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.

Psychiatry: pro and con

I write this as someone who had a career as a psychologist in the mental health system, working within the scientific/medical model of psychiatric treatment. So, I’m not writing to reject psychiatry outright, but to examine its efficacy. I’ve written about the value and limitations of models in previous posts, and about what I call the “model muddle.” Models are just maps, helpful only to the degree that they’re accurate. No one model is demonstrably superior to all other models, in all situations. Every model has its limitations.

First, I’d like to distinguish between psychology, psychiatry and psychoanalysis. Psychology is the study of human behavior, and provides the basic theoretical structure for psychotherapy. Sigmund Freud came up with the concept of “the talking cure,” the notion that dialogue with a caring professional could help to resolve symptoms and treat psychopathology. Psychiatry is a branch of medical science, based on the concept that the accurate assessment of symptoms of mental illness can lead to an accurate diagnosis, which will result in an appropriate treatment. Psychiatrists are medical doctors who specialize in the treatment of mental illness. Freud was a psychiatrist, and psychiatrists who are trained in the system of Freudian psychotherapy are called psychoanalysts.

While I believe that psychiatric (medical model) treatment has helped a lot of people with debilitating metal and emotional symptoms, like any model, it has its limitations. Since the 1960s, the efficacy of psychiatric treatment has been questioned – with good reason. A primary critic was psychiatrist Thomas Szasz, who wrote The Myth of Mental Illness. Another psychiatric rebel was R.D. Laing, and yet another psychiatrist, David Cooper, coined the term “antipsychiatry.” Critics of psychiatry argue that mental illness/madness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. This core of criticism has led to the current antipsychiatry (alt. recovery) movement.

A primary criticism of psychiatry is that psycho-diagnosis isn’t rocket science. It’s imprecise relative to the diagnostic precision for most common physical medical conditions, and can be selective and subjective in its diagnostic criteria. Unlike with physical medical conditions that can be diagnosed by tests and procedures that reveal “markers” of a specific condition (i.e. pneumonia vs. tuberculosis), there are no such markers that distinguish schizophrenia from schizoaffective disorder or bipolar disorder. I’ve known many people with chronic mental and emotional disorders who have gotten a wide range of psychiatric diagnoses, over years of treatment. Ideally in the medical model, an accurate diagnosis results in appropriate and effective treatment. This is less often the case in psychiatry, because there’s more “educated guesswork” involved.

Proponents of the antipsychiatry movement contend that psychiatric treatment is all too often more damaging than helpful to patients. Extreme treatments such as prefrontal lobotomies haven’t proven to be effective; and the negative side effects of some psychotropic medications and mood stabilizers seem to outweigh the benefits for some patients. The term “iatrogenic effects” refers to treatments that do harm.

Another valid criticism of psychiatry is that it’s over-reliant on pharmaceuticals, and that the psychiatric profession has had incestuous ties to Big Pharma. I believe that, as a culture, we’re too dependent on medications as a panacea for health problems related to bad lifestyle choices. Drug company ads suggest that we can eat whatever we want and take pills to control any gastro-intestinal symptoms that result from a poor diet.

Having said that, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need to rely primarily on drugs as the default treatment for psychopathologies.

The concept of recovery from mental illness doesn’t necessarily mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom control or remission. There are recovery centers in cities around the country that offer alternatives to traditional psychiatric treatment, recognizing that community and peer support can be important components of treatment. Such programs don’t preclude psychiatric interventions, but don’t rely on them as the default mode.

Factors such as physical health, stress, social stigma, chemical dependency, poverty, homelessness and nutrition can all play a role in mental health and mental illness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that give people who have been labeled as mentally ill more autonomy and more options for resolving their problems.

You can find out more about the antipsychiatry movement, the recovery model, and alternatives to traditional psychiatric treatment at <madinamerica.com>.



The meaning of dreams

We spend roughly one third of our lives unconscious, and when we’re asleep we’re unaware of our immediate surroundings. But sometimes during sleep, we’re aware of ourselves in a realm of illusions. We remain ourselves in our dreams; but the people, animals, places and things we encounter may transform.  A dream has a sequence of events but, unlike a story, it has no contrived plot. So, why do we dream, and what is the meaning of our dreaming? It depends on who you ask.

