High Octane Phobia Treatment and Enhanced Exposure Therapy – Newly Revised!

Newer, More Effective Therapy to Overcome Anxiety and Phobias

David I. Mellinger, MSW, LCSW

Anxiety disorders are so common that more than 1 in every 10 Americans will contend with one at some point in their lives. Anxiety, fear, worry and panic attacks inhibit and incapacitate those with anxiety disorders from accomplishing valued goals, taking actions that they care about, and feeling free and vibrantly alive. Fortunately, anxiety disorders can be treated, generally with effective and cost-efficient methods (1).

So much is at stake, and for so many of us!  Disturbing anxiety can engender self-doubt and tangle our thinking. A sense of threat can build up that jangles our nerves and sickens us with worry. Our capacity to cope can be compromised if it persists.  Our confidence can erode, and our happiness may be jeopardized.

For over four decades, psychologists, neuroscientists, and psychotherapists have devoted immense effort to developing and implementing effective treatment for anxiety and phobias. The result is a remarkable achievement: Exposure Therapy (ET), a psychological treatment that enables people to see through the illusions of irrational fear and find the determination and courage to stride forward and do what’s needed to get the upper hand over anxiety.

Exposure therapy is a cognitive-behavioral therapy in which therapists create a safe environment in which to “expose individuals to the things they fear and avoid.” (2) Clients doing ET “repeatedly face situations, activities, or events that are feared, avoided, or endured with dread in order to learn new, more adaptive ways of responding and to reduce their anxious, fearful reactions.” (3) Using ET, a great many anxiety disorders sufferers have overcome panic disorder, fears of riding in elevators, driving on busy streets or freeways and situations like marketing, shopping in malls, movies, going to concerts, and social and sporting events, to name a few. In fact, ET has helped millions of people confront their fears and is now recognized as highly effective for phobic disorders, including panic, agoraphobia, social anxiety disorder, and obsessive-compulsive disorder.

These great accomplishments have been borne on the shoulders of giants of clinical psychology – most notably Joseph Wolpe, Jack Rachman, Edna Foa, David Barlow, and Michele Craske. I had the great fortune and privilege to learn to use exposure therapy from some of these greats starting in the mid-1980s, when ET became refined and proven effective.  Because I’ve been continually learning about scientific developments in the understanding of anxiety and its treatment, as psychological science and therapeutic strategies have evolved, I’ve been able to treat my clients using the latest, best practices.

A fable that has been going around for far too long is that anxiety can actually block courageous action and prevent individuals with anxiety disorders from being brave at crucial times.  That myth is untrue: Anxiety disorders are not courage disorders.  They’re built around false fear when no danger is present.

Through learning, progressing toward valued goals, and taking action that requires confidence and assurance, exposure practice shapes and molds clients into becoming aware of their courage and channeling it when facing their fears. Traditional ET, which continues to be the principal treatment, has been enhanced by newer strategies that empower people to face their fears more actively and directly, and treatment is often swifter.

In recent years, the main emphasis in treating anxiety has shifted from eliminating anxiety to learning to face fears and progress in valued directions while, at the same time, coping with anxious and fearful feelings. Doing so accomplishes lasting changes in the underlying mechanisms of the disorder while regaining the ability to do what matters.

“ET 2025” has become stronger and more laser-focused on underlying causes, tailored to individuals’ needs, capabilities, and values, and in many cases swifter.

Please Note: Exposure Therapy can be gradual, if that is best.  ET always is based on collaboration between therapist and client and is paced by what the client can handle in order to best progress.

A Brief, Highly Informative History of Exposure

• Introducing Exposure
  Anxiety disorders were widely considered chronic, and effective treatment was scarce until the first exposure therapy was developed during the 1950s by behavior therapy pioneer Joseph Wolpe. Dubbed “systematic desensitization,” Wolpe systematically and repeatedly exposed individuals with phobias to the stimuli they feared – situations, activities, and events – until their fears diminished. (4)

• A Recipe for Success
  In the early1980s, the tides of change swept in: Leading psychologist Jack Rachman introduced a recipe for successful exposure therapy for fear, suggesting that effective treatment should entail “the transformation or neutralization of emotion-provoking stimuli [through repeated presentations in a carefully structured fashion] and by inducing a low level of arousal” (5).

• The Integral Concepts
  In their pivotal article published in 1986, distinguished psychologists Edna Foa and Michael Kozak (6) helped lay critical groundwork for ET. They underscored the fact that for a person to learn to be less afraid, he or she must be exposed to a situation, activity, or event that evokes anxiety. They presented a model of the psychological mechanisms of anxiety disorders known as “fear structures” that create and maintain anxiety, irrational thinking, avoidance, and disturbing emotions and behavior and impair our ability to cope and function optimally.

• The Launching of Exposure Therapy Treatment
  By this time, psychological researchers and expert clinicians created and were testing out cognitive-behavioral protocols for treating anxiety disorders and began widely training therapists [like me!] in exposure therapy for panic disorder and agoraphobia. In 1989 and 1990, psychologists David Barlow and Michele Craske broke new ground when they published Mastery of Your Anxiety and Panic, a treatment workbook for clients and a scientific treatment manual for therapists (7, 8). Clients learned what to expect when they approached and engaged in feared, avoided activities during practices.  Psychotherapists learned to do skillful exposure therapy, optimizing the duration and quality of the exposures.

