Facing Your Fears: Gradual Exposure

 by Sara Dalrymple, RSW MSW BA Psych., BANA Clinical Therapist

____________________________________________________

Throughout the decades of research on psychological techniques, one method for challenging anxiety that has shown to be effective and reliable is exposure. Very simply put, exposure is a means of facing your fears in a way that is planned and strategic. While there are many different forms of exposure, BANA utilizes gradual exposure frequently in treatment for challenging eating disorder behaviours and maladaptive beliefs.

Gradual exposure is the process of facing your fear in a series of steps; each step becomes incrementally more difficult than the latter. By focusing on one step at a time, gradual exposure allows you to grow confident in your ability to cope with your anxiety at a pace that is not overwhelming. But how does exposure work, and why is it effective?

HOW DOES EXPOSURE WORK:

There are two very important elements of gradual exposure. The first is to repeatedly face the fear, as frequently as possible (research typically recommends at least 5 times a week). Secondly, while facing the fear, the individual must prevent themselves from trying to escape or avoid. Repetition paired with full engagement during the exposure episode has been typically shown to yield best results.

Exposure is an effective way to overcome your fears for four main reasons.

  1. Habituation, or acquired extinction. These words are quite clinical; therefore, we suggest that exposure is effective due to the fact that it desensitizes you to the stimulus you fear. The concept here is that the more you are exposed to what you fear, the less fearful you become because you get used to it. For example: when starting nursing school, some students may cringe when having to give injections. Overtime, the student may get used to having to use a syringe and the act of giving injections becomes second-nature; the cringe reaction eventually goes away. When it comes to eating disorder treatment, that stimulus is typically food or your body.
  2. Fearful predictions are disconfirmed. The nature of our anxiety causes us to anticipate the worst-case-scenario in many situations where our fears our present. When we actually face our fears, we have the opportunity to realize that our worst-case-scenarios do not come true often. We can learn that although sometimes (rarely) our fears are supported, more often than not our predictions are wrong and bad does not always An eating disorder treatment example is eating a “forbidden food” (a food that is feared, and tends to be of low-nutritional value) and weighing oneself – while weight-gain can occur overtime with consistently eating highly processed foods with low nutritional value, less frequently eating these foods will not impact weight in a noticeable way. However, one would need to eat the food with curiosity in order to see what truly happens to one’s weight – this would be exposure.
  3. It allows you to process the feared stimulus. Hypothetically, we can make all of the assumptions we want regarding what will happen, and what the feared stimulus will be like. However, we will never know for sure unless we are exposed to it. In order to process this information, we need to face our fears. An example of this could be when your parents told you as a child not to do something due to repercussions, but you went ahead and did it anyway because you were curious. Our parents may have had good reason to warn us against that action, but we wanted to see for ourselves just how right or wrong they were. We may have thought “their experience is probably going to be different than mine,” or “everyone goes through things differently”. In order to make sense of it on our own, we wanted to experience it first-hand. If we take the same approach with our fears, we will get more accurate information about the situation/object/person/place – information that is not skewed by our anticipatory anxiety.
  4. It increases your feelings of confidence, mastery and/or self-efficacy. Often when it comes to our fears, we underestimate our ability to cope with what could happen. We believe that we will be faced with our fear and be weak, or incapable of handling whatever is thrown our way. Exposure allows us to realize that we are stronger than we think, and more skilled in handling difficult situations than we ever could have imagined. However, the only way we will know this is by trying. Every time you engage in the exposure, you learn that you can get through it. You also develop stronger coping skills in the moment – skills that can be applied to every consecutive exposure episode. Overtime, this confidence and these coping skills will cumulatively weaken how fearful you are of the stimulus at hand.

HOW TO BREAK DOWN FEARS INTO STEPS: HIERARCHIES

As noted above, facing fears can become much less overwhelming when broken down into steps. Each step becomes incrementally more difficult due to gradually becoming more and more exposed to the feared stimulus. This process of breaking fears down into steps is often referred to as a “hierarchy”.

