Coping with anxiety a guide to exposure therapy

• “What if I fail this exam? My career will be ruined before it starts. I feel so sick just thinking about it that I can't study. But I have to study or ...”

• “Every time I leave the house 1 feel sick, I think I'm going to collapse and have to go back home. I can't go anywhere unless someone is with me.”

• “When I have to talk to strangers I start to sweat and panic I feel trapped and can't think of anything to say.”

• “It sometimes feel very tense and uncomfortable, worrying about things that I've got to do the next day, or even the next month. I can't seem to get rid of these worrying thoughts no matter how hard I try.”

• “Each time I feel a panic coming on I have to leave the situation, it seems the only thing that works.”

• “I get so anxious I start to sweat and breath really shallowly and rapidly, I then feel very faint.”

Such are the thoughts, emotions, behaviours and physical feelings that sweep over those who suffer from anxiety and phobias. Since both anxiety and phobias are rooted in fear, they both indicate the dread of some danger or threat to ones well being. This sense of threat is manifested by a wide range of physical symptoms anxiety's body language which are distressing in themselves, rapid breathing, accelerating heart rate, dizziness, nausea, headache, sweating, dryness of mouth, tightening of the throat, pain in various sets of muscles, etc. When the state of anxiety is prolonged or chronic these frightening, uncontrollable symptoms may take the form of what seems to be a real disease or disability.

One of the most important facts for a severely anxious person to learn - and recall to mind at critical moments - is that the symptoms he/she is experiencing are not dangerous. The racing pulse or pounding heart, the dizziness or nausea, the desire to scream or cry or pound the table - none of these physical or emotional reactions indicate that the person is dangerously ill or going crazy. They are unpleasant. They are uncomfortable. But they can be tolerated until they go away. And they will go away.

The phobias cause intense anxiety, accompanied by its various physical and emotional symptoms, the phobic individual is reacting to a specific abject or situation which can to some extent and without great inconvenience be avoided. As long as the feared event, object or situation is not an integral part of the person's life, he/she can remain free from the anxiety effects of phobia. For instance, someone who has an intense fear of flying can usually find ways of getting to places without going on an aeroplane. The anxiety sufferer however, cannot always pinpoint the source of his anxiety. And even if he can identify the cause, he cannot avoid encountering it; either the demands of his daily life force him to confront the feared circumstances, or he has so completely internalised his fear that the source of it is within himself. Sometimes it is necessary for a person to experience fear in order to acknowledge the threat of a real danger and prepare himself to meet it. A certain degree of anxiety may accompany such fear. But the person who suffers from excessive anxiety or phobic reactions is not responding to the realities of the situation. He may be anticipating a threat to his well being when there is little likelihood of it happening.

If he/she is facing a challenge of some sort an exam or a job interview, he will magnify the difficulties and dwell on the horrors of a negative outcome. At the same time he will underestimate, overlook or discount his own ability to cope with whatever he fears. In other words, he misinterprets and distorts reality so that he feels anxious about dangers which either do not exist or which he could cope with effectively if he were not so disabled by his own anxiety reactions. To make matters worse, when the severely anxious person becomes intensely aware of his own unpleasant physical and emotional reactions, he may begin to dread and fear the symptoms themselves even more than the situation that triggers them. The more upset he gets, the more exaggerated his symptoms become, and he is involved in a self-perpetuating spiral of increasingly intense emotional and physical suffering.

What has been found in research in the last 40 years is that people can learn to overcome their fears through exposure and other behavioural techniques. Exposure can be a very effective way of dealing with anxiety, in the long run. It means that you face up to or expose yourself to those situations, which made you anxious and which you have been avoiding, perhaps for a very long time. The aim is to learn that you can, in fact, cope with these difficult situations and that they are in fact not dangerous.

What is Exposure

Exposure involves entering situation which provoke anxiety and remaining in the situation long enough for the anxiety to subside. It is like re training your mind and body to relearn that the situation will not cause you any harm.

