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.

Working with juvenile sex offenders

I’m a compassionate person by nature, and felt a calling – like a calling to the priesthood or some other religious vocation – to be a psychotherapist. But the limits of my compassion have been tested from time to time throughout my career. I’ve encountered people who did very bad things, not because they were “sick” or mentally ill, but simply because they were evil. When I’ve heard someone utter the cliché that there’s some good in everyone, I’ve been tempted to say “You haven’t met everyone.” I’ve met some violent felons who got off on hurting others, felt no pangs of conscience, and only regretted having been caught. They fantasized about doing more of what earned them hard time in prison, without getting caught.

My first exposure to antisocial juveniles was when I worked at correctional institution for older teenagers serving time for crimes against people (not just  property). During my time in juvenile corrections I co-led sex offender treatment groups. One belief I had confirmed is that, whether you call it rape or molestation, it’s more about power-and-control than about uncontrolled sexual drives. I’ve led or co-led many different kinds of treatment groups over the years, but only once was it what I’d call hard-ass treatment. I was trained to be a treatment team member of the Sex Offender Treatment Program (SOTP) and was mentored in the sex offender group treatment model by my two co-leaders, two tough, competent female social workers. You have to be both tough and savvy to work with this treatment population, and I especially admire women who have what it takes to do this kind of work.

By the time they’re caught, tried and sentenced, most juvenile sex offenders have already gotten away with a progression of sexual assaults, usually on younger children. The more they’ve gotten away with, the bolder they’ve become. They fantasize about what they’ve done and what they want to do next. With fixated sex offenders, the connection between the thrill of having power-and-control over a person, and sexual gratification, becomes something neurologically akin to addiction. They want more, and their obsessive thoughts feed their sexual compulsions.

There’s a limit to the range of defense mechanisms that sex offenders predictably resort to in an attempt to distance themselves from their sexual violations, and I’ve heard them all. The first is outright denial: “I didn’t do it!” Faced with proof that he did, the next step is minimalization: “It was the only time I ever did anything like that. I never even thought about it before. It’s really not a big deal anyway.” The last defense mechanism to be employed is rationalization: “She led me on./It’s her fault./ I only did what he wanted me to do.”

The goal of sex offender treatment groups was to break through the bullshit barrier and get sex offenders to own up to what they’d done, to understand the harm they’d done, and to acknowledge that they were at risk of re-offending. In this regard it’s similar to the recovery model for substance abusers, in that you can’t recover from a compulsive behavior pattern without first acknowledging the nature of the problem. The next step involves coming up with a risk reduction plan. All we could hope to do in the SOTP was to reduce the risk of recidivism for as many sex offenders as we could reach.

I believe that some sex offenders can be rehabilitated, and that it’s worth the effort and expense to provide treatment opportunities in correctional facilities for those who are sincerely motivated to change. Some fixated sex offenders don’t want to change their ways, and can’t be helped by any treatment that I’m aware of.  That’s why we have life sentences without the possibility of parole.

The sex offenders I worked with weren’t internally motivated to attend group, and the SOTP groups weren’t mandatory. But most eligible boys eventually applied (there was a waiting list), once they learned that if they got honest about their crimes and made progress in the program, they might earn a positive parole recommendation to the Parole Board. The groups were “open,” meaning that new members joined ongoing groups with boys who’d been in the group for months and understood the group process.

This process was characterized by confrontations by both group leaders and peers, and every boy spent time in the “hot seat” – the focus of group attention. Every “old-timer” in the group had already been called out by professionals and peers on his denials, minimizations and rationalizations, and could see through the defenses of his peers. While in the hot seat every group member eventually heard something like this: “Most everyone in this room can see through your bullshit, and we’re waiting for you to get real about what you did, and what you need to do if you’re not going to do it again.”

The only way for a group member to avoid hard-ass confrontation was  to get honest and disclose in detail the circumstances (thoughts, situations, actions) of every sexual violation that led up to the crime for which he was serving time. In time, most of the boys came to understand that full disclosure was just the first step, and understood the phrase “reducing the risk of recidivism.” The boys knew that the Parole Board would be asking the SOTP team members about their relative risk to re-offend. SOTP recommendations might make the difference in the board’s decisions, and sometimes that meant the difference between parole at age eighteen, or transfer to adult corrections to serve the remainder of their sentence.

