As I noted in an earlier post, I have been suffering from illness anxiety disorder, formerly known as “hypochondria” for about twenty years. Five days ago, I had my last therapy session. The reason is that I reached the main goal of the therapy, that is: being able to live with uncertainty. Since I had so many kind reactions to my last post on this issue, I thought it would be nice to post an update and say a little bit about the therapy and how it helped. It was what is called cognitive behavioural therapy, and I received treatment for about eight months. On the whole, I think that the therapeutic devices are so straightforwardly mechanical that they might help with other troubles, too. At the same time, I am still struck by the rationalist thought patterns that might be responsible for part of my anxiety. Let me try and put some order into my thoughts now.
The worst of all possible worlds. – Imagine you notice something, for instance some unusual sensation like a spot on your arm that wasn’t there the evening before. You might think, “oh, a spot” and move on. The fact that I can think that, too, now is perhaps one of the greatest successes of my therapy. Usually, I would think that this is probably the symptom of an incurable disease. If you don’t believe this, it’s easy to shrug it off, but if you do believe it… But how did I get out of this structure of catastrophic beliefs? It’s helpful to break down this question into two parts: (1) What sort of belief made me enter catastrophic thought cycles? (2) How did I block them? Question (1) has a number of answers. Let me focus on the most surprising aspect. One of the most problematic thoughts I tend to have is that there is an explanation for the “symptom”. Now you might think that this is indeed a plausible thought to have. And indeed, as someone trained in the history of philosophy I know I am not alone in recognising this as a variation of the rationalist principle of sufficient reason (PSR). There is an explanation for everything. Fine. Problems start if you actually expect that you or your doctor or the internet can provide an explanation. For if you’re like I’ve been and there is no obvious or reassuring explanation available, you think, “hey, this might have a sinister or rare cause”. So the PSR keeps the search going until you either find reassurance or an even worse “symptom” to worry about. The thought I didn’t ever entertain is that there might be no explanation available.* So when my therapist suggested this idea I just gave him a blank stare. This leads us to question (2). A common approach in behavioural therapy is to “challenge” such thought cycles. So how do you challenge the PSR? Well, first you try to figure out and write down your precise thoughts. Then you raise challenging questions. The most successful question was this: “Is it actually helpful to worry about this symptom or search for an explanation now?” If you’re honest and not in an actual emergency, you’ll end up having to answer this question with “no”, again and again. What I learned to accept is that it is often more helpful to resign to the fact that no explanation is available rather than keep searching for one. This is, for me, a very concrete way of learning to live with uncertainty.
Magical thinking. – Observing my thought processes, I often wondered why I was so glued to certain patterns. One miserable day I was lucky enough to catch one of the culprits in the act. I thought something like the following: “If I don’t take this symptom seriously, it will turn out even worse.” The thought was so elusive that I had trouble ‘catching it’. But even when I got hold of it, I had trouble seeing what it meant. But suddenly it struck me: This is a variation of the magical thoughts I had as child. Magical thinking is the assumption that your thoughts or some neglect in thinking will cause bad events, like “if I think badly of my parents, they’ll have an accident.” I’m told this is fairly common in children, while adults grow out of it. And of course, I wouldn’t dream of ascribing such assumptions to myself. But here I was! I realised that my thought “if I don’t take this symptom seriously, it will turn out even worse” could most plausibly be rendered as a magical thought like “if I don’t keep fretting over this symptom, I will deserve the illness I ignore right now.” The causal assumptions in the magical thought are closely tied to a moral judgment of deserving or being guilty of my threatening fate, if I neglect it. Of course, it’s hard to be sure, but I’m pretty convinced that it’s this childish superstition that glued me to my anxiety variant of the PSR. While I was shocked and somewhat ashamed to discover this in me, I was equally relieved, because seeing this pattern greatly helped distancing myself from my obsessive search for explanations.
Moving on. – Catching precise formulations and what they mean is actually quite crucial for moving on. I know that I cannot be straightforwardly cured of anxiety, but I can aid the cure by “learning to live with uncertainty”. The reformulation of my therapeutic goals alone already helped me embracing them as something positive rather than as negative. Being interested in social philosophy, you can imagine that I often annoyed my therapist by venting about the missing social aspects in therapy, though. What you (or at least I) need is not just overcoming my mental habits. What I need is a social infrastructure that is understanding and able to deal with conditions like mine. It makes a hell of a difference how a doctor or indeed anyone articulates their diagnosis or suspicions. But you can support your social environment in this. To achieve this, I began to force myself to apply the question “is it actually helpful to worry about this now” not only to my “symptoms” but to all sorts of issues my interlocutors confront me with. Pushing back against concerns of others like this did not make everyone around me happy… But despite some misgivings here and there, this change in my conduct seems to have overall positive effects. What helps is taking the time to explain how and why I attempt to respond and challenge requests with this question now.
The upshot is that, despite my initial scepticism, I would really recommend this therapeutic approach. It is not a magical cure, but that might be for the better.
* I think this “anxiety PSR” is also an epistemic variation of what is known as the just world fallacy, but I might go into this another time.
Relatedly, I just came across a nice piece on the epistemic merits of CBT: “A common idea about CBT is that it does not contribute to the person’s understanding of reality (validity) but encourages ways of thinking that boost the person’s wellbeing (utility). In our brief commentary, we argue that CBT can also contribute to some of the person’s epistemic goals.”