Exposure Therapy

What is Exposure Therapy for Anxiety (and why is it so effective when used according to the evidence)?

Most of us are aware of the expression, “hopping back on the horse”.

It refers to being thrown from a horse, and the need to get back on and ride again immediately otherwise you’ll build up a fear response.

Exposure therapy, in the same vein, is a cornerstone set of techniques for moving from avoidance of a feared situation to returning to it, usually with lessons learnt.

It can be done well in the hands of a well-practiced therapist, or it can see patients drop out of therapy when poorly applied without due consideration for each patient’s needs, and without sufficient effort at establishing a working therapeutic alliance.

At its essence, exposure therapy posits that the key to anxiety is one’s avoidance response which needs to be recalibrated. Along the way, a scenario which may have been benign and neutral or even at one time pleasurable, has now taken on the characteristics of a feared scenario, tapping into evolutionary old, automatic responses: the flight and freeze reaction.

There’s a problem with the “flight and fight” cliche

Notice I do not use the familiar “flight and fight” phrase, which has now become dogma. It’s great for some animals in the wild, but for humans, it’s not as accurate a description of what happens compared to “flight and freeze”. I’ll write a complete entry about this soon.

So, I often see fear of flying patients who lament how they used to enjoy flying, but in recent years – often for reasons they cannot fathom despite searching through their memories of previous flights – their experience of flying has become tarnished with a variety of unpleasant and forebidding fear responses. This has left them flying less often, flying using alcohol or prescribed drugs, flying only at certain times of the day, feeling the need to carry lucky charms with them, or avoiding flying altogether.

These patients are aware of the lack of evidence for these “flying routines and rituals”, but present to me having tried unsuccessfully to change their behaviours and feelings.

Exposure Therapy, as its name suggests, asks the patient, under therapeutic guidance, to approach and enter their feared situation, and stay there long enough to experience a reduction in their response. It’s important to firstly know what the goals are: which aspect of the fear response should reduce to call the experience successful? Should it be one’s heart rate or sweat response? Should it be feelings of dread? Should it be thoughts of catastrophe or harm? Quite specific goals should be aimed for in each session of exposure.

For some specific situations, there is a body of evidence that suggests a single session of exposure can be very successful, perhaps starting with pictures of the feared stimulus, then a movie, then a smaller version of the most feared situation. This session might take a few hours to perform.

Some initial considerations

Their are some important things to bear in mind before you undertake this challenging set of tasks, whether it be in a single sessions or over several:

1. Expect to experience discomfort

and be prepared to give it a label. The label could be a quality of discomfort, or it could be a rating out of 10. In the first few experimental procedures, you’re likely to feel like you’re zooming from 0 to 10 immediately. This is because for many people, any experience of discomfort in what they think should be OK places or scenarios is bad news, and thus is rated 10 (the worst).

It’s important for the recalibration process to begin to use some yardsticks to gain some measure of discomfort. In my work I use biofeedback which measures heart rate and skin conductance. We measure changes, rather than absolutes, and so it’s important to learn that a 3 out of 10 is mildly unpleasant, but eminently manageable. A 7 out of 10 is considerably stronger and may elicit different thoughts and sensations.

2. Under therapeutic guidance, patients learn to tolerate the discomfort,

label it appropriately, know it’s safe to experience an elevated heart rate and more sweating or even dizziness, and wait until their discomfort subsides just by staying in the situation. Anxiety responses get stronger when you reward them, by escaping the feared situation into a “safe” zone, and perhaps being comforted by a well-meaning friend, or even therapist. We don’t want to do that.

3. Some situations require repeated efforts over time.

In previous times, people would be exposed to their feared scenarios in graduated steps, but more recent data suggests this is not necessarily a good thing, and the challenges should be mixed up randomly. Thus, an exposure session featuring elevators may randomise which floor to go to, and how long to stay in the elevator car before leaving it. The idea is that no matter what the elevator does, no matter which buttons other users press, the patient can handle the situation. Otherwise, you increase the likelihood of only using elevators when you can travel alone and “guarantee” success. Life isn’t like that, and I’d rather patients learn to manage whatever realistic situation life throws at them.

4. The recalibration process can be enhanced

by knowing what to do differently in the feared situation. So, in addition to the enhancement brought about by staying in the feared situation, the idea is to perform activities which are incompatible with the fear response, and more in line with a non-fearful response. A patient afraid of turbulence will initially imagine its presence, and move their hands from gripping their seat, to being cupped palms upwards in their laps. They will check and adjust their breathing to being more consistent with focussed attention, and review on flipcards more appropriate things to say to themselves such as, “Turbulence might be uncomfortable but it’s not unsafe”.

There is no shortage of YouTube videos of normal commercial flights to practice this, and in my Virtual Reality setup we can approximate turbulent flights in thunderstorms to really enhance the learning process.

5. Be wary of overusing distraction.

It can be a great technique often used by elite athletes when they reach a significant pain threshold in certain endurance events where it’s called dissociation. But you don’t want it to be your only tool. Often in training patients, I will have them be even more in touch with their uncomfortable feelings and the sounds and vibrations certain external triggers can make in normal flight. The task is to learn the normality of these events, label them appropriately, and then behave in a way consistent with reducing or switching off the “noise” of your false alarm. This isn’t instantaneous, so even when one begins the process – say, by commencing diaphragmatic breathing – your body needs about a minute (roughly three breaths) to recognise the danger is in fact a false alarm. In the hands of some therapists, this is known as Mindfulness.

This is a good place to say that I consider anxiety, when it becomes truly intrusive in one’s quality of life, to be a disorder of vigilance. Consider that our bodies have a variety of feedback loops to keep our life systems in the right zone. When you visit your GP, he or she might organise some tests, and the results will come back to say whether you are in a healthy range.

