Two of the major complaints presented to psychiatrists and psychologists are those of experiencing anxiety and feeling fear.

Medications are oftentimes helpful, but many people continue to experience unfounded anxiety and fear that, when questioned, they cannot explain why these feelings of anxiety and fear remain. Although the term agoraphobia is often referred to as “fear of the open market”, it certainly seems to me that the number of patients experiencing fear of being in public places or large stores, such as Walmart or Sam’s Club, has increased over the time I have been in practice. Patients frequently complain of difficulty with fear and anxiety, and will request information about what they can do to alleviate these feelings. I have given this issue much thought over the years, as the science behind the statements made by patients with regard to feelings of fear and anxiety, does not make a lot of sense. Why would an individual be frightened of going to a particular place or experience fear of an event when, in actuality, he has never been previously harmed at that location and no catastrophic, or even painful processes, have ever occurred? As a first generation Skinnerian, it bothered me that people could be wrong so frequently and yet not gain any insight from their experiences. There are concepts, such as Escape and Avoidance Conditioning, which I will cover shortly, but these concepts do not fully account for why people are able to maintain such a consistently inaccurate belief system, in spite of actual evidence to the contrary, while continuing to persistently feel anxiety and fear to such a large degree.

The answer came to me, again from a Skinnerian perspective, in contemplating the idea that people who have significant anxiety and don’t go to public places frequently, or who leave large public places quickly when they do go, do not experience any consequence directly related to the inaccuracy of their fear-based belief system. As a football fan, I made the analogy of betting on a football game and asked the question of how many times a patient needed to be wrong in betting a certain team would win (when that team never won) before the patient would change his bet. It would be one thing if the team won a game every so often, but it is rare to find instances where a patient’s anxiety or fear of a particular situation actually comes to fruition in the manner he imagined. When one learns a person actually has been injured or harmed in a particular situation, that person is then placed into another category, which will be discussed later.

In pondering the analogy of an individual’s anxiety or fear being like continually betting on a losing football team and his subsequent failure to learn from his mistakes, I conceptualized the idea of feeling fear or anxiety to be like that of placing a bet on one’s prediction of what might occur in a particular location or at a specific event. The bet a person makes is that he will be harmed in some capacity if he does not leave a particular location quickly or, if he even goes to the location in the first place. Without this “bet”, there would be no reason for the person not to go. Therefore, consciously or unconsciously, he is making a bet or creating a hypothesis, that something bad is going to happen and he is protecting himself from that possibility. 

I took this concept a step farther by contemplating what would happen if a patient had to actually place a monetary bet on the predictions he made based upon his anxiety or fear. What if he had to bet $1, $2, $5 or $25 each time he became anxious or fearful? The money would be returned if he was correct in his prediction and a terrible event did occur, however, he would lose the money if his prediction was incorrect and the feared terrible event did not happen.

 

It has probably been close to 45 years since I first read one of the early behaviorists writings about negative consequences such as I described above. As such, I developed a program I call “Betting on Predictions.” The basic concept of the program is that I staple three plastic bags together and on each bag I write either “BANK”, “OKAY” or “BAD”. In the bag labeled “BANK”, I ask the patient to place dollar bills in an amount totaling somewhere between $25 and $50. The patient is then instructed that each time he is fearful of going someplace or experiences anxiety, he must place a bet, usually a $1. The idea behind this request is that if he feels fearful and afraid, he obviously believes something bad is going to occur and, as a result, he must take $1 and place it in the plastic bag labeled “BAD”.  If he is wrong, however, and although he was fearful something bad would happen but nothing bad actually did occur, he would then lose the bet and lose the money.

I also conceptualized that if the individual was able to choose the entity where the money he loses is sent, such as the American Cancer Society or another charity of his choice, he will rationalize losing the money because it will be sent to a charity he supports. I believe it was the Behaviordelia comic book of the 1970's, which set forth the idea of making the recipient of money lost in a bet made on an inaccurate prediction, to be someone the bettor despised. Therefore, I will ask a patient who he despises the most. This despised individual may be a person who has been abusive toward the patient in the past, someone who cheated the patient in a business deal, a particular politician or even an enemy of the United States. The money lost in the bet is then sent to the individual or entity the patient despises most overall. With this process there is a two-pronged consequential punishment. The first consequence is that an individual learns he lacks the ability to accurately predict the occurrence of a frightening event, followed by the second consequence of having to send money to an individual or agency the patient thoroughly dislikes. 

If the patient begins to change his predictions, gains insight into the fact that nothing bad will happen to him and, in the end, his prediction proves correct, he is then allowed to keep the money and spend it on himself in a pleasant manner, such as going to a movie, buying a book he wants to read or going out to dinner.

The result is that a patient who follows the plan will get better.  I will initially ask the patient to return the money to me so this process is not just a cognitive exercise, but one which will force the patient to actually process what has occurred. Occasionally there is money in the “BAD” plastic bag that I will take out and send to the individual or entity designated by the patient as the one he most despises. Even in those situations, however, it is amazing the small amount of money the “BAD” bag ultimately contains, and how much better the patient feels because his rate of anxiety and fear has decreased so significantly. I also use a little cognitive dissonance in stating that if his anxiety or fear is not worth betting $1 on, there is no reason for him to have anxiety and fear if he won’t even bet $1 that trouble or a bad situation will actually occur.

 


 

In my next blog, I will talk about the issues of Escape and Avoidance Conditioning, as well as how fear and anxiety are learned without the presence of an environmentally negative response.

 

About TMS Solutions:

Depression is a serious and debilitating mental illness, affecting upwards of 16 million adults in the US. Getting out of bed is hard, relationships are hard, and everyday life has a "grayness" and heaviness to it. The people around you may not notice much, but you feel it constantly. As many with depression have found out, addressing the illness honestly, getting help from a doctor and utilizing technology like TMS Therapy, can provide hope and remission from depression. Learn more about the help TMS Therapy and TMS Solutions can provide depression sufferers.

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Topics: Depression, Treating Depression, Mental Health

Robert A. Sammons, Jr., M.D., Ph.D.

Written by Robert A. Sammons, Jr., M.D., Ph.D.

Dr. Bob Sammons received a bachelor's and master's degree from Auburn University, a PhD in clinical psychology from the University of North Carolina at Greensboro, and a medical degree from the University of North Carolina at Chapel Hill. He did a residency in psychiatry at the University of Virginia as well as a forensic psychiatry fellowship. While a Captain in the Air Force he helped set up and run the treatment phase of the Air Force Drug Treatment program in 1971. He has practiced adult psychiatry in Grand Junction for 29 years. He received training in TMS in 2006 from Dr. Alvaro Pascual-Leone, from Dr. Mark George in 2017 and returned to Harvard for Dr. Pascual-Leone's intensive course in TMS in 2018. He is Medical Director for TMS Solutions with TMS offices in various locations in the West. He has been known to cook a little BBQ.