Category: Anxiety Disorders

The 4 Types of Exposure Therapy

1/30/2019

In Vivo Exposure
Directly facing feared objects or situations, examples include:

Getting on a flight, touching a doorknob that feels “contaminated,” not going back to check a lock, or going to a social gathering.

Good exposure attempts to match the content and detail of a person's fear as close as possible. So, for example, if a person fears “going crazy” in a social setting, the best exercise will be working up to facing that, not just exposing to the thought or word. On the other hand, if the fear is that a person will have inappropriate impulses (to harm, sexually, etc.), sitting with the intrusive thought and being present will serve best.

Imaginal Exposure
Imaginal exposure involves accessing the content of fears and anxieties through cognitive means. For example, a fear that someone will fail, make the wrong decision, harm someone, die, or choose the wrong relationship are not accessed by activating these life occurrences. They are addressed imaginally.

There are many ways to practice Exposure imaginally, but the most common are writing scripts, stories, listening to recordings, watching videos, or using visualization.

To be clear, Imaginal exposure often is the most confusing and hardest to grasp of exposure practices, as it seems to be creating negative thoughts or “bringing” unrealistic and negative thoughts on- the seeming antithesis of most of psychology and cognitive therapy. But what is really done here is only facing what a person is already experiencing, thinking and feeling.

Interoceptive Exposure
Intentionally bringing up physical sensations that are feared, such as:

Heart racing, shortness of breath, sweaty palms.

Ways to do this when a person's health allows are breathing through a cocktail straw, breathing rapidly, or sitting up quickly.

Virtual Reality (VR) Exposure
With the advent of new technology, we have a recently emerging type of exposure. Some may class Virtual Reality into imaginal exposure, but it can be seen as a cross between in vivo (situational) and imaginal. This is especially helpful with treating disorders such as Flying Phobia, where the access to an actual plane and flight to practice can be cost-prohibitive and difficult.

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What Is Exposure Therapy & How Do You Do It?

1/30/2019

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What is Exposure Therapy?
Exposure therapy is a psychological treatment that is practiced in Behavioral and Cognitive Behavioral Therapy (CBT). It is indicated as a first line treatment for a number of disorders such as

Panic
PTSD
BDD
GAD
Even recent evidence for depression

It is considered the “gold standard,” or best treatment for

Phobias
OCD
Social Anxiety (some types)

A very natural tendency occurs when we experience fear- to avoid, neutralize, and suppress fearful thoughts and experiences. However, such responses tend to reinforce fear when not responding in-context to an an actual immediate threat.
Exposure therapy helps clients to systematically confront fearful stimuli along with changing fearful responses. This relearning increases confidence and decreases disruption in life. Over time, discomfort and fear typically decreases through active engagement rather than avoidance, suppression, neutralization, or ritualization.
The evidence base is very strong for its use and effectiveness, though it is currently only applied a minority of the time in clinical settings.

How Do You Do Exposure Therapy?
The principles of exposure may be simple, but the specifics- personalized to any one individual- involve many working parts.
Assessment

When diagnosed through functional assessment with a problem that exposure can help (think, OCD and phobias, not addictions and ADHD), treatment then begins the planning phase.
Don’t underestimate the necessary time to have a good plan!

Education

Education on the function of the problem and how treatment works

Planning

Tracking/Monitoring- catching the key ways the problem exists
Core Fears- recognizing what core fears are to be tested through exposure
SUDS scale use (and Urge / Willingness)
Hierarchy- developing a list
Targets- prioritization and commitments
Goals/Values

Exposure

Exercises- the formal practice of exposure
Review and incorporation of learning

Cognitive Therapy

As needed, identifying unrealistic/false beliefs and replacing these to varying degrees is usually helpful
However, without confronting fears “talk therapy” in a traditional sense may not be helpful

Adjunct supports

ACT (Acceptance and Commitment Therapy)
MI (Motivational Interviewing)
Mindfulness
DBT (Dialectical Behavior Therapy)
Family Therapy
Monitoring for detours, treating first priority concerns first

Relapse prevention and long-term recovery

Setting realistic expectations and planning for long term success

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Southwest Airlines and Fear of Flying

5/15/2018

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Photo by Owen CL on Unsplash

Did your anxiety increase over flying after news of the engine failure on Southwest Flight 1380? Even a little?

I have booked plane tickets twice since the incident in mid-April 2018, and when choosing seats, I hovered precariously as I decided whether to select my favored window seat, or if I go for the "safer" aisle. My wife mentioned slight concern over the window seat because of the tragedy that occurred.

Working closely with the CBT treatment of Anxiety Disorders and OCD, I knew the moment I read the news- first about engine failure and the sad death of a wife and mom, Jennifer Riordan, and more recently the loss of cabin pressure and a window crack on a separate flight- there would be increased fear and anxiety about flying. Why? Flying commercially is statistically more safe in the U.S. than it’s ever been. Even with these incidents. Even with 100 of these incidents.

The fear is natural, and even normative, to some extent. It makes sense that we’d instinctually be a bit curious about our well-being in a metal tube soaring at 500 mph with tons of jet fuel propelling it. Even the possibility of flight has been denied in most of human history.

But what about when fear starts to cause problems ? Affect choices? Leads to avoidance of life pursuits and goals? Or becomes one more in a cumulative list of anxieties and worries? One way to be 100% certain that you will increase your fear load is by giving the aforementioned flight(s) unrealistic credit. By associating personalized, catastrophic meaning to a situation that is one of the safest things you can do (safer than riding a bike), a distortion has taken place. Some disorders, such as Specific Phobias, PTSD or OCD, make it pathologically difficult (i.e., neurobiologically) to change how one feels and thinks, regurgitating fear quicker than your vertigo-experiencing seatmate with their airline-branded “barf” bag.

With Flight 1380 being the first fatality on a U.S. passenger airline since February 2009 (over 9 years), flying on a plane is a remarkably secure form of travel. Unconvinced? Check out Forbes’ mining of some reputable stats.

Here’s the thing; education and stats are helpful, but only go so far. Fear is more than a reasoning thing- or in neuro terms, more than a prefrontal cortex (PFC) thing. Fear is an emotional thing. An amygdala thing. A learned response and genetic thing, along with a pervasive attitude and decision thing. It’s something that can destroy, harm, and erode, or it’s something that can be used in its rightful context, and set aside when not useful (e.g., PTSD treatment where a person can balance both safe and smart decisions, while facing disordered fear, so they can live life more fully).

So if you’re like most people who need a bit more than statistical education to counter anxiety and become stress resilient, remember this:

What you think and believe (cognitively) is vitally important.
What you do (behaviorally) is vitally important.

Your health and well-being are intricately tied to these. Small decisions today can lead to a long-term impact. For many of us, the greatest threat we face today is fear. So I chose the window seat.

~Justin

“I am an old man and have known a great many troubles, but most of them never happened.”
~Attributed to Mark Twain

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The 4 Types of Exposure Therapy

What Is Exposure Therapy & How Do You Do It?

Southwest Airlines and Fear of Flying

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