When one of your loops go out of range, you may experience signs or symptoms, or sometimes there are no subjective signs, such as can be the case with blood pressure or cholesterol readings above the normal range.

When your senses experience a sudden change – a very loud noise, someone pushes you, you trip, you’re momentarily blinded by oncoming cars – your vigilance systems are pushed into another zone, leading to automatic reflexive activity. To do so, however, it has been continuously sampling the environment, often outside your own awareness it is doing so. But when it kicks in as a reflexive protective act of safety – the flight and freeze response – you really know it! And this response itself can be quite frightening, generating even more elevation in your stress response, but this time, it’s often accompanied by fearful thoughts too.

Just recall a time when you were driving and had to brake hard to avoid a dog or a child or another car? Do you recall the zing of electricity shoot up your back – that’s the release of adrenaline, from your adrenal glands sitting on top of your kidneys. It’s a quick and dirty hormonal effort to focus your attention completely on what needs to be done immediately.

Its release makes controlling things with your thoughts very, very difficult. It really feels like you go from 0 -10 in no time. When it occurs, it’s because there is no time to give considered thought to what your options may be. The brain reserves this maximal and quite scary effort for scenarios its sensors detect as truly dangerous. It may well be that later you discover it was a false alarm (it was not a bird swooping down upon you whose shadow you reacted to, but a newspaper sheet picked up by swirling winds), but it will still take some time to regain your physical and emotional equilibrium.

The case of Disordered Vigilance

Disordered vigilance is when the response – automatic or considered –  is to things that of themselves are not in fact dangerous, or where our response to potential danger is over the top (we zoom from 0 – 10 immediately). It can also be where we don’t come back to an even keel within a reasonable amount of time once the danger has passed or been assessed as a false alarm.

This is known as emotional regulation. It clearly has a thinking component, as well as a physiological component, and all ought to work in synchrony. For some people, life feels like it emotional regulation, and the ability to self-sooth or self-calm feels out of reach during much of their conscious day.

Let’s go back to the scenario of ducking when a newspaper flies overhead, when our sensory equipment feeds to our brain sudden overhead movement. Many people will duck, and in Melbourne it’s wise to do so especially when it’s Magpie mating season. In your recovery, you look up and, noticing the newspaper floating through the sky overhead, smile at how your brain warned you into taking immediate automatic evasive action. This is a form of self-compassion.

But now imagine across the road watching you are a group of rambunctious adolescents who now point and make fun of you. You might smile back and join in the fun and amusement. But you could also feel embarrassed at others noticing your very human reactions, and you tell yourself, “I shouldn’t have ducked, I should have remained in control.” You can see how a cognitive schema – “I must always exhibit self-control to others” – can quickly rush to the surface. Instead of having a laugh at your very human experience, you self-down, and add to your demand to remain in control. Your capacity for self-compassion takes a hiding.

More useful information about Exposure Therapy

Exposure therapy can take many forms, and it is by definition, a risky exercise, asking you to come into intimate contact with your fear responses and scenarios. A good therapist will help you titrate these exercises so you are not overwhelmed, but at the same time, not let you get away with avoidance behaviours which in some people can become quite sophisticated.

Distinguishing between internal and external sources of anxiety

Clinical Psychologists refer to two types of exposure therapy for anxiety disorders:

1. Exteroceptive Exposure

where the sources of distress and triggers for avoidance exist in the environment. It could be a person or group of people (such as giving a speech or being interviewed); it could be an animal, such as a dog, spider, snake etc., or it could be a situation such as might occur during a flight. Each of these can have a series of graduated exposure exercises constructed, and with a little imagination and some technologies, the match between the imagined and the actual can be very high. Each exposure exercise constructed between patient and therapist must have some element of arousal present if there is to be a recalibration process.

2. Interoceptive Exposure

in this case the source of distress is the patient’s own alarm system being triggered, with ensuing unpleasant, uncomfortable and indeed frightening physical sensations. These could be shortness of breath, sweating, a racing heart, dizziness,  disorientation, and so on. There can also be frightening thoughts and feelings of compulsion also, perhaps to commit rituals or acts of potential harm. I always lead patients through a series of multimedia exercises to help them understand the physical underpinnings to the body’s alarm system, so when confronted with alarms going off, it’s more easily interpreted as “normal” rather than “abnormal: escape!”

Clinical Psychologists and patients need to work together to develop an appropriate series of exposure sessions for behaviour to change. For those with a fear of injections, viewing and handling a series of knitting needles may start the exposure process (just the word “needle” can cause arousal), which may also then expand to videos of people self-injecting (no shortage of these on YouTube). For those with a fear of vomiting, exposure to their own vomiting is not necessary, as it actually rarely occurs. It’s the fear that one could vomit, or come in contact with those who could induce illness. Therefore, exposure is to the thoughts and accompanying feelings of distress when near others who appear ill and perhaps contagious.

The exposure in this presentation, known as emetaphobia, is also to not seeking reassurance and comfort form others, especially parents, in the case of children and teenagers. This can be in person or using texting apps on mobile devices. The patient is asked to delay seeking assurance, and be with their uncomfortable thoughts and feelings. Teaching children to delay seeking assurance and performing activities to contain their distress is often useful, and there are a number of apps to help with breathing, focus and attention, and journal writing, in a fun way.

UPDATE August 7, 2015:

UK Sky 1 TV channel has commenced a new series called Fright Club featuring groups tackling their phobias using Exposure based principles. It started in Britain June 3rd, and over several weeks, looks at groups of patients confronting some really difficult but common situations. Here’s the trailer (no news if it’s coming to Australia, but I wouldn’t mind doing a local version!):






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