Exposure Therapy

Most everybody knows what you’re supposed to do if you’re thrown by a horse. If you want to keep on riding, you get back up on horseback right away, to overcome your fear of being thrown again. The only way to get over your fear of drowning, if you swim in the deep end of the swimming pool, is to leave the shallow end and swim in water over your head.

The clinical term for this principle in psychology is exposure. Exposure is the antidote to avoidance, our very human tendency to reduce anxiety by avoiding activities and situations that tend to trigger anxiety. Avoidance is like a drug that immediately and reliably reduces anxiety or fear. For example, Tom is attracted to his high school classmate Jane, and wants to ask her out. He’s told himself that today’s the day he’ll get up his nerve and approach her, but he avoids doing it as the day goes by. As the end of the school day nears, he gets more and more anxious. But the moment he decides to postpone it until tomorrow, his anxiety dissipates. Avoiding and postponing work in the short-term, but serve to entrench our anxieties and fears in the long-term. Avoidance is one of the defense mechanisms  identified by Freud.

According to Dr. Marsha Linehan,  whose Dialectical Behavior Therapy (DBT) treatment of Borderline Personality Disorder has been empirically shown to be highly effective,, exposure is a necessary component of all effective cognitive behavior therapies. Two of the skills training modules in DBT, emotion regulation and distress tolerance, help to prepare clients for exposure to things they typically avoid.

Exposure therapy can be effective in treating Generalized Anxiety  Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), and phobias – irrational fears. It involves habituation to the feared stimulus/situation. Imagining exposure to successive approximations of the stimulus/situation (imaginal exposure) and teaching heightened awareness of physiological responses such as heartrate and muscle tension (interoceptive exposure) can be accomplished in the therapist’s office. Exposure to the actual stimulus/situation “out in the world” (in vivo exposure) is often the third step of exposure therapy. Being aware of the thoughts, emotions, and physiological responses involved prepares the client for in vivo exposure. Gradually working your way from the shallow end of the pool to the deep end involves exposure to “successive approximations” of the thing most feared. Jumping – or being thrown – into the deep end is an example of “flooding.”

The therapeutic method known as systematic desensitization was pioneered by South African psychologist Joseph Wolpe. After doing a behavior analysis of thoughts, feelings and physiological responses involved in a phobic reaction, he did relaxation training until the client felt some degree of control over his typical responses. Then he worked with the client to develop a hierarchy of fears, from the least fear-inducing to the most fear-inducing thoughts/experiences. Using this hierarchy, he would work with the client on relaxing as they went through successive approximations, leading up to the thing most feared.

Here’s an example of how I might use this method with a client who had never flown in an airplane, due to her phobia about flying. (Because flying is statistically much safer than driving, fear of flying is considered  an irrational fear, or phobia.) Having assessed Louise’s typical thoughts, feelings, and physiological responses/anxiety symptoms, and having trained her to relax, I might start a session with a relaxation induction, leading to a guided fantasy based on her hierarchy of fears. Louise has been instructed to close her eyes, to raise her right index finger whenever she felt an increase of anxiety, and to lower it when the anxiety decreased.

“You’re in your apartment and you’re packing for your flight . . . . Now you have your bags packed and you’re waiting for a taxi to the airport . . . . And now you’re at the airport and you hear the boarding call . . . . Now you’ve stashed your carry-on and are seated, buckling your seatbelt, etc.” Whenever Louise would raise her finger, I’d switch from the guided fantasy to the relaxation induction: “And as you breathe slowly and deeply, you can feel your muscles relaxing, and your anxiety is replaced by a calm feeling . . . . ” When the finger went down, I’d pick up where I left off on the guided fantasy.

Over time, Louise learns that she has increased control over her response to fearful thoughts, getting gradually closer and closer to the thing she fears most. Once she can imagine herself staying in control as the airplane takes to the skies, we might go on to in vivo exposure therapy, which might involve me accompanying her – at least at first. Some private practice therapists specializing in the treatment of phobias might even accompany his client on his first flight, coaching and encouraging him.

