Why Exposure Therapy Isn’t Enough

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Technique is overrated. Focus on your point of view.

In behavioral therapy, we have a term called habituation, a longstanding principle in the treatment of phobias and other irrational fears. Habituation means gradually learning to tolerate a relatively safe situation that has been scaring you. This technique has three key conditions: frequency, intensity, and duration.

Applying this principle means that you must face your feared situation frequently in the span of a few weeks. As you face your fear, you should generate at least moderate distress (on a distress scale of zero to 100, think 50 or above), and you should linger in that distressing environment for an extended period of time.

But wait a minute. I’ve had plenty of hardworking clients challenge me when I describe this approach. If they have panic disorder, they might say, “Dr. Wilson, I go to the grocery store at least three times a week, and I stay there for 45 minutes to an hour while I’m feeling anxious, but I’m still no better!” These clients are meeting the basic criteria for habituation: They’re exposing themselves to the fearful situation frequently enough; they feel sufficiently distressed, and they are “hanging out” with their distress for an extended period of time.

And yet it’s not helping them. Why not? Because as they stand there in the cereal aisle tolerating the threatening situation, their self-talk sounds something like this:

“Oh no, I hope I don’t have a panic attack. I wish I could get out of here right now, but I have all this shopping to do. I hate this feeling. How much longer? How much longer?!

As they remain in the threatening environment, their opinion of the present circumstance (“This is bad. I want to escape.”) is working against them. All this resistance is using up chunks of their working memory and crowding out thoughts of any positive coping skills.

And the same can happen to you. Your negative judgment is always going to override any techniques you might use to get stronger. That’s why this blog does not dwell on technique. Your resisting mind, just like mine, can push aside technique. Instead, we’re talking about altering our point of view. Technique is overrated. Acting on principle is the long-term solution.

. . .

Imagine you have social anxiety, and you are working on your fear of being criticized by others during your departmental meetings at work. You attend these meetings every week (frequency: check). Each of those meetings lasts a solid hour, and anxiety is taking its toll on you both before and after the meeting (duration: check). Needless to say, you get pretty darn distressed during that time (intensity: check). You’ve got the frequency, intensity, and duration of the habituation model, and yet, you aren’t getting stronger. What’s missing here?

If before each meeting you predict that things will go badly “just like they always do”… and if before you speak up you generate worried thoughts about what you’re going to say… and if you worry about how you expressed yourself as you leave the meeting… then you are standing in your own way of getting stronger. The messages of fear and worry generated by your prefrontal cortex won’t let you gain any ground. That’s why we must make some modifications in this habituation model.

I have a client (let’s call her Erica) with a fear of elevators. At one point, Erica was trying to get over it by riding up and down the 16 floors of her office building repeatedly. That’s a pretty good strategy, right? But what’s the chance that Erica will master that elevator phobia if this is her internal monologue:

“Well, I’ve been lucky so far. I wonder how many strands of that cable are still left. Could it snap at any moment? It hasn’t happened yet. That means I must be due for a tragic fall!”

While she was actively attempting to overcome her fear, Erica was generating interpretations that elevator riding was dangerous. That’s never going to work. When your negative interpretations run wild, completely unrestrained, they will always trump your courageous action, and you will stay stuck. I believe this is the primary reason why people in behavioral treatment for their anxiety disorders are not able to recover. You’ll continue riding that elevator up and down before you ultimately conclude, “It’s no use. I can’t get better. I guess I better take the stairs.”

With my anxiety patients, I lead with the cognitive: your thoughts and your attitude. Your prefrontal cortex is going to supersede any chance for habituation if it continues to reflect the point of view that says, “It is best to get back to where I feel safe and comfortable again.” To compete with this perspective, you need to take on an attitude that stems from habituation. Consider this logic:

“I need to frequently generate distress and sit with it for a while in order to get stronger. I want to get stronger. So I actually want frequency, intensity, and duration.”

Don’t just step into your threatening environment. Seek out frequent exposures to your threat. And if you then feel distressed and insecure, welcome those feelings. And if your doubt and discomfort seem to be lasting a long time, then want them to last.

The change we are looking for is a shift in your attitude toward your threat, your doubt, and your distress. That means you must courageously step toward what scares you. Don’t do it in order to habituate. Do it as a means to practice this shift in your point of view. To build your strength, you will need to move into territory that is now under anxiety’s control. You are going to feel clumsy, awkward, unsure, and afraid. Your job is to willingly choose to have those feelings when they show up. The truly unfamiliar territory you will be aggressing into is the psychological terrain in which you purposely scare yourself. I know all this sounds absurd, and perhaps it makes you feel uncomfortable. That’s good. Let’s want that discomfort—and let’s step toward it.

To learn more about this paradoxical approach, read about Learning to Love the Mat.

Adapted from “Stopping the Noise in Your Head: The New Way to Overcome Anxiety and Worry,” HCI Books, 2016.