Exposure Therapy Mistakes and Misconceptions

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While many panic disorder and agoraphobia sufferers have tried exposure therapy and succeeded, many have tried and called it ineffective or a failure. Often this is simply due to misconceptions about what exposure is designed to do and mistakes in exposure technique. Exposure therapy is – as part of an overall cognitive behavioral therapy strategy – one of the most effective tools we have to deal with our anxiety issues. Mountains of clinical evidence backs this up.

What Is The Goal?

The goal of exposure therapy is not to make your anxiety or panic go away. The goal is to teach you not to fear those things and to change how you react to them. HUGE difference. As is so often the case, many are primarily interested in stopping the symptoms and sensations of anxiety stop. This is often a frustrating endless game of whack-a-mole. Instead we’re better served by learning through direct experience that there’s no reason to be afraid. You can close your eyes tightly and hide under the covers all night or you can just look under the bed to see that there’s really no monster there.

There’s A Reason They Call It Exposure Therapy

Exposure means confronting your anxiety and having intimate contact with it, with each session lasting a bit longer than the last. This is the key, and where most make the fatal error. Exposure is not an arms length hit and run affair. Driving to the supermarket and virtually running through the frozen foods department in an effort to get back home as quickly as possible might be OK in your first few sessions, but the real goal is to start to slow down and to stay longer and longer in the situation you fear. This is the way we learn that being in the supermarket won’t kill or hurt us.

Quantity Is As Important As Quality

This isn’t something you hear often but in the case of exposure therapy it’s true. One trip to the dreaded shopping mall every two weeks when you feel up to it isn’t going to be terribly effective. You must push yourself to practice every day no matter how you feel. If that sounds hard, it is, but that’s how it works. Effective exposure is always gradual but is almost never easy or comfortable – especially in the early stages.

Safety Devices

This is a debated issue. Safety devices, safe people and safety rituals might be used to help you get the ball rolling, but you’re going to have to leave them behind and go it alone and “raw” at some point. Being able to pick up your kids from school only if your mother or girlfriend is with you is better than not going at all, but that’s not really your goal is it? Just as a child must take off the training wheels to learn to ride his bicycle, we must ultimately drop our shields and rituals to achieve our goals.

(Special note regarding stopping medication: If you’ve been taking a benzodiazepine (benzo) like Xanax or Valium or Ativan regularly (i.e. once or more every day, or ever other day) for any length of time, you can NOT simply stop taking it.  Stopping a benzo cold turkey can be dangerous.  Please involve your doctor should you decide that you do not want to take your benzo any longer. The same applies with many classes of antidepressants, which must be tapered slowly in order to avoid problems.)

When Failure Isn’t Really Failure

If you’ve decided that exposure doesn’t work for you, ask yourself if you’ve fallen into any of these traps. Were you doing the “hit and run” thing to escape your fear? Were you waiting for “good days” to do your exposure work? Were you expecting your anxiety to go away after five trips to the mall? None of this makes exposure therapy – or you – a failure. They’re very common mistakes and misconceptions that ambush lots of smart people. Maybe it’s time to reevaluate and make a new plan. Success might be right around the corner for you!

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Why Does EVERYTHING Make You Panic

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For people dealing with panic disorder and agoraphobia, a common complaint is that virtually anything can be a panic trigger.  Lets take a look at why that happens.

Fear Of Panic Symptoms Turns Our Focus Inward

When we do not accept our panic and anxiety symptoms, when we fear them and worry about when they will next appear, our mental focus turns almost entirely inward.  We become consumed with how we feel at any given time and we worry about how we will feel in the future.

Hyper-Vigilant

When our inward focus becomes extreme in nature, we enter a state of hyper-vigilance.  This has us scanning our bodies and minds almost constantly to find the early warning signs of danger.  Our mistaken belief that we need to be saves from our anxiety symptoms puts us on constant alert, ready for the next attack.  Often we go to great lengths to be ready to enter “safety ritual” mode instantly if needed.

Hyper-Sensitive

Being worried about the possible appearance of anxiety symptoms ultimately puts us into a state of hyper-sensitivity. In the same way that a world class athlete gets into “the zone” during competition, we often go into the zone ourselves, but on a 24×7 basis.  As any war veteran will tell you, being constantly prepared for battle is exhausting, draining, and can have negative impacts on our bodies, our ability to reason, and our emotional stability.

“Emotional Bad Aim”

When we erode our ability to reason and our emotional stability, our brains often lose the ability to effectively manage stress. We prepare for fear.  We worry about fear.  We dread fear.  We wait for fear.  We effectively train ourselves to have bad emotional aim.  Every stressor results in the fear response. Got a promotion at work?  Panic.  Fight with your spouse?  Panic.  Excited that your favorite football team is winning the Super Bowl?  Panic.  Whereas only dangerous situations would normally trigger the fight or flight response in our bodies, in an inwardly-focused-hyper-vigilant-hyper-sensitive state, any situation can trigger it.

