Exposed: Facing Your Fears

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Contributed by Associate Megan Pearson:

How experiencing frightening situations in safe ways can help us learn to live more comfortably.

One of the most effective forms of treatment for many types of anxiety is exposure therapy, a range of behavioural techniques that involve experiencing the feared situation(s), as well as the emotions, thoughts, and physical sensations associated with them. The purposes of these techniques are to help clients break patterns of avoidance and escape, and to teach the brain and the body that the feared situation is not objectively dangerous. Over time, these experiences typically allow people to reduce their anxiety and the resulting urge to flee, and to cope more comfortably and effectively with events and situations that created significant anxiety and distress in the past. Exposure techniques are often used in the treatment of specific phobias, and are often useful in reducing symptoms of anxiety associated with PTSD, compulsions associated with OCD, generalized anxiety, and other issues.

Many different therapeutic approaches incorporate exposure treatment, which is based on principles of classical (Pavlovian) behaviourism. Use of exposure as a therapeutic tool began during the 1950’s in South Africa, where it was introduced by psychiatrist Joseph Wolpe and behavioural psychologist James G. Taylor. Specifically, the central principle underlying exposure therapy techniques is called extinction. Using Pavlov’s conditioning of dogs as a simple example, he paired ringing a bell with providing food regularly and eventually the dogs would salivate as soon as they heard the bell, even when no food was present. If he repeatedly rang the bell and the dogs received no food, eventually the association between the sound of the bell and eating would disappear, and the dogs would no longer react to the bell. The disappearance of the association and the conditioned response is called extinction of the response. Experiencing a feared situation without the anticipated negative consequences, and over time with decreasing levels of distress and anxiety, can also lead to a weakening of anxious associations in the brain and body, and gradual reduction in anxious responses.

For example, in Cognitive-Behavioural Therapy (CBT), a client works cooperatively with a knowledgeable and experienced therapist to construct a fear hierarchy, a list of specific examples of circumstances associated with the anxiety-provoking experiences or situations. The list is then ordered from least to most distressing, and together the client and therapist decide on ways for the client to work gradually through the list, starting with the least fear-inducing circumstance. Throughout the process, the client typically gives a rating of their level of fear and anxiety, often using a scale called Subjective Units of Distress (SUDS ratings).

This type of gradual exposure treatment is commonly used in many forms of psychotherapy, and is also called systematic desensitization. A key factor in this kind of exposure treatment is that the client experiences anxiety-provoking situations in a context that is safe and controlled. It can involve one or more of three commonly used types of exposure techniques:

1. Imaginal – this kind of exposure involves thinking about and creating mental images of a feared event or situation. For example, for a person who has a phobia related to spiders, exposure treatment might begin with thinking about being close to a spider; imagining how it would feel to have a spider walk across one’s skin; picturing the act of removing a spider that has been found in one’s home.

2. In vivo (“real life”) – this kind of exposure involves firsthand experience of a feared event or situation, such as viewing photographs, watching videos, or later in treatment, engaging directly with the event or situation. If a person has a phobia of spiders, the progression might be: looking at pictures of spiders; watching videos of spiders; being in a room where there is a spider in a closed container; moving gradually closer to the container; touching the spider; and eventually, when the anxiety about spiders has reached a more manageable level, holding the spider in one’s hands. Recently, there has been some success in the use of virtual reality technology to simulate in vivo exposure experiences when they cannot be safely or practically created in a therapeutic or real-life setting, primarily for the treatment on combat PTSD. This type of treatment is not widely available anywhere at this time, but does appear to show promise according to preliminary research.

3. Interoceptive – this kind of exposure involves safely experiencing various physical sensations associated with a source of anxiety. For example, people who suffer from panic attacks can be very sensitive to physical signals that a panic attack might occur, such as shakiness, lightheadedness, or shortness of breath.

Flooding is an exposure technique most often used to treat specific phobias. It is distinct from other forms of exposure therapy because it involves starting at the “top” of a fear hierarchy – that is, experiencing the most intensely anxiety-provoking events or situations without building up to them gradually, while actively working to replace fear responses with relaxation. Flooding can be very effective, but its use can also be controversial, because it can be very intense and difficult for the client, and sometimes fears treated in this manner return. It is most often utilized when a person’s fear is having profound consequences on their everyday life and ability to function, and is generally thought to be used most appropriately in conjunction with systematic desensitization.

Exposure and Response Prevention (ERP) is another type of exposure technique that was developed for the treatment of symptoms of OCD. It involves making and maintaining a decision not to engage in compulsive compensatory behaviours that help to reduce the anxiety created by/associated with obsessive, troubling thoughts, not only in the context of therapy sessions but in everyday life. For example, someone who has persistent, intrusive thoughts about illness or contamination might compensate (that is, act to reduce the resulting anxiety) by washing their hands multiple times. ERP for this issue would involve engaging in actions that feel “risky”, such as using a public restroom, without washing one’s hands more than once, or perhaps at all.

Exposure treatment can have a profound positive impact on experiences of anxiety. It is important to note that in order for exposure techniques to be used safely and effectively, exposure situations must be planned, predictable, and manageable, which includes allowing the person engaging in the exposure to stop at any time. Therefore, it is strongly recommended that engaging in exposure to anxiety-provoking situations and contexts be discussed with a competent psychotherapist.


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