Exposure Therapy and How it Works

How can Exposure help with Anxiety and OCD?

I spent several years working at the Rogers Behavioral Health OCD and Anxiety Residential program where I learned to use exposure therapy to treat anxiety. I continue to work with OCD and anxiety since starting at Shoreside Therapies in Whitefish Bay, WI. Since COVID took over our lives, I’ve noticed an increase in anxiety and OCD. For many folks who may have been struggling with lower levels of anxiety or OCD, a global pandemic served as the catalyst that pushed their anxiety into unmanageable realms. There are a lot of unknowns with this pandemic and the risk inherent in the unknown is at the center of anxiety.

Anxiety: Avoiding The Uncomfortable Things

One of the common ways that humans deal with anxiety is to avoid the things that cause us fear. We avoid flying, heights, uncomfortable situations, social situations, and whatever else we fear- particularly if we don’t feel a sense that we can gain control. While we all have this common instinct to avoid, avoidance teaches us that the thing we are afraid of is really dangerous for us. Essentially, our brain tends to increase its overestimation of the probability that a negative event will occur. By continuing to avoid flying on an airplane, I maintain my overestimation of the probability that the airplane will crash. I may even know that it is much more likely that I would die in a car accident than in a plane accident, but I continue to avoid flying because the irrational fear center in my brain does not turn off simply because I know this fact. Based on this fact, I should have a much greater fear of driving than flying, but many people who fear flying drive every day.

Exposure Therapy Reduces Anxiety Through Experience

There is a reason for this, this reason is one of the core concepts of Exposure Therapy. By driving every day, or at least regularly, my experience helps me to realize that, while driving has risk, that risk is low. I can accept that risk because I think it’s improbable that I will get injured or die while driving. Essentially, experience has taught me that the risk of dying in a car crash is low because I’ve driven many times without being injured. New drivers who have just watched the scary videos of car crashes in their driver’s ed courses tend to drive with their hands at the 10 and 2 positions, fully turn their body to check their blind spots, carefully follow all traffic rules, and generally use great caution when driving. Cut to 6 months later, you see that same driver texting and eating a taco while driving… This change in behavior happens because that new driver has reduced their anxiety about a driving accident because they drove regularly and nothing happened. This is not to say that someone should be doing those things while driving, but that example illustrates how our brain estimates the probability of risk and how anxiety can respond to the experience.

Exposure Therapy Can Help

The core of exposure therapy is that exposing ourselves to feared situations repeatedly will help to reduce our anxiety as the brain will learn that the anxiety response is irrelevant to those situations. Now, this isn’t to say that you should simply expose yourself to every fear to reduce anxiety. Some things, like bears, we should be afraid of and our anxiety is warranted for those types of situations.

Exposure Therapy for Social Anxiety

We use exposure therapy to handle situations in which our anxiety is getting in the way of our life or when we rationally know that our anxiety is unwarranted. For example, someone with social anxiety feels depression, loneliness, and disconnected because they are avoiding social situations or find themselves avoiding talking or engaging in social situations. This avoidance is causing them distress making their life worse. The more this person avoids social situations, the more they think that social situations are fraught with risk. Risk of rejection, embarrassment and failure. Someone with social anxiety may have an inherent belief that avoiding social situations is the only way they can save themselves from being rejected and failing in those situations. This avoidance of those situations has another consequence though. It also prevents that person from having positive social experiences that teach the person that people can accept them and appreciate them for who they are. Avoidance prevents the person from challenging their negative beliefs that they will be rejected and realizing that they are overestimating the probability of rejection.

Exposure Therapy is a methodical way of exposing people to their fears. This therapy involves having a person rate different social behaviors that they are afraid:

• Talking to strangers (6)
• Asking people questions (7)
• Asking for favors (4)
• Asserting an opinion (4)

This range would be on a 0-7 scale (7 being the highest). When I work with someone with social anxiety, I then assign them several of those behaviors to engage in daily (if possible) that they rated at about a 4. The goal is for them to do behaviors that are anxiety-producing and challenging but that are also do-able for them to accomplish. This creates the fastest growth and change. When the person does a trial of this behavior, they rate their anxiety (on the 0-7 scale) at its peak when they are engaging in the behavior (talking to a stranger for example), and then the person times how long it takes for that anxiety to cut in half (going from a 4 on the anxiety scale down to a 2). I typically have people do five separate trials of that exposure a day if possible. As the person continues to engage in the exposure they notice that their peak anxiety when talking to a stranger tends to go down. They also notice that the time it takes for their anxiety to cut in half goes down. This is called habituation and it means that the brain is learning, via experience, that the probability of something negative happening when talking to a stranger is overestimated and that the anxiety response that their brain elicits in those scenarios is irrelevant and unnecessary.

Exposure Therapy for OCD

You can do exposures for OCD and other anxieties as well. For someone with contamination OCD, I would individualize the exposures to the person, but I might start by having the person touch a doorknob that they think could be contaminated without a barrier like their sleeve. This might be immensely difficult initially, but over time the person's anxiety in this scenario will go down. Over time we will progress through the persons list (otherwise known as a hierarchy in the Exposure Therapy world) of feared behaviors and the items that the person initially rated as high anxiety (5,6, and 7 ratings) will become possible to do as the person has engaged in easier behaviors associated with the fear. For example someone with contamination OCD who initially starts by touching a doorknob without a barrier could eventually touch a bathroom floor without a barrier. It’s important that as you build up to higher level exposures that one doesn’t go back to avoiding earlier/easier exposures that they have already completed (i.e. the person can’t go back to using barriers when touching door knobs as they start their exposure to touch the bathroom floor). The reason for this is that avoiding a feared behavior for an extended period of time can allow the brain to start overestimating the probability of risk again and the person may begin to believe that the only reason they haven’t gotten sick is because they have been avoiding touching doorknobs.

What can Exposure Therapy be Used for?

These examples of Exposure Therapy for OCD or social anxiety are just two easy examples of how one might use this treatment, but it can be used for things like:

• Public speaking
• Phobias
• Panic disorders
• Fear of flying
• PTSD
• General Anxiety
• Acute Stress

It can be used to address avoidance in general as well. This was just a very brief introduction to exposure therapy. It’s typically difficult for someone to simply run their own exposures on their own without being trained on how to set up their exposures, progress to harder exposures, and handle challenges that arise with exposures. After I work with people and teach them about exposure therapy and we have worked together for a while, the people I work with increasingly create their own exposures and build independence in managing this treatment. The goal is to build independence and skills so that the person no longer needs to meet with me.

If you think you might benefit from Exposure Therapy For Social Anxiety, OCD, or General Anxiety, reach out to me: