True story: When we adopted my now one-year-old dog when she was just two months old, one of my sons had a fairly severe dog phobia. When exposed to dogs before her adoption, he’d scream and run away. When we first brought our new puppy home, he screamed and ran away – again and again.
For about month, I kept her on a leash inside. Predictably, he’d run and scream if she came anywhere near him. Slowly, over time, he let her get a little closer. At some point, he became comfortable approaching her, then petting her, then lying with her, and finally, kissing her face. Now, he can’t get enough of her.
The exposure to her over time reduced his avoidance and panic around her and allowed him to conquer this phobia. He’s no longer afraid of her – or other dogs.
How did this happen? Exposure allows us to face our fears, often in a gradual, manageable way. With exposure, we acclimate to a feared stimulus (in this case, dogs) bite by bite, piece by piece, until the fear response fades and we no longer try to avoid or escape. Exposure exercises are generally approached from less challenging (being in the same room with the dog on a leash) to more challenging (allowing the dog to approach you off-leash). With exposure therapy, we use the DBT Skill, Opposite Action, to face our fears, to “avoid avoiding” or escaping from what we fear.
This example highlights how exposure, contact with what we’re afraid of, can heal even our most intense fears. Exposure can occur in our minds (imaginal) or in real life (in vivo). Here are a few areas where exposure has been shown to be effective.
As with the dog example above, phobias are good candidates for exposure therapy. If you’re afraid of spiders or elevators or heights, what works is to expose yourself to spiders, elevators, or heights. We typically use graded or gradual exposure to conquer phobias. So, we start off with smaller challenges (e.g., looking at picture of a spider) and then progress incrementally to more difficult ones (e.g., being in a room with a spider). With each exposure, the goal is to wait until anxiety decreases before moving on. If we don’t wait until we experience a natural reduction in anxiety – and instead flee the situation – we then associate any resulting anxiety decrease with fleeing, which is exactly the association we’re trying to break. If we stay, and remain in contact with the feared stimuli, anxiety will natural decrease with time, and we’ll realize that the stimulus isn’t as threatening as we once perceived it to be.
A treatment of choice for OCD (obsessive-compulsive disorder) is exposure plus response prevention (ERP). With ERP, we expose someone to the feared situation and prevent them from engaging in a compulsive or compensatory behavior. Let’s say someone’s OCD manifests in the form of checking, in this case the lock on their front door. As they settle in for the night, they find themselves checking their door lock multiple times. With ERP, we would expose the person to the anxiety that creeps up before checking (“What if it’s unlocked? I can’t remember if I turned the lock strongly enough”) and then work with them to avoid checking multiple times – in other words to tolerate the anxiety that arises without acting upon it. When anxiety appears, it feels “good” to engage in a compulsive behavior, like checking the lock. But rather than helping the symptom, this just increases its strength. With ERP, anxiety peaks early on but dissipates over time, and the need to engage in compulsive behavior fades along with it.
For those who have experienced a traumatic event or events, many symptoms relate to avoidance of memories of the event or associations (e.g., places, images, smells) to the event. It makes sense that with trauma, we’d want to push memories, thoughts, and feelings away. But this pushing away actually activates some of the symptoms we see with PTSD (post-traumatic stress disorder). With exposure for trauma, we expose folks to the memories, thoughts, feelings, and sensations of their trauma. Exposure is challenging but ultimately can set folks free from the symptoms of PTSD. Most of the commonly used trauma therapies (Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement and Desensitization (EMDR), Accelerated Resolution Therapy (ART), and Brainspotting, to a name a few, use exposure as a key element in their approaches.
Those who struggle with eating disorders often have a significant fear of food. As such, food exposures can be an important part of eating disorder recovery – actually eating the foods, at times, and in amounts that directly challenge their eating disorder rules. Over time, eating becomes easier and less anxiety-provoking. A similar process can occur with body image. Those who experience significant difficulty looking at their bodies are likely to experience less distress over time with exposure (i.e., if they continue to look at their bodies). If someone, for example, feels anxious and upset when looking at her stomach, looking at her stomach each day in a neutral/non-judgmental way may decrease her body image distress over time.
Sometimes, we come to avoid our emotions themselves. With emotional exposure, we allow ourselves to feel our feelings – to “sit with them,” as they say. Instead of trying to suppress or distract from a feeling (neither of which work long term), we would stay with it, noticing it, observing its intensity, locating it in our body, watching its rise and fall. All emotions rise and fall. By allowing them to do so naturally without suppression or intervention, they often dissipate more quickly than if we try to control them. Simply noticing or watching an emotion, without attaching to it or pushing it away, is a form of exposure. With time, we become less anxious and avoidant of our feelings and experience more in control of our emotional lives.