What follows is a guest post by a frequent contributor to the comments and Discussion Forum of this blog, Dr. Nate Eliason. Nate, who has an M.D. in Pathology, has written on the Discussion Forum about his own success in applying hormesis to vision improvement. As someone who sees the medical system “from the inside”, Nate has observed that medical interventions such as antidepressants often deliver short-term benefits while paradoxically causing long-term impairments. This is the mirror image of hormesis, which promotes long-term health by deliberate application of short-term “stress”.
In this post, Nate focuses on an interesting case where “controlled stress” is particularly useful: the treatment of phobias by exposure therapy.
Exposure therapy has interested me since my days in medical school. It is a very effective, but often underused therapy for phobias, Obsessive-Compulsive Disorder (OCD), and anxiety. In writing this post, I have relied on David Tolin’s excellent book, “Face Your Fears“. I highly recommend it.
When fear becomes a problem. Fear is a natural emotion, necessary for our survival. A good analogy for how fear works is a car alarm system. A well-functioning car alarm system protects our car by alerting us when someone is attempting to break in. A car alarm which constantly goes off, however, is more harmful than helpful. In the same way, some people have a “broken” fear system, in which fear becomes hyperactive, turning into anxiety. Common anxiety disorders include panic disorder, agoraphobia, phobias, social phobia, OCD, generalized anxiety, post-traumatic stress disorder, and separation anxiety disorder. All of these are categorized as specific disorders, they have many features in common, and all respond to exposure therapy. While exposure therapy is primarily used for dealing with pathologic fears, it can also help us deal with routine fears which aren’t severe enough to be pathologic. For instance, most people have some fear of public speaking–but not to the degree that it is pathologic. The same principles apply in overcoming non-pathologic fears. Towards the end of this post, I’ll give some examples on how I’ve used exposure therapy to deal with my own fears.
Fear is necessarily unpleasant because its “purpose” is to help us stay safe by avoiding dangerous situations. However, when it becomes overactive, our entire life can be unpleasant. Exposure therapy deliberately ‘exposes’ us to fear in order to help us learn how to bring it under control and experience it in a normal way. I need to emphasize that one of the primary objectives in exposure therapy is to feel the fear. That’s right–our goal is to feel fear, and then to learn to deal with that fear.
How exposure therapy works. The basic concept of exposure therapy is quite simple: you overcome fears and phobias by directly exposing yourself to them. But that doesn’t mean it is easy to carry out in practice. An experienced therapist can be a big help.
Let me give an example of exposure therapy to treat a fear of snakes. If you fear snakes, you should first make a list of possible exposure experiences, and then rank these from hardest to easiest, with 100 being intolerably high fear, and 0 representing no fear at all:
|Letting a python crawl on me||
|Approaching an open snake cage||
|Approaching a closed snake cage||
|Watching movies about snakes||
|Looking at pictures of snakes||
|Saying the word “snake”||
After making this list, conduct the exposure sessions. Start with an item relatively low on the list, and continue the exposure session until the fear level drops at least in half. In this example, approaching a snake cage might be too difficult, so you could start by looking at pictures of snakes. Continue looking at these pictures until the fear level drops from 40 to 20. Then proceed to the next higher item on the list. Watch movies about snakes–maybe Nature specials–until the fear level drops in half. Continue to move upward in the list of exposure experiences, until the fear is completely mastered.
While a therapist can be helpful, the exposure is what counts. In his book, Tolin documents that many people do quite well with a self-help book. He normally gives a copy of his book to clients, and most do well with just the book. Those who don’t, he sees in consultation.
Exposure therapy can be time-consuming and unpleasant, so why do it? Is it really effective? Phobias and OCD can be very debilitating. But once the fear is overcome, quality of life greatly improves. In controlled trials, the initial effect of exposure therapy is approximately equal to that of medication. However, over time, the effect of medication wanes, while the effect of exposure therapy actually becomes stronger. In addition, many of the medications often used to treat anxiety are addicting, and have harmful side effects. Of these medications, the benzodiazepines (Xanax, Valium) are particularly addicting and harmful–over time they often increase the anxiety.
There are four main theories on how exposure therapy is thought to work:
- Habituation. Just as you acclimate to cold water after the initial shock, when you face something fearful, you get used to it, and you stop responding to it in the same way.
- Extinction. According to classical Pavlovian conditioning theory, fears dissipate or extinguish when they are not reinforced. For instance, if you have fear of dogs, perhaps at some point in your life you had a scary experience with a dog barking or biting. From that point forward, you associate the sight of dogs with those fearful experiences. Yet, by exposing yourself over time to dogs without new adverse consequences, you retrain your brain to understand that “dog does not equal bite”, extinguishing the original association.
- Emotional processing theory. Particularly in the case of social phobias, the brain attaches exaggerated emotional meanings to ordinary events. You might fear that stuttering would result in catastrophic embarrassment. A key part of exposure therapy is learning that while you might stutter, the consequences are not catastrophic.