Guidelines for exposure

Graded

Exposure is best applied usually in a graded way. This gives the individual greater control over their treatment. Ensuring the exposure is graded s involves making a list of situations which you find difficult, ranging from "extremely difficult" to "a little difficult", and arrange them in order from most to least difficult. Then start at the least difficult end and go into that situation, more than once, until you feel you can cope with it and the anxiety which arises, then work your way up the list. However some people and sometimes for very specific problems it can be quicker to tackle the most difficult situations first. Your therapist is in the best position to advise you regarding this.

Exposure does however need to be for as long as possible to the situation which provokes anxiety. In general one hour is better than two half hour sessions. the exposure is also best repeated. Once is rarely enough and a general rule of thumb is to carry out the exposure at least once daily until the situation hasn't bothered you for at least one week.

Exposure should therefore be:

• Graded

• Prolonged

• Repeated

Behavioural psychotherapists also use a variety of other treatment techniques such as coping self statements (learning to say things to yourself that reduce anxiety), reinforcement (praising yourself or getting others to recognise your achievements), problem solving (learning how to systematically identify problems, come up with solutions and putting those solutions into practice), relaxation training (learning how to progressively learn to relax), breathing exercises (learning how to breath in a way that calms your down) and some may even use hypnosis or meditation.

Steps in Behavioural Therapy

The first step is to recognise your own avoidance patterns or behaviours that are unhelpful whenever you feel anxious. Your therapist will help you with this and keeping a diary also often helps. It is also important to identify what are referred to as safety behaviours. These are subtle forms of avoidance. They are best though of as avoidance within a situation. Some common examples are:

• Leaning against something if you think that you are going to collapse or faint.

• Sitting deliberately on the end of a row at the cinema (In order to get out quickly if you feel anxious).

• Avoiding eye contact in social situations.

1. This type of therapy works best when there is a close working relationship between you and your therapist. This relationship should be collaborative one in which you both work together as a team. It should be an open relationship in which you feel comfortable talking about any doubts or anxieties you may have about your progress your personal life, or the way in which your therapist behaves.

2. Throughout therapy you will be given HOMEWORK to do between therapy sessions. This is very important part of behavioural Therapy and it is important that you understand both what you have to do, and why. It will almost certainly be useful to have a notebook and pen handy during therapy sessions so that you can take notes of anything that you need to remember.

3. During the first few sessions of therapy, as part of the general assessment of your problems and present circumstances, it will be useful to set specific TREATMENT GOALS. Setting goals gives impetus to the process of treatment. If you have in your mind a clear picture of how you would like to change and what you imagine your life could be like if you were free of anxiety, you will know what you are working toward. So share your ideas with your therapist so that he can help you reach your goal. In addition to the steps in Cognitive Therapy outlined above, there may well be other therapeutic techniques and approaches that you can use to learn how to control your anxiety, or to put yourself in situations that you have been afraid of, or to learn more effective ways of behaving in social situations. For example, your therapist may help you learn to relax, or how to approach fearful situations using a method called 'graded exposure', of how to become more assertive using role-play techniques. It is not always clear at the start of treatment which approach is likely to be most beneficial to you, and finding the right approach may involve some degree of trial and error.

4. Your therapist may also wish to involve a family member or friend in your treatment programme. This would only be initiated after discussing it with you. This provides people with moral support, hopefully positive feedback and encouragement.

5. Relapse is possible even after apparently successful treatment. Your therapist will discuss with you strategies for preventing this from happening. You must however continue to be vigilant after treatment and if the anxiety or avoidance begins to return it is important that you reapply the exposure or other behavioural strategies you learned during treatment as quickly as possible. If in doubt or you need advise then contact your therapist. They really won't mind.

This booklet has hopefully given you some idea of what is involved in Behavioural Therapy. Remember that the purpose of this type of treatment is to teach you skills that you can carry on using once therapy has ended. Learning to be confident about overcoming anxiety symptoms may take a while. It is something you will probably need to work at on your own whenever you come across situations in life that are stressful or problematic in some way. No ones life is ever completely free of anxiety or depression, the important goal is to free yourself of excessive anxiety that inhibits your ability to enjoy life and realise your potential. Learning how to do this is never a smooth, straight forward process you are bound to have some ups and downs and occasional setbacks. The important thing is that with hard work and practice you will gradually become more and more confident about doing things without anxiety that you had previously thought were out of reach.