Dreams are regarded as sacred and/or prophetic in some cultures, and the interpretation of dreams is an ancient and widespread practice. In many cultures the interpretations have been made by priests, priestesses or shamans, proceeding from the assumption that dreams mean something in our waking lives. Many modern sleep scientists would disagree, believing that dream content is the result of random neural  firings, connected to memory retrieval. One theory about why we dream is that it’s the way the brain sorts and edits new memories for later retrieval.

The history of modern dream analysis in Western culture starts with the 1899 publication of Sigmund Freud’s The Interpretation of Dreams, in which he called dreaming “the royal road to the unconscious.” Along with free association, dream analysis was a component of Freudian psychoanalysis, used as a key for the unlocking of repressed thoughts and feelings. Freudian dream analysis has to do with themes such as wish fulfillment, unconscious desires, and anxiety related to conflicts in the dreamer’s life.

Carl Jung is perhaps best known for his concept of the collective unconscious. Jungian dream analysis is similar to Freud’s, in that it delves beneath the surface content of the dream as described by the dreamer (latent content), to explore the unconscious, symbolic meanings (manifest content). Jung’s system differed from Freud’s, in that Jungian therapists related the dream’s symbolic content to universal mythic themes in the collective unconscious, and archetypes such as The Mother, The King and The Hero.

While in grad school, I attended a leaderless gestalt dream interpretation group. Both theory and method were different from Freudian and Jungian dream analysis. The constant focus in gestalt therapy is staying in the here-and-now of your direct experience; and in the dream group you first related all that you remembered of your dream, in the present tense: “I’m walking on barren ground, in the middle of nowhere. I see a house in the distance and I’m walking toward it. As I get closer, I see that the house is deserted and falling apart. The wood creaks beneath me as I walk up the steps to the porch. The wood is rotten and I’m afraid I’ll fall through the floor, but I have to go inside. . . .” After the whole dream had been related in this manner, the dreamer would then take on the role of objects from the dream: “I’m a house in the middle of nowhere. I look good from the distance, but I’m actually falling apart. Nobody would want to live in me. . . .” After the dreamer finished, a group member might ask what it feels like to be this house, and the group would discuss possible meanings, before going on to the next dream object.

Things that happen to us  in our dreams often mirror circumstances that arouse our anxieties in our waking lives. Fear, anxiety, helplessness, frustration, and shame (e.g. naked-in-public dreams) are frequent emotional states experienced in dreams. Most of us have gone to school, and I expect that we’ve all had school dreams. I’ve done some stage acting, and I imagine that every stage actor has had some variation of a recurring dream theme from my acting days:  I’m onstage, the curtain is about to open on a full house, and I can’t remember what play I’m cast in, let alone my first line of dialogue. I’ve had very few nightmares as an adult, but a frequent theme in the dreams I remember is frustration, e.g. I need to get somewhere from where I am in a foreign city, but I’ve misplaced my luggage (or my car key) and can’t leave until I recover it. And then I can’t find my car, and the streets and buildings keep changing. It’s such a relief to wake up and realize that I’m right where I need to be, with no immediate problem to solve.

I’ve had some dreams that were so vivid, I’ve had to convince myself that they weren’t real. Researching the subject, I’ve come to believe that they were hypnogogic hallucinations, which occur in the twilight state between consciousness and unconsciousness, before falling asleep. Similar hallucinations that occur in the twilight state between sleep and wakefulness are called hypnopompic hallucinations.

Another unconventional dream state is lucid dreaming, where the dreamer becomes aware of being in a dream, and can control its content. I’ve had a few lucid dreams and have heard many claims that it’s a learnable skill. Some proficient lucid dreamers say that they can fly in dreams, overcome any adversary, and have sex with anyone they want. If you want to learn more about lucid dreaming, I highly recommend Richard Linklater’s 2001 animated film, “Waking Life.”

Dreams are but one of the mysteries of consciousness, and I believe that what they “mean” is ultimately subjective. Ancient shamanic tradition has it that Dreamtime is a real world parallel to our own, and that those who can “journey” in Dreamtime can heal people and work magic in the waking world. Whatever clues or signals dreams may hold in regard to our waking lives, their interpretation is culture-bound, and there are no authoritative answers to our questions about this mysterious, otherworldly phenomenon.