Understanding the Act “As If” Concept for Anxiety Treatmentby Monica A. Frank, Ph.D.
Question: I've been reading your articles for some time and while I've made some progress in becoming less anxious, I still have trouble behaving the way I want to when I feel anxious. I think this is referred to as “Act as if” in CBT.
I think the main reason or issue behind it is that I see emotions as a true reflection of myself, at least in that particular moment. My question is, would you mind making a comment on “Act as if”' without relating it to “Fake it til you make it”? Since being real towards myself is quite important to me, I personally can't stand “Fake it til you make it” approach.*
Excellent question because it reflects how Cognitive-Behavioral Therapy (CBT) is commonly misunderstood when simplified versions of CBT become maxims such as “Fake it til you make it.”
First, let's review what acting “as if” means for learning to manage anxiety. This reader is referring to the “50 Tools for Panic and Anxiety”:
Suggestion 39: Act “As If”
One type of exposure is to act “as if” you did not have the anxiety. In other words, to do what you would do normally if the anxiety was not present. This type of exposure addresses the avoidant behavior and confronts the anxiety.
If you have panic attacks while attending meetings, for instance, instead of avoiding the meeting or sitting close to the door you would attend and participate in the meeting in the same way that you would if you didn't have anxiety. In a sense, this is a mindful approach in that instead of focusing on the anxiety thoughts you focus on participating in the meeting.
Although this method can be helpful in low level anxiety situations, it may not be very effective when the anxiety is particularly high. However, it can be combined in a step-by-step fashion similar to the systematic desensitization in which you practice it in easier situations and then gradually try it in more and more difficult situations.
My belief, as a rigorously trained CBT therapist, is that words matter. The way something is said can affect the acceptability of the concept, and therefore, the effectiveness of concept. So the confusion between “act 'as if'” and “fake it” may lie in the words used and their context. If you examine how “fake it” is generally used by people on the internet it usually coincides with “pretend” as in ”if you feel incompetent, pretend you are competent and confident and you will become confident.”
This is all to say that I think the “fake it” concept has gotten distorted from the original meaning in which it probably referred to the “act 'as if'.” How this came about is due to the need to simplify complex theory into easy-to-use maxims to guide people.
George Kelly, a psychologist and one of the early leaders of cognitive therapy, suggested in the 1950s that people are “naive” scientists who create their own view of the world based upon their experiences. What this means:
1) The scientific method. A “naive” scientist has the desire to describe, predict, and control their personal life just as the scientific method is used to understand the world around us. Unfortunately, though, a principles that required in science to determine causality are not available to the individual: random assignment and/or rigorous scientific analysis. In other words, you can not take two (or more) versions of yourself and give them different experiences to find out which experience may have a better outcome.
2) Making assumptions. This “naive” scientist, then, is making assumptions based on very limited information related to him or herself. So when a person makes an assumption such as “that moment was pivotal in my life” or “if I had acted differently, the outcome would have been better” they are only guessing that their life is better or worse than it would have been if not for a certain event.
The difference between a naive scientist and a scientist (as many psychologists are trained), then, is that a scientist bases assumptions on evidence from scientific experiments and/or statistical analysis that control for other possible explanations. Therefore, the value of a psychologist is not just an outside, unbiased observer, but also as a person who makes more informed assumptions based on evidence. Such an approach doesn't assure 100% accuracy but it increases the likelihood of the assumption being accurate and effective when used in treatment.
3) Constructing beliefs. According to Kelly (and cognitive theory) is that we then “construct” our beliefs based on this “naive” scientific approach. We create an explanation of ourselves and the world around us. However, that explanation can frequently be inaccurate because we don't take into account the things that didn't happen. “I wouldn't have been hit by that car if I had taken the bus” may be true but we don't know if something worse may have happened.
So, I think the “fake if til you make it” maxim is the naive scientist's (the public's) attempt to use the scientific CBT principle of “act 'as if'.” Unfortunately, it becomes over-simplified in this process so that people may be more likely to fail in their attempts to use the concept or it might create a negative reaction to the concept because it seems inauthentic (as the reader indicates).
Let's examine the components of this concept so that we can better understand how it can be used:
1) Difference between anxiety and an emotion. It is critical to understand that anxiety, especially clinical anxiety, does not always reflect emotion. This is a common error that many people, including health professionals, make. Sometimes anxiety is a learned response that is automatically triggered by a situation. And sometimes anxiety is present because a person is predisposed to having a higher level of anxiety. Or sometimes it is due to other factors that can affect the autonomic nervous system such as (but not limited to) lack of sleep, drugs, or illness.
But human nature is to try and explain everything, so if a person has a panic attack in a certain circumstance they are likely to believe it was the situation that caused it instead of they were just more susceptible to having a panic attack for some reason. Trying to explain anxiety as an emotional reaction is also an attempt to control. If a person believes that something caused the anxiety, then they believe they can control the anxiety by avoiding that situation.
In some circumstances, though, anxiety can reflect emotion. For instance, a person may be applying for a job and feels nervous about the interview. In this case, the arousal of the autonomic nervous which causes adrenalin to flow which, in turn, increases the symptoms is caused by the emotion of being afraid. However, notice that anxiety is not the emotion itself but the outcome of the emotion, in this case being concerned about the interview.