- Self efficacy theory. This theory was pioneered by Bandura and applied to treatment of phobias by Williams. People who live with fear and avoidance often live in a world of “I can’ts”. They consciously or subconsciously tell themselves “I can’t do this”, “I can’t donate blood”, “I can’t speak publicly”, “I can’t ask that cute girl out”, etc. When you face a fear without retreating, you begin to feel stronger. The “I cant’s” in your brain begin to be replaced by “I can”.
While each of theories has some validity and helps explain the success of exposure therapy, I think that the self-efficacy theory is the most powerful of the four. There is nothing as empowering as the feeling of self-confidence that comes from doing hard things successfully. Taking a medication for anxiety will not give you a feeling of self efficacy.
Success factors. A number of important key principles underlie successful exposure therapy:
- Exposures should be voluntary. If your friend has a phobia about snakes, throwing him into a snake pit against his will is not likely to cure his phobia–in fact it will probably be so traumatizing that the phobia will get worse. In order to be curative, the exposures should be voluntary. Todd has a nice post, “Voluntary stress”, which expands further on this point.
- Gradualism generally works best, but not always. Some exposure therapists advocate graded exposure while others suggest “flooding”, or facing the full-blown fear head-on. While most people prefer graded exposure, flooding has the advantage of working more quickly and effectively. I have an example from my life in which flooding was the best option, which I’ll discuss below.
- Expose yourself to the real object of fear. If your fear is public speaking, you should give lots of talks. The most effective exposure is the actual fear. For instance if your fear is dogs, you should pet actual dogs. That is called “in vivo” exposure. However, sometimes you can’t easily expose yourself to certain real life fears. For instance if your fear is flying, it may be too expensive to take multiple flights. In that case you can use “imaginal exposure”, where you imagine in great detail taking a flight. You might make an audio tape describing taking a flight and listen to it. You might watch movies about plane flights.
- Allow yourself to experience the fear. How long should an exposure session last? Exposure is meant to be a learning process. If you face a fear, and retreat quickly, what have you learned? That retreating makes you feel better. But a premature retreat can make the fear worse, by reinforcing it. Psychologists call this process sensitization. A good rule of thumb is to continue the exposure until your level of fear diminishes by one half. It’s even better if you can hold on until the fear vanishes entirely. That way, you are learning that fear will eventually decrease, even if you don’t withdraw. For instance if your fear is snakes, you might decide to do an exposure by looking at pictures of snakes, and continue doing it until the fear goes away on its own.
- Vary your exposures. If you have fear of social interactions, try to interact with people in as many different ways that you can think of. Talk to strangers on the bus, to your professor, people at church, your mother-in-law, the cashier at the store, etc.
- Repeat the exposure many times. If you have a fear of public speaking, giving one short talk will not be enough. You need to give several, possibly many talks. Every time you repeat the exposure you reinforce the “I can” circuits in your brain.
Finally, have a plan. If you can write out a plan of exposures, listing when and where you will do them, you will be more successful.
Safety Behaviors. In overcoming anxiety and phobias, avoidance is the enemy. When you do exposure exercises, you need to counteract the natural tendency to avoid fearful situations by resorting to what we call “safety behaviors”. For instance, if your fear is dogs, and you can’t avoid them completely, your might be inclined to carry pepper spray when you walk past the dogs, because it makes you feel safer, and enables you to walk past the dogs. But this safety behavior is counterproductive because it interferes with fully experiencing your fear.
People with OCD are very familiar with safety behaviors. For instance, someone with OCD and anxiety about hygiene might have the compulsion to wash his hands frequently. The hand washing temporarily relieves the anxiety–but as with all forms of avoidance, over the long run it reinforces the anxiety and behavior. Another example of OCD safety behavior is ritualistic religious behavior. For instance, repetitive thoughts of sinful behavior may intrude into the person’s mind. Temporary relief is obtained by saying a ritualistic prayer or repentance–but the compulsion, a safety behavior, reinforces the anxiety. For someone with social anxiety. a safety behavior may be going to a party with a friend, or socializing exclusively with people who they know. But accompaniment by the friend prevents the person with social anxiety from interacting with strangers.
All of us have some anxiety, and some safety behaviors. That’s fine as long as the anxiety and safety behaviors don’t intrude on our lives. But, as Tolin observes, a safety behavior can become a “crutch” that tends to undermine the effectiveness of exposure therapy. When you use this crutch repetitively, you reinforce the anxiety and build weakness. In this respect, exposure therapy goes against the idea of resorting to relaxation techniques or distraction to reduce anxiety. Because exposure therapy works by confronting fears, these techniques are counterproductive in the quest to overcome the anxiety.
A better alternative is acceptance of fear. Tolin gives the analogy of Chinese handcuffs: the more you struggle against them, the tighter they hold you. When you directly face or push into the fear, it very often diminishes.
The main point here is: Don’t relax. Don’t distract. Don’t try to feel better. Don’t use crutches. Instead, push into the fear.
Make a list of your safety behaviors, and eliminate them. While Tolin recommends graded exposure, he recommends eliminating the safety behaviors completely from the beginning.
You need to feel the fear.
