Anxiety Recovery Without Exposure? (Ep 298)

Picking Your Own Path To Recovery

Everyone gets to pick their own path. If that means you do not want to go down the exposure route, that is your right to make that choice and not my place to try to convince to do otherwise. I’m just primarily interested in people making choices based on accurate information that includes subtleties and nuances that sometimes get missed when information is passed around on social networks.

What Is Exposure? Does It Really Work?

Exposure is what we call it when we choose to come into contact with the things that we fear to intentionally feel that fear. Why?  In the old days … habituation.  Now … inhibitory learning. We do the exposures, we choose to not engage in the escape or safety rituals we usually engage in, we learn that we wind up capable of handling our fear (the internal experience of fear, that is) without using those safety responses. Things change. Inhibit the saving response … learn from that experience.

Does this work?  It’s not even a question at this point. We’ve been using exposure based therapies for decades now and especially when we started combining exposure (we can also call these behavioral experiments) with acceptance and process based strategies rather than control and content based strategies, things by and large go well for a large number of people and we see good clinical outcomes.

Criticisms of Exposure In Recovery

There are knocks against exposure. What are they?

High attrition rate. Exposure is hard to do! Nobody wants to do scary things, so when therapy clients engage in exposure based therapies there is a chance they will bail out of the process because of the difficulty involved in intentionally facing scary situations. This is a valid criticism. Where’s the nuance?  Well, when there is good preparation and psychoeducation before exposure is done, that attrition rate does drop dramatically, but I won’t try to convince anyone that exposure is easy and yes, when humans do very difficult or disturbing things they are at least somewhat likely to stop doing those things if it feels too hard.

Exposure is damaging or traumatizing. This is false.  Well, let me clarify. In exposure based therapies, it is CRITICAL for the therapist or counselor to be well versed in the treatment they are using with their clients, and able to look well beyond just the mechanics of exposure and what makes it effective. Almost every therapy client I work with in my admittedly fledgling career as a therapist has objections to exposure work and finds it difficult for specific reasons that are unique to them.

I could not simply repeat the principles of exposure to these good people, demand that they do exposure to get better, and totally ignore the experiences and beliefs they bring into the process. I have to know where they’ve been and what they’ve experienced. I have to take cultural and social issues into account.

If a client has lived through experiences where being in public placed has been threatening or truly dangerous to them in some way, then simply telling them to face fear – do it scared – or do it anyway without taking that into account might be traumatizing or re-traumatizing in some way. That is true.  But that would be my fault as the clinician. That’s not a flaw in the concept of exposure based therapies.  This is where the watering down and oversimplification we find in the endless scroll doesn’t accurately address an issue from all required angles.

With the right sensitivity, preparation, education, encouragement, and instruction, exposure is not inherently dangerous or traumatizing. Difficult … even scary … does not automatically equal trauma. It might for some people because of their background in which case we might delay or even forego exposure work, but be careful about declaring that exposure is structurally cruel or traumatizing because it is difficult and involves feeling sometimes extreme discomfort.

Third criticism – therapists don’t like to make clients do scary things.  Understandable. No knock there. But therapists – humans like the rest of us – that might be a bit too sensitive themselves or have a low professional distress tolerance threshold – do not constitute proof that exposure is cruel, traumatizing, ineffective, or not necessary. It’s OK for clinicians to choose other modalities for their clients. We just can’t draw universal conclusions from the opinions and emotions of helpers that I still think have the best of intentions.

Nobody Wants To Do Scary Things – Looking For Gentler Ways Is Understandable!

Let’s acknowledge that people do not want to do scary, difficult things. I don’t. Nobody really does when push comes to shove. So if exposure has proven to be difficult because you’re finding it hard to choose to be uncomfortable, it’s not just you. It’s virtually EVERYBODY that tries to exposure work. If you find exposure difficult or distasteful in some way – that’s no crime. Naturally, it will lead you to look for gentler or easier ways to get better. Not because you are weak or flawed or lazy. Just because you are human. Nobody blames you – at least I don’t blame you – for hoping to find a gentler or easier path to wellness.

When Unrealistic Promises Are Made …

This is where we run into problems though. I’ve seen the posts, the reels, the messaging about non-exposure recovery.  There are wellness frameworks that might suggest that exposure isn’t needed, and there are even formal, manualized treatments that are not based on exposure work. That’s fine, but sometimes when trying to spread the word about those frameworks or those treatments, it is strongly implied that no exposure is needed to overcome an anxiety disorder.  This is where I start to look sideways at the whole thing. I’m not picking on the framework or the modality. I’m questioning the use of extreme promises like that to get attention or gain credibility or engagement in the scroll.

Are all practitioners trying to fool you with click bait?  Of course not! Content creators and clinicians might get caught up in the excitement of finding a new treatment type that they really like for whatever reason. Sometimes they just accidentally get caught up in going with the messaging that gets the most attention in the algorithms. In other cases, content creators might be relying heavily on personal experience (which they certainly should be enthusiastic about) and maybe thinking that their personal experience is universal or even widely applicable to other people (that’s debatable in therapy circles for good reason).