People with severe OCD often engage in compulsive rituals to reduce their anxiety. Exposure therapy can help them to learn that they don’t have to rely on these rituals to reduce their anxiety. People with anxiety disorders can use the principles of successive approximation to gradually desensitize themselves to stimuli/situations that used to trigger anxiety. Exposure therapy can similarly help people with PTSD to control physiological arousal in response to stimuli/situations that used to trigger fear. But in order to overcome an irrational fear, you have to eventually face it.

High anxiety

A certain amount of anxiety is normal and inevitable in every life. It ranges from free-floating anxiety – unattached to specific issues or situations – and performance or situational anxiety, to deep existential anxiety. It can cause the same physiological responses as fear. With fear, you know what frightens you: a charging bear in the woods, an earthquake, a cancer diagnosis. Anxiety, on the other hand, may result from cumulative stressors in your various life roles. It’s a cliché that we live in the Age of Anxiety, due to the complexity of modern life. The average person’s stressors are many and varied.

In Western society we have a history of regarding the body as separate from the mind, but this dualism can be misleading. Much modern science supports the notion of a bodymind – a unity of embodiment and consciousness. The physiology of anxiety is a hard-wired stress response. I’ve written previously about the fight-or-flight response that we experience when we perceive ourselves to be in danger. In situations where we find ourselves in physical danger, the instant physiological response – rapid breath and heartbeat, increased blood pressure and blood sugar, tense muscles, etc. – can prepare us to fight or flee, as the situation requires. But sometimes this automatic physiological response can cause us to “choke,” to feel paralyzed or out of control. And if the perceived threat isn’t something you can fight or flee from, your bodymind’s response can be feelings of high anxiety. Triggers for anxiety (or fear) don’t even have to be actual threats. Sometimes they occur simply because we feel threatened or inadequate, even if we’re not truly at risk.

Mild-to-moderate anxiety can sometimes be helpful, if it motivates us to effectively address its causes. You can reduce your anxiety about an upcoming exam if you study hard for it. However, avoidance also works, if only in the short-term, to reduce performance anxiety. But whether anxiety is a spur or a hindrance, it’s never a pleasant  experience.  One manifestation of high anxiety or fear is phobia – an irrational fear – which often leads to avoidant behavior. The power of phobia is contextual. A phobia about crossing bridges may not be a big problem if you live in the desert Southwest, but may cause significant problems if you live in the Florida Keys. Another common symptom of anxiety is panic attacks, which can also lead to avoidant behavior.

Anxiety rises to the level of pathology when it impedes or disables us. Some people are crippled by their anxiety. I believe that there’s a physiological basis for clinical anxiety, and that people with anxiety disorders shouldn’t be blamed for their disabling symptoms. But I also believe that, to some degree, anxiety is something that we unconsciously do, not just something that happens to us. Irrational thinking is a significant factor that contributes to both normal and pathological anxiety, and cognitive behavioral therapy is an effective treatment for many anxious people. Anti-anxiety drugs like Valium and Xanax can be helpful in the short-term, but long-term reliance on pharmaceuticals (or recreational drugs) to control anxiety only leads to chemical dependency.

To a certain degree we create our anxiety by the way we think. I’ve written about how, when facing a challenge or an upcoming performance, we can either mentally rehearse for failure or for success. And we can make pessimistic assumptions about things we don’t really know, and fear things that don’t really present a threat. Our physiological response to a perceived threat can be identical to our response to an actual threat.

Cognitive behavioral treatment of anxiety disorders involves teaching clients about both the physical and mental aspects of anxiety, and teaching them to distinguish their rational thoughts from their irrational thoughts. The treatment may involve the technique of exposure, where the client is exposed to the thing she typically avoids, or does the thing he usually avoids doing. Treatment often involves “homework” assignments – things to be worked on between therapy sessions – that will help the client to develop new skills and establish new mental habits. The development of insight need not precede relief from anxiety symptoms. Positive behavior change often enables a client’s development of insight into how, and to what extent, he was “doing anxiety.”