In this blog post, I'll explain exposure, a technique used to address anxiety related to specific situations. I'll clarify what exposure means and why it's effective. Additionally, I'll discuss some common challenges that can arise when practising exposure. If you're looking to start exposure therapy or feel stuck in your current practice, I hope this article will provide helpful guidance. You're also welcome to contact me if you have any questions not covered here. Enjoy reading!
Exposure is a specific technique primarily used in anxiety treatment. It involves systematically exposing yourself to something harmless that you fear. For example, if you have social anxiety about being in crowded places, you might practise exposure by shopping in a supermarket or taking a bus.
This method is employed in most therapy approaches that address anxiety. Essentially, nearly all forms of therapy will incorporate some type of exposure. While different terms may be used, the core principle remains the same: gradually expose yourself to what you fear, and it will become less and less anxiety-provoking over time. Sounds simple, doesn't it?
Exposure is a technique you can use during therapy sessions and also practise independently between appointments. While highly effective, it does involve experiencing some discomfort. Therefore, it's wise to consider whether it's the right time for you and to create a well-structured plan before you begin. This can make the process more manageable and reduce the likelihood of giving up. And remember to reward yourself after completing an exposure exercise!
To understand why exposure is effective, we need to look at what perpetuates anxiety: avoidance. Avoidance is a very natural and understandable reaction when experiencing anxiety. In many situations, it's a sensible thing to do, as what we fear might indeed be dangerous. A classic example is seeing a snake, becoming scared, and then fleeing. It's wise to avoid snakes and places where you know they reside. However, when addressing anxiety, we're dealing with avoiding situations that are not inherently dangerous. By avoiding an anxiety-provoking situation, or fleeing when anxiety is high, you inadvertently maintain the anxiety.
Habituation: It's physically demanding for the body to be in a state of alarm. When you experience anxiety, you expend a lot of energy. Consequently, the body will naturally begin to de-escalate its alarm system and reduce anxiety when no actual threat occurs. Exposure therapy capitalises on the fact that anxiety will eventually subside on its own if nothing is actively fuelling it. This process becomes faster and faster with repeated exposure to the same situation until it no longer triggers anxiety.
Sense of Control: Practising exposure can provide a profound experience of reclaiming control and refusing to let anxiety dictate your life. Although exposure inherently involves discomfort, you can also experience positive emotions such as pride, courage, and hope.
Correction of Catastrophic Thoughts: When you're anxious about a situation, you often have catastrophic thoughts about what might happen. For instance, if you're anxious about shopping in a large store, you might worry about having a panic attack, fainting, or forgetting your debit card PIN. By entering the situation instead of avoiding it, you get the opportunity to test whether your fears actually materialise. Even if they do, you might discover that it's not the catastrophe you imagined. This experience can help you feel more secure next time.
Stopping Avoidance: Avoiding situations that are not dangerous helps maintain anxiety because it reinforces the belief that the situation is threatening. Often, anxiety can spread to more and more situations, progressively limiting your life. By practising exposure, you break this vicious cycle.
Begin by writing down your goal. What do you want to be able to do once you've successfully completed your exposure work? This is crucial, as it will serve as your motivation throughout the process and help you push through discomfort.
Examples of goals might include:
Create a plan. Now, devise a way to train yourself so you can slowly but surely get closer to your goal. When creating your plan, think of it as a staircase, with your ultimate goal at the top step. You'll need to take each step to reach your destination.
Each step represents a situation you need to expose yourself to. Only when you no longer experience anxiety (or very low anxiety) at a particular step should you move on to the next. Typically, you should practise exposure at the same step for a couple of weeks (2-3 times per week) before progressing. Begin with the least frightening situation (generating an anxiety level of 4-7 on a scale of 1-10). Once in the situation, observe how much anxiety it triggers. Remain in the situation until your anxiety level has significantly decreased (ideally, halved), then leave.
Congratulations, you've completed your first exposure exercise! Repeat the same step the next day or within the same week. Move to the next step when you no longer experience significant anxiety at your current level.
Goal: Shopping in a large mall
Step 1: Visit a small shop on a weekday morning when it's less crowded (it's okay to bring a trusted person with you).
Step 2: Visit a small shop on a weekday morning without a trusted person.
Step 3: Visit a small shop in the afternoon.
Step 4: Visit a larger shop in the morning (it's okay to have a trusted person on the phone).
Step 5: Visit a larger shop in the morning without a trusted person.
Step 6: Visit a large mall in the morning.
Step 7: Visit a large mall in the afternoon.
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I've spoken with several clients who have tried exposure but found it ineffective, noting that their anxiety didn't decrease. When we examine their approach, certain patterns emerge. I've compiled some common 'mistakes' or issues with exposure here, along with suggestions for how to address them.
When exposure is unstructured, it often means no plan has been made in advance. Individuals might approach situations randomly. If exposure isn't practised frequently (ideally several times a week), but only when an opportunity happens to arise, it can be challenging to make progress. This often leads to demotivation, as you only experience the discomfort of exposure without noticing any real change. Therefore, especially in the beginning, it's a good idea to create a plan outlining what you want to achieve and then break it down into smaller steps. Following this, schedule specific times for your exposure practice. Creating an exposure plan can be difficult. If you're in therapy, your psychologist can help you. Otherwise, you can ask someone you trust for assistance.
