OVERVIEW OF GRADUAL EXPOSURES

 

I refer to Gradual Exposures as the “Berserker” Style because they are the most forceful of the cognitive behavioral techniques. Despite the name however, one of the keys to exposures is that they must actually start out as mild.

Gradual Exposures are the treatment you would use for a phobia of spiders. You would start by looking at a picture of a spider, then holding a rubber spider, then looking at a spider in a cage... and so on until you worked your way up to holding a small spider in your hand.

There are three keys to exposures: They must be voluntary, they must be sustained, and they must be mild.

Exposures must be voluntary: Let’s say I misguidedly try to treat your phobia of spiders by locking you into a room full of spiders against your will. It won’t help at all! In fact, it will only traumatize you and make you more afraid of spiders. Similarly, if a friend forces you to go to a party or forces you to socialize against your will, it won’t help your social phobia. Exposures must be voluntary in order to be helpful.

In particular, it's not just the activity that has to be voluntary, it's the anxiety itself that has to be voluntary. An exposure is a very strange activity. You have to actually try to feel anxious in order for it to work.  For example, in college I went to dozens of parties to try to get comfortable, but it never worked. Parties still made me just as anxious at the end of college as they did in the beginning. But that's because when I went to the parties, I would try to keep calm. That's not an exposure. That was me practicing relaxation techniques.  Later in my twenties, when I did parties as exposures, I would go in trying to feel anxious.  I would talk to whoever seemed the most intimidating, I would purposely repeat negative sentences in my head, and I would push myself to be the last one to leave (I actually started with much easier exposures than parties).  As a result, parties eventually started inducing much less anxiety.

Exposures must be sustained: Let’s say you agree to hold a spider, but within two seconds you throw it down because it creeps you out. Well, even though that exposure was voluntary, it was be too brief to be helpful. Exposures only work if they are sustained long enough for your anxiety to at least starts to go down. Ideally, you should sustain an exposure until the anxiety is completely gone.

Exposures must be mild: The optimal exposure is always a low-intensity exposure. The problem with doing an exposure that is too intense is that it can backfire. If the anxiety is too high, then it becomes involuntary is no longer useful. There were some times when I would go to a party thinking that it would be a mild exposure, but once I got there I felt so out of it that I realized that the exposure is too intense for me that day. When that happened, I would leave. If an exposure is too intense, it won't help you. Low intensity exposures, in contrast, can help you expand your comfort zone.

Whenever you do an exposure that is voluntary, sustained, and mild it's like taking a stick and poking out your comfort zone in this direction and that direction, gradually expanding your comfort bubble.

Real-Life Exposures

This is the single most useful Cognitive Behavioral Therapy technique for treating social anxiety. It is the only technique which, all by itself, has been able to completely treat some of my patients. In fact, I have several patients who just see me for short visits every few months so I can track their progress with this technique alone.

Just to introduce this topic, each of us has a comfort zone. We all have certain people, places, and situations that are inside of our comfort zone, and we all have people, places, and situations that are outside of our comfort zone. For example, I used to have a lot of social anxiety, so my social comfort zone was very small. Just a few close friends and family member were inside of it and everyone else was outside of it. But over the years I’ve done lots of exposures (like the ones I’m describing on this website) and now my comfort zone is pretty big, probably larger than most people’s. But there are still a lot of things outside of it. For example, if I’m in a bar and there's a fight, I’ll get nervous. I’ve never been in a fight; whereas, my friend John has been in 60 fights and he actually thinks they're fun (which is why I don’t go to bars with him anymore). Another example, if you get me to give a lecture to a bunch of psychiatrists without any preparation at all, I’ll get nervous. We all have things that are inside and outside of our comfort zones

At least once a day I want you to do something on purpose that is just outside your comfort zone. Things that count as being just outside your comfort zone are usually things like: saying one "small talk" sentence to a cashier, calling a relative, inviting a friend to a movie, putting a status update up on Facebook, saying the word “hello” as you walk by a stranger on the street.

