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 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.
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.
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
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.
Do I want this, or do I not? Is this my actual desire, or what I don't want? Does this thought or desire define me? What if it's terrible or horrible?
Sometimes the things I think about are because I value them or desire them.
Sometimes the things I think about are because I don't value them or desire them.
What the heck?
Egosyntonic and Egodystonic are two psychological terms to describe phenomena of thoughts/urges that are synonymous and antonymous to what a person desires or wants. Sometimes our thoughts reflect very much what we desire or want, but around 90% of people endorse having "intrusive thoughts," or unwanted thoughts.
It is crucial to do a good functional analysis on a thought/behavior to determine whether someone is doing something in order to pursue- or to avoid- the very same thing.
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.
“I am an old man and have known a great many troubles, but most of them never happened.”
“Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.” – Helen Keller
I don’t want to live my life being overly cautious, but rather appropriately cautious.
We are discovering in the research of anxiety disorders, OCD, and now depressive disorders, that possessing an Intolerance of Uncertainty (IU) is a common construct linked with higher anxiety and life disruption.
What is IU?
My favorite definition: “Belief that uncertainty, newness, and change are intolerable because they are potentially dangerous” (Steketee et. al 2005, p. 125). IU links threat with uncertainty.
But is uncertainty a threat? Take a moment and ponder one of your favorite memories. What did it involve? Was there any risk? Any vulnerability? Any chance of failure? Most of the best life stories I hear are of those that involve, well, all of these things.
A person who cannot tolerate not knowing actually misses out. How? Isn’t knowledge power?
What happens is this: the more control a person must have, the less control a person has. The more certainty that is sought, the more narrowly circumscribed life becomes. Quick examples:
Want to know how you handle uncertainty? Take the free IUS-12 assessment here. [Go to "Read More" below to find out how to score the assessment.]
Let’s be clear: everyone is uncomfortable with some uncertainty. And reasonable protection from risks is part of being wise- which can also be subjective. But the more you necessitate that certainty must exist, the following is more likely to happen:
In the research on IU, there are also two subset strategies identified: Prospective anxiety (desire for predictability) and Inhibitory anxiety (uncertainty paralysis) (Fourtounas et. al 2016).
If you struggle with any of these, the next questions is this: How do I live with uncertainty and anxiety, while also taking suitable precautions?
The solution is fairly straightforward, but not easy.
Once a problem area has been identified (along with what is reasonable, normative, or within your values), gradually and consistently gain ground by pressing into your fear without using a false reassurance strategy that reinforces the false threat of uncertainty.
In therapy, one of the most powerful tools that exists to deal with uncertainty is what we call Exposure and Response Prevention (ERP). This is the single most effective tool in treating OCD, and it is very valuable in other disorders. The reasons it usually has to be done in therapy are several:
I personally love Exposure because it helps me face life with a “bring-it-on” attitude rather than a “stumble-through-best-I-can.” ERP in therapy is very specific, very structured, and very powerful. However, even the person who is not in therapy can benefit from its principles:
“Some men storm imaginary Alps all their lives, and die in the foothills cursing difficulties which do not exist.” ~Edgar Watson Howe
So what uncertainty are you not letting yourself live with? When is ‘not knowing’ unacceptable to you? Uncertainty is not the problem. It is unrealistic to be 100% certain about most everything in life. Life has few certificates of guarantee, and those are only as good as what is backing them. Ready to face your uncertainty?
A Psychotherapists' thoughts on healthy living.
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