I received a request from a colleague preparing for their psychiatry board exam. Today I tackle this fairly common problem by explaining procrastination, its formation, and treatment.

Procrastination is a type of avoidance, and avoidance is a common strategy used by many to cope with unpleasant life situations and also is part of several psychiatric conditions. Any disorder with “phobia” in its name is a type of avoidance. The problem with avoidance is that often it is counter-productive and makes the situation worse. My motto for avoidance is “short-term gain for long-term pain.” In procrastination both 1) the task that needs to be done is left undone and 2) the attempt to avoid thinking about the doing of the task is unsuccessful. After all, avoiding thinking about something is a form of thinking about that something. As often happens with counterproductive coping strategies, since they don’t actually solve the problem, they are continually deployed and (for reasons I’ll not discuss today) gain strength with each failed attempt at using it to manage one’s discomfort.

There exist at least a couple of cognitive distortions that can contribute to the development of procrastination: perfectionism and entrapment. (If you notice others in yourself or others, let me know and I’ll include them in future versions.) Below I cover these cognitive distortions, and later explain how to overcome procrastination.

Perfectionism

It’s common for an exam candidate to think about two things related to their exam: 1) the complexity and amount of material they need to cover and 2) their perceived inadequacy in meeting the challenge of mastering all of it. This gap between the perceived task complexity and one’s ability to meet it triggers several possible aversive emotions. These may include anxiety about failing the exam, sadness over its consequences, and self-deprecation over one’s perceived inadequacy. Note that in the first sentence I used the word “think,” but thinking includes self-talk and imagining scenarios in the form of mental images and video clips. These “thoughts” are experiential and very effective in triggering the aversive emotions I noted.

Many of these thoughts are framed in terms of “all this material to master” and “I need to master all of it.” Notice the common (explicit or implicit) use of the word “all.” This way of framing the situation is a disguised form of perfectionism: “If I can’t get it all done, then it’s not worth even starting.” This way of thinking is simply illogical. Instead, think about exam preparation like this: whether an exam-taker passes or fails their exam is based on a probability function. The more the exam-taker knows, the better their chances of passing. Yes, after the exam is completed, the probability function collapses into a binary – pass or fail. But beforehand, a person’s chances of passing are spread across a range of probabilities. Where a person is on the range of probabilities is based in part on how well prepared they are.

So, if the more you know the higher your passing chances, it makes sense that every single minute you spend preparing for your exam incrementally increases your chances of passing. There is no lower threshold to the amount of time you can spend on exam preparation that will help your odds of passing: even doing one practice question increases your chances a tiny bit.

The perfectionist frames the situation as “I’ll never get through all of this.” The realist (who is much less likely to procrastinate) thinks, “I’ll probably never get through all this material, but every minute I spend preparing increases my odds of success.”

Entrapment

A second cognitive distortion involves framing exam preparation as a long and complex journey one enters and cannot disembark from. This is false. You can study for five or 10 minutes and then take a break or never return to studying again.

Let me give an example of entrapment to illustrate. I’ve had several patients over the years with agoraphobia that included avoidance of grocery shopping. Some patients would go to all-night grocery stores to avoid being caught in a line. Invariably, when I questioned these patients about their fear of being caught in a line, they responded with a version of, “Well, if I have a cart full of food and I get a panic attack, I can’t just leave!” My response invariably was, “Yes, you can. There is nothing or no one holding you back. You can escape any time you want.” Patients would often respond with, “But I can’t leave all that food in a shopping cart in the middle of a checkout line.” My response to this was, “Oh, yes you can. Imagine you had a feeling that a bout of explosive diarrhea was coming on. You would high-tail it out of there as fast as your legs would take you. So, pretend you have a medical emergency and leave!” I had one patient come back with, “But if I have ice cream in the cart, it will melt.” I said, “That is a huge tragedy, I’m sure. Well, you can accept that and leave anyway. Or you can tell the cashier or service desk person that you have perishable food in the cart and that you have an emergency forcing you to leave immediately. Or you can pick out the ice cream and return it to the freezer yourself. At least, then you’re moving and not feeling trapped.”

It was both mildly amusing about how hard it sometimes was to convince a person that they weren’t trapped in a grocery line, and gratifying as the lightbulb would finally go off in their mind.

Solutions

So, we are left with procrastination as a form of avoidance. Since avoidance has behavioral and cognitive components, it benefits from behavioral and cognitive interventions. Consider these:

  • Systematic desensitization: Give yourself a time frame of – let’s say – 10 minutes to study. Set a timer and stop studying when it goes off. You can then up the time to – let’s say – 15 minutes once you feel good with the 10 minutes. Repeat and increase as you see fit.
  • Cognitive reframing: Perfectionism: Tell yourself a version of what I wrote above: “I won’t get through all the material and I’ll master even less. This is OK because, with every few minutes I spend preparing, I’m improving my chances of passing.”
  • Cognitive reframing: Entrapment: Tell yourself: “I can start and stop studying anytime I want. I don’t have to see my exam preparation as one monolithic task that overwhelms me. After all, as the kid’s book asks, ‘How do you eat an elephant,’ it answers with, ‘One bite at a time’.”
  • Cognitive reframing: Regret: This is a distortion that can arise only after you get yourself successfully on the path of exam preparation. You can look back at all the time you wasted beforehand procrastinating and feel a great sense of regret and frustration. And this quickly can spiral into another version of perfectionism (and catastrophizing), “I wasted so much time. What if I fail because of this? Is it even worth bothering now with so little time left?” My answer is … well, by this point I know you’re able to challenge this way of thinking without my help.

All the best on your exam. I’ll be thinking about you.

Dr. Jack

Language Brief

“Procrastination is like a credit card: It’s a lot of fun until you get the bill.” – Christopher Parker

“If it weren’t for the last minute, nothing would get done.” – Rita Mae Brown

“It is easier to resist at the beginning than at the end.” – Leonardo da Vinci

“Procrastination is one of the most common and deadliest of diseases and its toll on success and happiness is heavy. – Wayne Gretzky

“Obstruction can be caused by so many factors – perfectionism, distraction, faltering confidence, external demands and pressures. At some point, of course, you’ve got to push through it all if you’re to write, and if you don’t, or can’t, you’re sunk.” – Claire Messud