Exposure therapy. - Reforming Trauma Coaching & Counselling.

Jason Brien.

Exposure therapy is based on the very simple notion that it is always better to face your fears rather than avoid them. Exposure therapy therefore advocates for approach coping rather than avoidance coping. It is extremely important to understand that exposure therapy is not a ‘push you into the deep end of a pool to teach you how to swim’ approach. Exposure therapy is designed to help people to GRADUALLY approach their fears because gradual and sequential exposure gives the client time to learn how to manage the emotional, cognitive and physiological responses to the fear at multiple stages/levels. Just like you would find it hard to ‘think’ how to swim when you are drowning, so too will you find it hard to control your responses to your biggest fears when your biggest fear is currently drowning your body in fear, adrenaline, anxiety, etc.

Exposure therapy is normally used to treat complex mental health conditions like trauma, ptsd, cptsd, phobias, ocd, etc., however you can use the principles of exposure therapy to help you to better manage everyday stress and anxiety. Again, it all comes down to avoidance coping vs approach coping. Avoidance coping is largely a product of its reinforcement history. Let me explain more. Let’s say you are hungry and there is a pie cooking in the oven. You go to get the pie out of the hot oven and you burn your hand. You are really hungry and determined though and so you grab at the pie again and again you burn your hand. If you keep trying to grab the pie without changing your strategy (putting on oven gloves, turning the oven off, etc), your hands are going to be burnt red raw and you will likely adopt a “F this. The pie can stay in the oven and I’ll just starve” attitude.

Sure, you could keep grabbing at the hot pie and hope that you eventually develop what is known as ‘chef hands’ (higher tolerance to hot things) but are the ‘chef hands’ worth all of the pain and scars? Probably not. This hot pie in the oven metaphor/analogy can help you to understand how most people end up resorting to avoidance coping. They have approached a stress, anxiety, conflict or problem in the past using a particular strategy, that strategy hasn’t worked , they have repeated the same strategy, the same strategy has again not worked and so they ‘give up’ and resign themselves to avoiding everything because “I can never fix anything”, “Nothing will change” or “The same thing that happened last time will just happen again this time”. The more entrenched these beliefs become, the harder they are to overcome. This is where the gradual component of exposure therapy comes in.

If you want someone to believe that they are capable of accomplishing something (or overcoming something), they must have the belief that both change and success are possible. The primary reason why any competent exposure therapy practitioner won’t throw their client straight into the deep end is because doing so will most likely lead to failure and will simply reinforce the “nothing will change” beliefs (reinforce the reinforcement history of avoidance coping). So, by starting off with smaller, more manageable and more controllable fears/tasks, the client has a chance to both practice new skills (without being completely overwhelmed) AND accomplish successes. Each success, no matter how small, changes and disempowers the old reinforcement history and starts a new, more positive reinforcement history (which will hopefully lead to more approach coping and far less avoidance coping).

Let us look at social anxiety/phobia within the context of avoidance coping, approach coping and exposure therapy. A person feels uncomfortable around other people. Maybe they are socially awkward and struggle to understand social cues. Each ‘failure’ to read social cues properly, or each ‘failure’ to make or maintain conversation leads the person to want to avoid social interactions because “I’m just making a fool of myself so what’s the point”? To encourage approach coping, and so encourage social interactions, exposure therapy suggests starting with a situation or task that induces the least amount of social fear and anxiety as possible. This can take some fine tuning and may involve using anxiety scales or questionnaires. Everybody is unique. Going from most fear/anxiety to least fear/anxiety you may come up with something like the following list;

Going to a concert/party.
Interacting in person with a group of 10 people.
Interacting in person with a group of 5 people.
Interacting in person with 2 people.
Interacting in person with 1 person.
Role play interacting with 10 people.
Role play interacting with 5 people.
Role play interacting with 1 person.
Having an online conversation with 10 people.
Having an online conversation with 5 people.
Having an online conversation with 1 person.
Having an anonymous online conversation with 10 people.
Having an anonymous online conversation with 5 people.
Having an anonymous online conversation with 1 person.
Imagining having an in-person conversation with 10 people.
Imagining having an in-person conversation with 5 people.
Imagining having an in-person conversation with 1 person.
Imagining having an anonymous online conversation with 10 people.
Imagining having an anonymous online conversation with 5 people.
Imagining having an anonymous online conversation with 1 person.

You may ask yourself “Are all of these steps necessary”? You may even ask why you should have to start with imagining social interactions rather than just jumping straight into having an in-person conversation. The reason is because you want a STRONG history of successes to overcome the current history of ‘failures’ (which has reinforced your social anxiety/fear and avoidance coping). Again, the best way to rack up these successes is by not being flooded with intense fear and anxiety to the point that it shuts you down and so stops your from practicing new skills. Think of the swimming analogy used at the very beginning of this article. You are unlikely to learn how to swim if you are thrown into the ocean because you will be more focused on not drowning (or not getting eaten by a shark) than you are in trying to apply newly learnt swimming skills.

Exposure therapy does use the principle of flooding in some cases (the equivalent of jumping straight into the ocean) but this strategy must be monitored very, very closely. It would be unwise to take a person with extreme agoraphobia to a concert with hundreds of people as the resulting fear, stress and anxiety could cause more harm than good. Ideally though, you (and professionals) want to use exposure therapy to help build up successes, confidence and perceptions of control. Everyone is more likely to want to approach those things that they feel they can influence. Of course, approach coping and exposure therapy are limited and/or redundant within certain situations. Take extremely toxic people for example. Sometimes it doesn’t matter what strategies you try; you are met with ‘failures’ simply because they are so rigid and self-absorbed.

To go slightly off topic, the list of successive steps shown earlier is also the way to approach goal setting. You want to build up successes as successes build up confidence and successes STRONGLY motivates the desire to keep engaged in something (or to keep doing something). To go even further off topic, the reason why most toxic people engage in toxic behaviours (like manipulation for example) is because they have had successes in the past which motivates them to continue the behaviour. Why would they stop if their strategies and behaviours are so successful? Setting boundaries, being assertive and being mindful of your vulnerabilities not only protects us from these toxic people, they also inadvertently or unintentionally help to break and disempower the toxic persons reinforcement history (as they will experience less successes).

Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476932/

https://www.sciencedirect.com/topics/medicine-and-dentistry/coping-strategies

https://dictionary.apa.org/approach-copinghttps://www.goodtherapy.org/learn-about therapy/types/exposure-therapy