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.

Post-Traumatic Stress Disorder

In the course of my career I worked with many people who had experienced significant trauma. Something I heard from many of them was along the lines, “What’s wrong with me? I think I’m going crazy! I can’t stop crying (worrying/ having panic attacks/having nightmares/having flashbacks/losing my temper/thinking about suicide, etc.) I didn’t used to be like this!” Once I was confident in my diagnosis, I’d respond in this manner: “You’re not going crazy. You’re having a normal reaction to an abnormal, traumatic life event. Your symptoms are consistent with something called post-traumatic stress disorder (PTSD) – the same thing that affects some soldiers who’ve been in combat. In World War I it was called shellshock and in World War II it was called combat fatigue, but it doesn’t only happen to soldiers.”

I’d go on to explain what happens in the brains of some people who’ve had traumatic experiences. The amygdala – which helps us to process emotions and is linked to the fear response – can be activated by trauma and sensitized to react to triggers: things that the brain has come to associate with the original traumatic event. A sudden loud noise might trigger an instant fear response in a combat veteran. Seeing a depiction of an assault on a cop show on TV might trigger a flashback in an assault victim. Sights, sounds and sensations reminiscent of the trauma can re-stimulate the amygdala and trigger symptoms. Thoughts can also be triggers.

Two people might experience the same traumatic event, only one of whom will develop PTSD; and science can’t predict which one. You can’t put a timetable on recovery from trauma, but all too often people suffering from PTSD are blamed for the persistent changes in their behavior. Many get told things like “Just get over it!” and “What’s wrong with you?” – as an accusatory statement in the form of a question.

PTSD can be caused by a single event or by serial traumas, such as ongoing child abuse. It can result from physical or sexual assault, surviving a terrible accident, or witnessing bloodshed and/or death. It can be caused by weeks or months spent in combat zones, even if there was no single major traumatic event. Soldiers are often reluctant to admit to symptoms of PTSD, as the military culture tends to stigmatize the diagnosis as a sign of weakness. But it isn’t; it’s a brain disorder.

My wife Maria and I served as Red Cross Disaster Mental Health Volunteers at a Red Cross Family Service Center near Ground Zero after 9-11. Although we were both licensed mental health professionals, as disaster mental health workers we weren’t there to do therapy. We were there mostly to listen, and to help people understand and process  what they’d gone through on the day when the twin towers fell. We also provided referral information to those we met who might need therapy from local practitioners. One thing I remember saying to a number of trauma victims I encountered was, “You’re not going crazy. You’re a civilian who suddenly found yourself in a war zone. Nothing in your life has prepared you for that. Your (symptom/symptoms) is/are a normal reaction to an abnormal circumstance.”

Hundreds, perhaps thousands, of Manhattanites were traumatized to a greater or lesser degree by the events of 9-11. You didn’t have to be near Ground Zero to be affected, and it seemed that the whole city was on edge, anxious about the possibility of another attack. I met a woman who had watched the falling bodies of people who’d jumped from the burning towers, transfixed by the horror of what she was witnessing. I spoke to a young man who’d ridden the subway his whole life,  ashamed because he was terrified to do it again. I heard story after story from people who wondered if their lives would ever be the same again. Another thing I said to several people I encountered was, “Nobody’s qualified to tell you when you ‘should’ get over this. It may get better as time goes by, or it may not. There’s no guarantee that you’ll completely recover, but don’t give up on the likelihood that you will, in your own time. You may need professional help.”

There are highly effective treatments for trauma victims. Just as physical wounds can heal over time, so can the “invisible wound” of PTSD.