  The principal mechanism through which traditional exposure therapy achieves emotional change and gives clients the upper hand over anxiety is habituation learning – a fancy term for learning that decreases the anxious response.  Early ET was dubbed graduated exposure in which clients are generally advised to proceed gradually – by “baby steps,” in order to learn most effectively that they need no longer fear.  Gauging and limiting the discomfort level during exposure seemed important somehow – although in retrospect it’s not clear that it ever truly or demonstrably was.

Why So Cautious?

Through repeated practices facing fear in anxiety-provoking situations, fear of fear (aka “panic anxiety”) impacted clients less and less. When clients succeeded, they became much less apprehensive that crippling fear would overwhelm them and more confident in situations where they had been phobic – their apprehension became less and less credible.

But the baby-stepping engrained in the gradualness of graduated exposure creates a false impression that fear itself is way too hot to handle. Consider this: Acute and disturbing anxiety is formidable, but there’s actually no real threat. What we’re avoiding was never a danger to us in the first place. Skillful use of exposure therapy to face irrational fear is not dangerous, either: It can never cause tissue damage.

Skillful use of ET to face irrational fear is not a dangerous technique. And it’s not an all-or-nothing affair, either: Psychologists no longer believe that treatment success depends on eliminating anxiety and panic. Importantly, we now know that intensive, more rapid exposure is equal or in some cases quite superior to graduated exposure (9). Anxiety treatment experts recommend that “exposure begins with a moderately difficult task and that steps be taken to increase the difficulty of the exposure as quickly as the patient is willing” (10).

As I have treated clients with exposure therapy to enable them to face their fears and overcome anxieties and phobias over the years, I find myself moved by their bravery or courage. When I remark on their courage, they often seem rather surprised to realize that this often edgy part of their character is helping them through.

The Face of Anxiety Therapy is Changing Lately

    The most advanced anxiety therapies increasingly entail facing fear at a deeper, more elemental level and acting with bravery. More robust and resolute approaches to exposure are now coming into use. In the last several years, psychological research has led innovative clinicians to propose that clients can contend with anxiety more effectively if they learn through therapy to recognize the healing potential of acting bravely and experience the adventure of leaning into their fears – “Let’s try it out and find out what happens!” (11)

Cutting edge research on the techniques of inhibitory learning, also known as Exposure Through Inhibitory Retrieval, has led to the development of strategies that can improve and enhance exposure therapy (12).  Through Exposure Through Inhibitory Retrieval practice,

1. Clients are asked to briefly retrieve – to revisit in a controlled way – situations or actions resembling those in which they originally experienced fear reactions, which consequently emotionally inhibited them in their ability to engage in or manage them again.
2. By revisiting them in the context of therapy, clients learn to work with their phobic anxieties more directly, actively, and skillfully – with new tools and techniques – and thus can weaken the grip of avoidance and apprehension and may ultimately overcome their phobias.

     While traditional ET reduces phobic fear by decreasing the sway of the sense of imminent danger in phobic situations, in Exposure Through Inhibitory Retrieval, exposures are designed to “test out” objectively whether the feared outcome actually even occurs – outcomes such as being too afraid to control one’s actions, unbearable panic, or otherwise being “on the verge” of emotional overwhelm.  When they do not occur, clients’ association between the situations and the feared outcomes begins to loosen, and the grip of their fear weakens until they ultimately can become free of it.

In their seminal article on optimizing exposure therapy with an inhibitory retrieval approach, psychologists Michael Treanor and Michelle Craske explain that paying attention to the scariest aspects of phobic situations and learning to resist distraction, flinching, and turning one’s focus aside (avoiding) is essential to learning through exposure therapy.  Attention is essential to learning: “Staying with it” – focusing their thoughts and sensations squarely on inklings of the aversive outcome – whether it is the pounding of one’s heart, the thoughts and feelings of driving in heavy traffic, or maintaining eye contact while speaking with one’s boss is a powerful way to fight fear.

People engaging in exposure are also asked to get themselves to “Throw [it] out – the self-protective actions they take when they don’t’ need to, such as “the presence of a trusted person, cell phones, or medications like Xanax”, as well as the use of cognitive therapy phrases meant to reassure themselves when they are about to practice facing a situation where they fear their aversive outcome may occur.  The effects of safety signals and behaviors have been shown to be detrimental to exposure therapy, whereas instructions to refrain from safety behaviors were found to improve outcomes.

Many willing clients, with the strong encouragement and support of a therapist, can go much further when exposure is enhanced by Inhibitory Retrieval, and their recovery is more lasting and durable.  More precisely, clients can learn to overcome the need to hold back and avoid that discourages them from fully engaging in and benefiting from exposure and regaining their freedom of action.

Knowledge can be the remedy for fear.

  Bravery can be the negation of anxiety.

