Artarticle written by: Ariel Minici, Carmela Rivadeneira and José Dahab.
Exposure therapy is definitely the most used and most effective technique in the treatment of pathological anxiety. Some of the initial ideas, put forward in the 1940s by Isaac Marks and other behavioral psychologists of the time, seem to remain practically unchanged today. As he stated, no treatment for fear or anxiety can be considered effective if it does not include some ingredient of exposure to what the person fears.
In fact, someone who pathologically fears some real or imaginary event in their environment cannot consider themselves cured if they do not put an end to the avoidance and finally come into contact with it. There are those who fear cats, spiders, crowds, monsters, people or what they may say to us, do to us or think about us, needles, diseases, germs, etc., etc., etc. In any of these cases we could spend days talking about our fears, remember how they were created, reflect on what factors produce or maintain them, or discuss long hours about their irrationality; but if we do not manage to approach and make contact with them, if we do not stop escaping from them, we are not cured; spot. The spider-phobic will have to be able to kill the insect, the one who is afraid of crowds will finally have to go to a football game, the one who is afraid of monsters will have to be able to open his closet at night, the one who is afraid of people and his possible statements will finally have to face social situations where he may be judged negatively; In no case can a person who suffers from any of these fears be considered cured if he or she has not managed to engage in behavior to approach what triggers the fear.
Just by thinking with a little common sense one reaches conclusions like the above, and it is truly surprising that there are still psychological treatments applied to fear and pathological anxiety that do not include exposure as a key element.
Exposure therapy, in its minimum and simplest definition, consists of the patient making contact with what they fear, remaining in that situation, allowing anxiety to increase, and reach a maximum peak and then descend; This action will have to be repeated until it becomes habitual, that is, the stimulus in question no longer generates anxiety. Now, why does this described process happen? Why does anxiety rise, peak, and then go down? Why does this anxiety curve occur in pathological fears? Or, in other words, why does exposure work by producing this typical pattern of anxious arousal response that, in the long term, always decreases and dies out? This question, which goes to the very heart of the mechanism of exposure therapy, also investigates why anxiety does not disappear in pathological cases.
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If one wants to understand how and why the exposure technique works, we will have to look for the answer in the maintenance factors of pathological anxiety. Said briefly and clearly, in avoidance and escape behaviors. Thus, those who suffer from pathological anxiety not only fear, but also flee; Avoidance and escape are the behaviors that maintain the pathological anxiety process, since they interfere with the natural extinction process that would take place if the person did not avoid. That is to say, if the phobic of insects, storms or balconies did not avoid these stimuli, in the long term it would end up extinguishing his anxiety. The same thing happens with any of the forms that pathological anxiety takes.
In simple phobias the mechanism is easier to observe, but in the entire range of anxiety disorders we will always see a set of avoidance and escape behaviors. These behaviors may be more or less evident, more or less subtle, at different levels of responses and intensities, sometimes typical of the condition and on other occasions very idiosyncratic, but they are always present.
Therefore, as therapists we must be attentive to such behaviors, given that not so much what the patient fears, but above all what the patient avoids, is what constitutes the most solid guide for establishing the exposure therapy protocol. What is feared and what is avoided are two critical questions in the formulation of the case, what is feared and what is avoided sometimes coincide, sometimes not, but they are always functionally related.
So, reformulating the previous ideas, the basic principle of exposure is to expose the patient to what he avoids, allowing the anxiety to increase and peak and then descend, repeating this action until it becomes habitual and no longer occurs. generate more anxiety. So said, things seem very simple and very complex at the same time.
Is it as simple as the person who fears confinement, for example, getting on a subway for an entire afternoon and walking from end to end of the route for hours and, thus, when they get off they will be cured? Well, theoretically yes, but things are not that easy. Let’s think about the office situation, where a person arrives and tells the therapist that he is afraid of confinement and, therefore, cannot travel by subway, elevators or trains. The therapist tells him that to be cured what he must do is get on a subway, an elevator or a train for a long period of time… exactly what the patient cannot! Most likely the patient will not feel understood, he will not return and will leave thinking that the psychologist is inept.
No treatment for fear or anxiety can be considered effective if it does not include some ingredient of exposure to what the person fears.
Although it is correct that the core of exposure therapy consists of the patient making contact with what he avoids, the means to achieve this objective vary greatly and by virtue of them we will have a line of variants of exposure therapy. On the other hand, people who suffer from pathological anxiety do not come to the office with the diagnostic clarity to tell the psychologist what they fear and what they avoid. For example, in the recent case of the person who suffers from fear of confinement, what is the focus of his fear from which he escapes? The subway? Being trapped? Not being able to breathe? Suffering from an attack of Panic and not being able to receive help? All of the above? The patient with social anxiety will typically tell us that she is afraid to attend a meeting, speak in a group, take an oral exam, complain if they brought her cold coffee, and ask her boss for a few extra days of vacation; We as therapists will have to unite all these examples in the common denominator “fear of negative evaluation and rejection from others.”
A large part of the effectiveness of the exposure treatment will depend on the adequate identification of the focus of fear and avoidance, which in turn gives us another criterion to establish a set of variants of the technique. We refer to this last point in the following of this work.
Identification of fear
Anxiety is pathological when its focus does not constitute a real danger. It is for this reason that we can treat it by helping the patient to expose himself to the stimuli that trigger it, because we know that there will be no objective danger. Now, how do we know what to expose the patient to? What is the focus of fear and, therefore, avoidance in each case?
, the son of the great psychologist, proposed a model of pathological anxiety called “four factors”. The basic thesis maintains that people with some form of anxiety disorder suffer from an attentional and interpretive bias in the processing of information directed at one of four major focuses.
- In panic disorder the focus of anxiety is proprioceptive, that is, focused on the functioning of one’s own sensations.
- In social phobia, the bias is directed at one’s own behavior, that is, one’s own action is monitored for its interpersonal communicative aspect.
- In the case of OCD, the bias is oriented toward one’s own thinking, that is, the person perceives his or her own thinking as a source of danger.
- In GAD the anxious bias is broad, directed at a large number of situations.
The theory has received strong empirical support and to a large extent, by making use of some diagnostic labels, the hypotheses guide us a lot about the environment of stimuli towards which we will have to direct the exposure.
Exposure in simple phobias
This is surely the clearest case of all. Someone with this diagnosis may fear dogs, cats, storms, thunder, ghosts, spirits, or some other relatively easy-to-demarcate object in the external environment. The exhibition will involve some form of approach to that object. This approach can be carried out gradually, implosively, or somewhere in between; It may take an imaginary or live form, but yes or yes, in the long run, the person must make direct contact with what he fears, abandoning avoidance and escape behaviors; there it will have been cured. And what about ghosts, spirits and other resurrected ones?
Already from the simplest pictures, exposure therapy encounters some challenges of this type, ghosts do not exist nor the dead return, but people are afraid of them anyway. In these cases, fear constitutes a response to an imaginary event, a fact of the same mind of the person who suffers from it. In general, and if it is only a matter of simple phobias, it is enough to expose oneself to the environments that trigger the appearance of images that evoke fear, such as exposing oneself to sleeping in the dark and uncovered or opening closet doors during sleep. evening.
In some cases, these fears are embedded in a more general context of pathological anxiety that warrants an idiographic evaluation and another type of treatment. But note that from the simplest pictures we already operate with the principle of “exposing oneself to what is avoided”: the patient is afraid of ghosts, which is why he avoids looking at his closet during the night; Consequently, the treatment will consist of him gradually looking, approaching and finally opening the tackle, which is what he avoids, not what he fears. And just in case it’s not clear, with some rare exceptions, we do not guide you to imagine monsters and ghosts.
Exposure in panic disorder
Of all the psychopathological aspects of panic disorder, one of the most outstanding is the fear of one’s own bodily sensations and, therefore, their avoidance. Those who suffer panic attacks react with fear to sensations in the body, such as their own heartbeat, heat or perspiration. Such sensations in turn act as triggers for new waves of anxiety that increase them again, a vicious circle in which the patient becomes trapped. By…