Episode #157

Exposure Therapy & CBT

Exposure therapy is often used to help anxiety sufferers.

The concept can sound scary, because it involves exposing you to the thing you fear.

Why can exposure therapy make such a difference?

How does it work?

Join me, Dr Julie, as I share with you the powerful ways exposure therapy can help you challenge and conquer your anxiety.

Click to listen now!

 
 

Full Episode Transcript

Hi, it's Dr. Julie. Welcome to My CBT Podcast. I'm a Doctor of Psychology and a Licensed Clinical Social Worker specializing in Cognitive Behavioral Therapy. I'm here to help you bring the power of CBT into your own life.

So I hope everybody's doing well. And as always, thanks for taking your time to hang out with me right now and learn some new tools. I wanted to share a really great email I received that I thought might be helpful for everybody, and I'm going to keep her name confidential.

But it says,

“Hi, Dr. Osborn. I am a counselor, and I just listened to your latest podcast. I like how you speak, and I like your approach. I've gone through my own mental health issues that I haven't always done the best sorting through. I want to work on being a happier, more confident person and a better therapist. I recognize where that needs to start, and that would be with me. I understand people have listened to your podcast to help themselves. I see you have 154 plus. Do you have pointed ones that address many of the CBT tools and concepts, or do you recommend people start from your first and listen to all of them? I'm on a mission to be the better version of myself personally and professionally. I appreciate any suggestions you may have.”

So thank you to that listener that reached out to me. So I thought it'd be a good one to reach out, or not reach out, I'm sorry, to share with you guys and give you a little direction as well, because I do have some people ask which ones would be the best to listen to. So There are so many. And what I did respond to, I was saying that most of them are 30 minutes or longer. And so you can definitely get through all of the ones you're listening to, and it's not going to take too much of your time. But if you're new, I probably will listen to maybe my first three that just talk about what CBT is, talk about depression, talk about anxiety. And then one of my most popular ones is the ABCs of CBT, which walk you through a thought record from beginning to end. And then And as you look through my list, they all have a little bit of a definition next to what the information is.

So just scroll through and pick what you think is best for you. If you're listening to it halfway and it's not working, then you can always pick another one. But again, I think because I purposely make them short, I want you to be able to listen to all of it and be able to get through it and walk away with some tools. So I'm probably being biased, but I don't think there's any that would not be worth your time. There's just a lot of really good topics I've been able to cover over the last five years. So that would be a start if any of you guys are new and just figuring out how to get started. And I don't want you to feel overwhelmed because there's so many. They're there forever and you can get to them whenever you have time. So again, please keep sending me your emails, any feedback, any questions, any particular topics you want me to cover on a future show, all those things. I read all of them, I respond to all of them, and I really find them helpful. And I love hearing that it is making a difference for all of you that are listening to my podcast out there.

So today, I thought an interesting topic would be talking about exposure therapy. So exposure therapy is a form of cognitive behavioral therapy, and it is exposing yourself to the fears that you have. So It is hard, but living with anxiety is even harder. So exposure therapy is definitely for anxiety disorders or anxiety situations that you're dealing with. So I know when people think, Oh my God, expose myself to the thing I fear, that's too hard. But I always tell people, when anybody says to me, Oh, that's hard, because I hear that often, I always say to them, That's because it's important. Anything hard in life is important. If it was easy, you would have done it already. And I've never, and I don't use that word lightly, been able to find anything in life that's easy, that's also important. And what I mean by that is loving people is hard. Being a good employee, being a good friend, being a good listener. Those things are hard because it takes effort and we need to be mindful and really put our best foot forward. You might be like, Oh, well, yeah, it's easy to do this or that.

But there's times that it is a little hard because I have to, Am I doing what's best? Am I really being there for the person in my life? Am I taking the time? Am I really being a good listener? Am I really doing the best job I can at my work? Things like that. So as soon as you catch yourself saying, Oh, that's hard, just remind yourself it's important. But again, living with anxiety is harder than going through the exposure therapy. Exposure therapy is short term. Anxiety can stick with you forever if you don't address it. And you want to know that you can fight back. You're not stuck with this fear of whatever it is in your life that you're avoiding. And that's where the exposure... Research shows, it definitely is one of the quickest ways to resolve your anxiety because you're just jumping into the deep end, as they would say, with some tools, though. So a couple of things before you would even get started with the exposure therapy. And hopefully, you can do this on your own, but if you're really struggling, it's great to have a therapist, right? And you want to have a good relationship with your therapist and feel like you're in a safe environment.

