Part 8: Opposite Action, Behavioral Activation, and Exposure
Lasting Behavior Change
Early on in this workbook, we mentioned that behavior can affect thoughts and feelings, too. Well, here is where we outline some ways you can use behavior to change thoughts and feelings. You have learned some ways to guide your thoughts to more helpful directions. In this chapter, we’ll introduce you to some ways you can make your behavior work for you, too.
Opposite Action
Marsha Linehan, one of the foremost researchers in the area of treating emotional dysregulation and creator of Dialectical Behavior Therapy (DBT), coined the term “opposite action,” short for opposite-to-emotion action, to refer to a behavioral approach to modulating overwhelming emotions. In a nutshell, opposite action is using a behavior opposite to your emotional urge to turn down the volume on your emotion. You act opposite to what your emotion would ordinarily have you do.
Remember the CBT model? Well, just as thoughts and feelings have an effect on behavior, behavior can powerfully affect thoughts and feelings. Making significant behavior changes can also have a big effect on our emotions. By interrupting the pattern of mood-dependent behavior, you allow for new thoughts and feelings to arise.
This concept may run counter to your assumption about how to dissipate negative emotion. For a while, it was thought that engaging in a lot of emotional expression would help dissipate intense emotions by providing a catharsis. For example, you may have heard that it would be helpful for an angry person to pummel a punching bag and "let out that anger" or “blow off steam.” However, modern psychology research has found that this activity actually increases the intensity of the emotion. The more you engage in an emotion-driven behavior, the more that behavior fuels your emotion. Fortunately, the opposite is true, too. The more you engage in an opposite-to-emotion behavior, the less of the negative emotion you have.
Steps to Use Opposite Action
Step 1: When you have a strong emotion, check to see whether it’s working for you or against you. You may remember from earlier in the workbook that emotions, even unpleasant ones, can have beneficial functions. Fear alerts you to danger; anger inspires you to act, etc. Sometimes, though, the emotion doesn’t quite fit the situation or is unhelpful (for instance, anger when a friend tells you good news), or it is too intense to function effectively (as is the case with overwhelming panic). If it’s not working for you, opposite action may be helpful.
Step 2: Determine the urge associated with your emotion. Every emotion carries with it an urge for us to act in some way. Here is a short breakdown of some of the urges associated with different emotions:
Anger: Aggressively engaging or attacking
Disgust: Avoiding or pushing away
Sadness: Withdrawing from activity and isolating from people
Fear: Avoiding or escaping
Joy: Engaging with people and engaging in activity
Step 3: Engage fully in the exact opposite behavior of the emotional urge until you notice the emotion has significantly lessened in intensity. Here are some ideas:
Anger:
Take a short break from the source of anger.
Say something nice to someone, whether it’s the person you’re angry at or not.
Give your pillow a hug.
Let go of tension in your body.
Exercise.
Disgust:
Physically approach what you find disgusting and sit with it.
Mentally approach by seeing clearly the source of your disgust without avoiding.
Let go of physical tension.
Sadness:
Engage in pleasurable activities, even if you don’t “feel like it.”
Connect with someone you care about.
Get active with exercise.
Engage in activities that help you feel the time was well spent.
Fear:
Physically approach what you found frightening and sit with it.
Mentally approach by seeing clearly the source of your fear without avoiding.
Make eye contact.
Joy:
Focus on your breath to ground yourself in the present.
Feel your body’s heaviness while sitting still.
Opposite action works best when you persist in the behavior for several minutes straight. It will probably feel awkward and unnatural at first, but that’s the point. After a few minutes, you should start to notice your emotion ratcheting down somewhat. Like all other skills, the more you practice, the better you get at it.
Behavioral Activation
Behavioral activation is a CBT treatment for depression. It is like opposite action in that it works by engaging in the opposite of your mood-dependent behavior. Unlike opposite action, which is best for modulating momentary episodes of intense emotion, behavioral activation is designed to treat clinical depression. Clinical depression is feeling sad or depressed most days for at least several weeks consistently.
Steps to Use Behavioral Activation
Step 1: Track your behavior for one week. Every day, jot down all of the activities you engage in throughout the day. You can do this in a calendar on your phone, a computer spreadsheet, or you can create your own paper version. Log everything you did in the past few hours several times each day. As you do, rate your level of pleasure and mastery for each activity on a scale from 1 to 10. Pleasure refers to how much enjoyment you had, and mastery refers to a feeling of competence or engaging in something you felt was time well spent.
Step 2: Identify and eliminate the energy drains in your day. Energy drains are activities you engage in but provide no real purpose and do not add any additional pleasure or mastery. Once you identify them, eliminate them. Whatever you have to do to no longer engage in these wasted activities, do it. You might delete certain apps from your phone, block certain phone numbers, unplug your TV, etc. The point is to eliminate the things that take energy but don’t provide anything in return.
Step 3: Brainstorm a list of pleasurable and mastery-oriented activities. As many as you can think of. Large projects and short diversions. Anything that might provide pleasure or mastery is acceptable for this list. If you’ve been feeling depressed for a long while, it might be difficult to create this list. One way of thinking about it is to remember what sorts of things brought you pleasure and mastery in the past. If you get stuck, take a look at the sample pleasure and mastery list below.
