Exposure Therapy: Eliminating Anxiety Disorder’s Fear, Part 1

The neighbor’s dog barks night and day. If you have gotten used to it, you have used one of the root principles of Exposure Therapy.

Exposure therapy is a type of Behavioral Therapy used to help the patient confront a feared situation, object, thought, or memory and dispel its power over them. It involves reliving a traumatic experience in a controlled, therapeutic environment.

In a way, Exposure Therapy is related to the old maxim “face your fears,” but instead of jumping into a terror-inducing situation with both feet, therapy usually advocates a carefully planned, gradual approach to alleviating fears.

Exposure therapy has been shown to be effective with many of the Anxiety Disorders, including Social Phobia (SAD), Generalized Anxiety Disorder (GAD), panic attacks and Panic Disorder, Agoraphobia, Adult Separation Anxiety Disorder (ASAD), Post Traumatic Stress Disorder (PTSD), and specific phobias.

This two-part series of articles describes what Exposure Therapy is, and offers tips to make your Exposure Therapy successful. Today’s installment has these headings:

• Exposure Therapy is based on habituation
• Exposure Therapy counteracts Anxiety Disorders’ avoidance
• Exposure Therapy is a part of Cognitive Behavioral Therapy
• Characteristics of a typical Exposure Therapy plan

Tomorrow’s part of the article will continue the discussion under these headings:

• Exposure Therapy: Better in real life or in imagination?
• Tips for successful Exposure Therapy experiences

Exposure Therapy is based on habituation

Habituation: Just getting used to the annoying things in life

Exposure therapy is based on the principle that we get used to things that are just annoying and not truly dangerous if the experience is not overwhelming. This is called habituation, and it occurs naturally in over 95 percent of all people.

For example, you visit a friend in a large city who lives in an apartment right beside an elevated railroad. It is very annoying every time a train screeches by, shaking the building and rattling the windows to the point that conversation becomes difficult.

You might say to your friend, “How do you live in all this noise?” And the friend might answer, “What noise?”
If you only visited for a few days, you would leave with a belief that your friend lives in an impossible situation. If you were to stay for a week or two, you too would become habituated to the noise, and no longer be annoyed by passing trains.

In the same way, Exposure Therapy gradually habituates the patient to the feared thing — be it a situation, an item, a memory, or a thought. Through exposure, it gradually loses its power to produce fear and anxiety, with the goal being that it is no longer even noticed.

Exposure Therapy counteracts Anxiety Disorders’ avoidance

Avoidance is the key features of Anxiety Disorders

One of the key components of the Anxiety Disorders is the tendency to avoid the situations, thoughts, and objects that trigger anxiety. This avoidance builds upon itself: real things that cause anxiety are avoided, then more related real things are avoided, then imaginary things related to the real things, then imaginary things related to the imaginary things — until your life is a minefield of things to be avoided.

Avoidance does provide temporary relief from anxiety, but it never lasts. There’s always a new situation that requires some sort of negotiation with your anxious fears, causing you to once again use avoidance as your first line of defense.

Exposure Therapy works in opposition to the typical, self-prescribed avoidance approach. It recognizes the fears behind the learned avoidance behavior, and names the triggers that produce your Anxiety symptoms. Exposure Therapy uses a carefully devised plan of exposure to the feared situation to gradually defuse its anxiety-producing power, to the point that it has no ability to produce anxiety at all.

Exposure Therapy is a part of Cognitive Behavioral Therapy

Cognitive Behavioral Therapy is effective treatment

Cognitive Behavioral Therapy (CBT) has been shown to be one of the most effective kinds of psychotherapy for dealing with the Anxiety Disorders. It has two basic components:

• It helps to change thinking patterns (cognitions) that have prevented individuals from overcoming their fears.
• The behavioral component helps individuals to slowly come in contact with their fears. This is done through Exposure and Response Prevention Therapy (ERP) and is designed to systematically desensitize a person to their fears.

Exposure Therapy within CBT is based on our natural tendency to habituate ourselves to situations, along with a concept called cognitive dissonance. “Cognition” is simply any mental process that we have involving knowledge, attitude, emotion, belief, or behavior. “Dissonance” is a term borrowed from music, meaning the grating together of two conflicting, incompatible notes. The theory of cognitive dissonance states that contradicting cognitions serve as a driving force that causes the mind to acquire or invent new thoughts or beliefs, or to modify existing beliefs, so as to reduce the amount of dissonance between cognitions.

For example, you may enter Exposure Therapy with the fear of flying. You hold the thought in your mind that flying is unsafe, which produces fearful sensations in your mind and body. Your therapy will teach you that airplanes have an admirable safety record, and though uncomfortable, flying is nothing to fear. During the course of your Exposure Therapy, the two conflicting, or dissonant, thoughts — fear of flying and the safety of flying — gradually resolve themselves into a belief that flying is safe and nothing to fear: a consonance of thoughts.

Characteristics of a typical Exposure Therapy plan

What a good Exposure Therapy plan looks like

Your therapist will work with you to determine what your root fears are, and to develop a plan to confront them in a controlled manner. While some therapists may determine that the best solution is what is called “flooding,” wherein you are exposed to the full situation all at once, most will create a plan that will gradually expose you to the fear until it is dissipated.

Along with an exposure plan, you will be taught relaxation techniques, such as breathing exercises, and other coping skills to deal with emotional and physical distress and fear. Using these techniques helps you maintain a sense of control whenever you are confronted with the feared object, situation, or distressing thought or memory.