As I mentioned before, whenever you do a Real-Life Exposure, it’s like taking a stick and poking your comfort zone out a little bit in this direction and a little bit in that direction, gradually expanding your comfort bubble. Typically speaking, if you do something that is a mild exposure four times, you will find that it is easier to do the fifth time around.

One thing to keep in mind about the comfort zone is that it changes every day. When you’re in a good mood, you have a big comfort zone. On a really good day, you may need to go to a bar alone and chat with a complete stranger in order for it to make you anxious. On a normal day, your comfort zone is “normal” size, so (depending on where you are in your treatment) asking a coworker about their weekend might count. On a day where you’re feeling really anxious or sad, your comfort zone can literally shrink to the size of your bed. On a day like that, even getting out of bed feels like an effort. So, on a day like that, getting out of bed actually counts as an exposure. It’s not about the activity. It’s about wherever your comfort zone happens to be that day and purposely stepping just outside of it.

Remember, the optimal exposure is always a low intensity exposure. A high intensity exposure is not helpful (it induces too much anxiety, which can become involuntary). Don’t pick something that is too hard to start out with. The section on Exposure Hierarchies can help you get a sense of where to start.

If you do something that you think will be a mild exposure, but then it accidentally turns out to be too hard, then stop and/or leave. Doing an exposure that is too hard doesn’t help you. For example, when I was doing exposures to parties, there were times where I would go to one figuring it would be OK. I knew most of the people there, and I had been to a similar party in the past so I figured it was fine. But then, once I got there, I realized that I was having a bad day. When that happened, I would try to pull out of the anxiety by using my techniques, but if it didn't work and it still felt overwhelming, I would leave. Remember, the optimal exposure is a low intensity exposure. If you are doing something that you feel is too hard then stop, pick something easier, and/or wait until you are in a better mood to try again.

There are some times when you have no choice but to do a “hard” exposure. This comes up most often with patients who need to speak in class, give a presentation, go on a job interview, go on a date, or ride in an airplane. You are either doing the activity or not doing it and there is no middle ground. In those cases, Role-Play Exposures (described later) and Sentence Exposures can be very useful in helping you prepare. Another option is to use a medication (such as a beta-blocker or a benzodiazepine) to “artificially” turn the activity into a mild exposure. If you use a medication, don’t take so much that you feel no anxiety at all (or else it won’t be an exposure). As time goes on, you can use less and less medication until the activity itself is just a mild exposure even without any medication.

As with all exposures, in addition to being mild, Real-Life Exposures must be voluntary and sustained. Don’t let someone “force” you into doing something. It won’t be helpful. On the flip side, you can’t count something that you have to do anyways (for example, going to class or a business meeting) as an exposure. That’s still not truly voluntary. Ideally, push yourself to talk a little more than you normally would or to do something that you would not have done anyways. In addition, you will need do the activity long enough (or repeat it often enough if it is a brief activity like saying Hello) for it to at least start to get boring. That is the best way to expand your comfort zone and gradually get rid of your social anxiety.

If you'd like some ideas for possible exposures, you can find them here: Example Real-Life Exposures

Hierarchy vs. Ad Hoc vs. General Goal Exposures

There are three ways to select Real-Life Exposures:

Hierarchy-Based Exposures

An “exposure hierarchy” is a list of activities that would trigger your social anxiety. You write the list yourself, rate each activity from a 0-100 scale (with 0 being totally calm and 100 being the most anxious you’ve ever felt), and order the activities from easiest to hardest. You then pick an activity with low anxiety (i.e. about at 20-40) and do that activity several times (as a Real-Life Exposure). You repeat that activity until the anxiety it produces is a 20 or below. You then move up to a harder activity on your list. You gradually keep progressing until you are able to do all the activities on your list with only minimal anxiety.

You do not have to do every single activity on your hierarchy. Exposures tend to “generalize”, meaning that they rub off on each other. So talking to an acquaintance at work helps with talking to a friend at a party. Speaking with a friend on the phone helps with calling a customer service representative. Saying an extra sentence to a cashier helps when chatting with a classmate. In addition, you can leapfrog over certain activities if you feel ready to do something harder. Harder exposures naturally help easier ones. So, if you feel ready to have a brief conversation with a total stranger, it will help you feel more comfortable in a conversation with a friend. Finally, easy exposures also help prepare you for harder exposure. Saying “Hello” to strangers makes it easier to say an extra sentence to a stranger later on.