Its Not Just Stress

When we’re on a hair trigger, its not just stressful events that can trigger panic.  Virtually any stimulus can do it.  A change in temperature.  The variation in lighting as a fluffy cloud passes across the Sun. An odd smell. A bite of food that “doesn’t taste quite right”.  The sound of an ambulance in the distance.  In our over-sensitized state almost anything can trigger an anxiety or panic attack.

When you’re working to overcome panic disorder or agoraphobia, the last thing you need is to feel that you can’t control your anxiety in any way.  The good news is that you can, but the trick is to stop trying. They key – as always – is learning not to react in fear to your symptoms.  When you learn to truly accept your anxiety and panic symptoms as uncomfortable but harmless, when you learn to relax into them rather than bracing, fighting and fleeing, when you no longer fear them, then there’s no reason to be on alert 24×7. You’ll begin to come down from that hair-trigger over-sensitized state and not everything will be an anxiety trigger for you any more.

Lose the fear.  Win the war.

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Overcoming Anxiety Is An Active Process

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Recovery from anxiety, panic and agoraphobia is an ACTIVE process.

Nothing will improve if you just wait passively.

When we get sick (i.e. cold, sore throat, etc.), we retreat, rest and recover.

Retreat:  We take off from work or school. We cancel engagements and appointments.

Rest:  We lay in bed or on the sofa in our comfy clothing with our tissue box and asprin.

Recover:  We feel better after a few days and get back to the business of living.

Our bodies will fix things naturally through the magic of our immune systems. There’s no such mechanism for anxiety disorders. In fact, retreating and resting generally means avoiding, and that can actually make it HARDER to recover by making the disorder even worse.

YOU ARE NOT A HELPLESS VICTIM.  Everything you need to improve your situation is inside you right now. There are steps you can take – steps you NEED to take – to get better, and those steps should be taken right now.

STOP WAITING. 

  • Waiting for time to fix you won’t work. There’s no automatic background process going on that will get you your life back.
  • Waiting until you’re having a good day isn’t helpful. Anyone can accomplish stuff on a good day. You need to act on your worst days because progress happens when you actually experience panic and anxiety without avoiding or trying to escape.
  • Waiting until you find the right method is going to keep you stuck, because looking for the right method usually means looking for comfortable way out. None exists.
  • Finally, waiting for someone else to fix you is also not going to work. We all need support from other human beings, but support and encouragement won’t get you your life back. It helps, but by itself it doesn’t do anything. Its up to you to put in the work.

Before you can start to make real forward progress, you have to buy into the idea that there’s work to do, and that sometimes that work is going to be difficult.  If you’re ready, then lets go!

Start small.  Progress comes in small steps piled on top of each other.

Take a shower.  Get dressed.  Sit in your garden for a while.  Clean the house.  Take a short walk.  Drive down the street.  Do something you’re afraid to do.  Then do it again.  And again.  Then do something a bit harder.  Then do that again.  You get the idea.

Above all, once you stop waiting and start acting, keep acting.  Don’t stop.  No breaks.  No rest.  No vacations.  No rewarding yourself with a day under the covers.  At least not for the first few weeks. You need to build momentum, so be tenacious and be consistent in your action.

Understanding and accepting the concept of an active process can – by itself – change your outlook for the better.  Give it try!

 

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Hands Showing Body Language

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This was my very first YouTube video from way back in 2015!

Your body language is a very strong indicator of how you’re reacting to your anxiety symptoms.  Since our goal is to learn to be non-reactive and not fuel the fear cycle, its really helpful to be aware of your body language.  Knowing your rituals and tics and physical habits can help you see how you’re adding fuel to the fire.  Once you become aware of your anxiety-related body language, you can start the work of extinguishing all these little things so your brain can learn that they’ve never been needed to keep you safe.

I talk about the use of video as a tool here.  I suggest that everyone video themselves at least a few times during periods of high anxiety and panic, even if nobody ever sees the video but you.  The value as a self-teaching tool is enormous.

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Anxiety Disorders and Relationships

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Anxiety disorders impact more than just us.  They can often have major effect on our close relationships.  Understanding how this happens and having some tools to use to address the negative impacts can go a long way toward improving things for everyone involved.

