Rules for “fair fighting”

Lovers are going to fight sometimes – hopefully, only with words. It’s inevitable, because no two people in an intimate relationship are a “perfect match” in terms of habits, preferences and expectations. Boundaries have to be set (and re-set) because each of us is unique, and adjustments are inevitable in a healthy relationship. The balance of power is an issue in many or most romantic relationships. Joni Mitchell wrote  (and sang) “You and me are like America and Russia,/ We’re  always keeping score./ We’re always balancing the power,/ And that can get to be a bore.” I know a lot about balancing the power, not only from my own personal experiences, but from years of doing couples’ therapy, as a psychologist.

Knowing that conflict is inevitable in lasting intimate relationships, I studied, and came up with my own set of rules for “fair fighting,” to minimize destructive messages and to keep open the possibility of mutually satisfactory resolutions. Dialogue can be constructive or destructive. Destructive arguments can leave wounds, which can either fester or heal over time. If both partners act in good faith with one another over time and earn to fight fairly, old wounds can heal, and they can avoid lasting damage to the relationship. Here’s my list of rules:

(1) Practice the Golden Rule, and remember that there needn’t necessarily be a Winner and a Loser when you and your partner have a disagreement. The Golden Rule doesn’t mean that you always have to treat your partner the way they want to be treated; it means mutual respect for boundaries. “Okay. I agree to stop bringing up that time you got drunk and cheated on me ten years ago, but you don’t get to shout at me.” Yelling, cursing, and degrading language are all counterproductive to mutual understanding and harmony.

(2) If one or both of you has lost your temper, either of you can call a time out. Stop talking, trying to get the last word in. It’s hard to be rational when you’re angry. You may or may not need to  physically separate during the time out, but don’t resume the discussion until both of you have cooled down. Repeat as necessary. It might help to write down your thought and feelings during the time out, if that helps you to get perspective.

(3) Stay on topic. Deal with one problem/issue at a time. Avoid “and while I’m at it . . .” digressions, and don’t drag in past grievances. Don’t stonewall, i.e. refuse, over time, to discuss a topic that your partner thinks is important. Don’t deflect or pivot: “Let’s not talk about me, let’s talk about you.” Try to avoid blaming statements. Take turns doing active listening and ask for clarification if you need it. Ask neutral questions that elicit feedback, such as, “Does that make sense to you?”

(4) Try not to generalize. Be as specific as you can, and avoid absolutes like “always,” “never,” and “every time.” These generalizations are seldom objectively factual, and tend to elicit defensive responses. Statements like, “We never make love anymore” trigger thoughts counter to that statement, i.e. “We made love last Wednesday.”

(5) Avoid questions-that- aren’t-really-questions – statements phrased as if they were queries, usually starting with “why” or “what.”: “Why are you always on my case?” “Why don’t you act like a real man (or woman)?” “What do you take me for – your maid?” “Why are you such a big baby?” Such statements in the form of questions invite a defensive, and sometimes angry, response. There’s no “answer” to the “question” that would satisfy the asker.

(6) I-statements (first-person) are usually much easier to digest than you-statements (second-person), which can be contradicted, argued over. If you start a sentence with “I feel/want/think/wish . . . ” your partner can’t contradict you, because you’re the final authority on how you feel and what you think. It’s easier to hear and understand, “I wish you’d spend more time with the kids” than ” You hardly ever spend tome with the kids,” let alone “Why don’t you ever spend time with the kids?” It’s easier to hear “I think you’re wrong” than “You’re wrong.”

Metacommunication is talking about the way we talk. Here’s an example: Pat “How do you think we’re doing, applying those fair fighting rules we learned in counseling?” Lindsey “I think we’re doing better, but I wish you’d stop bringing up the past when we argue. How do you think we’re doing?” Pat “Well, we haven’t had a shouting match in weeks, so there’s improvement. I need to work on ‘one topic at a time.’  But I don’t like it when you get angry and keep going on, after I call a time out. We need to stop talking and cool off when either of us calls a time out. It’s just not important for one of us to get in the last word.”

