Getting the Most Out of Exposure Therapy for Anxiety and OCD:
Five Reasons Your Anxiety Therapy is Not Getting You Where You Want to Go
By Ferdinando “Ferd” Palumbo, MSW, LCSW, Founder and Director, Northern NJ CBT
For the uninitiated, Exposure Therapy is a term to describe an evidence-based treatment for Anxiety, Panic Disorder, Obsessive Compulsive Disorder (OCD), Phobias, and even Posttraumatic Stress Disorder (PTSD) where clients and therapists identify feared stimuli, sensations, thoughts, etc and help the client face these feared experiences. Research suggests that this ought to be done usually in a gradual, sustained, and repetitive manner which leads people to be less afraid over time.
We humans in our imperfect nature have a tendency toward avoiding things, people, places, scenarios, thoughts, etc which make us anxious. We have a “fight, flight, freeze” response that is hardwired into our brains. These functions might serve us well if we were to be faced with a bear or a king cobra but our brain, if we aren’t careful will have us treat anything from checking our email, to preparing food for our families, to observing our religious beliefs with the same kind of threat response as if we were faced with real danger. In Acceptance and Commitment Therapy (ACT) they refer to this as “the avoidance trap,” like most traps there’s something attractive placed in the trap as bait. For individuals seeking therapy for anxiety, phobias, OCD, panic disorder, and many other conditions the trap is baited with relief that seems ever elusive. You just avoid the thing that’s scaring you and you’ll feel so much relief. In the short-term there is a relief there after we avoid or escape something causing us distress, but it comes at a high cost. The cost it comes at is we end up not engaging in our lives as fully and we end up fearing whatever it is much more and having less confidence in ourselves to face the discomfort.
Exposure therapy for anxiety, phobias, OCD, panic disorder, and even PTSD has been demonstrated to be safe and efficacious in helping people get out of the avoidance trap and into their lives. There are many theories as to why exposure therapy work, and this can be beautifully debated in the halls of academia and conferences for the International OCD Foundation (https://iocdf.org/) or the Anxiety and Depression Association of America (https://adaa.org/), but we know for certain Exposure Therapy works. If people face whatever thing or things they fear, multiple times, in a wide variety of settings, reduce internal and external safety behaviors (we’ll get into this later), they can have really marked improvements and less fear while connecting to life without these challenges getting in the way.
Here we look at a graph comparing avoidance and escape to exposure. Notice that the person engaging in avoidance and escape (the red line) gets instant relief but the last thing they will remember about facing whatever it is they fear is the height of the anxiety and that they felt better escaping. We notice that when the person engages in exposure for the first time (yellow) their anxiety goes up, and up, and up, but when they don’t escape they have the opportunity to allow that feeling to decrease. The second exposure (light blue) their anxiety doesn’t go up quite as high because they remember from the first time that the discomfort doesn’t last forever. In the third exposure (darker blue) we see the anxiety doesn’t spike as high as the previous times. We could imagine that the 257th Exposure the anxiety spike, if there were any at all would be very small and resolve itself quickly.
So let’s examine five common pitfalls in exposure therapy for anxiety, OCD, and Panic.
1. You or your therapist are looking for the “root cause” of the anxiety instead of how it is being maintained.
The field of psychotherapy owes a great debt of gratitude to Sigmund Freud, the founder of the first type of psychotherapy called psychoanalysis, for creating this field. In his theoretical model, the answers lay deep in the past for clients and the analyst and client are both psychological archaeologists looking for answers in the past. In this treatment, understanding the past is understood to be necessary and sufficient to alter behaviors. Respectfully, this doesn’t make a lot of sense to me. Let’s for argument’s sake suppose it was possible to find the “root cause”, the thing that happened in the past, that caused Anxiety, Panic or OCD in the first place. Well, that neglects to address what the client is doing in the here and now to maintain that Anxiety, Panic, and OCD. Suppose I were a cigarette smoker (which I am not), and I smoked my first cigarette because of the Marlboro Man ads from the 1950s through the 1990s. Well how would us examining the Marlboro Man ads in therapy help me alter the behaviors I’m doing today to maintain the smoking. In CBT for anxiety, we really can’t be certain of a specific cause but it’s not relevant for our purposes as we can see how avoidance is feeding the Anxiety, Panic, and OCD in the here and now. Let’s focus on what is maintaining the anxiety today rather than what could have potentially caused it.