Working with sex offenders and antisocial criminals was some of the most difficult work I’ve ever done, emotionally, because of my compassion for their victims. (I’ve worked with many more victims of violence and abuse than perpetrators.) I believe that in some instances compassion can be learned. But I’ve encountered people who understood the concept and might be able to mimic it, but have never felt it, or only in a very limited way. I remember asking a boy who had admitted to torturing cats if he’d ever tortured a dog. He look at me like I was stupid and said, “Of course not! I like dogs.” As if that explained everything.


Defense mechanisms

In the classic boomer movie “The Big Chill” Jeff Goldblum’s character asserts that rationalizations are more popular than sex. When his friends look at him questioningly, he asks, “When was the last time you’ve gone a week without a rationalization?”

Many of Sigmund Freud’s psychoanalytic notions have been discarded as the art and science of psychotherapy has evolved, but one of his contributions has, I think, proven valuable over time: defense mechanisms. Dr. Freud and his daughter Anna described specific ways that people defend themselves from frightening or unacceptable thoughts, feelings, or memories. A thought may be unacceptable because it threatens our cherished self image, or because it might open a door we’d rather remained closed. Freud said that to the unconscious mind, a wish is identical to an act. As a therapist I’ve seen many people who had terrible guilt for having had unacceptable thoughts or feelings, although they’d never acted on them, and didn’t want to.

I don’t intend to cover all of the defense mechanisms in this post, but here are some of the things people do to defend themselves against the unacceptable: denial is an extreme form of avoidance. “If it’s not true I don’t have to deal with it.” Confronted with mounting evidence that she’s lost control of her drinking behavior, denial will allow an alcoholic to continue drinking, because the thought of getting and staying sober is terrifying. Denial that a loved one is dead allows you to avoid the pain of mourning.

In therapy I’ve described avoidance  as being a surefire drug that always works to eliminate here-and-now anxiety, and therefore can become an addictive habit. Take the case of someone who’s been unfaithful to his lover on one occasion, and knows he has to admit it, because it will eventually come out anyway. So he promises himself he’ll tell his lover about the one night stand by the end of the weekend. He puts it off until Sunday, and as the day goes on his anxiety mounts. Will his confession wreck the relationship? As midnight approaches, he decides to postpone his confession (a kind of avoidance), and immediately experiences a reduction in here-and-now anxiety – as if he’d taken an anti-anxiety medication that works instantly. That immediate relief from anxiety is “reinforcing” and increases the likelihood that he’ll resort to avoidance again. In this manner, defense mechanisms can become habitual.

Habitual avoidance can perpetuate dysfunctional or irrational behaviors. If your response to a deep-seated fear of flying is to never fly, your avoidance reinforces your irrational fear. You may want to travel to Europe and may understand intellectually that air travel is statistically safer than driving, but the prospect of giving up all control and entrusting your life to the pilot may seem intolerable. Fear of a real threat is a reasonable response, but phobias (irrational fears) only serve to limit our options in life.

The only effective way to overcome phobia-based avoidant behaviors is what cognitive behavioral therapists call “exposure.” To get over your fear of drowning, you have to (eventually) swim in the deep end of the pool. Only by facing the thing feared can you grasp that the fear was irrational. This principle also pertains to regaining confidence in something you were good at, but now avoid because of a bad experience. We all know what you’re supposed to do if you’re afraid to mount any horse because another horse threw you; but that doesn’t make it easy. You either get back in the saddle, or you avoid horseback riding.

Having started with rationalizations, I’ll conclude this post with some thoughts on that defense mechanism, also known as intellectualization. I’ve found that highly intelligent people who have risen above the “more primitive” defenses of denial and avoidance have found rationalization as their anti-anxiety drug of choice. The essence of rationalization is,  “I don’t have to deal with it if I can explain (rationalize) why I don’t have to deal with it.” Or “I’m not responsible because I have an explanation.” Or “I didn’t want that, anyway.” The fox in the Aesop fable about the fox and the grapes is a classic representation of an intellectualizer in popular literature. When he couldn’t reach the grapes, he concluded that they were probably sour.

Like denial and avoidance, intellectualization gives a temporary respite from unwelcome thoughts and feelings, but like the other defense mechanisms it can perpetuate dysfunctional behaviors. Defense mechanisms are often barriers to insight and personal growth. I’ll write more about them later.