Shakespeare wrote, “Love does not alter when it alteration finds . . .”. True, lasting love involves tolerance. True love will find a way to rise above conflicts, in service of harmony.

Changing habitual behaviors

Everyone has habits – some good, some bad, some inconsequential. One study suggests  that something like 43% of our behavior is habitual. This includes sequences of behavior that we’ve “chunked” together, and often perform automatically, so we don’t have to make myriad decisions every day. When you get in your car to drive to your friend’s house, you’re probably thinking about your destination or what you want to say to your friend. You don’t have to decide on each action as you automatically depress the clutch, turn on the ignition, fasten your seat belt, release the parking brake, shift into first gear or reverse, and  step on the gas pedal while easing off on the clutch. You don’t always have to be mindful about driving until you’re in traffic. We spend part of each day on “automatic pilot,” not having to make individual decisions about routine behavior sequences – which can include such things as drug abuse or “screen addiction.”

Throughout most of history, an individual’s habits arose from the culture and that individual’s circumstances and proclivities. These days, many of our habitual behaviors have been conditioned by corporate social engineers, applying principles of social science in the fields of advertising, marketing, public relations, and political consultancy. Using classical (Pavlovian) conditioning and other psychotechnologies of influence, they “invisibly” shape habitual behavior on a mass scale. I’m convinced that America’s obesity epidemic is largely due to the constant barrage of advertisements for tasty, if not necessarily healthy, foods. I’ve written about this corporate social engineering in my book, Ad Nauseam: How Advertising and Public Relations Changed Everything.

Everybody knows how hard it can be to change a bad habit. During my career, I had many clients who entered therapy because they needed professional help in order to change a bad habit. Willpower by itself is seldom sufficient to establish a desired change, because you have to maintain mindful awareness of your triggers and urges/cravings every waking hour, and to persistently resist temptation. The rewards of (for instance) dieting are long-term; the reward of giving in to a food craving is immediate. The good news is that once you’ve successfully changed a habit, it gets easier and easier to  maintain the change as time goes on. Quitting smoking, my nicotine cravings used to last all day. Eventually they only lasted for seconds, and now I haven’t had one for years.

Whether smart phone use can be addictive depends on your definition of addiction. I’m “old school” on the subject and believe that tolerance (needing more over time to meet your need) and physiological withdrawal are hallmarks of true addiction. Sex and gambling and screen time don’t qualify as addictions by the classic definition, but the physiological responses of gambling/sex/smartphone/gaming “addicts” are very similar to the responses of drug addicts. There may be withdrawal, in the form of cravings, but they’re psychological in origin.

Changing a habit often requires  a strategic approach to the problem. What mental, emotional, and social factors tend to keep the undesirable behavior in place? Once you’ve analyzed the factors that support your bad habit, make a plan. Visualize how your life will be better when you’ve succeeded.

Here are four things you can do to replace a bad habit with a good one. (1) Your plan should take into account the things related to the bad habit, such as time, place, emotional states, and social factors ( i.e. It’s not a good idea to hang around with your drinking buddies early in sobriety). (2) Declare your intention and your criteria for success to friends and family. This gives you an added social incentive to succeed. (3) Build-in  consequences, positive or negative. They can be natural consequences, or constructed. A natural, positive consequence if you’re quitting smoking is to add up the money you’re saving, and when you accumulate enough, treat yourself to a trip to Disneyland, or Vegas, or wherever. A negative, constructed consequence might be writing a $100 check to some organization that you despise, and giving it to a friend, to be mailed if you fail to change the targeted habit. (4) Don’t rely on good intentions and willpower, but structure your environment to make the bad habit more inconvenient. You can’t binge on cookies and ice cream while watching TV if you don’t buy them and bring them home in the first place. Other environmental factors are social – enlisting the support of those around you to help you meet your goal, and avoiding those who might undermine your resolve.

I’d never say “Good luck” to someone who announced his or her intent to kick a bad habit. Luck has nothing to do with it, and willpower is only one of the things you’ll need to succeed.