2. Your therapist or you (if you’re a therapist) isn’t rooted in an evidence-based theoretical approach to treatment.
Research shows that most therapists are eclectic in their practice. This means they borrow bits and pieces from different theories of therapy. This can lead to a lack of direction and the exposure therapy, if it’s being used at all, is not being used in a consistent manner. It is absolutely okay for you as a client to ask your therapist “Ferd, how is this supposed to help me get better?” If your therapist cannot succinctly answer that question in a 30-90 second elevator pitch, chances are they are not rooted strongly in any theory and they don’t have the direction necessary to guide you through treatment. I would encourage you to find a therapist who has the training, skills and is being guided by a theoretical model rather than just throwing techniques at you. If you’re a therapist who this applies to please consider joining my training group! LINK HERE FOR CONSULT GROUP I’d love to help you get the training and skills necessary to treat clients with anxiety , panic disorder and OCD and speak confidently about why you’re using a specific intervention.
3. Your therapist (or you, if you’re the therapist) isn’t dialing up the intensity and/or dialing in the specificity of exposure therapy enough.
In this scenario the therapist is using exposure therapy—which is great!! The trouble is that for some fears we can get used to the less scary stimuli but still maintain a debilitating level of fear for what we believe is an insurmountable challenge. Take for example social anxiety, a therapist may have a client engage in normal social interaction, like talking to shopkeepers about the products they sell. This is great! But let’s say the client’s worst-case scenario is that they will make a mistake in front of an attractive person that they’re interested in. Well, no amount of normal conversation with a shopkeeper is going to help us see if making a mistake in front of an attractive person is the end of the world. In this scenario, the client may benefit from intentionally making a mistake instead of engaging in normal social conversations to see if making a mistake is that terrible. It may also be good to challenge the client to speak to people they’re attracted to in order to further approach the possibility of their worst-case scenario so they can see for themselves if they could survive that outcome. Intensity and specificity matter in exposure therapy. Ask yourself “what is my worst-case scenario and is my exposure leading me toward facing that possibility?”
4. You aren’t engaging in exposure in between therapy sessions and/or your therapist isn’t helping you engage in exposures in between sessions.
I once had a client who could engage in extreme exposures in session with me but his quality of life had not improved much at all. When I asked about how the homework between sessions he admitted he hadn’t been honest about the exposure homework. Being able to face scary stimuli with a therapist isn’t the most useful skill unless you can convince your therapist to go everywhere with you for the rest of your life. The purpose of facing fears in session with the therapist is to prepare you to face it between sessions. The real therapy occurs on your own facing what you fear and realizing you are more capable than Anxiety, OCD, and Panic would have you believe. Find ways to face your fears in between sessions in a variety of settings.
5. You are still engaging in safety behaviors/compulsions/ experiential avoidance even when facing the feared stimuli.
This is what happens when someone is facing their fears at least on paper but they still are either distracting themselves (experiential avoidance) or they are engaging in some sort of behavior which reassures them they will be okay or, at least in their minds, prevents the feared outcome from occurring. I worked with one client doing significant exposure therapy for panic disorder and was improving rapidly, then he experienced a plateau. I checked for safety behaviors and he informed me that before every drive he checked his vehicle for one single benzodiazepine pill he was prescribed and would mentally remind himself he could take that single pill if he had a panic attack. Although that is true, he absolutely can take a pill prescribed to him, the ritualized checking before each drive and reassuring himself ended up communicating to him that he really couldn’t tolerate driving while having a panic attack. We worked to reduce and eventually eliminate this checking behavior and he progressed toward being less afraid of panic sensations in his body.
These are 5 common pitfalls which get in the way of successful treatment. If you are interested in scheduling a free consultation Anxiety, OCD, or Panic Treatment in Northern New Jersey or virtually in New Jersey, please feel free to fill out the contact sheet here.