GENERAL RULES:

  • Because you are facing a fear, anxiety, distress and discomfort are inevitable. If you are comfortable, you are not changing. Expect distress, and plan for a positive activity after the exposure episode is complete in order to deescalate and distract from your emotions.
  • Keep a journal or chart of your anxiety/distress before and after engaging in the exposure episode. By doing so, you will be able to track your progress and know when you are ready to move on to the next step.
  • Do not stay in a step that you have grown comfortable in. Once your distress has diminished by about 50% within a given step, you should move on to the next. Otherwise, you risk getting stuck and further avoiding.
  • Do not start an exposure episode and stop halfway through – this can reinforce your anxiety and avoidance of the feared stimulus. Stay present the whole way through.
  • Be on the lookout for “safety behaviours” – these are behaviours that you may use to avoid during the exposure episode to alleviate some of the distress. These behaviours are not helpful, as they reinforce your avoidance and anxiety, and prevent you from fully “facing” your fear. In an example of facing a fear of snakes, a safety behaviour could look like covering one’s eyes, looking at one’s phone to distract, holding your breath, looking away, etc.
  • Come prepared with self-talk or mindfulness activities that can help you stay engaged and get through the full exposure episode.

STEP ONE:

Make a list of situations, people, objects or places that involve your fear. It may be helpful to group items with similar themes together. Consider your “worst-case-scenario” and add this to the list – this will likely be your last step. Also consider a situation that is only incrementally more difficult than how you face your fear now – this could likely act as your “step one” in the hierarchy.

STEP TWO:

Build a hierarchy by ranking your list from step one. Ask yourself how much anxiety you have for each item, and rank them from least-to-most feared/anxiety-provoking. You may want to add different “features” to each item to further break down complex or highly distressing steps. Consider the following:

  • Length of time: for example, talking to someone for 30 seconds is probably less scary than talking for five minutes.
  • Time of day: for example, driving over a bridge in the middle of the afternoon versus evening rush hour.
  • Environment: for example, swimming at a local pool versus swimming in a lake.
  • Who is with you: for example, going to the mall with your spouse versus alone.

STEP THREE:

Begin to face your fear by following the hierarchy. Remember to make note of your anxiety before, during, and after every time you engage in the exposure exercise. We also recommend rewarding yourself after you have gotten through each episode – this will help to positively reinforce the change, and build on your feelings of pride and self-efficacy.

OVERVIEW:

Exposure is an effective way to overcome fears and anxieties, and it is a method commonly used in eating disorder treatment. If you are a client of BANA awaiting treatment, you will have the benefit of working with your clinician and dietitian on exposures in a guided and supported manner. However, exposure is not specific to therapy. You can develop exposure exercises for yourself at any time, as exposure can be applied to a vast array of concerns.

If you want to get started on an exposure exercise, we recommend visiting the Centre for Clinical Interventions Website. They have a range of “Looking After Yourself” workbooks on different topics/areas of concern, many of which include modules that guide you through developing and completing an exposure.

https://www.cci.health.wa.gov.au/en/Resources/Looking-After-Yourself

REFERENCES:

American Psychological Association. (2017). What is exposure therapy? Retrieved May 26, 2020, from https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy

Anxiety Canada. (2019). Facing your fears: Exposure. Retrieved May 26, 2020, from:
https://www.anxietycanada.com/sites/default/files/FacingFears_Exposure.pdf

Centre for Clinical Interventions. (2019). What are safety behaviours? Retrieved May 26, 2020, from:
https://www.cci.health.wa.gov.au/-/media/CCI/Mental-Health-Professionals/Anxiety/Anxiety—Information-Sheets/Anxiety-Information-Sheet—07-What-are-Safety-Behaviours.ashx

Fursland, A., Byrne, S. & Nathan, P. (2007) Overcoming Disordered Eating. Perth, Western Australia: Centre for Clinical Interventions

Goodtherapy. (2015). Exposure therapy. Retrieved May 26, 2020, from https://www.goodtherapy.org/learn-about-therapy/types/exposure-therapy

Kaplan, J., & Tolin, D. (2011). Exposure therapy for anxiety disorders. Retrieved May 26, 2020, from https://www.psychiatrictimes.com/anxiety/exposure-therapy-anxiety-disorders