Why Exposure Therapy?
So here’s the thing, before I learnt about exposure and saw it in action, I thought anxiety was a kind of struggle that can take years to overcome. I always kind of knew about the concept of exposure but did not know therapists who did it formally as a form of treatment. Looking at those therapies now, I can point to so many parts of them that are forms of informal thought and emotion exposures. Because bottom line if the client had something they were afraid of and they no longer are afraid, exposure happened to make that switch. And that’s why I am so passionate about systematically and formally using exposure in treatment, because it works.
The first important piece to know is that exposure has been established as a key mechanism for change. That means when researchers boil down all forms of therapy to come up with the common thread that actually gets people feeling better, one part always was exposure. So, no matter your orientation, background, theoretical lens of your therapy, if you are a therapist that wants to help their client reach their goals, either you are already using exposure (and maybe you call something else) or you should be!
So what is exposure therapy?
Exposure therapy helps individuals conquer anxiety by exposing them to their fears in a controlled environment. By facing fears directly, individuals learn that the fear was either unfounded or tolerable enough. Getting a client on board with exposure is by simply explaining to them the rationale behind it. It sounds something like this: Anxiety will generalize and grow and grow through avoidance. If we want the anxiety to go away for good, we need to stop avoiding it, i.e EXPOSE.*
Sounds simple enough?
Keep on reading:)
What makes exposure complicated is not actually doing exposure but successfully doing the second part of exposure treatment called response prevention. They have to come together and that’s why exposure is usually referred to by both names: Ex/Rp. Response prevention is an essential aspect of exposure therapy that involves consciously refraining from all safety behaviors and distractions.
Safety behaviors are anything and everything your client does to manage anxiety and maintain a sense of control. These coping strategies provide temporary relief but ultimately hinder progress in exposure therapy. These safety behaviors prevent individuals from fully engaging in the process and reinforce the belief that fear is intolerable. Safety behaviors can manifest in so many forms. Common ones that I see include what I am calling reassurance thoughts, non-acceptance thoughts, emotional substitution, and actions that alleviate anxiety.
Reassurance thoughts, such as "I am safe, it’s ok" or "It won't be so bad," are examples of safety behaviors that provide temporary comfort. While these thoughts may alleviate anxiety momentarily, they undermine the core principle of exposure therapy: facing fears directly. By seeking reassurance, individuals inadvertently perpetuate the belief that anxiety is intolerable and should be avoided. Instead, what you want to think is, I can do this no matter what happens. I might not be ok. This line of thinking creates more contact with the fear and will allow the exposure to make magic happen! (enable the new learning to occur, in other words:))
Similarly, non-acceptance thoughts involve denying or rejecting the reality of anxiety-inducing situations. “This isn’t happening,” “It’s not that bad.” By denying and downplaying the severity of the fear, individuals create a false sense of security. However, this avoidance mentality prevents them from fully engaging in exposure therapy which will hinder their progress in overcoming anxiety.
Emotional substitution occurs when individuals replace their anxiety with another emotion, such as anger or frustration. While anger may temporarily mask the fear, it does not address the underlying anxiety. This emotional substitution not only detracts from the true nature of the fear but also prevents individuals from fully experiencing and understanding their anxiety triggers.
One of the most common and known safety behaviors are engaging in actions that alleviate anxiety, such as chewing gum, washing hands excessively, or the like. These actions provide a temporary sense of relief, reinforcing the notion that anxiety can be avoided or controlled. The formula created usually works like this “I am safe only and if '' instead of full on approaching and exposing and sitting with I might not be safe right now and I am not going to do anything to protect myself. By relying on such behaviors, individuals miss out on the opportunity to confront their fears directly and challenge the core beliefs that underpin their anxiety.
So let's get started!
Doing exposure:
The first step is pinpointing what the core fear actually is by understanding the worst case scenario and its outcome.
Second, try finding all relevant safety behaviors and avoidance behaviors that the client is currently doing. Draw up a list. (Optional but rewarding: write down subjective units for distress [SUDS] for each fear inducing behavior)
Explain rationale again and again and again and again, until the client can say it better than you.
Do the exposure without engaging in any safety exposures. If the exposure is in session, ensure you are not providing any reassurance or distractions and stay focused on exposure until it's completed. (Optional: During and post exposure ask clients for their SUDS)
Process the new learning. Ask, “what was the feared outcome?” “Did it happen?” “Did you manage and survive it?”
Watch your clients SUDS go from 100 to 0 and love the mastery your client feels!!!
So to sum this up and be pretty blunt. Anxiety is a full treatable thing. Anxiety cannot be fully treated without exposure. Most likely if you are a therapist and have successfully treated anxiety, you have done some form of it. Call it what it is and focus on it, explain it to the client so they understand it just like you, and stick to simply doing what works.
If you are someone struggling with anxiety, please know that your anxiety, in any form and severity, is not a lifelong chronic thing. Get the right kind of help!
By fully facing your fears, and allowing yourself to experience the anxiety in its entirety, the fear will lose its power and control. As counterintuitive as it may seem, embracing the full intensity of the fear, including the thoughts of potential catastrophe and overwhelming distress, is a necessary step towards liberation.
*Want to understand more how anxiety generalizes? Read the anxiety loop here.
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