So that's important. If you're in therapy now and you don't feel like you can really be honest, or you don't feel your therapist giving you enough time, or they're paying enough attention, or they give you enough time to talk through things, whatever that might be. I would say, you're coming for a service, and not to feel obligated to stay with the therapist because, oh, that's the therapist. Do not put them on a pedestal. They're just another person. If you don't feel like they're a good fit, then go find somebody else. There's lots of us out there. So just listen to your gut regarding that. But if you want to do the exposure therapy or if your therapist brings that up to you, that they feel it would be helpful, you ask yourself, do I feel safe and do I have a really good relationship with my therapist, really good therapeutic relationship that I feel I can really trust this person? It's having a good what they call a therapeutic alliance where you're going to sense that your therapist is trustworthy and competent. That's really important. So there's some questions I want you to ask yourself before you just say, Yeah, sure.

Let's just go do this exposure therapy, because I really want it to be helpful. And when you have the foundation of a good therapeutic alliance, it's really going to make a big difference for you. Now, I want to say the research shows that exposure therapy is not helpful with substance abuse. If you have some physical health conditions or any paranoia, those would not be diagnosis that be using the exposure therapy, but there's lots of others that we can use. So I just wanted to put that out there. And when you do the exposure therapy, you're going to learn that your earlier ways of responding to your anxiety may have soothed you then, but actually you're just perpetuating your anxiety. Because when you avoid it, you're just putting it off, putting it off, putting it off. So it ends up perpetuating because now you're telling yourself like, Oh, yeah, that is a scary thing. I shouldn't do that. And your brain is like, Okay. Because remember, your brain believes whatever you tell it. So again, I want to repeat that, that your earlier ways of responding to your anxiety may have soothed you, but you're perpetuating the anxiety.

So you have to see not dealing with it. I'm really making it worse, which is I know that's not what you want to do. So let's use our tools to get past it and be able to manage it. I always say that you want to manage your anxiety. You don't want your anxiety to manage you. And you also want to remember, because this is true with the exposure therapy, that often when you go into therapy and you start working on your issues, that you often feel worse before you feel better because you're dealing with your stuff. I know I've shared this before, but I have a lot of my clients, they're working with the Mind Over Mood book with me, and they're like, God, I feel more depressed and anxious when I read this and I say, Exactly, because you're getting to your root issues quickly and you're really looking at what's going on and why do you feel bad? So that's normal. That is normal. When you start therapy, it goes up and down, up and down. Some days are better than not, but slowly you'll start to feel better, feel better for better when you start having these tools that you can use.

So that's all normal. You also want to recognize when you do the exposure therapy, you're going to see that all these fears I have actually don't come true. I'll say, Oh, I didn't have a heart attack. I didn't pass out. I didn't faint. I didn't die. Nothing bad happened. That's important to take the time and recognize that. And again, when you're doing this with your therapist, You have to see this is something I'm doing with my therapist. We're doing this together. This is not that your therapist is doing this to you. So you need to be on board. Don't do this because your therapist is pushing, pushing, and quote, making you do it, because then it's not going to be therapeutic for you because now that just is more anxiety. And then you're like, Oh, I don't want to disappoint my therapist. My therapist is going to be upset if I don't do this well. That is not the point at all of therapy. It's not about, please You're making your therapist or making them happy with you. This is all about you. So you want to know that you're doing this with your therapist.