Presentations, talking in person, and talking on the phone usually have to be done separately. They don’t seem to generalize to one another. For me, talking on the phone was actually the last activity that I got comfortable with. I had to push myself to stay on the phone a little bit longer each time (as an exposure) even though I was already comfortable talking in person and giving presentations.

You should re-rate the activities on your hierarchy periodically, both to track your progress and to see how the hardest thing on your list gets easier with time. By the time you work your way up to the hardest thing on your list, it should actually be much less intimidating (and so should only be a 20-40 anxiety level).

If you would like to view examples of exposure hierarchies, I have posted them here: Example Hierarchies

Ad Hoc Exposures

Ad Hoc Exposures are done “as they come up.” If you are in class and you feel up to it, raise your hand. If you are in a coffee shop and in a good enough mood, ask the cashier how her day has been. If you are at work and want to do an exposure, ask your coworker how his weekend was. If you are having a really bad day, just leave the house and walking around the block without speaking to anyone. Ad Hoc Exposures are based on your comfort level that particular day, always shooting for something that feels “mild”.

Nowadays, I make use of Ad Hoc Exposures to push myself to say Yes to invitations, to talk more to waiters, to leave the house when I’m in a bad mood, and to stay longer at social activities (i.e. I resist the impulse to leave the first time around). I also use Ad Hoc Exposures to push myself to discuss my problems to my friends and to be assertive when people have upset me.

Ad Hoc Exposures have the benefits of being flexible and organic. They are flexible in the sense that they are based on how you are feeling that day. This has the advantage of being less likely to overshoot the mark by picking something too hard. They are organic in the sense that you will be making use of activities that come up in your everyday life (rather than pushing yourself to do something that might not come up naturally).

Exposures via General Goals

General Goals are similar to New Year’s resolutions, but are usually more behavioral and specific. Once or twice a year, I’ll set a General Goal (usually at New Years and on my Birthday). About 5 years ago, my goal was to get comfortable around groups of guys my age (which triggered memories of being teased in grammar school). So I started hosting weekly events at my house (to watch TV shows, science programs, or sporting events). About two years ago, I set a goal of getting comfortable with one-on-one dinners with close friends. So, at least once a month I made sure to do that until it no longer made me anxious. I have had patients work on getting comfortable playing golf, going to the gym, showing their skin at the beach, wearing non-black/non-sweat-shirt clothing, being in public for more than an hour, going on dates, saying “I Love You” to family members, texting close friends at least once a week, and communicating their emotions. Setting a General Goal is a good mix between an Ad Hoc and Hierarchy-Based Exposure. It is organic (i.e. based on your daily life) but also directed (rather than waiting for things to come up on their own).  Examples of real-life exposures that can also be used as general goals can be found at the following link: Example Real-Life Exposures

Which type of exposure you do depends on your personal style. If you like being spontaneous and/or it’s hard to know what will trigger you each day, do Ad Hoc Exposures. If you like to plan things out and keep close track of your progress on paper, use Hierarchy-Based Exposures. If you like setting long-term goals, then set General Goals periodically. I usually recommend a mix of Ad Hoc and General Goal Exposures to my patients. I reserve Hierarchy-Based Exposures for patients that specifically like a very systematic, homework-based approach.

Just to remind you: exposures must be mild, voluntary and sustained (or repeated if a brief activity). If you do an exposure that you think will be mild, but it turns out be too intense, then stop the activity and/or leave. Switch to an easier task and/or try it again on a day you are feeling better. In addition, remember that you can’t count activities that you had to do anyways because those are not truly voluntary. Stay in the activity or repeat the activity (if brief) until you notice your anxiety level has decreased. Generally speaking, as long as you do at least one Real-Life Exposure a week, you will make progress.