SENTENCE EXPOSURES

 

A Sentence Exposure consists of repeating an anxiety-provoking sentence over and over again in your head until it gets boring. It's counter-intuitive but it's also highly effective. I think of this technique as my “breaking the emergency glass” technique. It’s the one I go to when I am extremely anxious, angry or sad.

It's important to keep in mind that the purpose of Sentence Exposures is actually to STOP thinking about a negative thought.  The point is that sometimes, the only way to get something off of your mind is by "burning it out" first.

As with all exposures, the optimal Sentence Exposure is one that produces mild anxiety. Once you get comfortable with this technique; however, you should be able to use it even when you are extremely anxious.

There are three rules for Sentence Exposures: The sentence has to be able to make you feel bad, you are only allowed to repeat one sentence at a time, and you should keep repeating the sentence until it gets boring.

The sentence has to be able to make you feel bad: The sentence you pick should be able to produce at least a mild amount of negative emotion and at least some physical sensations when you repeat it. An anxious sentence should be able to make you feel tense in your shoulders, chest, or stomach. A depressing sentence should make you feel heavy. An angry sentence should make you feel hot. Although you can eventually use Sentence Exposures for intense and extreme emotions (i.e. once you get comfortable with the technique and it no longer seems intimidating), you should first practice with mild emotions until you get the hang of it. For example, if the sentence "I'm going to be terrible on this date" feels overwhelming, start with "This date might not go perfectly" instead. Remember, the optimal exposure is always a mild one. Work your way up to the most difficult sentences as you get the hang of the technique.

You’re only allowed to repeat one sentence at a time: This is by far the most important rule because it’s the biggest difference between a Sentence Exposure and the way that we normally feel bad. Normally, when we feel bad our brain jumps from sentence to sentence because it knows we will get bored if it just stays on one. For example, it might go from from "She doesn't like me" to "I have no friends" to "Nobody loves me" to "I'll be alone forever" and then we're off to the races. With a Sentence Exposure what we're saying is “No. No. Screw that. I’m just going to do one sentence at a time” so that you can finally see how the sentence gets boring. THEN, you can move on to the next one. This is the hardest rule to follow when you’re feeling really anxious or sad, because you’ll find that all these other sentences want to come in. But, you have to be very diligent and say to interfering thoughts, "No. No. Screw you. Take a number.  I WILL do you, but I'll do you NEXT after I'm done with this first sentence." 

If you picture an image while you are repeating a sentence, it’s also important to focus on just one sentence/image combo at a time. For example, if you pick “I suck on dates,” you should actually just picture one particular date you were bad on (rather that going through every date that sucked). Once you are bored of the first sentence/image combo, you can then go onto the next one. If you jump from image to image, or example to example before you get bored, you are actually doing several different Sentence Exposures without giving any of them a chance to get boring.

Keep repeating the sentence until it gets boring: You’ll know what I mean by this after you practice the technique a few times. Basically, when you repeat a sentence it initially makes you feel worse, but if you do it long enough it starts to sound like a song, or a chant, or a tongue twister. Soon after that, your brain spontaneously starts talking back to the sentence and/or you get distracted. Fairly often, I have patient’s complain that they couldn’t do the Sentence Exposures because they kept "getting distracted." Actually this was usually a sign that the sentence got so boring that they could no longer focus on it.

Doing a Sentence Exposure is a lot like focusing a laser beam on a piece of metal. At first, the metal gets hot. But if you keep the laser beam focused long enough, it always eventually pokes a hole through to the other side.

Exercise 1: Trial Run of Sentence Exposures

Grab a pen and a piece of paper and write down a sentence that you think could make you feel anxious if you repeated it over and over again right now. Examples might include, “I’m bad at small talk”, “I don’t have enough friends”, or “I could be better at dating.” Try to pick a sentence that makes you feel only a little anxious to begin with.

For three minutes, I want you to repeat your anxious sentence over and over again silently in your head. As you repeat the sentence I want you to try to feel anxious about it. If you use an image or example in your mind as you repeat the sentence, remember to just stay with one image/example the whole time. Three minutes might actually be too long (i.e. you might get bored of the sentence and get distracted before the time is up), but that’s OK, we’re just doing this as an experiment the first time.

OK, do the trial run now. For three minutes, repeat a sentence (silently in your head) that makes you slightly anxious.

What happened? If the sentence made you feel at least some level of anxiety, but then eventually got boring (i.e. you got distracted, it started sounding like a chant, or your brain started talking back to it) then the technique worked great. If you were unable to get into the sentence and it didn’t make you anxious at all, then you should pick a harder/more anxiety provoking sentence and try it again. If you still can’t get anxious, then wait until the next time you are already feeling bad and try it then.