Step 4: Schedule pleasure/mastery activities. Looking at your calendar, choose one item from your list for each day, and schedule them in the coming week. It doesn’t count if you don’t put it in your calendar, and here’s the reason: It is hard to do things that you don’t want to do. That’s why mood-dependent behavior comes so naturally because it’s easy. Behavioral activation has been researched extensively, and it is the treatment of choice for depression. But it won’t work if you wait to engage in rewarding behavior until you feel like it. That’s why scheduling is so important. It takes the in-the-moment choice out of the equation.
Step 5: Engage in the scheduled activities. Do each activity as it’s scheduled. Just as in step one, track the pleasure and mastery you receive from each activity. Review your work at the end of the week and decide what activities to include in the following week.
Behavioral activation is not a complex psychological intervention, but it is difficult. We’re actually working against biology when we engage in behavioral activation. And that’s the whole point. One of the reasons you continue to be depressed is you continue to avoid rewarding behavior. The worse you feel, the less you want to engage in pleasure/mastery. The key is to stick with it even when you don’t feel like it.
Another reason it can be difficult is that with depression, feeling better takes time. Little by little, week after week, the depression lessens. This means that it requires consistent effort over several months. That doesn’t mean that it will take months before you start to feel better, but that it will take some time before your depression has completely lifted. Each week is slightly better than the previous week. Usually, people need between two and four months of behavioral activation for a full course of treatment. And because it’s best used with clinical depression, it’s usually much more effective when you’re engaging in behavioral activation while working with an experienced CBT therapist. There’s just no substitute for getting weekly guidance and feedback from a trained professional.
Exposure Treatment for Anxiety
Similar to opposite action, exposure therapy uses behavior to lessen intense feelings and cognitive distortions. Because we tend to avoid what we fear or are anxious about, our anxiety and fearful thoughts increase. In CBT for social anxiety, If social situations make you anxious, you avoid social situations. The longer you avoid them, the more your mind tells you frightening stories about them that don’t accord with reality. Because you have been avoiding them consistently, you don’t have any evidence against those fearful stories, so you believe them even more. Over time, just thinking about social situations might start to arouse feelings of panic, which feeds into the scary narrative your mind has been building up all this time. And the cycle continues.
Exposure interrupts this pattern by helping you approach things you had previously avoided. The more you approach the objects of your fear and anxiety, the more you get used to them. As you get used to them, your thoughts seem to restructure themselves. The less worrisome thoughts you have, the more confident you feel, and the easier it is to approach rather than avoid in the future. That is how exposure works. Again, it’s not a complex process to understand, but it can be difficult. Just like behavioral activation, exposure has you do things that are unpleasant. Just as with all of the other CBT skills, practice is key.
Steps for exposure:
Step 1: Create a list of feared situations. Write down as many anxiety-provoking situations as you can think of. Most people find it helpful to limit the list to just one area of anxiety. For instance, if you have a fear of heights and you get anxious in social situations, pick one, and create a list for and focus on that one area.
Step 2: Arrange them from least anxiety-provoking to most anxiety-provoking, creating an exposure hierarchy. As you do this, you should have several items that are high anxiety, some that are moderate-, and some that are low anxiety. If one of these areas doesn’t have any items, use your imagination to concoct a situation that fits.
Step 3: Pick one of the items on the list, and write out a thought record for it. Most people prefer to start with one of the lower-anxiety items, but some people prefer to start with a more challenging item. It’s totally up to you. Once you pick an item you feel confident you can approach, create a thought record identifying all of the automatic thoughts that make the idea of this item anxiety-provoking. Then, go through the steps from parts six and seven of this workbook to restructure those thoughts.
Step 4: Plan your exposure sessions. For exposure to work, each session needs to be at least a half hour, and you need to do it at least three or four times a week. For each session throughout the week, use the same exposure item. The point is to do the same thing so frequently that you get used to it by the end of the week.
Step 5: Engage in the exposure repeatedly. Right before you begin, review your completed thought record. Then, spend a half hour or more approaching what you ordinarily avoid. Once you’ve done this four or five times, you should feel more comfortable with the trigger. If so, move on to the next item in your exposure hierarchy.
As with behavioral activation, if you feel your anxiety is very intense or significantly impacts your life negatively, you would likely benefit from working on exposure with a trained cognitive behavioral therapist. The form exposure takes can vary depending on the anxiety disorder, and only a trained CBT therapist can guide you through exposure when you have more severe anxiety. However, you can use the steps above to get a taste of what facing your fears is like using low-anxiety situations. Opposite action can also be effective with anxiety. Ordinarily, we interpret anxiety as a stop light, telling us we need to avoid whatever we are anxious about. However, opposite action can help you learn to approach those things instead. (Of course, you don’t want to use this skill with things that are actually dangerous!)
Choose one of these behavioral skills to work on for several weeks while completing three to four thought records each week. As mentioned earlier, if you believe you have a more significant psychological problem or psychiatric disorder, consider beginning work with a cognitive behavioral therapist. You owe it to yourself to get the best level of care that you can. You can visit the links below to find a cognitive behavioral therapist in your area.
Association for Behavioral and Cognitive Therapies https://www.findcbt.org/FAT/
Academy of Cognitive Therapy https://www.academyofct.org/search/custom.asp?id=4410
CBT For Anxiety Disorders: A Practitioner Book. Wiley-Blackwell: Hoboken, New Jersey. – Simoris, G., Hofmann, S.G. (2013).
Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition. The Guilford Press: New York. – Leahy, R.L., Holland, S.J.F., McGinn, L.K. (2011).
DBT Skills Training Manual, Second Edition. The Guilford Press: New York. – Linehan, M.M. (2014).