Why writing works as exposure

Obsessive thoughts and compulsive-thought rituals can’t be observed by others. Since they aren’t physical, creating a strategy that exposes a person to the feared stimulus is somewhat challenging. If we think of homework as we do with medicine, it is prescribed by the dose size and the dosing frequency. Likewise, if we want to understand the effects of cognitive or behavioral exercises, we need to know something about dosing: how often the exercise was performed and how long it lasted (the size of the dose). If we ask the client to write out their anxiety triggers and fears of what might happen, we get a very good idea from the length of the handwritten material exactly how large and how frequently the doses of exposure were taken.

Writing the anxiety triggers and narrative stories of feared outcomes carries several other advantages. When you write your thoughts down, you capture them. Now, instead of having obsessive or fear-evoking thoughts float in and out of your mind, you can see what you’re thinking. Most people with obsessions or excessive worry recognize their thoughts are distorted or even ridiculous, but writing their fears helps them gain more perspective.

Note that writing down your fear-evoking thoughts (or doing any exposure exercise) can stir up a lot of anxiety. Some clients believe that writing down their fear-evoking thoughts will make them come true (magical thinking). This shows how powerful and palpable thoughts can become. However, stirring up anxiety by facing fear-evoking triggers and WCSs is just what we want to do. Habituation to triggers and fear-evoking thoughts cannot be accomplished without exposure. By writing them out, we can control the level of exposure, the duration, and the frequency.

We usually tell clients something like, “Okay, you have about an 86% chance of getting a handle on your fears if you complete treatment (Ref 29), and you are ready to invest your time. Make sure that you are ready to go all the way with this activity before you begin. We would hate for you to try this for a day or two or five and drop out because it’s inconvenient or doesn’t seem to be working for you.” There seems to be a tipping point for many psychotherapeutic interventions. If you stop short of the recommended dosing, you may never find out for yourself if it will work for you. What if you stopped writing when you were only two or three days from noticing a large reduction in your anxiety in response to your triggers?

This is hard work. If you can't commit to sticking with it, put this workbook down and set it aside. Wait until you have the motivation to stick with it. Talk it over with your counselor and discuss smaller steps, alternative types of exposure, and coping techniques.

The next page carries the manuscript's three clinical examples in full — two trigger hierarchies with their SUD ratings, and three narratives written by clients: a college student's social-anxiety loop, an adult's contamination fear, and a child's account of spreading illness to the people he loves. They are written to be as frightening as the fear itself, because that is what makes them work. The page after that is where you build your own.