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Introduction to Exposure How Exposure Works Exposure therapy works through two mechanisms: habituation and disconfirming evidence. 1. Habituation is the well-studied phenomenon whereby the more often you encounter something that causes an emotional reaction, the less potent the emotional reaction will be. An example is playing peek-a-boo with an infant. The first few times you uncover your face, the child giggles with delight. But the more often you do it, the less excited the infant becomes until ultimately the infant becomes bored. The same phenomenon happens with fears. Q: Think of a time you were afraid to do something at first but got used to it eventually. 2. Disconfirming Evidence-When participating in exposures, you will unlearn the belief that the situation or stimulus that you fear is dangerous, and you will begin to accommodate new evidence that the situation or stimulus can be safe. • For example, several years ago a woman came to an Anxiety Disorder Clinic with a severe case of social phobia. She had a strong belief that if she appeared nervous, people would think she was defective and weak. Through repeated exposures in which she would engage in “small talk” conversations with strangers, she started to disconfirm her belief that people would judge her negatively and began learning that most people are quite friendly and nonjudgmental. Q: Can you think of times when you were afraid to do something but you did it and what you feared didn’t happen? Exposure is done gradually-most exposure therapy is conducted in a graduated fashion whereby smaller manageable fears, or easier variations of the fears, are confronted first, building slowly to the more difficult fears. • We typically aim to begin with exposures that would elicit moderate anxiety for you (SUDS ≈ 50), Different Types of Exposure • In Vivo (In Real life) - Involves exposing yourself to what you fear in real life. For example, if you fear spiders it would involve touching an actual spider. • Imaginal- Involves imagining exposing yourself to what you fear. For example, if you fear spiders it would involve imagining that you are touching a spider. Imaginal exposures are also used when you fear your thoughts. This involves thinking about what you fear over and over until it loses its emotional power over you. • Worry/ trauma script exposures A worry /trauma script simply involves writing out the details of a memory or worry as if it were a story or a movie script and repeatedly reading it over. Some clients narrate the story out loud, record it on a CD or MP3 player, and then listen to it repeatedly. It should be a detailed account from beginning to end of the memory as it happened or the worry as the client envisions it happening. • Interoceptive exposures-This involves exposing yourself to the sensations of anxiety in your body so that you can learn they are not to fear. • Analogue Exposures-Involves role-playing the feared situation in person or through virtual reality. Information adapted from: Norton, Peter, J. (2012). Group Cognitive-Behavioral Therapy of Anxiety: A Transdiagnostic Treatment Manual ©Qualia Counselling Services 2016 Helpful vs. Unhelpful Exposure Many people do informal “exposure” work either out of necessity or because they have received some incomplete information from a friend or paraprofessional. For example, if you are afraid of public speaking but must give a class presentation you may consider this “exposure” work. Unfortunately, these misguided exposure attempts may actually be harmful and may make your anxiety worse. Characteristic Unhelpful Exposure Therapeutic Exposure • Unhelpful exposures are not done very frequently so • Therapeutic Exposures are done very frequently and you do not gain the momentum needed to overcome specifically planned to occur within short time-intervals. the anxiety. • There is no avoidance of the situation in between exposure Frequency • Exposure to feared situations is often combined with trials so you do not send your body mixed messages. avoidance of those situations. • Consistently doing exposures builds the momentum needed • If you do not consistently do exposures, each time you to overcome your anxiety. Each time you do an exposure, do it is like starting over and losing your progress. your anxiety will decrease until it is eliminated. • Unhelpful Exposures do not last very long. • Therapeutic Exposures are deliberately prolonged until • Typically, a person enters into the feared situation anxiety decreases. Duration and then leaves as soon as possible. • The goal is not to leave the situation as soon as possible but to • This reinforces the idea that the situation is dangerous endure the situation until anxiety decreases. and should be avoided. • This provides the evidence needed for the person to see that no disaster would result. • Unhelpful exposures are often done out of necessity • Therapeutic exposures are planned and predictable. or involuntarily. • The person makes a decision to expose themselves to the Predictability & • The exposure is not planned but just happens. For feared situation with full knowledge of what this entails. Control example, a person