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The following methods are considered exposure methods. An exposure is a behavioral method in which a person is exposed in some way to the situation that creates anxiety. The specific exposure varies from person to person based upon the fear as well as their thoughts about the fear. What causes anxiety for one person may not cause anxiety for another person even if they have the same fear.

For instance, two people may have a fear of having panic attacks while driving. However, if I have them imagine having a panic attack while driving one may be able to imagine it fully and have a panic attack during the imaginal exposure while the other one says "I know it is not real right now so it doesn't cause anxiety." Or, one may have a panic attack while driving because of thoughts such as “What if I have a panic attack? I might have an accident” whereas another might have thoughts such as “What if I can't get help quickly?”

Therefore, these exposures need to be designed for each person's unique situation and fear. For this reason, not all of the following methods are appropriate for every person. However, these methods are often a critical part of treating panic and anxiety especially if significant avoidance is occurring.

As I have indicated previously, to truly learn how to manage panic and anxiety it is necessary to confront uncomfortable situations. Without the willingness to be uncomfortable and confront the fear, you can develop some limited ability to cope with the anxiety but not your full coping potential. I once had a woman come to my intensive program for anxiety disorders who said to me when I asked if she was willing to face discomfort, "If you told me that it would help for me to stand on my head on the sidewalk, I would do it." The willingness to face fears indicates the greatest likelihood of managing panic and anxiety.

Not everyone with an anxiety disorder requires exposure therapy to satisfactorily manage the anxiety. Some people find that using the previously described mindfulness and cognitive tools are sufficient. As they change their thinking and gain greater control over the anxiety, they naturally begin to confront feared situations and do not require a structured approach. However, others may still have significant avoidance and need the exposure therapy to address the anxiety.

Generally, although the exposure methods may be best after developing a foundation using the mindfulness and cognitive skills, sometimes the exposure methods may be preferred initially. In particular, the exposure methods tend to be quicker especially the more intensive methods. Also, sometimes a person may already have the foundation skills to the best of their ability but still engages in avoidance of the feared situation. In this case, the exposure methods can help enhance the cognitive and mindfulness skills.

For these exposure methods to be conducted properly, a therapist skilled in CBT for anxiety disorders is required. This is true for several reasons:

1) Intensity of Methods. Therapeutic methods that are intense have a higher likelihood of not only failing but even worsening the condition if done improperly. In particular, with exposure treatment we are concerned with the possibility of sensitizing someone further to the fear when our purpose is to desensitize or lessen the fear.

This can even happen when the therapist is involved and being cautious. I once treated a man with panic attacks in large enclosed spaces. We had been doing some step-by-step exposures and his next assignment was to walk inside the entrance of a large mall, stand there for a few moments and leave. However, he was so prepared for the assignment that he didn't have any anxiety. In his excitement of not having anxiety he decided to walk further into the mall against the therapeutic instructions. However, he was not prepared for this higher level exposure and as a result he had a full-blown panic attack and we had to start over in the desensitization process.

Having a therapist develop the exposure treatment decreases the likelihood that sensitization will occur. However, be sure that your therapist has training and experience with this type of treatment. Not every therapist is trained in these methods and the likelihood of sensitization increases with less experience. I have heard from clients too often that previous exposure therapy didn't work and when I asked them to describe how it was done they reported “My therapist (or psychiatrist) told me to do the things I was afraid of.” The way you can tell if a therapist is specially trained in CBT with anxiety disorders is that the process of doing exposures is very structured. It has to be or the risk of sensitization is high.

2) Therapist Experience. A CBT therapist who has expertise with anxiety disorders has the training and experience to develop a plan that is likely to be successful if followed precisely. The therapist knows the pitfalls and how to proceed in a way that is helpful to each individual client.

There is no "one size fits all" method and the skilled therapist will design a plan that fits for the needs of each client. Your therapist can determine when you are ready for exposure treatment, which type of exposure method is best for your situation, and how to best proceed.

3) Therapist Assistance. Some exposures may require direct therapist assistance. Such assistance may be coaching through the exposure or it may be part of the step-by-step plan. For instance, for someone with a fear of having a panic attack while driving it may be necessary to drive with the therapist present prior to driving alone. Or, it may be necessary to have the therapist available by phone initially. Once the anxiety level reduces with the therapist present the therapeutic support is gradually withdrawn until the person can do the exposure alone.