If the sentence made you anxious but didn’t get boring at all, that’s OK too. That usually means that you need more than 3 minutes to "finish" the sentence. I’ll discuss how some sentences can take a long time a little bit later. For now, just use the same sentence at the start of the next exercise.

If the sentence felt too overwhelming and you stopped repeating it before the three minutes were up, then you picked something that was too hard. Pick a gentler, less anxiety-provoking sentence and try it again. Remember, all exposures should start out as mild at first. You need to work your way up to the harder sentences.

Exercise #2: Sentence Exposure Series

Now I’d like you to do the exercise for 5 minutes, so a bit longer. But this time, I just want you to repeat a sentence until it gets boring. Then, I want you to write down a new sentence and repeat that until it gets boring too, and then another sentence and another sentence until the five minutes are up. How many sentences you do just depends on how good they are. If you find a really good sentence, it might last 3-4 minutes. Whereas, if you write down a sentence that you can’t really get into, then maybe after 20-30 seconds you’ll be bored with it and write down a new one. The sentences don’t all have to be on the same topic. One can be about a friend, the next one about dating, and the next one about a work meeting. The only rule is that each sentences should be able to produce mild anxiety as you repeat it.

Try the Sentence Exposure Series now for 5 minutes. Write down a sentence, keep repeating it until it gets boring, then write down another sentence and so on.  

What happened? The results should be fairly similar to the first trial run except that you probably were able to move on to at least one new sentence. Remember to refer to the three rules of Mental Exposures if you are having trouble.

There are some times when a Sentence Exposure can take 30-60 minutes to get boring. This is most often true of depressing sentences (although it can sometimes happen with anxiety provoking sentences as well). For some sentences, it’s almost like you have to “break their back” the first time around, then they become much quicker the next time you try them. My best example of a really long Sentence Exposure happened 14 year ago. I was dating a girl and broke up with her after one year. This was the fourth girl in a row that I broke up with after exactly one year and I started thinking “I’ll be alone forever.” So I went home and started repeating that sentence over and over again as a Sentence Exposure: “I’ll be alone forever. I’ll be alone forever. I’ll be alone forever.” It was working. I was feeling really sad, like I was sinking into a worm-hole. After half an hour, the sentence was still working so I kept on repeating it. Finally, after an hour I pulled out of it and my brain started saying: “Lindsay, you’ve been dating healthier and healthier women as time goes on, and you’ve been getting better and better at relationships.” Finally the sentence was done. When I ran into that girl a few weeks later I could tell she was mad because I had gotten over it. For me, that one hour of intense pain was preferable to the several months of intermittent pain I usually experienced after break-ups. From then on, whenever I did the sentence “I’ll be alone forever” my brain would talk back to it within a few minutes.

I think the reason that some sentences can take so long the first time around is because you are secretly thinking of more than one situation. For example, that first time I did the sentence “I’ll be alone forever,” I was probably secretly mourning not just my most recent break-up, but also the three that came before it. Once I had taken out all this mental “baggage” the sentence became much quicker because I was only doing it for the situation at hand. You should expect that particularly intense or recurrent sentences might take a while the first time around (especially for a depressing sentence that has been with you for a while). Be prepared to give the technique some time - for example, block out an hour before you go to bed one night. The technique will probably make you tired and put you to sleep once you are done.

Some of my patients have brought up the concern that repeating a negative thought over and over again will "make it come true" or have a negative effect on their psyche. It's important to keep in mind that the point of a Sentence Exposure is actually to STOP thinking about the sentence. This is the same technique I use when I get a song stuck in my head. If a song has been in my mind for several days in a row, I get rid of it by doing an exposure. I "sing" the song over and over again in my head, just the chorus or one small bar of instrumental, for five minutes straight. Once I finish, the song is out of my head. Similarly, we all have "top hits" of negative thoughts that get stuck in our heads. Sometimes, the only way to get rid of those thoughts is by burning them out through voluntary repetition.

If you imagine anxiety as being on a 1-10 scale (with a 10 being the most anxious you've ever felt and a 0 being totally calm), a Sentence Exposure will take you from where ever you are to a "3". So if you do a Sentence Exposure when you are in a good mood, all you will do is make yourself feel a little bad. In contrast, if you do a sentence exposure when you are at an 8-10, then you will notice a huge benefit. That's why I call this my "breaking the emergency glass" technique. I typically use it when I am feeling really bad. If I can't push the thoughts away, and if I can't talk back to the thoughts, then do I do a Sentence Exposure. I'll do the Sentence Exposure until I can finally distract myself or until I can finally talk back to the thought. Either way, the point is actually to get the thought out of my mind.

Sensation Exposures

Sensation Exposures are also known as “I feel it” exposures. They are like Sentence Exposures, except that you repeat the sentence “I feel it” over and over again in your head. “I feel it. I feel it. I feel it...” While you are repeating that sentence, you focus on any part of your body that feels uncomfortable.