who fears driving learns her ride to • The person has a subjective experience of control that work is sick and that she must therefore drive her reduces anxiety. parent’s car to work. Nature of • Unhelpful exposures are accompanied by distorted • Therapeutic exposures involve recognizing and countering Thoughts thinking and predictions of catastrophe. distorted thinking and making balanced predictions. • Unhelpful exposures often involve subtle avoidance • Therapeutic exposures involve identifying and eliminating all Avoidance strategies such as drinking, having a safe person or safety behaviors so that you can endure the feared situation Strategies doing something else that prevents enduring the and learn that your predicted catastrophes do not occur. actual feared situation. • These are not gradual but involve immediate • Involve constructing a “victory ladder” and gradually doing Intensity immersion in most feared situations. exposures to feared situations of lesser intensity. • No prior opportunities to build confidence in process. • Confidence in the process is gained. ©Qualia Counselling Services 2016 Safety Behaviors What is a Safety Behavior? Safety behaviors are behaviors that a person does in order to cope with situations that make them anxious. They are problematic because they prevent the person from seeing that feared predictions do not come true. 3 Types of Safety Behaviors 1. Direct Avoidance: This would involve simply avoiding situations or places. 2. Escape: This involves leaving a situation after starting to experience anxiety. 3. Subtle avoidance: This involves other behaviors that we think make us safe. For example, in panic this could involve having safety plans, carrying anxiety medication or bottles of water or leaning against a wall (to prevent fainting). The mere availability of a safety behaviors can be the problem rather than their use. If you have panic disorder and are carrying around anxiety medication but not using it, this is still problematic. You may attribute your safety to the fact that the medication is in your backpack rather than to the idea that you aren’t in any danger. Safety Behaviors Maintain Anxiety Safety behaviors are often fairly effective tools in managing anxiety in the short term. If an individual, who fears public speaking, avoids activities where she must give a presentation then this “safety behavior” will minimize her anxiety. Unfortunately, although safety behaviors can reduce distress and anxiety in the short term, research consistently shows that these behaviors help maintain anxiety disorders. As a result of the safety behaviors, the person is able to attribute the lack of feared consequences to the safety behavior, rather than as a challenge to his/her belief that the situation was threatening. Safety Behaviors vs. Healthy Coping Not all coping behaviors are unhealthy. Healthy Coping includes things that we do in order to reduce anxiety but which do not maintain or worsen future responses to the same anxious situation. Healthy vs. Unhealthy Coping Safety Behaviors Healthy Coping Short-term relief but long-term increase in anxiety. Short-term increase in anxiety but long-term reduction. Motivation is to avoid a catastrophe. Motivation is not to prevent some feared catastrophe. Prevent person from learning there was no danger. Allow person to see if feared outcome occurs or not. ©Qualia Counselling Services 2016 Source: Norton, Peter, J. (2012). Group Cognitive-Behavioral Therapy of Anxiety: A Transdiagnostic Treatment Manual Safety Behaviours Safety behaviours are things that we do to with the intention of keeping us safe. It is natural to want to keep ourselves safe, but sometimes the things we do can have the unintended consequence of prolonging a fear. Homer Simpson gives a great example of the beginnings of a safety behaviour. Homer: Not a bear in sight. The Bear Patrol is working like a charm Lisa: That’s specious reasoning Dad Homer: (Misunderstands) Thanks Lisa: By your logic I could claim that this rock keeps tigers away Homer: How does it work? Lisa: It doesn’t, it’s just a stupid rock Homer: Uh-huh Lisa: ... but you don’t see any tigers around do you? Homer: Lisa, I want to buy your rock Now imagine that Homer starts to carry the rock around all the time, and that he is more worried about tigers when he doesn’t have it with him. How could Homer learn that the rock doesn’t keep him safe from Tigers? Do you think he would believe someone if they simply told him the rock was not actually keeping him safe? How do you imagine he would feel, to begin with, if he experimented with leaving the rock behind? Would this feeling be likely to last forever? If not, why not? Dialogue and images from The Simpsons Season 7, Episode 23 “The Simpsons” TM and © Fox and its related companies. All rights 21 reserved. PSYCHOLOGYT LS PsychologyTools is not authorised by or affiliated with Fox Safety Behavior Inventory Feared Situation Direct Avoidance Escape Subtle Avoidance Alternative Healthy Coping (List all relevant situations (List Ways You Directly (List ways you come up with the (List other safety behaviors) Response that make you anxious) Avoid The Situation) escape anxious situation) (List