Suggestion 38: Gradual Desensitization

A core component of many of the exposure methods is gradual desensitization also known as systematic desensitization. This method involves developing a structured plan of small, successive steps towards a goal which usually involves some sort of avoidance. Repeatedly engaging in each step causes the anxiety to reduce. Once a step no longer creates significant anxiety you then take the next step in the plan.

Gradual exposure work involves determining the goal, developing a hierarchy of exposures, creating a plan for doing each exposure, and cognitively restructuring your thoughts after the exposure. Therapeutic assistance is important in this process.

1) Determining the Goal. Developing the first step is often more difficult than it seems. My clients frequently view the suggested first step as something too simple that they “should” just be able to do and they want to start with a more difficult goal. However, if the goal is too difficult there is a greater likelihood of failure. Early in treatment failure can be very discouraging. Therefore, the goal needs to be achievable. Keep in mind that even though you may have an overall goal such as being able to drive anywhere, that goal may be broken down into several goals: driving to the local store, driving to work, driving on the highway, etc.

Often, this means that initial progress may be slow. However, I explain to my clients that it is better to lay a solid foundation upon which we can build than too quickly confront fears with a high risk for failure. I find that my job as a therapist at this point is often holding the client back from setting too lofty of goals. I understand that they want their life back but we are more likely to be successful if we approach it in a structured stepwise fashion.

2) Developing the Hierarchy. When I am working with a client to develop a hierarchy of exposures for the goal we have chosen, we start by identifying all the possible steps to achieve that goal. For instance, driving to work may be the goal but there may be a number of steps within that goal depending upon the level of anxiety: sitting in the car, driving around the block, driving to a nearby store, driving to the gas station, etc.

Once we have a list of steps I ask the client how much anxiety (on a scale from 1 to 10) they anticipate experiencing when they do each step. In this way, we can order the steps from the least amount of anxiety to the most. Also, it allows me to see if we have a starting point. If all the exposures are rated a 9 or 10 we need to start again with breaking the goal down into even smaller steps until we have a starting point that is more reasonable. Initially, I like the starting point to be about a level 5 but as the person gains experience and confidence with doing exposures the starting point for a particular goal can be higher.

For some people, the process of writing down the list of exposures and having a concrete list may make facing their fear seem less overwhelming and more manageable. Whereas others when initially developing a list of exposures may exclaim “I will NEVER be able to do that!” referring to the high level exposures. However, I explain to them that their perception of those high level exposures will change as they successfully manage the lower level exposures. In fact, often by the time we are ready to do the high level exposures they are no longer rated as high by the client. This is due to the development of confidence and the increased ability to tolerate the discomfort of the anxiety that has developed due to completing the lower level exposures.

For those with especially good imaginations, even the process of developing a hierarchy can be an exposure. In other words, their anxiety level increases greatly just by talking about possible exposures. If that occurs, then we may start by using the hierarchy development process as imaginal exposures. I will explain this further in the method (Suggestion 44) about imagining the fear.

3) Plan for the Exposure. Each exposure for each client is different. There is no cookie-cutter method of doing exposures. Which is why having a specialist with this type of treatment is critical. The way in which the exposure is done varies according to the goal and what elicits the anxiety. For instance, for some clients I might assist with the exposure such as riding along with them when doing a driving exposure and coaching them. However, other clients may not have any anxiety if I am present in which case it is not really an exposure because an exposure is meant to elicit anxiety.

In addition, the plan might vary in terms of whether the client should use any anxiety management skills and which ones or whether they should focus on mindfully tolerating the anxiety. The plan also needs to include how to handle unexpected situations or if the anxiety increases to a higher level than expected. So, when I give a client an exposure assignment it includes very explicit instructions on how to manage the exposure.

4) Cognitive Restructuring. I know many experts with anxiety believe that since the fearful thoughts about the exposure will change as a person faces their fear it is not necessary to make this process more explicit. However, I find that many of my clients are self-critical and that even though they have a successful exposure in my view they tend to see it as a failure: “Oh, anybody should be able to do that!” or “I didn't do it exactly the way I was supposed to” or “I was very scared.”

Therefore, after the exposures I assess how they are thinking about the exposure. If they are being self-critical or feeling discouraged, I point out the successes within the exposure and what they achieved. For example, “Of course you were afraid. But you were doing something that you have been avoiding” or “Exposures have an element of uncertainty so you might not do them the way we planned, but you still did it and you also dealt with the uncertainty!” READ MORE: page 14

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