I use this technique most often for pain. When my knee hurts or my lower back hurts I focus on the pain and repeat “I feel it. I feel it. I feel it” over and over again in my head. The pain initially gets worse, but after a few minutes the pain either goes away or the pain gets “boring” and I start thinking about something else. For example, when my knee hurts, I’ll focus on the pain and really try to feel exactly what part of my knee is hurting. The pain gets worse at first, but after a few minutes it goes away and I literally can’t feel it anymore. When I focus on my lower back, the pain doesn’t go away. Instead, the pain decreases slightly but then it gets boring and I start thinking about my day. Either way, I am no longer focusing on the pain.

Sensation Exposures are very useful for people who primarily feel their social anxiety through physical sensations. I have patients who get nauseous, have a strong urge to use the bathroom, get a lump in their throats, blush, sweat, or just “feel tense” without any particular sentence running through in their heads. In my own case, my social anxiety almost always takes on the form of sentences (“I’m boring”, “They don’t like me”, “I don’t know what to say”), but I have had some occasions where the anxiety primarily manifested as nausea or a lump sensation in my throat. On those occasions, I use Sensation Exposures.

When you do a Sensation Exposure, you must focus on only ONE discomfort at a time. So, if you have a headache and you are nauseous, just focus on the most intense sensation first. Wait until that sensation is gone or is hard to focus on and only then move on to the next sensation.

As with all exposures, Sensation Exposures must be voluntary, mild, and sustained. They must be voluntary in the sense that even though the feeling might have come up against your will, your decision to focus on it was on purpose. Sensation Exposures must also be mild at least initially. If focusing on nausea or chest tightness seems too hard at first, then focus on an itch instead. Once you get the hang of the technique, you can then work your way up to more intense and anxiety-provoking sensations. Finally, Sensation Exposures must be sustained. You should continue focusing on just one sensation until the feeling starts to get boring.

I’d like you to do an experiment right now so you can see how it works:

Sensation Exposure Trial #1

I want you to try not to move at all for three minutes. You are allowed to blink and move your eyes, but you are not allowed to move your body. I’m hoping that at some point you’ll really want to move. Your scalp will itch or you’ll want to move your ankle or you’ll want to shift your position. When that happens, don’t move. Instead, do a Sensation Exposure and focus on exactly what part of your body you want to move. If you want to scratch your arm for example, say “I feel it. I feel it. I feel it.” and focus on the itchiness. The itchiness should get more intense at first, but after a while, it will break and your mind will wander somewhere else. Then maybe your scalp will itch, then maybe you’ll want to move your feet, then your wrist, and so on. Keep following the sensations as they migrate through your body. If enough time passes, you’ll literally forget to do the Sensation Exposure and you’ll start thinking about your day.

Try Sensation Exposure Trial #1 now: For 3 minutes, don’t move and do Sensation Exposures.

Sensation Exposure Trial #2

On the link below you’ll find a picture of a man scowling. Studies have shown that pictures like this trigger the amygdala (a part of your brain involved in producing fear) in patients with social anxiety (ref).

For three minutes I want you to stare at the scowling man's eyes. Hopefully you will notice some anxiety symptoms. You might notice tightness in your chest, or a lump in your throat, or the hairs rise on the back of your neck. When that happens, focus on each sensation one at a time while repeating “I feel it. I feel it. I feel it” silently in your head. If that does not make you feel tense, then repeat "He hates me. He hates me. He hates me." silently in your head and focus on any sensations this brings up. It's important to just focus on the face in this picture (i.e. don't start imagining different people in your life, because that is the equivalent of moving on to a different exposure before allowing this particular face to get boring).

Try Sensation Exposure Trial #2 now. Remember to set a timer for 3 minutes, then click on the following link: Man Scowling.

What happened? If you noticed least some physical discomfort and were able to focus on it then you are off to a good start. Hopefully, you noticed that after a while, the physical discomfort got less intense and/or disappeared. Within a few minutes, most people start seeing “through” the picture and have trouble focusing on it because it gets so boring. If the anxiety did not completely go away, then try it again for 3 more minutes and keep repeating it until the face no longer produces any physical reaction.

If the discomfort was too intense and you stopped, you may need to a more gentle or neutral face to practice on (remember, exposures are best is they start off as mild). If that's the case for you, try the exposure again with the following picture: Neutral Face

If the picture of the scowling man did not produce any discomfort at all, then you made need to start with a more intense picture (or try it again when you are already feeling anxious). If that's the case for you, try the exposure again with one of the following pictures: Angry Man, Irritated Group

I like this experiment because it is a good example of how exposures work: anything that you focus on voluntarily will eventually get boring – even pictures that have been proven to activate a fear center in your brain.

The next time you are feeling anxious, if there are no particular sentences associated with the anxiety and/or your physical sensations are the most prominent, try a Sensation Exposure.

