Affirming Progress During Exposure

Exposure therapy is considered a standard of treatment for the anxiety disorders. Exposure is where the “rubber hits the road.” You can talk about your anxiety all day, but until you’re faced with the thing you fear, it’s just talk. Eventually, what happens in therapy must translate to the real world. The question we want to consider in this article is: What happens when clients try to take on their anxiety and have to pull back? How do we frame that in order to support therapy, and why does it make theoretical sense?

To better consider the question, let’s look at a simple case. Let’s say a guy comes in with a fear of crossing bridges. Let’s call him Jimmy. Every day for the last three years, Jimmy’s been driving twenty miles out of his way to avoid a particular bridge, turning what should be a 10-minute commute to work into a 40-minute commute. He says he “hates” doing this, mainly because it’s a “huge time waster.” To and from home, it’s an extra hour on the road each day, which adds up to an extra 20 hours per month, not to mention the extra gasoline costs.

Jimmy’s phobia is also a drag on his masculine self-concept. His wife thinks he’s silly. She drives to work over the same bridge and for her, it’s totally boring. She doesn’t understand why he can’t just “get over it.” Rationally, Jimmy knows that thousands of people cross the same bridge every day. Monday through Friday, they make it to work and make it home safely. Not once has the bridge collapsed. All inspections show the structure to be sound. In short, Jimmy’s fear is completely irrational, and he knows it.

What Jimmy doesn’t understand is that his fear is sustained by negative reinforcement. Negative reinforcement is jargon from the field of behavioral psychology. The “negative” part means an aversive stimulus is being removed. The “reinforcement” part means that the frequency of behavior is increased as a result. Whenever Jimmy thinks about “taking on” the bridge, his heart starts beating faster and faster. His breathing becomes shallow and he breaks out in a sweat. A few times he’s thought seriously about “taking a run” at the bridge, and each time, his symptoms escalate to the point of near-panic. So Jimmy “backs down,” and the symptoms go away. The symptoms are the aversive stimulus. Every time he “backs down,” he gets relief from the symptoms, which reinforces the avoidance.

So Jimmy sees a psychologist, and the psychologist explains the importance of exposure. Jimmy objects that he’s already tried exposure, and so far, he’s a consistent failure. He’s pessimistic.

What should Jimmy and his psychologist do at this point? Recognizing the importance of attitude is one option, an option fundamental to the treatment of all anxiety disorders. Jimmy is stuck in a loop that creates anxiety about anxiety. Jimmy won’t be able to take on the bridge all at once. He’s already tried that, and failed, to the point that he’s now pessimistic about success with his psychologist. When the psychologist suggests that Jimmy drive toward the bridge, then pull off on a side street and wait until the anxiety goes down, Jimmy objects that he’s already doing this. He’s been doing this for years.

Affirmation versus Failure

Unfortunately, Jimmy is pulling off the road with the belief that doing so is a failure, and that by doing so, he becomes the failure. By framing the situation this way, Jimmy reinforces his anxiety about anxiety, and diminishes his own self-esteem and self-efficacy in the process.

His psychologist explains that Jimmy has to reframe each such attempt in order to work on his attitude. Instead of labeling himself a failure, he needs to allow himself to feel good about each such attempt. By doing so, he is practicing self-affirmation, building himself up. After a certain amount of self-affirmation, Jimmy begins to understand that it was his own labels that prevented him from succeeding. Jimmy and his psychologist work on a series of small steps, and Jimmy learns to self-affirm his progress at each step. Eventually, they do guided imagery, because Jimmy knows that once you start across a bridge, there’s no turning around. You have to go all the way. Jimmy rehearses the drive across a hundred times in his own mind, to the point that he complains to his psychologist that his treatment has become very boring. The psychologist replies that bored is good, because you can’t be bored and anxious at the same time. He explains that Jimmy is now ready to take on the bridge.

As Jimmy approaches the bridge, he knows exactly what to expect from his body. He understands the symptoms that might appear. He also knows they’re not dangerous, and that he can do some deep breathing right there at the wheel of the car to calm his body down a little if necessary.

The Bigger Picture: Jimmy’s Self-Labeling

In the course of therapy, Jimmy also comes to understand that in life, he’s often labeled himself a failure when things didn’t quite work out. He further understands that he doesn’t need to do this anymore. Not only is it not realistic (labeling is a cognitive distortion), it prevents him from taking steps that would advance his career and enrich his life. Rather than take on risk and feel anxiety, he chooses to label himself a failure at the first setback. Then he withdraws, gives up. No more anxiety, nothing at risk. Jimmy finally understands that setbacks are a normal part of living, and that setbacks are only setbacks if you 1) learn nothing, and 2) give up trying. To make sustained progress, Jimmy needs to affirm all his efforts. Whatever the short-term result, the ultimate outcome is progress.