Exposure is a CBT technique used to treat anxiety disorders that requires us to face triggers that cause anxiety, but are not dangerous. It is a very effective albeit occasionally uncomfortable treatment. Its effectiveness is attributed to habituation and learning.
We can understand habituation by thinking of the times when a slightly paralyzing dip into a cold lake is followed by a refreshing swim as our body habituates to the temperature. Similarly, after a few weeks, a young couple that lives close to the airport, can sleep soundly through the noise. Yet, the very same couple would wake up immediately upon hearing a whimper from their 3-month-old, even if baby related interruptions occur with greater frequency or at a lower volume than the raucous generated by the overhead flights. That is because we can only habituate to stimuli that are not relevant to survival. The initial toe dipping confirms that our body can tolerate the temperature and no piranhas are lurking under the otherwise calm waters. Having spent a few sleepless nights in a new flat next to a major transport hub shows that the living space is safe. All the associated noises can be ignored, exhaustion takes over and we drift into blissful slumber. All the exhaustion notwithstanding, trying to ignore a newborn will only reassert the importance of the trigger.
So, how does it translate into therapy? Let’s look at some simplified examples.
Jim survived a serious car crash. He startles with little noise and started avoiding his friends. He is plagued with memories of being inside a spinning vehicle. He hates these memories, remains agitated and on guard. He is currently on sick leave and considers quitting the job that he loves as the accident occurred near his workplace.
Sushima is a proud new mum. She loves her baby. One day, Sushima watched a documentary that featured teenage runaways. Sushima imagined that her daughter might become a runaway as well. Since that time, Sushima has been paralyzed with visions of not being able to protect her daughter from a life of homelessness and abuse.
Radek tends to blush when nervous. He hates it. He wants to ask his schoolmate out on a date but does not dare to do so as Radek is convinced that nobody will want to date someone like him.
The experiences of Jim, Sushima and Radek seem different, but their triggers share something in common. Most of their anxiety relates to mental events, that is, things that happen inside of our minds.
Jim believes that he would be fine if only he could protect himself from having his memories retriggered. As a result, he remains especially vigilant about his mental state and becomes very guarded whenever he sees vehicles in motion. Jim says that he is willing to do anything to get rid of his traumatic memories.
Sushima is preoccupied with a possibility that her toddler will become a homeless teen. She is spending an extraordinary amount of time devising strategies that aim at protecting her child from such abject fate and consequently her attention wanes. During one of her more recent mind drifts, Sushima became inattentive and spilled coffee all over herself. She took it as a confirmation that her daughter will become homeless because she, Sushima, might develop multiple sclerosis or Parkinson’s, which in tourn will lead to the destruction of her otherwise stable family. Sushima’s anxiety is triggered by intrusive worries that show up in her mind as little videos of possible future events.
Radek still has not asked anyone out. He has been spending time devising strategies to camouflage blushing with makeup and by avoiding well-lit spaces. He is preoccupied with the idea that others now see him as “this weird token gay that you just have to put up with”. His triggers consist mainly of assumptions of judgement and rejection.
Although exposure might not be the only component of therapy with Jim, Sushima and Radek, it is a necessary one. Therapy is about trying to make sense of things in a supportive environment. We can do exposure in a supportive manner. I am assuming that all three of them would like to sort their lives out. But what happens when anxiety comes whenever you want to discuss what is important? Can you imagine reading a book when your commuter train is about to plumet off the bridge? That would be a rather bizarre reaction. In fact, a feat of incredible cognitive stamina. Emotions do interfere whenever we try to face what is important and I do find myself on the receiving end of accusations of not understanding my client’s experiences. The implied message is that these emotional experiences are too frightening and as a caring therapist I should not cause such experiences in my clients. How then can we tackle what hurts?