I have many patients who alternate between a Sentence Exposure and a Sensation Exposure depending on what is most prominent at a given time. So, you might first focus on the sentence “They can tell I’m anxious” and then switch to focusing on your shoulder tightness once the sentence gets boring. Keep doing this process, alternating between sentences and sensations until you are feeling calmer.

Exposures While Talking

Whenever you are talking to someone, there are two things competing for your attention: the conversation and the distracting thoughts. When the distracting thoughts are making you feel anxious or sad, they can take away so much of your attention that you’ve only got ten or twenty percent of your brain even available for the conversation. When you are really going bad, you can’t even hear what the person is saying so when it’s your turn to speak you're thinking “Nuts, I don’t even know what you just said.” For me, it’s in these situations, where I am so distracted that I can’t even listen, that I do a Sentence Exposure while I’m talking to people.

A good example of when I would use this techniques was at parties. There would be times where I’d go to a dinner party and feel totally self-conscious and have trouble focusing. I would try to calm myself down and use relaxation techniques, but sometimes it wouldn’t work and I would start feeling detached and begin fake-smiling. It’s in those situations that I would “break the emergency glass” and start doing Sentence Exposures while in a conversation. For me, the sentences were always the same: “I’m boring”, “I don’t know what to say”, or “They don’t like me” So I’d start repeating one of these sentences over and over again “I’m boring. I’m boring. I’m boring” while I was pretending to listen to the person. (Don’t do this out loud.) The experience I had was always the same. I would try focusing on the Sentence Exposure. It would be my intention to focus on the Sentence Exposure. But eventually, I would get bored of the exposure and I would start listening what the person was saying to me. It’s almost like the situation reversed itself. Instead of being distracted by my self-conscious thoughts, I would be distracted by the conversation.

I’d like to give you an example of what I mean. I want you to pick an anxiety-provoking sentence. Once you’ve picked one, I want you to read the story below out-loud simultaneously while you’re repeating the sentence in your head. You should notice that at first, your voice sounds kind of choppy and you are reading on autopilot, but as time goes on your voice should sound smoother. You should also notice that after a while, it becomes harder and harder to focus on the sentence, and you get more and more sucked into what you’re reading out loud. I’m going to cheat by having you read a really good story.

OK, start doing a Sentence Exposure and simultaneously start reading the following story out loud:

I’m going to tell you a story about a panic attack one of my patients had (and gave me permission to share with others). The situation was that my patient was smoking a huge amount of pot with a friend of his. They were watching the movie The Big Lebowski and it’s the first time my patient had ever seen that movie. There’s a scene in that movie where the main character does acid and starts tripping out and sees Sadam Hussein giving him bowling shoes. All of a sudden, my patient decided that he was crazy, that he needed to call 911, and that he needed to go to a mental hospital. Then he started thinking that his friend slipped him something so he didn’t want to tell him. So he said “Hey Joe, I’m feeling kind of tired. Is it OK if I crash in your spare room?” Joe said “Sure” so my patient went in there. He was still freaking out. He was trying to decide whether or not to call 911. He tried relaxing, it didn’t work. He tried telling himself that it’s just a bad trip from the pot. It didn’t help. So he did what he had been practicing to do when his back is against the wall. He "broke the emergency glass” and start doing Sentence Exposures: “I’m crazy. I’m crazy. I’m crazy” until that got boring. Then “Eric slipped me something. He slipped me something. He slipped me something” until that got boring. Then “I need to call 911. I need to call 911 . I need to call 911” until that got boring. Finally, after about 10 minutes my patient went to sleep. The next morning he felt kind of good about it because he had a panic attack and remembered to use the technique. About a month later, he invited that exact same friend specifically to smoke a lot of pot and watch The Big Lebowski, because when something kicks your butt, you want to go right back into the situation as soon as you feel ready. He was totally ready to do Sentence Exposures, but it never came up and he was basically fine.

OK. So, what did you notice?

You probably noticed that as the story went on you found it harder and harder to focus on your sentence and you got more and more sucked into what you were reading.

If I was secretly doing a Sentence Exposure right now while I was talking to you, it would affect my performance, but I would still be able to say something. Basically, I would still be able to pretend that I was paying attention. I might say something like "Hmm. Interesting. Wow, tell me more.” But the key is, I would only do Sentence Exposures if I was already having trouble focusing on the conversation. So, doing the technique won’t make me any worse. It’s only going to make me better as the sentence finally gets boring and I start listening to what you are saying.

Doing a sentence exposure while talking to someone is much quicker then when you do it alone.  That's because, when you are in front of someone, the competition for your attention is much better.  When you are alone, the sentence has to get REALLY boring before you start thinking about your day.  When you are in front of someone, the sentence only has to get a little boring before you start focusing again on what they are saying to you.