Bravery and Acceptance

Clients’ courage and their capacity for radical acceptance–learning to recognize what is true in the present moment and embracing whatever is seen with an open heart (13) — are recruited and instilled during exposure enhanced by inhibitory retrieval. Michelle Craske and Amy Sewart (14) call for bravery and fear acceptance in the following coaching instructions they offer for engaging in Exposure Through Inhibition Retrieval:

• Removing safety behaviors – “Throw [it] out”– the self-protective actions people take when they don’t need to
• “Facing your fear” – The therapist may occasionally arrange for one of the original anxiety-provoking events to “pay a surprise visit” during practices. Contrary to expectations, these seemingly unwelcome surprises can open clients’ eyes to their tenacity and bravery and bring about significant emotional change.
• Focusing your attention – “Stay with it” – Intentionally focus and maintain your attention on what you are afraid of during practices. We can counteract in adaptive ways the disruption of our ability to focus attention that strong emotional distress creates.
• “Varying it up” – At times, the therapist may pile on additional anxiety triggers during practices. For example, she may request that a client with freeway phobia who’s driving at 60 mph with trepidation on the freeway speed up and safely pass a semi-truck (another “inhibited behavior” for which she is phobic) or turn the heater up too high – although it’s a very hot day – to intensify the discomfort of the situation.

Both provoking of greater anxiety and increasing a client’s physical discomfort in the context of therapy with a skillful clinician are actually therapeutic in Exposure Through Inhibitory Retrieval – they’re likely to result in emotional change and improvement of self-efficacy and self-confidence – and have no significant downside. In fact, confronting fears in this way—the feeling of “I can do it” (and you can!) is greatly empowering.

Overcoming the Power of Inhibition

Through Exposure Through Inhibitory Retrieval, clients can get the upper hand over or overcome:

• Instinctual, fight-flight-freeze reactions that automatically hold them back from engaging with phobic situations, activities, and events
• Excessive avoidance of the sense of vulnerability during exposure. Vulnerability does not mean you will be harmed.
• Experiential avoidance – Inhibited or overly intensely focused attention that prevents us from seeing what really is
• Intolerance of uncertainty linked to feeling frightened during exposure. Yet given the benefits people reap, isn’t it worth it?

Practicing Exposure Through Inhibitory Retrieval, with the dedicated support of the therapist, enables individuals to learn that they’re safe–even while undermining their inhibitions and letting them step through the avoidance that sustains their fearfulness.  Their strengths emerge, mobilizing and enabling them to achieve what matters to them deeply. They can earn their liberty, the sense of self-efficacy, and perhaps pleasure and pride.

Traditional exposure can enable clients to act with the conviction that their phobic fears are very unlikely to actually occur. Exposure enhanced by inhibitory retrieval enables clients to believe that their phobic fears could never have become a reality in the first place.

Anxiety Therapy 2025 can enable clients to focus on accomplishing what matters the most to them and enhancing their ability to function in essential situations while building self-confidence and satisfaction in their substantial achievements.

References

1. Association of Behavioral and Cognitive Therapy website, Anxiety Disorders” paper.
2. American Psychological Association (2019). “What Is Exposure Therapy?” Viewed online at https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy on Feb. 24, 2023.
3. Davies, C.D. & Craske, M.G. (2018). Exposure Strategies. In Hayes, S.C. & Hofmann, S.G. (Eds.), Processed-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy (285-297). Oakland, CA: Context Press.
4. Wolpe, J. (1964). The Systematic Desensitization treatment of Neuroses. In Experiments in Behaviour Therapy. Oxford, England: Pergamon Press Ltd.
5. Rachman, S. (1980). Emotional processing. In Behaviour Research and Therapy, Volume 18, Issue 1, 51-60.
6. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99 (1), 20–35.
7. Barlow, D. H. & Craske, M. G. (1989). Mastery of Your Anxiety and Panic. Albany, NY: Graywind Publications.
8. Ibid, (1990). Mastery of Your Anxiety and Panic – Therapist Guide. Albany, NY: Graywind Publications.
9. Hayes, S. C.; Strosahl, K. D.; Wilson, K. G. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press.
10. Antony, M. M. & Swinson, R. P. (2000). Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment. Washington, D.C.: American Psychological Association.
11. Ehrenreich-May, J. & Coyne, L.W. (November 2022), Shaping         Bravery: A Clinical Demonstration of Shared Processes Across ACT and CBT That Target Youth Anxiety and Avoidance. Master Clinician Seminar, Association of Behavioral and Cognitive Therapy.
12. Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (July 2014). Maximizing Exposure Therapy: An Inhibitory Learning Approach. Behav Res Ther. 2014, 58: 10–23.
13. Brach, T. (2003). Radical Acceptance: Embracing Your Life with the Heart of a Buddha. New York: Bantam Books.
14. Sewart, A. R., & Craske, M. G. (2020). Inhibitory Learning. In S. Abramowitz & S. M. Blakey (Eds.), Clinical handbook of fear and anxiety: Maintenance processes and treatment mechanisms (pp. 265–285). American Psychological Association.