Psychotherapy in movies

In this post I’ll write about realistic depictions of psychotherapy in movies. Not many get it right. Barbra Streisand’s portrayal of a psychiatrist  in The Prince of Tides comes to mind. Her approach to therapy relies on the inaccurate cliché that when the client recovers the repressed memory of his trauma, he will be cured. More often than not movies about psychotherapy (i.e. Analyze This and Anger Management) treat it as a joke  – probably because the idea of being in therapy makes a lot of people nervous. Therapists routinely hear nervous jokes about their profession when they’re introduced to people as a psychotherapist. I can’t tell you how many times I’ve heard comments along the lines of, “I’d better watch what I say around you.” or “My wife really needs to talk to you.”

One of the most realistic depictions of psychotherapy I’ve ever seen in a movie was Ordinary People (1980), the first movie directed by Robert Redford. It depicts the dissolution of a family after the elder son of a loving couple dies in a boating accident. Timothy Hutton won an Oscar for his portrayal of the younger son, who feels guilty for surviving, when his brother died. Mary Tyler Moore distinguished herself as a dramatic actor in her role as the devastated mother, Donald Sutherland was totally convincing as the grieving father, and Judd Hirsch was perfect as a skilled and caring therapist who has to win the trust of his grieving, suicidal client. It’s a sad, beautiful movie, for which Robert Redford won an Oscar.

Good Will Hunting (1997) is another movie that portrays psychotherapy realistically. Matt Damon plays Will, an alienated, self-taught mathematical genius, orphaned and raised in foster homes. He’s grown a hard shell, to keep people out, and trusts nobody other than – to some degree – his best friend, played by Ben Affleck. Robin Williams portrays the therapist, who is willing to try to connect with this tormented genius. Will has to go to therapy in order to stay out of jail, but that’s his only motivation. He does everything he can to provoke and alienate his therapist, and to sabotage therapy. Robin Williams convincingly portrays a therapist who immediately sets boundaries when Will disparages his deceased wife. He’s briefly unprofessional, physically accosting and threatening Will; but this scene reveals that psychotherapists are also flawed human beings.

He clearly sees the sarcasm and hostility that he encounters as weapons that Will uses to push people away. He knows not to take the attacks personally, and works with patience and good humor to win Will’s trust, and to “disarm” him. I’ve dealt with well-defended clients like Will, working to get to the place where they were ready to hear something like this: “Look, we both know that your armor works. It makes you feel safe. The thing is, the only way you can learn that it’s safe – at least sometimes – to go out into the world without your armor is to take it off and venture out into the world.” The final therapy session in Good Will Hunting is riveting, and rings true to me as a therapeutic breakthrough.

Although it takes place in a “mental institution,” there’s not much psychotherapy in Girl, Interrupted (1999). Winona Ryder plays a young woman diagnosed with Borderline Personality Disorder and Angelina Jolie plays an antisocial manipulator. Parts of the movie are melodramatic and implausible, but the acting is good. One thing that the primary therapist in the movie – played by Vanessa Redgrave – says has stayed in my memory, because it’s point I’ve made in therapy about the meaning of the word ambivalence. Ambivalence doesn’t just mean, “Oh, I really don’t know if I want to do this or do that.” or “I don’t care if it goes this way or that way,” serving to deflect or minimize an issue. It can also mean being deeply conflicted regarding two opposing courses of action. An addict can both really want to quit using, but also really want to get high. Suicidal people can be ambivalent about living. Part of them wants to live, but another part wants to die.

The most realistic portrayal I’ve seen of therapy on TV was HBO’s series, In Treatment, with Gabriel Byrne as a therapist with, let us say, an extremely challenging caseload. He’s an excellent therapist, but his own life is something of a mess. One thing I liked about the series was that it not only depicted therapy sessions with a variety of clients and issues realistically, but it also showed us the therapist’s weekly sessions with his own therapist and clinical supervisor, played by Diane Wiest. Healers often need healing, themselves.