  • The people close to us are being forced to adapt because we change our behavior to accommodate our fear. Forced adaptation that they can’t understand can then lead to frustration, anger and resentment.
  • We can unwittingly place very high demands and expectations on the people in our lives because we’re focused inward and on guard all the time.  This is especially true in the case of your “safe people”.
  • Why don’t they get it?  Do they even have to get it?
  • Be brave.  Start to make an effort to face your fears.  This can turn things around in your relationships all by itself.
  • Take responsibility for your fear. The fear is real but the danger is not.  Let the important people in your life hear this because they need to know that you understand this.
  • Don’t be a victim.  You have the strength and power to improve your life.  Don’t expect anyone else to fix you or to enable a fear-driven lifestyle forever.
  • Be aware of people in your life that would rather have you entirely dependent upon them.  Those are controllers and they have a vested interest in keeping you where you are now.
  • Be aware of self-centered people in your life.  Those people can be difficult to maintain relationships with regardless of your mental state.

 

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Facing your fear without fighting or fleeing is a skill that requires practice. Before we get started, we need to be in an objective frame of mind. Let’s learn to assess your physical and mental state objectively. Stick to the facts without adding judgement, interpretation, inference or prediction because this is vital to the success of your recovery efforts.  Lets look at what this means.

When struggling with anxiety disorders – especially panic disorder and agoraphobia – we are focused almost entirely inward.  We are hyper-aware of every sensation in our bodies and we spend most of our time “inside our own heads”.  This means that we make a full-time career out of constantly evaluating and assessing our physical and mental state. This fuels the fear cycle, especially when we fall into the trap of adding judgement, interpretation and even predictions of the future to our self-assessment.

Often the trigger that leads to full blown panic is a simple phrase like “it feels like” or “what if“.  Learning to be objective – sticking to just the facts when it comes to our thoughts and bodily sensations – is the key to getting past this common hurdle.  This is especially important when it comes to the effectiveness of exposure therapy. Too many capable people label exposure therapy as a failure because “it stills feels like”. In that case its not exposure that’s failing us, its the cognitive patterns we drag into it.

Learning to be objective in our viewpoint means abandoning anything that involves predicting the future, guessing, or inferring. From a practical standpoint, this means completely abandoning the following phrases:

  1. I think …
  2. It feels like …
  3. What if …
  4. Is this …
  5. I can’t … 

Its important to understand the difference between the following statements:

“I’m feeling unsteady and disoriented.”

It feels like I’m going to die.”

See how the first is simply a statement of fact, while the second is a subjective interpretation of the situation?  A statement of fact stops after describing observable reality. It does not attempt to predict what might happen or explain why things are happening. Its just the facts. ma’am!  State the facts, then move on. Eliminating subjective interpretation is a HUGE step in not allowing that hot flash, dizzy spell or twinge in your shoulder to trigger a full on panic attack.

Of special note is the phrase “I can’t”, which will be the subject of its own podcast episode in the future.  This one is particularly evil because it allows small obstacles to blown into insurmountable difficulties all due to irrational subjective interpretations.  For now, I will tell you that before you ever say “I can’t”, you better be sure that you’re bleeding or have actual broken bones.What you think might happen should never lead to “I can’t”!

Finally, learning to be objective – sticking to the facts then moving on – can turn your long history with anxiety and panic into an asset! Its true.  When you can think objectively and rationally instead of going into  “Oh my God” mode, you can use the fact that you have not died or otherwise been damaged by the previous 10,000 panic attacks to your advantage.  That might seem like common sense, but common sense does not apply when our thinking is fueled by irrational fear.

 

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Let’s build on what we’ve already learned in last few episodes to make an anxiety/panic/agoraphobia recovery plan. Since we know that anxiety disorders including agoraphobia are cognitive in nature we’re generally going to ignore the physical symptoms. Instead we’re going to address behavioral and cognitive issues, because that’s what makes a lasting difference.

We’ll lay out five general strategy points, then we’ll put a broad action plan in place.

Strategy Points

  1. It’s all about goals and expectations. Have the right goals in mind. In our case, making your anxiety and panic stop or go away is NOT the goal. Our goal is learn through experience that anxiety and panic are not actually dangerous and therefore are not to be feared and avoided. The end game here is to simply not care if you experience anxiety or panic because you no longer fear them.
  2. Be resigned to the fact that you’re going to have to be afraid and uncomfortable – especially in the beginning – to get things moving forward. Sorry.  There’s just no way around this.
  3. Stop focusing on your physical anxiety and panic symptoms . Stop thinking about what you can swallow – natural or otherwise – to make them go away.
  4. Think and start small. If you haven’t left your house in three weeks or you haven’t gone shopping alone in two years, don’t start by planning a three week trip to Paris. Don’t worry about how impossible it might seem to get back to being “normal”.  You’re  now in the business of un-learning negative behaviors and re-learning old skills.  That’s done in small steps.  Every step, no matter how small, is a step you can build upon.  Its all matters.
  5. Be consistent, persistent, and tenacious. This is what matters most. A panic-fueled white-knuckle run through the shopping mall you’ve been avoiding – followed by four days of not leaving the house – is pointless. Walk around your block four times every day for a week. That’s more effective. When you win a battle, don’t stop to admire your work or reward yourself with a rest. Don’t make excuses. Keep going! Be tenacious.

