February 10, 2011

Exposure Therapy

People say that the best way to overcome a fear or phobia is to bite the bullet and face it head on. Facing your fear is somehow supposed to make you less fearful.

Is this good advice?

Yes. Overcoming fears and phobias by facing them directly is the foundation of exposure therapy, a psychological intervention used when a person has a severe and debilitating reaction to a certain stimulus (object, animal, or context). Exposure requires the person to interact more and more closely with the feared stimulus until they’re no longer scared.

How does it work?
1) Exposure therapy is based on the tenet that fears and phobias are learned relationships. That is, the feared stimulus isn’t inherently scary, but is something that you learned was scary through a dramatic or traumatic experience. For example, I flew easily many times as a child, and wasn’t scared of flying until I was 15 and experienced severe turbulence on my very first plane trip alone. It only took five terrifying minutes of thinking I was about to die for me to learn a relationship between airplanes and danger, and for years subsequently, I cried in fear through every plane trip. Similarly, a 12-year-old with a dog phobia may have loved animals until she was ten and was bitten by a scary dog, requiring an ER visit and stitches. That one experience was enough for her to learn a relationship between dogs and danger, and now she feels automatic fear at the sight of any dog. Think similarly of someone who enjoyed driving, but became scared to drive following an accident.

Exposure therapy works by helping you unlearn the relationship between the feared stimulus and danger by repeatedly exposing you to the feared stimulus in the absence of danger. If the girl with the dog phobia interacts enough times with a dog without the dog doing anything menacing, the relationship between dog and fear will fade and will be replaced by an association between dog and neutral or maybe even dog and friendly. The person who had a car accident is encouraged to keep driving until he unlearns the association between driving and accidents. Sometimes exposure therapy happens naturally: In the past 15 years, I’ve taken many plane trips without incident. Through repeated exposure to flying in the absence of danger, I’ve largely unlearned the relationship (although whenever there’s turbulence, the old relationship is reinforced and I make strangers hold my hand).

2) Exposure therapy also rests on the principle of habituation. Habituation refers to the fact that it’s impossible to maintain an elevated level of anxiety for a prolonged period. That is, no matter how anxiety provoking the stimulus, your racing or pounding heart, sweaty palms, and dry mouth will always fade naturally if you wait long enough. For example: the girl who is scared of dogs sees a dog coming toward her on the sidewalk. Her heart races and she feels dizzy with fear so she crosses the street. Her symptoms abate, reinforcing her idea that the dog was dangerous. Through avoidance of the feared stimulus, she denied herself the opportunity to experience the physiological inevitable: that her heart rate, breathing, and blood pressure would have automatically returned to baseline even in the presence of the dog. Habituation to a feared stimulus decreases fear, whereas avoidance maintains it; exposure therapy forces habituation.
Final point: Exposure therapy is almost always gradual (e.g., looking at a picture of a dog, hearing the sound of a dog barking, being in the same room as a dog, approaching and petting the dog, letting the dog lick your hand). You may have heard of flooding, a type of non-graded exposure designed to stamp out your fear in one shot (e.g., a person with a snake phobia would be enclosed in a room with fifty slimy but benign snakes). Flooding is effective, but it can also be traumatic and there is a greater risk of spontaneous recovery of fears; graded exposure is appropriate for the large majority of phobias.

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