They're not doing this to you. So that's why you have to have, again, that therapeutic alliance and feel the trust, feel they're competent, feel like we're a team working together and we're going to create whatever this exposure therapy is going to be, which one is going to work best for me. And the other thing I want to share, which I've said before, too, is that you want to remember that you can't feel relaxed and anxious at the same time. So that means that when I am anxious, what's my first tools I can go to? Is my breathing exercises, right? To take my time. I love the 4, 7, 8 breathing, where you are breathing in for 4 seconds, holding quick for 7, exhaling for eight. But when you're doing this, you're having your tongue hit the back of the roof of your mouth or your teeth and your gummeat. I've shared this before, too. But if you go on to YouTube under 4, 7, 8 breathing. Dr. Andrew Weil goes through a whole little video with you, which is really great. So you want to get some breathing that you feel comfortable with, that you feel like it works for you.

And whenever you're anxious, that's the first thing you can do. Let me get my body If your body is calm and you have enough oxygen, you can't feel both at the same time, like I was saying. So what do I need to do to help my body get more relaxed? And that's something that I can use while I'm doing some of the exposure therapy as well, which I'll talk about in a second, how that can work for both. So like I said, there's more than one exposure therapy, and we got to figure out which one is going to be right for you. So let's get started. I want to educate you guys a little bit on the different ones, and then you can figure out if you want to try this, if you're in therapy, take this to your therapist and say, Is this something you could help me with? I think this would be helpful. If you feel there's some of these things you could try on your own or have someone you trust with you to go with you. If it's a particular place you have to go to, if it's an elevator or that thing, you can have somebody at least go with you and be waiting outside while you're on the elevator.

So there's lots of creative ways you can create exposure for yourself to get you over those fears. So the first one is called in vivo exposure, and that is confronting the feared object, the situation, or the activity in real life. An example of this might be if you have a fear of dogs, you would gradually interact with dogs, first from a distance, then closer, and eventually you could pet one. So if you can find a situation, if you have somebody maybe in your family that has a dog, say, Oh, can I come over? I just want to sit in the living room. If you can have your dog on a leash and hold your dog until I feel more comfortable, until I can feel like I can maybe sit a little closer. Eventually, I can pet your dog, maybe give your dog a treat. If you have someone in your life with a dog or a neighbor, you could say, I really want to get over this. I wonder if that's something you could help me with. I know some therapists actually have dogs that they bring into their offices that can be soothing and therapeutic with their clients.

So if your therapist has a dog, that will be helpful. So that's just some ideas. What is it that I'm afraid of? So I'm going to confront the fear, regarding an object, a situation, activity in real life. An object might be, say, if you're afraid of needles, that might be an example of that. I happen to have a group of neighbors that we call every day. We have puppy happy hour. So Paisley gets to come with me. And around four o'clock, we all meet at a park nearby. One of my neighbors brings treats, and everybody comes and they have dogs. And now we've created this friendship, and it's turning into a really nice social event. But there's all different dogs. And I was thinking, if somebody was afraid of dogs, that would be a place to... They could just stand far from us, right? And then get a little closer. And then if they're like, Oh, can I give your dog one of the treats? There's lots of ways you can go slow. Again, we're not just always jumping in at the deep end, but we're actually exposing ourselves to that fear because we can use our thought record to get started, right?

What are my hot thoughts that's going to happen if I am close to a dog? But then you really are going to have to do the behavioral part, which is the exposure, and put yourself in the situation and see, I am safe, I am in control. I can find some dogs that I feel comfortable with, that are really calming, and that I can be okay. So again, that's just one example, but you can fit that into whatever whatever fear you have of something that you want to get over. It's definitely... So the second one is imaginal exposure. So this is when you vividly imagine the fear situation or memory in detail. So a good example of this would be someone who has post-traumatic stress disorder might recount a traumatic memory repeatedly to reduce the emotional reactivity they have to it over time. So this is your imagining it, right? What's the feared situation? And you're recounting what happened. And over time, your brain will be calmer with that memory. So this is something that you can do on paper. Maybe you could write out the whole situation. You could read it to your therapist. Your therapist could help you walk you through the memory.

