The next part of treatment is the most difficult and painful – confronting the feared situations and traumatic memories. It is also the most important. Your therapist will not start this process until you are ready and will take you through at a pace that you can manage. Most people find that it is not nearly as difficult as they expect it to be and there is often a tremendous sense of relief and achievement as the feared situations and painful memories are confronted and dealt with.
Not surprisingly, anxiety frequently causes people to stay away from frightening situations. It is quite normal for people to want to escape or avoid situations, thoughts, memories, or feelings that are painful or distressing. However, this is one of the major impediments to recovery. Avoidance and escape provide temporary relief – the anxiety reduces – but the next time the person encounters that situation again, he or she is likely to become anxious long before it is planned to occur. We call this “anticipatory anxiety”. The more the situation is avoided, the more the person continues to believe that it is dangerous. Further, even if the person does not avoid, the anxiety may continue to build once they are in the situation. Very often people believe that if they do not leave the situation they will “lose control”, “go crazy”, “have a heart attack”, or have some other dire consequences. At the very least, they are likely to believe that the unpleasant feelings will be intolerable. Exposure therapy aims to show that this is not the case by helping the person to confront the feared situation. The important thing to remember when you are confronting something that you are frightened of (whether it is a situation or a memory) is that the anxiety will come down if you stay there long enough. There is no answer to the question of how long is enough. In some cases, the anxiety may drop considerably in 15 to 20 minutes. In other cases, it may take as long as an hour or more but it will reduce eventually. It is vital that you try to stay in the feared situation long enough for the anxiety to reduce. It is important to note also that anxiety often increases before it starts to drop. This temporary increase is often enough to make people avoid or escape – it is vital that you stay with the feared situation through this phase until the anxiety reduces. This pattern is shown in the figure overleaf. You will notice that the drop in anxiety is not smooth – you may notice occasional small increases – but the general trend is downwards. Exposure is done in a controlled and gradual fashion so that discomfort is kept manageable. By building upon repeated successes in facing these feared situations, you will eventually be able to confront them without anxiety and no longer avoid them.
In many ways, this approach is common sense. Let’s take an example of a little boy who is standing on the beach when a big wave knocks him over. He becomes very frightened of the sea and refuses to go to the beach the next day. How would his mother or father help? In order to overcome the fear, his parents may take him for a walk along the beach, staying away from the sea, holding his hand and reassuring him. Gradually, they walk closer and closer to the water’s edge. Eventually, the boy is able to go into the sea again unaided. This is a simple example, but exactly the same process applies to treating more severe and complex fears in adults.
This section discusses confronting activities, places, people, or objects that you have become frightened of since the trauma. We call this type of exposure “in vivo”. In vivo simply means “in real life”. When we are confronting memories, we have to do it in imagination, so we call it imaginal exposure – which is discussed in the next section. In conducting exposure treatment, your therapist will work with you in constructing a hierarchy – a list of feared situations in order of difficulty. Treatment involves tackling each item, one at a time, and moving on to the next only when you are confident to do so. More difficult items may be broken up into several steps. Exposure treatment can be difficult and painful, but it is the most effective way of treating many anxieties.
Planning your program
1. Draw up a list of goals that you would like to achieve. These are likely to comprise places and activities that you have avoided since the trauma. The goals should be very specific and should vary from relatively easy to extremely difficult. Don’t worry if the worst ones seem unachievable at the moment – they will become easier as you progress through the others. List them in order of difficulty, starting with the easiest. For example:
• To be able to go shopping at the local shopping center
• To be able to catch public transport into the city
• To go back to where the trauma occurred
As a general rule, as you work through the list you should be aiming to confront situations that produce a Subjective units of distress level of around 70. For the first one or two, however, we suggest that you start with ones that are a little easier than that (say, around 50) – it is important that you experience some success early on in the process.
2. If something is too hard to try in one go, break it down into smaller steps. For example, if you were assaulted in a particular park, the first step maybe to go to the end of the street and look at the park from a distance. The second may be to go to the edge of the park, the third to walk into the park a short distance, and the final one to go back to the spot where the assault occurred.
3. You may want to work on more than one item at any one time, but do not overwhelm yourself. When you have mastered one (i.e., you are able to do it with minimal anxiety), move on to the next more difficult one.
Implementing your program
1. Try to do at least one of your selected goals every day. Avoiding something one day will set you back, as you will have built up the fear you are trying to reduce. Sometimes you will have bad days and feel that you are not progressing. It is important to still do something, although you may choose just to go over steps that you have already mastered.
2. You will need to do each step several times until you master it. Once you can do it without too much anxiety, it is still important to do it once in a while to make sure you don’t slip back. The general rule is: the more you fear it, the more frequently you need to confront it.
3. Keep a careful record of your progress. Take a sheet of paper and divide it into columns. In the first, write down your goal. In the second, note the date. In the third and fourth, write the time you started and (when you get back) the time you finished. In the fifth, write down the maximum Subjective units of distress you reached and in the sixth the Subjective units of distress level when you left the situation. The final column should be used for making any comments about the exercise. This will help both you and your therapist keep track of your exposure progress.
Practicing the steps
1. Try to relax using the techniques described above before you start. Get yourself as calm as possible.
2. Mentally rehearse the activity. Go through it in your mind and work out strategies to deal with difficult aspects. Practice the coping self-statements that you will say to yourself when you become distressed. Good preparation will make success more likely.
3. Go about the exercise in a slow and relaxed manner – give yourself plenty of time.
4. Keep an eye on your Subjective units of distress throughout the exercise. If they become very high (80 or more) before you’ve reached your goal, stop and wait for a while until the anxiety comes down a bit. When you feel ready, move on again slowly.
5. Try to stay in the situation until you feel yourself calming down. Ideally, the Subjective units of distress should reduce by half (e.g., from 70 to 35). The longer you remain in the situation, the calmer you will become and the faster you will overcome your fears.
6. Never leave the situation while your anxiety is still high. Try to face the fear, accept it, let it fade away, and then either move on or return. If you leave while the anxiety is still high it will be more difficult next time. Remind yourself that you have done really well to get this far; just hang in there until the anxiety comes down.
7. Congratulate yourself for your achievements. This is very hard work and you deserve a pat on the back. Don’t put yourself down by saying that you could do this kind of thing easily before the trauma or that anyone should be able to do it without getting upset. It’s a vital part of your recovery.