Act Opposed

Inwardness and placebo

Opposite action, one of the skills you learn in dialectical behavioral therapy, is intentionally doing the opposite of what anxiety is telling you to do. When I first heard about it, I thought it was silly. It sounded like a fancy way of saying “Just do it,” which is only so helpful in the face of adversity. 

Opposite action and “just doing it” look identical from the outside. Someone wants or needs to do X, but anxiety blocks their path. They pause for a moment, build up strength, and then push through the psychic barrier and do X. 

However, the two practices differ in their internal content. Opposite action requires an additional step in which the person self-consciously identifies their anxious condition. This move in consciousness makes a practical difference because it reinforces behavior patterns at two levels of action simultaneously. It strengthens the ability to do X specifically and the ability to overcome anxiety generally. 

Of course, people who do not know the DBT name for this skill still practice it. They may reflect, “I need to get in the habit of overcoming my anxiety,” or something to that effect, before doing X. As long as anxiety itself is consciously identified in the act of X, then doing X reinforces at both levels of action.

The possibility and implications of this inward movement explain much of the variance in the personal outcomes of a practice. For example, two people hear about the alleged benefits of ice bathing and plan to take an ice bath every morning the following week. Persons A and B, who like most people feel anxious before plunging into an ice bath, perform this action identically each day from the outside. They take the baths at the same time, with the same amount of ice, and for the same duration. Only their internal dialogues before their respective plunges differ. 

Anxiety says the same thing to A and B, “This ice bath will suck and make you uncomfortable, so don’t do it.” A accepts anxiety’s assumption that taking an ice bath is only that. A responds, “It will suck, but I will do it anyway.” 

In contrast, B mindfully asserts the general in the particular, self-consciously expanding the scope of the discussion. B says, “I am anxious. That means this ice bath is an opportunity for me to practice the skill of opposite action. So, even though it will suck, I will do it anyway.” This internal movement makes the ice bath more than an ice bath for B. What “it” (the ice bath) is now differs between A and B’s consciousnesses.

If everything about A and B’s life situations and approaches to ice bathing are held constant except for this inward maneuver, the outcomes of their ice baths will differ because B is practicing two skills while A is only practicing one. B practices the additional subjective skill of overcoming self-conscious anxiety. Subjective skills like this operate at a “meta” or domain-general level because they can be applied to many different objective actions. The way B takes the ice bath helps B confront anxiety in future situations better than A, who is only practicing the domain-specific skill of ice bathing. 

The psychic dynamics of placebo are at play here. After the week of ice baths ends, A and B compare the practice’s personal benefits and find that B personally benefitted more than A. In the absence of a clear physiological explanation for this asymmetry, the difference in benefits could be rightly attributed to the placebo effect.

To many the placebo effect is mysterious. It certainly is to the extent that the mechanistic relationships between the mind and the body are not well understood scientifically, but the inward movements necessary to produce a placebo effect can be evident without that scientific understanding. We can talk practically about how consciousness can be manipulated to produce “surplus” placebo-derived benefits from a particular practice. 

This is discussed using therapeutic vocabularies about mindfulness or emotion regulation, mystical vocabularies about spiritual discipline, and religious vocabularies that focus on character formation. Speaking through any of these vocabularies in the face of anxiety involves a self-conscious apprehension of anxiety and the recognition and representation of the general in the particular. 

Angst in its universal form may be subjectively interpreted as “intrusive thinking,” “emotional distress,” “spiritual unrest,” or “sin,” but as long as the undifferentiated angst is brought into the foreground of consciousness and situated within a broader interpretation of life, the requisite condition for placebo to effectuate is established. The unique aspects of the applied vocabulary may, and likely do, influence exactly how placebo effectuates, but using any of them in the moment creates the opportunity for placebo to operate.

This idea is captured in a sign hanging in my group therapy room which reads, “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”