The basic principles of Exposure Therapy are:

• Gradual exposure
• Repeated and regular exposure
• Prolonged exposure

Gradual exposure
You and your therapist will create an exposure plan, with gradual steps that lead to full exposure to the feared situation. Each step should be difficult enough to provoke some anxiety, but easy enough for you to be fairly confident you can do it. Once you can successfully cope with a step, you can move on to a more difficult situation and gradually work up your most feared scenarios.

It is important not to confront a feared situation that is far too difficult for you. If you tackle something too stressful without sufficient preparation, you may become extremely anxious or even have a panic attack. Such a negative experience would only strengthen the association between fear and the setting that provokes it. Therefore, it is important to follow your plan exactly, without skipping steps.

Repeated and regular exposure
You need to confront your feared situations frequently and regularly if you are going to overcome your anxiety. If your exposures are too far apart your fear will rise again by the next time you confront it. Your therapist will likely give you exposure assignments to practice between sessions. It is important that you do these assignments several times in order to become confident enough to move to the next step.

Prolonged exposure
You should stay in the feared situation until your anxiety starts to decrease. Your past pattern was to attempt a feared situation, but then choose to escape or avoid it. When you avoid or leave feared situations two things happen:

• Your fear of the anxiety-triggering situation increases even more.
• The idea that avoidance is a helpful strategy is strengthened because your escape caused a decrease in anxiety.

However, if you stay in the feared situation your anxiety will eventually decrease, and the next time you confront the situation you will be less anxious. A good exposure plan will never put you in a situation that is too much for you — keep this in mind as you challenge yourself to cope with each exposure step.

Don’t miss tomorrows’ installment with tips for success!

Today’s installment discusses what Exposure Therapy is and what a good plan looks like. Tomorrow’s part of the article will continue the discussion, and also provides tips for making Exposure Therapy a successful experience:

• Exposure Therapy: Better in real life or in imagination?
• Tips for successful Exposure Therapy experiences

What do you think?

As mentioned, Exposure Therapy has a lot in common with the notions of conventional wisdom. We know that we must face our fears, but the only way we know how is to face them in all their fury, which is bound to be unsuccessful and produce even more anxiety. The advantage of formal Exposure Therapy is that the therapist is experienced in helping people discover their core fears, and developing a plan for gradually confronting them. The therapist can also help you learn techniques to cope with your fears during your exposure practice — techniques that will help you for the rest of your life.

I’m reminded of when I was a little boy. My uncles threw me into the deepest part of the swimming hole to “teach me to swim.” All that did was almost drown me and reinforce my fear of the water. It was only through swimming lessons — with its gradual steps toward learning the skill — that I learned to swim and not fear the water.

The old maxims tell us to throw ourselves into the middle of feared situations and just be brave. All that does is to create more fear and cause for avoidance. It is only through a well-planned and executed program of exposure that we will learn to conquer our fears and dispel the power they have over us.

• Have you had any experience with Exposure Therapy? How has it helped you?
• Exposure Therapy is closely related to normal habituation. Have you been able to overcome fears on your own using a gradual approach?

©2009 Michael L Nichols. All rights reserved.

Resources used in this post:
Andrews, G.; Crino, R.; Hunt, C.; Lampe, L.; Page, A. (1994). The Treatment of Anxiety Disorders. Cambridge, England: Cambridge University Press. (Quoted) Retrieved October 1, 2008 from Shyness & Social Anxiety Treatment Australia Web site: http://www.socialanxietyassist.com.au/treatment/exposure.shtml
Anxiety Treatment Center. (2006). Exposure and Response Prevention Therapy. Retrieved October 1, 2008 from Anxiety Treatment Center Web site: http://www.anxietytreatmentexperts.com/cbt_exposure_therapy.asp
Atherton, J.S. (2005). Learning and Teaching: Cognitive Dissonance and Learning. Retrieved October 3, 2008 from Learning and Teaching Web site: http://www.learningandteaching.info/learning/dissonance.htm
ChangingMinds. (2002). Cognitive Dissonance. Retrieved October 3, 2008 from ChangingMinds Web site: http://changingminds.org/explanations/theories/cognitive_dissonance.htm
HealthyPlace. (2008). Exposure Therapy for Anxiety Disorders, Panic Attacks. Retrieved October 1, 2008 from HealthyPlace Web site: http://www.healthyplace.com/Communities/Anxiety/treatment/exposure_therapy.asp
Hoffman, Hunter. (2008). VR Therapy for Spider Phobia. Retrieved October 1, 2008 from HITLab Web site: http://www.hitl.washington.edu/projects/exposure/
Katz-Wise, Sabrina; Poore, Ralph. (2006, November 10). Exposure therapy. Retrieved October 1, 2008 from RevolutionHealth Web site: http://www.revolutionhealth.com/articles/exposure-therapy/aa131258
Madison, N. (2008). What is Exposure Therapy? Retrieved October 1, 2008 from WiseGeek Web site: http://www.wisegeek.com/what-is-exposure-therapy.htm
Mindsite. (2008, March 12). Exposure Therapy. Retrieved October 1, 2008 from MindSite Web site: http://www.mindsite.com/article/229/exposure_therapy
PTSD Facts for Health. (2008). Exposure Therapy. Retrieved October 1, 2008 from PTSD Facts for Health Web site: http://ptsd.factsforhealth.org/exposure.html
Rapee,R.M., (1998), Overcoming Shyness and Social Phobia. Cambridge, MA: Lifestyle Press.
Terri. (2007, February 24). Exposure Therapy for Treating PTSD. Retrieved October 1, 2008 from A Soldier’s Mind Web site: http://soldiersmind.com/2007/02/24/exposure-therapy-for-treating-ptsd/