 

Authenticity and congruence

This a continuation of my last post, “How to be more like you,” in which I wrote about phoniness vs. authenticity. Most of us come by the inauthenticity that Fritz Perls described as phoniness quite  honestly, via the process of socialization. As children, we learn from the adult role models in our lives, and we’re often taught to be inauthentic. The template for prescribed phony behavior might be “politeness,” or religion, or social expectations about “correct  behavior” or even “correct feelings.” I’ve known people who were abused and/or  neglected by their parents who still, as adults, felt guilty about not loving them the way they “should.” Many children are taught who they are “supposed to” love, from grandpa to God. Genuine love can’t be forced.

A kiss that is anything other than an expression of affection or love or sexual passion is a phony kiss. Jane may not have even liked Aunt Sadie, but her parents taught her to give her a kiss anyway, whenever she visited. Children are often given admonitions such as: “Don’t cry! You’re a boy!” and “Don’t you get angry at me, young lady!” and “Of course you love him; he’s your grandfather!”

Some people have jobs that require them to act cheerful, no matter what they’re really feeling. Behavior arising from authentic feelings might be judged by others as impolite or inappropriate in certain situations. We’ve all been in circumstances where we felt the need to hide our true feelings; but some people go through life feeling that way every day. They have their reasons.

Con men, sociopaths and bullshitters are purposefully inauthentic. Others have learned to habitually cover up their true feelings; it’s their default mode. One of the ways I would confront a client who was putting on an act in therapy was, “You’re always on stage, aren’t you?” The look in their eyes (busted!) told me that I was on target, and that this was something they needed to know that other people could see through. People whose default mode is authenticity know themselves better than people who constantly put on an act to win approval. They are also more secure and self-accepting. I know this from personal experience, as I used to be a people pleaser, myself. My phoniness arose from feelings of insecurity.

A related concept that was important to me as a therapist was congruence. There are two kinds of congruence. One has to do with they way you come across when communicating. If someone being threatened says to his antagonist, “You don’t scare me” in a soft, tremulous voice, with body language that indicates fear, his verbal message won’t be believed. It’s incongruent with his other modes of communication. If someone says “I’M NOT ANGRY!” loudly, with fists clenched and an aggressive posture, he’s giving incongruent messages. When a person’s words are matched by her vocal tone, facial expression and body language, her message is congruent. People who are seen as charismatic are highly congruent communicators.

As a therapist with training in gestalt theory, I became very good at spotting subtle incongruities in therapy. In gestalt therapy, incongruent messages get challenged by the therapist. If a client claims (incongruently) that it really doesn’t bother her when her husband calls her stupid, the therapist might ask her to say the opposite: “It really bothers me when my husband calls me stupid!” (“But it really doesn’t bother me!” “Try saying it anyway.”) This technique is very effective in getting clients to recognize their true feelings, which often rise to the surface as the client repeats the opposite of their initial rationalized statement.

The other kind of congruence is role congruence. Do you act like a different person in your different life roles, or would family members and close friends recognize you as the same person they know, if they saw you at work? Obviously, some jobs – like a drill sergeant at a military boot camp – require you to take on a badass role that is (one hopes) incongruent with how he behaves in other situations. But under most circumstances a congruent person is recognizably the same person as a worker, a spouse, a parent and a friend. Incongruent persons are role-bound, and might be a tyrant at home and a reasonable person at work – or the other way around. Congruent people are authentically themselves in all the roles in their lives.

The intrinsic reward for being yourself – warts and all – is that when people who know you give you messages (feedback) about who you are, they’re revealing the things you need to hear, to be self-aware. I’ve written before about the paradox of identity. You can’t have self-knowledge in a social vacuum. We need other people who know us, in order to know who we “really are.” They’ll tell us, and if there’s some disagreement, it’s all grist for the mill. A consensus will emerge over time about who you are.