Because a lot of times we avoid like, I don't want to think about that. I don't want to think about what happened. But actually thinking about it decreases the anxiety. So that's imaginal exposure. The next one is interoceptive exposure. So that's when you're deliberately triggering physical sensations associated with anxiety to learn they're safe. So one thing, and actually, when Dr. Greenberger was training me, he did this with me in one of my trainings, is I was sitting in a chair in his office and he had me spin my chair until I felt dizzy. So spinning a chair to create dizziness If you have panic disorder, right? Because the fear is like, if when you feel that panic, like something bad is going to happen, I can't handle it. So I've had clients, and I've done this with clients since I learned this from Dr. Greenberger, is whether I have a spinning chair or I'm having them stand up and go in circles and doing that to create a real feeling of dizziness where they're starting to feel like, Oh, no, the panic's coming, the panic's coming. And then I can intervene and help them relax and talk them through and see that they're safe and nothing bad happened.

So that is where you're actually deliberately triggering the physical sensation. I know that can sound really scary, especially if you have panic disorder. And that's why if you're in therapy or if you're not, to go find a therapist that doing this with someone, do not do this one on your own, because if you're struggling with panic disorder, it's not going to be able to do that on your own to calm yourself. You need another person, again, where you feel safe and they're calming and they can talk you through and you say, Oh, nothing bad actually happened. A side note, because I learned this from Dr. David Burns, I always thought it was great, is if you're having a panic attack, when you're feeling that you want to do jumping jacks, which I know sounds a little like, What? But But when you do enough jumping jacks, people actually start to giggle at the end because then you can see, if I can do jumping jacks, I am okay. And you get distracted and the panic goes away. So that's just a little side note, not to the exposure, but I always like to share that because it really works.

I have a podcast just on panic disorder called Don't Panic, and I talk more about that in there. But I just wanted to share that because I had that memory of that was a really great tool that I really liked that he taught me. So the next one is virtual reality exposure. So this one's really cool. So this is using a virtual reality technology to simulate the... I'm sorry, the feared environment or situation. So the virtual technology where you have it looks like goggles, right? And you can actually see the situation. So if you have a therapist that has that technology in the office, that is pretty cool because I've done this before where I've, not for exposure, but just to wear them. And man, you feel like you are right there in the situation. So that could be a really cool way to put yourself in a situation that you fear, but you're still in that safe environment to be able to get over whatever that fear is. So one example would be simulating an airplane flying take off if you're afraid of flying. You could really get that sensation of taking off and however you feel or if your stomach starts to sink, like in having the therapist be able to walk you through that.

So that's super cool with the virtual reality. Now that that is something that's out there. The next one is prolonged exposure. So that's a specific type of exposure therapy used primarily for posttraumatic stress disorder. And it includes both the image exposure I was talking about and in vivo exposure. So this is where they repeatedly describe the trauma while confronting the avoided reminders. So this is doing both. And so the prolonged... It takes a little bit of time because they're repeatedly describing the trauma over and over again. And they're confronting the void of reminders, whatever that might be for that person. So that's another one. Then there's flooding. So flooding is a type of exposure where there's immediate and intense exposure to the feared stimulus until your anxiety diminishes. If you're afraid of spiders, this would be placing yourself with some spiders in a room, knowing there's one spider in the room. There's a lot of potential distress in this situation. So again, that's why you need to be with a therapist that you're really comfortable with. It could be if you are afraid of needles, right? And your therapist could just put some needles on her desk and you would be close to them.

And then eventually, you would go over, you would touch the needle, that type of thing. So the flooding is, it's immediate, it's intense. And again, that's why you want to be with a very skilled therapist to be able to deal with this anxiety anxiety and feel safe that I can get through this. I'm safe. Nothing bad is going to happen. It could also be, again, when a lot of people are afraid of elevators, so it would be like, Okay, we're just going to go get on the elevator and go up and down and up and down and stop on this floor and stop on that floor. And you just keep going and keep going until the anxiety starts to diminish. And this is an exercise I've talked to many people that have done and have found it very helpful. It's like, Well, no, that's the thing I'm avoiding. Can't we talk about it first? Can't I? And we can talk a little bit, but then we just got to get on it. We just got to get on. If you're afraid of roller coasters, you need to go on that roller coaster, probably five, six, seven, maybe 10 times, over and over and over and over until like, Okay, I'm having fun now.