Also, emotions can be triggered by the anxiety. For instance, when a person becomes fearful of having a panic attack in public and being embarrassed. In this case, the emotion is the fear of embarrassment.
So, what all this means, is think of the anxiety as a set of symptoms caused by the arousal of the autonomic nervous system. However, that arousal may be due to emotions or it may be due to other causes. But the arousal itself is not an emotion.
2) Act “as if” is an exposure. If you read the “50 Tools of Panic and Anxiety” you will see that the tools are divided into categories of relaxation/mindfulness, cognitive training, and exposure (behavioral) methods. Although there is overlap with cognitive training, the “act 'as if'” method is primarily an exposure method of treatment.
What this means is that when anxiety is a learned response, exposure to situations helps you learn a different response. Acting “as if” puts the person in the situation while creating a different response to the situation. However, and this is very important as to the difference with the “fake it” concept, it doesn't mean you don't have anxiety, it means you engage in the desired behavior anyway. So the “different response” refers to the behavior, not the anxiety.
For example, when I was younger I was terrified of public speaking but I forced myself to choose that option whenever possible: if a college class gave the choice of giving a talk or writing a paper, I chose giving the talk. In this situation, “act 'as if'” meant giving the talk without the focus on the anxious thoughts and instead focusing on the talk and my audience. It did not mean that I no longer had anxiety but with exposure to public speaking my anxiety was reduced. In addition, cognitive changes occurred so that I interpreted my anxiety as “wanting to do well.” In other words, if a particular talk created more anticipatory anxiety, it just meant that it might be more important to me and I needed to prepare more.
3) Mindful approach. As I indicate in the above description of “act 'as if'” it is a mindful approach. What that means is that you don't ignore what you are feeling especially if the anxiety is triggered by emotions, but instead, you accept what you are feeling as “being there.” At the same time, you can recognize that the anxiety and/or the emotions don't have to be acted upon. It may be helpful to review my series of articles/audios on “Understanding Mindfulness” especially the concept of developing a tolerance of emotions.
By mindfully being aware of anxiety but not acting upon it, anxiety becomes more of what it is supposed to be rather than controlling your life. Normal anxiety is supposed to be a message to let us know about situations so that we can examine the underlying emotions or situations that might have triggered the anxiety. In this way we can determine what to do whether that is dealing with emotions of being threatened or just accepting that we don't feel good because of poor sleep or illness.
4) Normal behavior, not extraordinary behavior. Notice when I describe “act 'as if'” I state: “to do what you would do normally if the anxiety was not present.” The “fake it” concept has often been used (especially in the personal growth movement) with developing a pretense that you are better than what you are. If you pretend long enough that you are great at persuading people, you will be. This is not necessarily true because people have different talents and you can't become something you're not.
Yet, people often create self-fulfilling beliefs that they are not capable of something when they are. So the true meaning of “fake it til you make it”, in my estimation, is very similar to “act 'as if'” in that it has to do with not letting the anxiety get in the way of who you truly are. So many of my clients at the end of therapy have said something to the effect of “I was afraid that therapy would change me but what I found instead is that therapy helped me be who I really am.”
So neither of these concepts are meant to create an extraordinary version of yourself but to allow you to fully explore your capabilities without the negative beliefs interfering.
5) Normal anxiety vs. an anxiety disorder. Although this method can help those with anxiety disorders, as I indicate in my original description, it is not likely to be effective for debilitating anxiety especially early in treatment. It is most well-known for helping people manage the normal anxieties of life. What I mean by normal anxiety is anxiety that is not excessive to the situation but is a message about dangers that could occur under certain circumstances. However, once people with anxiety disorders have reduced the anxiety using other methods to a more manageable level this method can help with reducing avoidant behavior patterns.
Confusion about this method is that sometimes people are sent into situations with only the instruction to act “as if” without any further training. However, there are several steps to this method that I didn't clearly describe in “50 Tools”:
1) Determine the behavior. This is probably best as a written exercise as people are more clear when they write something down rather than just thinking it. So, write in detail the specific behavior that you want to engage in. Be careful here to not focus on the feelings or thought—instead, just focus on the behavior.
2) Simple steps. Break the desired behavior down in simple steps. For instance, if you are afraid of public speaking, don't start with giving a talk in front of a large group. Instead, start by asking a question in a small group. Then, you can move on to gradually more and more difficult situations.
3) Practice. Whatever the desired behavior is, don't just expect yourself to be able to do it. Instead, practice the behavior. You can do this either with actual practice such as giving a talk in front of a mirror or imaginal practice such as imagining yourself engaging in the behavior. Whichever you choose, be sure you know how to engage in the behavior. Don't expect yourself to just “be confident.” Instead, determine what confident behaviors look like and then practice those behaviors (making eye contact, smiling, etc.).
Finally, keep in mind that the 50 Tools for Panic and Anxiety are meant to select the best tools for each individual. In other words, not every tool works for every person. In fact, David Burns in his book “When Panic Attacks” says to quickly fail at using a method so as to be able to move on to one that will work. He suggests selecting the ones that seem they will be most helpful. Obviously, “quickly fail” has different meanings depending on the tool that is used because some of them take longer to master or implement than others. But the point is to not to worry about failure but to focus on finding the tools that will help.
* By the way, I love questions because it allows me to discover where I may need to expand on these concepts.