Many therapists use grounding techniques to manage the distress that our clients might feel during the appointments. I don’t shy away from these techniques, but believe that these techniques should be used with caution least we trap our clients in a game of emotional whack-a-mole. Feeling distressed? Quick, use your strategy or things will become incontrollable! [1]
This can be prevented if grounding is introduced as an experiment to show that emotions can be attenuated even when triggered. A couple of appointments later, this can be followed by another experiment: What will happen if we just continue talking without using any soothing techniques? Chances are that the anxious state will dissipate by itself. Then our clients can learn that, however painful, talking about what is underneath our pain is more productive than building a reliance on emotional Band-Aids.
Now, back to Jim, Sushima and Radek. There are many triggers that we could have them face as part of exposure exercises. Going back to the place of the accident for Jim. Going for a walk and leaving her daughter in the care of someone else for Suhima. Practice joining conversations for Radek. There is definitively room for each of these interventions, but I prefer to start with exposure to mental events for a number of reasons. First, all three are already experiencing mental events spontaneously and I am not introducing any new triggers. Second, exposure to mental events has already taken place in our initial appointment as clients are being asked to describe their problems. Third, exposure to mental events can be done in the therapist’s office – there is no need to search for anxiety inducing situations. That allows the therapist to ask many clarifying questions, assist with grounding when indicated, while at the same showing our clients the most important lesson that there is: Getting stuck inside of our minds prevents us from living in reality.
Jim would be asked to describe the accident, provide a detailed account of what he felt and saw when his car started to spin out of control. His reactions would be carefully monitored and, when indicated, Jim would be asked to look around, bring himself to the current moment and to contrast the experiences from within his mind with the experiences in the office. Spinning car vs. comfy chair and a cup of coffee. Overtime, Jim’s body would produce much less agitation in response to the memories as he would learn that there is nothing that he has to do to protect himself now. Remember the couple living next to a transport hub? Jim would learn that memories are the noise overhead and not a cry of a fragile infant. Memories might remain painful but there is no urgency, no need for an escape, no physiological agitation.
With Sushima, we would recognize her tendency to worry as a way that her mind devised to ensure that her daughter is protected and as a reflection of her desire to be a good caring mother. Then we can start imagining things, from winning a million dollars to being mugged on the street. This would help Sushima realize that having an intrusive thought does not imply that the thought would come into being. Our worries represent our fears, not the external reality. In the next appointment, Sushima would be asked to imagine her daughter being injured while Sushima is attending the session. This would require collaboration from Sushima’s spouse who would be available on the phone in case we needed some reassurance. The exercise is done to help clients realize that a worry is a mental event with no connection to reality. Just because I have imagined something, it does not mean that it will happen. Not worrying does not mean that we do not love our kids. Not worrying affords us the presence of mind that is necessary to help them when such help is required and to know the difference between anxious imagination and reality.
Radek would be asked to describe what he believes others think of him in excruciating details. We would measure his anxiety at few points during the exercise. Chances are that Radek’s anxiety would be much higher when he is telling his story or immediately afterwards than at other times during his appointment. This is an important demonstration, as we can use it to show Radek that his emotions changed in response to his story and in the absence of the people whose judgment he wants to avoid. There might be people who are prejudiced or wish us poorly. Still, isn’t life easier when we take people’s actions at face value? What is the benefit of being immobilized by our own predictions? Work with Radek might take us outside of the office. We might go to a mall and wear exaggerated makeup that makes both of us stand out in the crowd. We might encounter some judgmental glares, but that discomfort is temporary. Fear of judgment of far worse than the experience of being judged. Fear of judgement is self-perpetuating and makes us hide from the world.
Now, back to the toe in a cold lake analogy. You get used to the water and enjoy the swim. On the next day, the water still feels very cold compared to the sun saturated sand. You still notice the cold and it might take some time to get comfortable. Yet there is a crucial difference: You have learnt to trust the process.
[1] During the nineties it was popular to recommend using an elastic band to manage panic attacks. The idea was that the person who felt themselves on the break of an anxiety attack would snap the elastic and that this elastic snapping process would somehow redirect their attention and prevent panic from building up. Research has shown otherwise. Use of the elastic band made panic more difficult to treat as the affected persons became very vigilant about their symptoms trying to snap the band quick enough to stop the unwanted feelings.
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