If you were living alone on a desert island, like Robinson Crusoe, how could you possibly know what kind of person you are? How could you know if you’re generous or stingy, witty or dull? We depend on other people in our lives to have an accurate sense of our own identity. Being authentic and congruent helps us to know who we really are, and what we might like to change about who we are.

Your “self” is either a rigid construct – “that’s just who I am!” – or a work in progress. Whatever your age.

 

How to be more like you

My title for this post is ironic. How could I possibly know who you are or how you should be “more yourself”?  But surely you’ve known some people who sincerely believed that the world would be a better place if other people were “more like them.” When people think this way, they are probably not  referencing the “self'” that is known to others – warts and all –  but rather an idealized, cherished self-image. I believe that all of us have a cherished self-image that doesn’t necessarily coincide with the consensus image of ourselves as others know us. When you hear someone say something about you and your reaction is “I’m not like that!”, you’ve probably identified a piece of your cherished self-image.

Attachment to this cherished self-image is especially strong in people who have tried throughout their lives to live up to others’ expectations of them – parents or extended parental entities  such as church and culture. Many of us are taught how we “should” or “shouldn’t” feel in this or that situation. This attachment can also be strong in people who have tried hard to shape themselves in reaction to “parental” expectations, i.e. “I refuse to be who my parents (or the church or the State) want me to be.” I’ve known quite a few parents whose cherished self-images kept them from seeing that they were dealing with their own children in just the same dysfunctional ways that their own parents had dealt with them. When you’ve sworn to yourself, “I’ll never do that with my children,” it’s often hard to recognize when you do.

Each of us – even those with low self-esteem – is the hero of our own personal drama, because we all live at the center of our perceived world, and none of us can be completely objective about ourselves. Our “heroic self” may wear the mask of the conquering hero or the rescuer or the wronged victim. But this heroic self is just as much an artificial construct as any image of ourselves projected onto us by others. I remember an epiphany I had as a young man. Seeing my reflection in a mirror, I thought “That’s who they think I am!”

One’s true self isn’t a thing, fixed and immutable, but is best seen as an evolutionary process, a work in progress. Buckminster Fuller put it this way: “I seem to be a verb.” Rather than trying to nail down some finished portrait of one’s self, I think that it is more helpful to have a picture in mind of who you are today, in the here-and-now of your experience and behavior. Your actions, not your thoughts, ultimately define you as the unique person you are.

A concept that was important to me as a psychotherapist was authenticity. In studying gestalt therapy in grad school, I became aware that many of my habitual behaviors were what gestalt guru Fritz Perls called “phony.” I was a people pleaser, always trying to guess what was expected of me in each situation and to behave in ways  that were attempts to please or impress the people around me. I realized that I wanted everyone to like me – even if I didn’t especially like them. But, to the extent that I was phony, if someone seemed to like me, what they liked was my act, not me.

I knew that if I was going to be a good therapist, I had to become more spontaneous and authentic – even if that meant that some people wouldn’t like me or approve of my actions. I stopped making phony excuses for myself, like saying “I really have to leave now,” when I really just wanted to leave. I stopped rehearsing for social occasions such as parties. I learned to walk into a roomful of people with an “empty mind,” primed for spontaneity. I wanted to get to know the person behind the masks that I wore. Some people may have seen me as blunt or curt, or even rude, as I worked on becoming “more myself.” I knew that not everyone liked me, and that was okay. The work that I did on myself enabled me to help therapy clients to identify and confront their own inauthentic behaviors, and to work on changing them.

Gestalt therapy is especially effective for working with people who want to discover their authentic selves. Some gestalt techniques (which I described in a prior post) serve to unmask phony roles that people play, leaving them bereft of their usual defenses, and open to sudden insights. Fritz Perls is perhaps best known for what is called the Gestalt Prayer: ” I do my thing and you do your thing. I am not in this world to live up to your expectations and you are not in this world to live up to mine. You are you and I am I, and if by chance we find one another, it’s beautiful. If not, it can’t be helped.”

More about authenticity, and the related concept of congruence, in my next post.