I'm not so afraid of it. Whatever it is, whatever your fear is that you want to get over, that's affecting your life, then we want find a way to expose yourself to that, to be able to get past it. And again, there's different steps to take. I had a client who had some trauma at her work, but she was going to plan to go back after she was feeling better. And so we came up with a plan where she drove to the parking lot of the mall and she just sat in her car. Well, even before that, I think she just drove by the mall, drove by. Then she went and sat in the parking lot. Then eventually she went into some other stores, not the one she worked at, but she walked first into some other stores in the mall. Then she stepped into her store, and eventually she was able to go back and felt comfortable. But as she was sitting, say, in the parking lot, she started feeling that her heart started beating fast. We walked through doing the breathing exercises. I can be calm in this place. So that's where you can, which is...

I'm going into my next one, actually, which is systematic desensitization. So that is the gradual exposure paired with the relaxation exercises. So again, what I was saying, I'd say, Okay, I want you to go park in the parking lot at the mall, and practice our relaxation techniques that we've learned, whether it's deep breathing, progressive muscle relaxation, doing imagery in your head of being at work, greeting the customers, checking them out at the cash register, walking, seeing the old employees you worked with before saying, Hello, how am I going to handle when they say, Where have you been? What am I going to say? And being able to breathe through all this at the same time and be like, Oh, I can feel relaxed and I can handle the situation. So using the breathing techniques while gradually working through your fear hierarchy can really work. In mind over mood in chapter 14, which is understanding anxiety, there's a fear ladder exercise. If you think of a ladder, you take one step to the next, till you get to the top. So there's lots of examples in there, but someone did a fear of public speaking. So at the top of the ladder, it was to be able to give my speech and be okay.

So at the bottom, there's all these different steps. First, he wrote out the speech, then he practiced it in the mirror, then he practiced it with family, then he practiced it with friends, and so on and so on. But during that time, you can also practice the relaxation techniques as I'm doing each thing to build up your confidence. Another example would be, say, you're afraid of snakes. If you're looking at photos of snakes while doing the relaxation exercises, then you might watch videos of some snakes, and then eventually, maybe you'll go to the zoo and see the snakes. So what is it that I want to get past because it's getting in the way of my life? I say that a couple of times because I can tell you for myself, I love snorkeling. I am not going to scuba dive. I don't need to. I'm sure it's a wonderful thing. My husband does. Sure, it'd be great to go, but I'm not comfortable, and it doesn't affect my life in any way if I don't do it. So I'm not going to push myself, and that's my choice. So I'm saying, Don't be like, Oh, I got to do this.

I got to do that. I want you to pick things that are affecting your life negatively. If you're afraid of needles, maybe you won't go get your blood work done. That's important, right? To go to the doctor. Or with the snake thing. I don't know, maybe you want to go visit a country. You know, there's some snakes I'm going to not go visit that place because I don't want to maybe see a snake, right? I mean, that's where it's like, how is it affecting your life negatively? Not getting on an elevator is a factor, right? I can't walk 20 floors to go up to my appointment because there are some buildings that are that tall. I need to use the elevator. So how is it affecting my life negatively? How can I get past that? I also wanted to address how you can use exposure therapy if you have existential fears. So a lot of people have what they call this existential dread, these fears of the unknown. What's the purpose of my life? What's going to happen? So some things you can work on to address that instead of just avoiding them like, Oh, don't think about it, because then it's going to come up, especially when you say, Don't think about it.

You can practice mindfulness, and you want to make some meaning or create some meaning, I'm sorry, out of the fears that you have. You want to process your thoughts and your feelings associated with the existential dread. So there's your thought record. And you can imagine a scenario related to the end of life, for example, if you're afraid of death. What if in the future I make wrong choices? I need to learn to accept that there's uncertainty without engaging in the avoidant behaviors. So how do I deal with existential dread? It's not so much that we're here to look for evidence or not because it's really about things a lot of times we don't have answers to. So we want to be able to be mindful. Okay, these are just my anxious thoughts. I'm thinking about the future. I don't have answers. What's the meaning behind them? What are these thoughts that are going through my head that feed into this existential dread? And then think about, what is the scenario I have related to the end of my life? Regarding the thinking that it's meaningless of my existence. Or again, if I make wrong choices.