This means you've entered a situation that triggers too much anxiety (anxiety level above 7). Perhaps you didn't anticipate the anxiety would be so high. It might have been a long time since you were in a similar situation, causing you to be surprised by your reaction. While experiencing anxiety symptoms isn't dangerous, if the symptoms are very intense, it's almost impossible to remain in the situation until the anxiety subsides. It can also be difficult to think clearly. Overall, it's unlikely you'll benefit much from such an intense exposure, and you might instead choose to leave the situation. This happens quite frequently. Instead of viewing it as a failure, try to use it as important information for yourself. 'Now I know this situation causes more anxiety; I need to take a step back down the ladder.' Try to be compassionate with yourself. You can't always know how much anxiety a situation will trigger. Wait a couple of days and try a less challenging situation (anxiety level 5-7).
Choosing a situation that only causes mild anxiety isn't very effective. While it might feel safe and comfortable to stay in the same situation, it won't bring you closer to your goal. If you need a break from exposure, it's better to make a conscious decision to do so (you should, of course, continue with the progress you've made in your exposure plan). When you feel ready and have renewed energy, find something that elicits moderate anxiety. Remember to move up the exposure ladder when a situation no longer causes significant anxiety (anxiety level less than 3). And don't forget to celebrate your progress towards your goal!
Many people overlook the behaviour they engage in during exposure, yet it's a very crucial aspect of the process. Behaviour refers to what you do in the situation itself that either helps to calm or maintain your anxiety. Sometimes this is very conscious, other times you might not even be aware you're doing it. For example, a conscious behaviour (also known as a safety behaviour) is bringing someone with you to the shop when you need to buy groceries. This can make it easier, as you feel more secure and experience fewer anxiety symptoms. However, the problem is that you don't learn the situation itself isn't dangerous. You might continue to think, 'I managed the shopping, but it was only because I had someone else with me.' In this way, you don't progress in your exposure, and your anxiety level doesn't decrease. Another type of behaviour is looking down at the ground. If you have social anxiety, you might avoid making eye contact with others. This can maintain anxiety and prevent the exposure from being effective, as you don't get to prove to yourself that other people aren't judging you critically. Problematic behaviour can also include walking very quickly or tensing your body. If you rush and your shoulders are hunched up to your ears, you're essentially continuously telling your body that the situation is dangerous. Consequently, your anxiety level won't decrease on its own. Once you've identified safety behaviours or other behaviours that help maintain anxiety, you must try to stop them. This means going into the shop alone, looking up at other people, or walking slowly while practising your breathing to relax your body. If this feels too difficult, you can take a step back down your exposure plan until you're ready to try again.
A common 'mistake' is ending exposure too soon. If you rush into a shop, grab your items, and immediately leave, that's not effective exposure. In an exposure situation, it's crucial to stay until your anxiety has significantly decreased. A rule of thumb is that your anxiety should be halved before you leave the situation. Alternatively, you can leave once you no longer feel the urge to flee or escape. If you leave while anxiety is still high, it will have the opposite effect, reinforcing the anxiety and making it harder next time. Therefore, you should enter the situation, wait until your anxiety is halved and you no longer feel the urge to escape, and then you can calmly leave. If this feels too difficult, it's better to take a step back down your exposure ladder.
Thoughts can initiate and maintain anxiety. For instance, repeatedly thinking, 'I can't remember my debit card PIN' as you approach the checkout in a shop will increase your anxiety level, even if you weren't initially nervous. We cannot simply stop our thoughts; it's a battle you'll likely lose or expend immense effort on. If you're nervous or anxious about something, anxious thoughts will naturally arise. However, we can decide in advance how to manage these thoughts, thereby reducing their intensity and preventing them from controlling us. For example, you might tell yourself, 'Oh, there's that debit card thought again. It's okay; if I can't remember the PIN, I can simply leave the shop without my items. That happens sometimes, and it's not a catastrophe.' You can also choose to focus on what you feel in your body rather than the thoughts in your head. Most people find it strange to pay attention to anxiety symptoms. 'But I don't want the anxiety!' or 'That will just make it worse!' are common responses when I suggest this. Yet, anxiety actually worsens when we try to ignore it. A more effective approach is to notice it and try to describe what you're feeling in a neutral way. For example, you might say to yourself, 'Now I can feel my heart starting to pound... now it's getting a little faster, I can feel myself getting warm on my back... now the palpitations are easing a bit.' This shifts attention away from anxious thoughts and can, in itself, help to calm your anxiety. Finally, you can choose to direct your attention to something outside yourself. For example, you might try to find different colours where you are, count tiles, or identify round objects.
Firstly, you must be motivated. If you don't see the purpose of exposure or if the goal (e.g., being able to shop) isn't important to you, I wouldn't encourage you to pursue it. Exposure is demanding, so it's vital that you've decided for yourself if you're willing and ready. It can also be a matter of timing. If you're currently in a particularly stressful situation, exposure might not be appropriate right now. Similarly, if you're experiencing a crisis, I wouldn't recommend expending energy on exposure. For example, if you're going through a divorce, have experienced a loss, have recently endured a traumatic event like an accident or assault, or are otherwise in an unstable place in your life, it usually makes sense to wait until you feel more stable.
If you have an untreated psychotic disorder or experience significant dissociation, I recommend contacting a psychologist or another mental health professional for advice regarding exposure. This is to prevent you from becoming overwhelmed by anxiety and potentially overstressed. Similarly, if you engage in very serious problem behaviours, such as suicidal ideation or self-harm, I would also advise seeking help for these issues before attempting exposure.
Last but not least, you should never expose yourself to something that is genuinely dangerous! If you suffer from a fear of heights, you shouldn't stand on a high railing without safety measures. However, having an activity like bridgewalking as the ultimate goal in an exposure plan can be a great idea, as long as it's approached safely and gradually.