Specific applications. If you have a particular anxiety disorder, I’d highly recommend that you buy Tolin’s book, which goes into much greater detail than I can in this post. But to better illustrate how exposure therapy works, I’ll briefly discuss a few specific examples:
Obsessive compulsive disorder (OCD). This anxiety disorder has two parts. Obsessions are recurrent and persistent thoughts that feel intrusive and inappropriate, and they cause the person anxiety and distress. Compulsions are repetitive behaviors the person feels they must perform in response to the obsessive thoughts, often according to specific rules. For instance, a person might have anxiety about hygiene (the obsession), coupled with excessive hand washing (the compulsion). A religious person might have intrusive thoughts of a blasphemous or sexual, sinful nature-feelings of unworthiness (the obsession), coupled with a ritualistic prayer, or the need to think “good thoughts” in order to neutralize the bad ones.
Note that the compulsions are a form of “safety behavior”. While they cause a temporary relief from the anxiety of the obsession, over the long term, they perpetuate it. Everyone has some intrusive and inappropriate, unwanted thoughts. There is evidence that people with OCD overreact to these thoughts, and think their thoughts have more meaning more than they actually do. Those with OCD,feel compelled to control their thoughts.
Here I’ll give an example of how exposure therapy works for OCD with cleanliness as the obsession: In the case of OCD, it is often helpful for the exposure therapy to go “beyond normal”. Tolin recommends that a person with a washing compulsion stop washing altogether for three entire days. Another suggestion is to touch as many doorknobs as possible–with no washing. Both of these behaviors are objectively safe; people who don’t wash at all during a weeklong campout typically do not suffer any negative health consequences. Likewise, people touch doorknobs all the time without washing, to no ill effect.
The important point is to expose yourself to the obsession, without resorting to the safety behavior–the compulsion. With time, the obsession will extinguish.
Social anxiety. Most people, while not having a pathologic anxiety disorder, probably have some degree of social anxiety. While I don’t think I have a social anxiety disorder, I can recall a number of instances of mild social anxiety:
- Many times I’ve gone to a party and socialized only with people who I already knew.
- When I used to play the piano, I would often practice a piece to the point of perfection alone, only to have performance anxiety on performing before an audience-and completely mess up the piece.
- While I frequently give public talks, I often become anxious before or while speaking.
- Back in my younger, dating days, I recall becoming nervous about calling girls for dates. At times, I definitely engaged in some avoidance and “safety behavior”.
Some degree of social anxiety, coupled with avoidance and safety behavior, is so common that it is almost normal.
To overcome social anxiety, expose yourself to the uncomfortable, fearful situation. Don’t fight the fear, embrace it (remember the example of Chinese handcuffs). If possible, continue the exposure until the fear drops by half. With social anxiety in particular, you may find that once the fear begins to drop, you actually enjoy the social interaction. You may make new friends or find that you enjoy your piano performance.
I have applied exposure therapy to my own discomfort with public speaking. I’ve tried to seek out and embrace the opportunities I have for public speaking. I’ve also tried eliminating safety behaviors–for instance speaking without a written copy of my notes. I’ve also tried to have several different options for the “flow” of my talk, tried to get a feel for the audience, and taken my talk on different route depending on the feel.
Blood donation. This was actually the first phobia of mine that I can recall! As a child, while weeding a rosebush I cut my hand on a thorn–deeply. I ran into the house. As my mother was bandaging the cut. I looked at it. My hand seemed to be bleeding profusely. In my young mind, I thought I was bleeding to death–and I passed out. Later, while in college, a friend managed to sign me up for a blood donation. During class on the morning of the donation, the teacher just happened to talk about blood donations. As he talked, I began to feel light-headed. I remember thinking “I might pass out”, and fighting that feeling. Then I remember waking up on the floor of the classroom with my classmates gathered around–very embarrassing.
I first tried my own naïve form of exposure therapy for blood donations on several occasions–psyching myself up to donate blood, trying to relax and block the feelings of anxiety before donating blood. Once more I passed out. Another time I didn’t actually pass out, but came so close to passing out that they had to stop the donation. Finally, I simply practiced avoidance: “I just don’t donate blood because I can’t”.
A blood donation phobia is a very minor one. It is easy to live life without donating blood. However, it always kind of bothered me. After reading Tolin’s book, I decided to try to overcome it. It never bothered me to merely think about blood donation. It was the actual act donating blood that made me anxious.
As soon as the blood drive came to our community, I signed up. I eliminated all safety behaviors. In the waiting room I read blood donation literature. When anxiety came, I didn’t try to calm myself, but rather embraced the anxiety: “This is why I am here–to feel this”. I deliberately watched as they inserted the needle into my vein. I talked with other donors.
And what happened? It was kind of anticlimactic. The anxiety never came on very strong, and went away rapidly when it did. I just sat in the chair, gave blood, and walked out. Actually, no big deal.
While exposure therapy is a great way to deal with phobias and anxiety, it has applications for growth far beyond just overcoming negative experiences. It is a way to begin experiencing real growth and to create positive experiences. Exposure therapy is a good example of hormesis–the application of stress to overcome weakness.
If you directly confront your fears, you can overcome them, rather than being limited by them.