Our Action Plan For Recovery

A. Learn to calm your body and your mind. These are skills that must be learned and practiced all the time. Star with muscle relaxation, relaxation breathing and basic meditation skills. The goal is to be able to use these skills to relax “on demand”. It’s hard. Work at it!

B. Intentionally put yourself into situations that make you anxious. Do this every single day, as often as you possibly can. When you feel the anxiety or panic, start using your relaxation skills. Don’t run or fight. Do not expect to be able to make your symptoms go away. Focus on your breath and the tension in your body and work on those things. Ignore the catastrophic thoughts racing through your head. This is where the meditation skills help. Do these things and truly accept that you are not in danger, then you will find that your symptoms will not escalate. Your symptoms will begin to level off or even decrease in intensity as the adrenaline gets flushed out of your bloodstream.

That’s it – the whole plan!  There’s nothing else. Everything else is mechanics and fine tuning.

The situations you expose yourself to will naturally change over time. Start small. Very small. Gradually expand your circle and take on larger challenges. Be consistent. Be persistent. Be tenacious. Expect to fail sometimes. Expect to be terrified – especially at the start. Expect to be uncomfortable. Expect to work hard, but that’s hard work you’ll be happy you did. If you stick to this plan and really work it, you will be amazed at how fast you can progress. Things you thought impossible will begin to seem within your reach. You’ll start to build confidence and you’ll be emboldened to keep going. Above all, you’ll learn that YOU are in control of the process and that you are not a helpless victim of some horrible mental illness. You’re not! Your brain has just gotten into some bad habits and it’s time to set things right again.

In upcoming podcast episodes we’ll talk about the specifics of things like relaxation, calming your mind and exposure therapy. In the meantime you can get started right now by talking your first step forward. There’s no need to wait for any reason. You can do it!

 

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How Panic Attacks Become Panic Disorder

Panic disorder.

Do you understand the difference between panic attacks and panic disorder?  You should, because knowing can be an important part of building your recovery foundation.  Lets learn about the difference between panic attacks and panic disorder so we can learn to focus our recovery efforts more efficiently and effectively.

The highlights:

 

  • Panic attacks are physical.  Panic disorder is cognitive and behavioral.
  • A panic attack is a discrete physical event with a beginning and end.
  • Having panic attacks does not mean one has panic disorder.
  • Panic disorder is characterized by focus on panic between attacks, and by changes in lifestyle designed to avoid or prevent the next panic attack.
  • Many people have regular panic attacks without ever developing panic disorder.
  • Panic disorder develops based on learned cognitive connections between perceived danger and the behaviors we engage to either escape that danger or avoid it altogether.  We teach ourselves that avoiding panic is keeping us safe, but this is not true.
  • Panic disorder is cognitive, so focusing on eliminating the physical sensations of panic tends to be a dead end.  You must work on the cognitive and behavioral side because this is shown to be most effective.
  • Working on facing your fear without engaging in escape, safety or avoidance behaviors is the best approach. This is how the cognitive connections that fuel panic disorder are broken and un-learned.

 

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Therapy for anxiety disorders is a not a generic thing. There are different types of therapies and not all are equal when it comes to anxiety disorders.  These differences are important, so should be aware of when looking for a therapist.  Lets take a look at some of those issues in this episode.

Because they undergo different training and focus on different things, there is a big a difference between a psychiatrist and a psychologist.  In general, a psychiatrist is going to take a different approach to your anxiety issues than a psychologist will.  Its important to understand this when choosing a therapist.

There are several common types of therapy.  Each is different, and not all are effective therapies for anxiety disorders. Just talking about how you feel tends to be ineffective.  Because of the nature of anxiety problems, behavioral therapy is shown by a large body of research to be the most effective therapy for anxiety disorders.

When looking for a therapist, there are some key things to look for and important questions to ask. Get to know a potential therapist before hiring him or her.  Not every therapist will be a good fit for you personally.  Its quite common to have to “interview” several therapists before finding the one that you feel is right for you.

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Memory can trigger anxiety symptoms. Lets talk about.Memory has the power to trigger anxiety symptoms and sensations. When we understand this powerful process, we can use it to our advantage. We can even use it as a tool!  This can really propel you forward, even when you think you’re going backward.  Lets talk about how to recognize when your memory is triggering anxiety issues and what to do when that happens.

 

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