If I can accept the certainty, then I will be able to move on and find some peace and be more present, which is where the mindfulness can help. So that's just a little exercise you can get started if existential dread is an issue for you. Again, it's not just like, Oh, everything will be okay. Don't worry about it. I really need to deal with this. And I wanted to talk about what are some things that people go through that exposure techniques can work for. And there's different Like I was saying earlier, different exposures for different situations. So there's the book I would refer for today, which is Dr. David Burnsberg called When Panic Attacks. Really great book. Goes through tons of the CBT tools I talked to you guys about. But You can use exposure for chronic worrying, panic attacks, agoraphobia, any fears and phobias, shyness, test anxiety, public speaking anxiety, performance anxiety, obsessions and compulsions, post-traumatic stress disorder, health concerns, and body dysmorphic disorder, which be concerns about your appearance. So the The cognitive exposure involves confronting your worst fears in your mind's eye. And again, this can play a really huge role in the treatment of getting past your anxiety, which is what's most important.

And so all of these things I just mentioned, if that's something that you're going through, to think about and say, Okay, I'm going to maybe read more about this. I'm going to take this back to my therapist, see what my therapist knows about it and how we can incorporate the exposure therapy into my therapy because I am ready to challenge this. I've had a few clients I've seen that had a fear of driving. Maybe they had a really bad accident, or if you live out here in California, our freeways are huge. They're like five lanes. They're a thing. So I can only imagine if people are afraid of driving, like getting on the freeway is a big deal. But they're frustrated and they want to get back to driving. So I remember I had one client, I said, On your way home, because she could take the freeway. You can always find side streets, right? But she wanted to take the freeway. So I said, Get on the freeway and just get off on the next exit. That's all you need to do. And then take the rest of the streets home like you always do.

So she agreed, I will do that. I will get on the freeway, stay in the right lane. I tell everybody, When you first get started, don't go all the way to the left. So you feel like you can always get off or you can pull to the side if you're just feeling too nervous behind the wheel because that's a real concern. So Get on the freeway and just get off on the next exit. And next session, how did you do? Swear this is true. She's like, I got on and I was like, Screw this. And she stayed on until she got all the way home. And bam, she was good. That's how fast this stuff can work, right? Because what you're telling yourself, what you're telling yourself, your hot thoughts, I can't handle this. Something bad will happen. I will have another accident. That's what you're telling yourself. Then you go put yourself in that situation. Like, I can handle this. I'm a good driver. I'm in control of my driving. I'm going to stay in the right lane. Have a plan. I'm going to stay in the right lane. If I'm feeling too anxious and there's not an exit right there, I'm going to just pull to the side.

I'm going to do some breathing exercise. I'm going to calm down again until I'm ready to go. And then if I need to get off on the exit, get off on the exit. And if you're ready to go back on, go back on. Again, it's free flowing here. You're not stuck once you start an exposure experiment. You can always stop. I don't want you to feel like it's all or nothing. We're looking for shades of gray. I'd love you to finish to the end. That's going to give you the best outcome. But it doesn't always happen the first time. It takes time. I had another client with the whole elevator fear, and it took a handful of sessions where she would go get on an elevator, go get on an elevator. She normally likes to go to a doctor's appointment. And she also had some fear of driving. And by the end of our therapy, she was laughing at herself. She's like, I can't believe I was so afraid of this. Now I just walk in an I don't even think about it. I don't even think about what floor I need to go to.

I just get in my car and I just jump on the freeway and I get to where I go. I have my life back now. And it's funny how people can look and be like, I can't even believe this was a fear I had before. So of course, easier said than done, but it is really possible. And I know you guys have the strength. I know you have the motivation, the willingness, the fact that you're listening to my podcast and you're really practicing these tools, right? That you want to remember how brave, courageous, and resilient you are, that you can work on these things and get past it so that you can have the life that you want and deserve, and not to let some fear get in your way and not have the life that you do want. So I hope you found this helpful. I know I went through a lot. You might want to listen to it again. Again, if you look at Dr. David Burns' book, When Panic Attacks, goes through all the things I talked about today and It gives you more specific examples and that thing. So that would be the one that I would recommend.

Always my Mind Over Mood book, but this is specifically for this.

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