healthy coping options) Safety Behaviors Healthy Coping Short-term relief but long-term increase in anxiety. Short-term increase in anxiety but long-term reduction. Motivation is to avoid a catastrophe. Motivation is not to prevent some feared catastrophe. Prevent person from learning there was no danger. Allow person to see if feared outcome occurs or not. ©Qualia Counselling Services 2016 A Step-By-Step Guide to Exposures Step Guide Step 1: Victory • Start by constructing your victory ladder by listing all of the relevant situations that make you anxious and then grading them from Ladder easiest to hardest. Start at the bottom of your ladder and work your way up. The bottom of your ladder should not include anything that is too easy. Only do exposures around situations that are least a 6 on the SUDS scale. Step 2: Plan Your • Begin planning your first exposure. Decide on what your exposure will be and where it will occur. Plan how long you will stay in First Exposure the situation and schedule it in your calendar. Step 3: Pre- • Consult your exposure monitoring form and identify anxious thoughts that are likely to arise. Develop beliefs that will counter Exposure Work those anxious thoughts in the moment. Record all of your predictions for what will occur as well. Step 4: Safety • Identify and eliminate any possible subtle safety behaviors that you might be inclined to engage in. Behaviors • Don’t drink alcohol, bring safety people, distract yourself or do anything else that prevents you from enduring what you really fear. • Enter the feared situation and begin the process of gaining victory over your anxiety. Step 5: Prolonged • Begin by recording your SUDS and then repeatedly record this every minute using your form (or in your head if not practical). Exposure • Stay in the situation until your SUDS decreases until at least half of what it was when you started. • DO NOT LEAVE the situation until your SUDS has decreased half-way or you may increase your anxiety around the situation. • DO NOT engage in safety behaviors that you had earlier identified. • Use your cognitive coping strategies that you brainstormed before beginning the exposure. Step 6: Post- • Return to your exposure monitoring form and ponder your experience. Compare what actually happened to the predictions you Exposure Work had made earlier. Record whether this experience has supported your fears or disconfirmed them. Step 7: Exposure • Continue to plan and schedule regular exposures until you have achieved victory over your anxiety. Practice • The more frequent your exposures, the quicker your anxiety will diminish. Step 8: Move up • After you have done enough exposures so that you no longer feel anxious in one situation, move onto the next step in the ladder the Ladder and repeat the process until you have climbed the entire ladder and your victory is complete. • Expect to feel anxious and uncomfortable. Exposure work is not easy, but it is incredibly effective. Other Tips • Your anxiety will at first increase but after staying in the situation will decrease. Don’t be alarmed when you see this initial increase in anxiety, this is normal. • Don’t’ fight your anxiety but let it in. Resisting your anxiety will only make it worse so accept it. ©Qualia Counselling Services 2016 Victory Ladder Describe what victory over your anxiety will look like. What are you able to do that you weren’t able to do previously? __________________________________________________________________________________________________________ List all the different situations you are avoiding that is related to your anxiety. On a SUDS (*Subjective Units of Distress Scale) rate your anxiety in the situation and how much you avoid it. Next, construct your ladder and record when you complete each step. SUDS Scale: 0=No anxiety or Avoidance 10=Maximum Anxiety, Complete Avoidance. Situation Ranking Date of (SUDS) Victory Anxiety: Avoidance: 1. Anxiety: 2. Avoidance: Anxiety: 3. Avoidance: Anxiety: 4. Avoidance: Anxiety: 5. Avoidance: Anxiety: 6. Avoidance: Anxiety: 7. Avoidance: 8. Anxiety: Avoidance: 9. Anxiety: 10. Avoidance: Anxiety: Avoidance: ©Qualia Counselling Services 2016 Exposure Monitoring Form Exposure: ___________________________________________________________________ Ladder #:_____ Date and Time: _______________ Starting Anxiety Level: /100 Ending Anxiety Level: /100 Exposure Duration: ____________ Pre-Exposure Work Post-Exposure Work Describe Your Emotions about Describe Your Thoughts and Record Your Predictions What was the outcome of this exposure? Was your fear confirmed the Exposure or disconfirmed? What new evidence has this experience provided? Anxious Thoughts & Predictions: Outcome: Fear Confirmed or Disconfirmed? How does this experience fit with your old beliefs? Balanced Coping Statements: What new belief can this experience lead to? Anxiety Monitoring (Rate your anxiety from 0-100 every x minutes until the exposure ends) 1.____ 2.____ 3.____ 4.____ 5.____ 6.____ 7.____ 8.____ 9.____ 10.____ 11.____ 12.____ 13.____ 14.____ 15.____ 16.____ 17.____ 18.____ 19.____ 20.____ 21.____ 22.____ 23.____ 24.____ 25.____ 26.____ 27.____ 28.____ 29.____ 30.____ ©Qualia Counselling Services 2016