Guidelines for Doing Exposure Therapy
Happy New Year and all the best in 2020. It is my intention to post to this blog once a week (most likely on Friday - like today). The more feedback I get, the more likely I will keep this going so if you find what I write useful please let me know! And if there are topics you’d especially like me to address in this blog, let me know that as well.
Exposure therapy (which is basically facing what you fear) is at the heart of what works for treating anxiety of all kinds and so it is important to know how to do exposures to get the most out of the work you do. Here are some guidelines for how to maximize the benefits you can get from exposures:
1. Accept that you must do exposures regularly. I believe you must approach exposures the same way you do exercise. To get and stay in shape you can’t just exercise once in a while, you need to exercise regularly. Same with exposures if you want to live the type of life you want.
2. Early in treatment, and especially if your anxiety/OCD has been around for a while and/or significantly interferes with your daily functioning, I recommend doing exposures daily (or even more often if possible).
3. Focus your exposures on the things/behaviors/places that you most frequently avoid or that scare you the most. Unless the exposure feels challenging/scary/difficult it probably is a waste of time.
4. Turn on your “willingness switch” before you attempt the exposure. You must be willing (eager?) to feel uncomfortable to get the most out of the exposure.
5. We used to think it was important to stay with an exposure until your anxiety came down, but recent evidence suggests that is less important than we thought. Just keep doing the exposures whether or not your anxiety comes down.
6. The goal isn’t necessarily to reduce your anxiety and it usually backfires if you focus on anxiety reduction as your primary goal and your anxiety may actually increase. The focus should be on living your life the way you want even if you are anxious. It is likely that your anxiety will reduce, but don’t focus on that as the goal.
7. We also used to think it was best to create a hierarchy of things that scare you and rank them from easiest to hardest. Then start somewhere close to the bottom and work your way up from easier exposures to the harder ones. We now believe this isn’t the best approach. Assuming you have 10 items in your hierarchy, we now think you will get the best long term outcome if you bounce around a bit. Start with item 4, then to item 7, back to 2 and so on. If you think about it this makes sense as life doesn’t present challenges in a neat hierarchy but gives us those in a random order.
8. Another more recent evolution in our thinking about the best way to do exposures is focus on what is called expectancy violation. Before doing an exposure predict what you think the outcome will be, do the exposure and then see if your prediction was correct. The greater the difference between your prediction and the actual outcome of the exposure, the greater the benefit of the exposure. The more surprised you are the more you benefit.
9. It’s important to do exposures under different conditions. If you’re afraid to drive and you only practice (do exposure) driving when there isn’t much traffic, sunny weather, daytime and on side roads your exposure won’t help much if your goal is to drive freeways at night when it is raining. Similarly, if you are afraid to touch doorknobs (for fear of them being contaminated and that you might catch some sort of disease) and only touch certain doorknobs - the ones you are sure are “safe” - then you will make little progress. You need to touch all sorts of doorknobs: the door to my office, the doors into restaurants, the doors at department/grocery stores, the doors into bars and even bathroom doors. The more you vary the exposures the better the long term outcome.
10. A mistake many of my clients make is not taking big enough steps with their exposure work. They are so afraid that they take tiny steps, make very slow improvement (or none at all), get discouraged and stop treatment. Taking too big of a step can also be a problem but my experience has been that this is much less frequently a problem than taking too small of a step.
11. Many of my clients want to wait until they can manage/control their anxiety before they face what they are afraid of and I believe this is backwards. You must accept the anxiety, do the exposures and then will you start to experience results. If you wait until you can already manage your anxiety, you will likely have a very long wait.
12. Finally, and this is a particularly important tip, you must do the exposure even though you aren’t totally certain what the outcome will be. You must “take the chance”. This is the essence of exposure. If you are certain of the outcome then it isn’t really an exposure in the first place. Accept the uncertainty and keep going.
I hope you find these tips helpful. And let me know what you think or if you have any further tips that I can pass along.
And once again Happy New Year!!
Best,
Dr Bob