There are a million reasonable explanations for the recent uptick in “exposure isn’t necessary” posts in our community. We’re not here to accuse anyone of wrongdoing or trickery at all.

There’s Always Going To Be Exposure In Some Way

BUT … I contend that unless there is some set of ideas or some treatment method that has the ability to completely wash away fear, doubt, uncertainty, and discomfort with only cognitive restructuring or spiritual interventions … there’s still gonna be exposure involved.  That exposure might need to be planned and formal in nature like it would usually be in therapy, or life is simply going to create exposures even after all the explanations, podcasts, videos, and cognitive restructuring modules.

A client that was able to use the psychoeducational and preparatory part of ERP to find solid ground from which to resist their compulsions and allow scary catastrophic thoughts without resorting to soothing rituals is still doing exposures every time those old thoughts pop up and they feel afraid, unsure, or like there is something dangerous or risky afoot.  A podcast listener that loves the non-exposure method they found online is still messaging regularly to ask how they can be sure about not harming their children. My comments section sometimes loves the idea of non-exposure recovery, but collectively still can’t seem to actually do the things, stop the scary thoughts, or resist the safety rituals even though all the logic and reason and spirituality has been presented in a feel good kinda way.

There Is A Place For Non-Exposure Work

Do those non-exposure principles and methods have a place in recovery?  Of course they do! Even in a dyed in the wool exposure based therapist is going to engage in psychoeducation and extensive preparation with a client before starting actual exposures.  Those principles and methods can be VERY useful and effective in that phase.  No doubt!  I am using quite a bit of inferential work with my clients as part of prep, and it is proving to be quite helpful to many of them with respect to helping them understand why its safe to do exposures and what lessons they can learn from them.  I love all that stuff. I really do.

Reality Is Going To Create Exposures – Planned or Otherwise

In the end, all the cognitive or spiritual work ultimately gets put to the test when you come into contact with reality.  Your brain will still make thoughts. Just feeling more confident that they are not dangerous does not stop that process. The situations and contexts you will in with trigger longstanding fears sometimes. You will be forced to do things that you’ve believed are impossible or risky. Life will force you to test your newfound understanding in real world conditions where you must act rather than just thinking or talking.

When this happens, unless the non-exposure approach has turned off longstanding beliefs, thoughts, or fear (which I have yet to see happen), you will be in an exposure, like it or not.

The need to allow discomfort to let EXPERIENCE teach the ultimate lesson is still baked into the process.

Thinking, Feeling, and ACTING … All Are Required

So … can we engage in prep work and coaching that helps people accept that it safe to allow discomfort or fear to learn from that?  We can, and we should! It would be cruel and unethical to not do that part.  But do we have ways to turn off thoughts, instantly banish fear, erase doubt and uncertainty, and suddenly see the world in a totally new way just by talking, thinking, and pondering metaphors?  It does not seem like we do. 

Our brains are prediction and error-correction machines that rely on cognition AND experience in combination to build new schemas and models of the world. Experience alone doesn’t cut it, nor does cognition alone. They work together so in the end, we need experiences – sometimes still difficult and challenging experiences – to change our beliefs and change how we expect our tomorrows to be.

Summary

If you’ve been trying non-exposure recovery and finding that it makes you feel good to hear all the words, but that you’re still kinda stuck and find yourself still looking for ways to not be afraid, not have scary thoughts, or really believe that you’re safe … you’re not doing it wrong. You’re just like every other human on the planet and that’s OK.

Can you recover without exposure?  Well you can do a lot of really helpful non-exposure work that does help move you forward. No doubt. But there are always going to be challenges  – experiences and experiments – that put your new words and images to the test and those – like it or not – are still exposures. Sometimes challenging ones. That’s OK.

References

Harned, M. S., Dimeff, L. A., Woodcock, E. A., & Contreras, I. (2013). Predicting adoption of exposure therapy in a randomized controlled dissemination trial. Journal of Anxiety Disorders, 27(8), 754–762.

Norton, P.J. & Price, E.C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders.
Journal of Nervous and Mental Disease, 195, 521-531.

Links Of Interest

• My Panic Attacks Explained Workshop
• My Agoraphobia Explained Workshop
• My Panic and Agoraphobia Recovery Guidebook
• Follow me on Instagram
• My YouTube Channel
• Disordered – With Josh Fletcher

 

Disclaimer: The Anxious Truth is not therapy or a replacement for therapy. Listening to The Anxious Truth does not create a therapeutic relationship between you and the host or guests of the podcast. Information here is provided for psychoeducational purposes. As always, when you have questions about your own well-being, please consult your mental health and/or medical care providers. If you are having a mental health crisis, always reach out immediately for in-person help.