 and 2 can be so bad as to induce panic attacks or render a person temporarily non-functional. And Step 3 is often a lifelong process, as the objects of one's anxieties shift and change instead of going extinct.

My experiences with CBT have taught me that we are more like animals than we like to think we are. Emotions are sometimes, or often, simply not under our rational control. This is why talk therapy tends to fail. We need to condition ourselves out of our anxieties like we would train a dog. Above all, it is important to understand that this process, while worthwhile, is often long, ugly, shameful, and exhausting. So, "facing your fears" is easier said than done.

guthrie writes:

I agree with psjw.

If you've never experienced the joy of stage fright, let me enlighten you as to how an irrational fear of 'being looked at' can induce very real physical reactions:

The throat tightens so that breathing is inhibited (making it more shallow and one more prone to hyperventilation), blood pressure raises and the skin flushes, pupils reduce to pinpoints and one's peripheral vision constricts, movement feels restricted and you bump into stage furniture, whereas in life one would easily slip around such obstacles, one can't seem to 'hear' properly... you get the picture. Most people would rather die than speak to a group. I was one of these people at one time.

It works as long as the exposure to the fear is gradual and as long as the patient is not made to feel 'failure', per se. If someone afraid of birds starts this process, then suddenly finds themselves amidst a flock of pidgins, they'll likely have to start over.

But it works. I'm on stage without a script on a regular basis these days. I'm sure it would work for parents as well.

guthrie writes:

Oops! I meant pjsw! Sorry!

mobile writes:

Let me give a couple of reasons that modern parents' fear is rational even in an environment of decreasing risks. First, life is dearer today than in the past. This fact is reflected in risk premiums and other quantitative measurements of "the value of a human life". Second (and possibly related), there are fewer children per household these days. In the past, families faced decreasing returns on protecting the lives of all their children. Families today face increasing returns for overprotecting their kids, even if the value of the kids is the same as in the past.

Dr. T writes:

"How can a Szaszian take this stuff seriously? Easily. Szasz would deny that anxiety disorders are a "disease.""

Yes, he would. Just as he denies that psychosis, schizophrenia, bipolar disorder, clinical depression, etc. are diseases. No, those are just different states of mind that people have, and everyone (including the patient) should accept that they are just variations of normal. Szasz is the worst kind of fool: he had the information, knowledge, and training to know better, but he spouts nonsense anyway.

By the way, most of us physicians call anxiety disorder a treatable psychiatric condition. Does that make it a "disease?" That only matters to people like Szasz. We just recommend counseling and, if the condition is bad enough, medication.

Eric Johnson writes:

Szaszianism is just the closing of a question that should legitimately remain open for quite articulable reasons. Would a Szaszian have believed narcolepsy was a disease in 1995, a time when it had one genetic correlate but no known physiological correlate (it does, now).

Does Szaszian believe in evolution and believe that non-pathological traits should be reasonably non-fitness-reducing?

I'd love to know whether there is any Szaszian, other than (perhaps - ?) Szasz, who knows med bio and disease bio. Or just one who isnt a libertarian philosopher! (Just kidding about the latter.)

Eric Johnson writes:

I guess Szasz has probably seen multiple (more than ten) hospitalized schizophrenics firsthand. Have any other Szaszians? (I have.)

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