Stacy G. Smith, MS, LPC
4 Reasons Why Exposure Therapy May Not Be Working
Exposure therapy is an effective treatment for numerous anxiety-based struggles. It is widely used to treat social anxiety, panic disorder, fears/phobias, and with some modifications, Obsessive-Compulsive Disorder. The premise behind exposure therapy is to gradually immerse yourself in feared thoughts/situations, with the goal of ultimately becoming desensitized, so that you no longer react with your original, fear response. In other words, exposure therapy helps you "get used to" the feared situation, so that it no longer leads to avoidance.
However, some clients who undergo exposure therapy may sometimes wonder, "why isn't my treatment working?" Before labeling exposure therapy as ineffective, it is important to keep in mind the following barriers to successful exposure sessions.
1.) UTILIZING SAFETY BEHAVIORS
Safety behaviors are any behaviors used to help prevent, or reduce, anxiety. The problem is that these behaviors limit your exposure by not allowing you to fully experience the event or situation you are in. Without full exposure, the amount of desensitization you experience becomes limited, at best. While relying on safety behaviors is comforting, they only help you to "get by" in anxious situations, rather than embrace and welcome them.
Safety behaviors for panic disorder, as well as generalized and social anxiety, may include (but are not limited to):
Carrying an as-needed anxiety medication
Looking for nearby escape routes/exits
Standing in a corner at a party
Not making eye contact
Using your phone to look occupied
Performing an activity quickly to "get it over with"
Calling someone when you know they are unavailable, and leaving a message
In Obsessive-Compulsive Disorder (OCD), safety behaviors are otherwise known as compulsions. It is essential for individuals with OCD to not only expose themselves to their feared thoughts/situations, but to then prevent themselves from engaging in any accompanying rituals to temporarily reduce their anxiety - washing, counting, tapping, repeating words/phrases, reassurance-seeking, etc... This form of treatment is specifically called Exposure and Response Prevention (ERP), and is the gold standard treatment for OCD. Exposure therapy alone is not enough to target OCD symptoms - Response Prevention is crucial.
Completely eliminating safety behaviors, or compulsions, can be a challenging task. As a result, many individuals may work with their provider to gradually reduce these behaviors, rather than eliminating them cold turkey. However, the ultimate goal of treatment is to fully immerse oneself in total response prevention, or safety behavior removal, where maximum benefit and relief is found.
2.) NOT SITTING WITH THE ANXIETY UNTIL IT DISSIPATES
I often call this the "hit and run" approach. In other words, engaging quickly in an exposure activity, then quickly leaving the room and moving on to something more relaxing, or enjoyable. When exposing yourself to an anxious situation, it is essential to notice your spike in anxiety, and then mindfully observe it until it dissipates, or at least reduces by half. Only then would you remove yourself from the anxiety-producing situation. This allows for maximum desensitization/habituation to take place.
Distracting yourself and/or pushing your anxiety away is like jumping into a pool on a hot, summer day, and then getting out because the water is too cold. You never give your body the chance to get used to the water, and ultimately have a good time swimming.
3.) YOU HAVEN'T DONE THE COGNITIVE PART OF COGNITIVE-BEHAVIORAL THERAPY (CBT)
Often, behavioral therapy alone is not enough to fully target anxiety. It is important to evaluate all the unhelpful, irrational thoughts you may be having about yourself, as well as social and feared situations. Some examples may include: "I'm going to make a fool out of myself," "My anxiety will get so high I just know I will lose control," "I'm responsible for keeping everyone safe," etc... By working to evaluate and restructure these thoughts, you may find that your overall anxiety level decreases, and your tolerance for the anxiety that surfaces during an exposure may be higher. This may allow you to stay in feared situations longer, where you will be able to fully experience the exposure exercise, and successfully ride out the elevated anxiety.
4.) NOT PRACTICING OFTEN ENOUGH
Practice, practice, practice. The more often you engage in your exposure exercises, the better the results. When it comes to exposure, there truly is no such thing as too much exposure. While it may feel uncomfortable, it is important to remember that this anxiety and discomfort is short-term, and is designed to produce long-term gains. It can be helpful to set aside specific times during the day to practice your exposure exercises, and time on the weekends for more prolonged exposures. When you collaboratively set homework assignments for yourself in therapy, these assignments/exposures are intended to be practiced every day. If you find yourself not engaging in exposures as much as you would like, speak with your therapist about discussing ways to overcome any barriers that may be standing in the way. If your exposure assignments feel too challenging, design an exposure that elicits slightly less anxiety. It is better to feel successful by taking small steps, than to repeatedly feel defeated trying to take a step that is too large.
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