 

Non-suicidal self-injury

I think that one of the most baffling phenomena in the repertory of human behavior, to people outside the mental health field, is self-mutilation. Most of us fear and avoid physical pain and disfigurement, and it’s hard for us to understand why anyone would intentionally hurt themselves of self-mutilate. Over the course of my career as a psychologist, I discovered that there are a variety of motivations and explanations for self-harm.

Some people harm themselves because they are in a psychotic state of mind. It may be that voices nobody else can hear tell people to hurt themselves, or that self-harm is the result of delusional beliefs. I’ve known a man who gnawed off several fingers and another who gouged out his eyes for incomprehensible reasons, while psychotic. Other people injure themselves impulsively, because their distress impairs their judgment and they don’t know what else to do; so they bang their heads against the wall, or punch through a pane of glass.

Yet others learn from experience that cutting, or otherwise hurting, themselves provides immediate relief from overwhelming emotional pain; and it becomes a habit. The brain often responds to pain by releasing endorphins, whose molecules resemble morphine. (I recently learned that one reason some people enjoy eating really hot peppers is that the pain gives them an endorphin high.) This substitution of physical pain for emotional pain is hard for many of us to understand, but it reliably meets a need for some people. It can be viewed as a kind of masochism, with the distinction that it’s not done for pleasure, but rather for relief from pain.

What I would say to a client when I learned that they were self-mutilating was something like, “I believe that if you knew better ways to cope with your emotional distress, you’d use them, instead of hurting yourself. So let’s work on finding better ways.” Non-suicidal self-injury (NSSI) is a pathological behavior for many people diagnosed with Borderline Personality Disorder, and its elimination is one of the first goals of the most effective treatment available for people with that diagnosis – Dialectical Behavior Therapy (DBT).

DBT is the creation of Dr. Marsha Linehan. She designed it to help people who feel like they’re living in Hell, as a way out. Each patient in a DBT program is assigned an individual therapist, and is required to attend skills training groups twice a week. Two of the skills modules that are geared to the elimination of  NSSIs – or parasuicidal behaviors – are distress tolerance and emotion regulation. Borderline traits and symptoms are characterized by emotional imbalance. In learning to tolerate distress and regulate emotions, the clients learn how to achieve emotional balance. They no longer have to rely on the endorphin rush they get from cutting or burning themselves, once they’ve found better ways to cope with emotional distress.

The most extreme instance of self-mutilation I ever encountered in my career, not involving psychosis, was a long-considered and carefully executed self-castration. I speculate that the man’s motivation was related to either or both fear of a strong sex drive and/or disturbing sexual fantasies and urges. A fundamentalist Christian, he believed himself to be tempted by demonic “powers and principalities,” in a battle over his soul. He was quite intelligent and had a rationale for his agenda.

When he’d asked a surgeon to castrate him, he’d been told that no doctor could ethically accommodate his request, as there was no medical reason for the surgery. So he studied books on surgery until he felt confident that he could operate on himself. He decided to castrate himself in two  separate surgeries, coached his wife to serve as his surgical assistant, and set up a surgical suite in their home. The first surgery went off without a hitch. I never would have encountered the man if he hadn’t botched the second surgery. When he and his wife couldn’t stop the bleeding after he’d severed his remaining testicle, they had to call 911.

The local hospital contacted me to evaluate him. He was medically stable and ready for discharge, but his doctor wanted me to make a recommendation regarding any possible suicide risk. The man showed no signs of either depression or psychosis. He was pleasant and cooperative, explaining his rationale for castrating himself and answering all of my questions. He seemed somewhat embarrassed by having been found out, but seemed to have no other regrets about his actions. He persuasively denied any suicidal thinking, and he didn’t meet the criteria for involuntary psychiatric commitment. So I recommended that he be discharged. I gave him my card and told him that I was available if he wanted to follow up, but he never contacted me.

As an adult, I’ve never referred to mentally ill people as “crazy” – only behaviors. This was an example of how a legally sane person can do a carefully-considered, but crazy, thing.

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.