By Brian Robinson.
Exposure Therapy is an approach used in the treatment of various anxiety disorders, and particularly, in the treatment of phobias and OCD. But in one sense, Exposure Therapy isn’t a therapy at all. It is just something that happens naturally given the right circumstances. What we have to do, is create those circumstances, that state of affairs.
We’ve all watched those wildlife programmes on TV where a presenter is seen either close up to or amongst wild animals. In some cases, the presenter is even interacting with these creatures. This state of affairs between humans and animals does not arise naturally, or indeed because the presenter has a particular affinity with them. This interaction can only happen when the animals have first been desensitised to the presence of human beings. This desensitisation process is something that happens naturally and gradually over a period of time. The people will get closer and closer to the animals, and because they do not threaten them in any way, the animals will take less and less notice of them and begin to tolerate their presence more and more.
What happens, is a connection in the animal’s brain, i.e. the idea that humans are dangerous, becomes modified and the association with danger weakens and is eventually lost. And then, once the desensitisation process is complete, along comes David Attenborough who is then able to be amongst the animals and interact with them and make his programme. This modifying of a brain connection is known as habituation and it can work in much the same way in humans. This happens for example when we become desensitised to road traffic noise or the noise of aircraft passing overhead. In the end, the sounds do not register in our brain and so we don’t become stressed by them. That makes perfect sense, because why should we become stressed by something that will never harm us?
There are two essential elements to the habituation process that have to be in place before it works. These are sometimes referred to as ‘in trial habituation’ and ‘between trial habituation’. To understand this, let’s look at an example where a man has developed a supermarket phobia. He had a severe panic attack while in a supermarket, and ever since then, the association between supermarkets and danger has been made. Whenever the man enters a supermarket he gets a phobic reaction and immediately becomes anxious, or indeed, he may even become anxious just thinking about going to the supermarket. This is quite disruptive for the body, but his brain is quite happy to create that disruption because it does so in the interests of safety. This phobic reaction then encourages the man to leave the supermarket, and his brain achieves its purpose. We shouldn’t be too worried about the idea of these connections made in the brain. This is something that happens all the time. These act as short-cuts to our understanding of the world and they are always open to change.
For Exposure Therapy to work, the first thing the man has to do is go to the supermarket and resist the urge to leave. And ideally, he should stay there for quite some time. When he does that, he will find that his anxiety levels will gradually fall as time passes. This is known as ‘in trial habituation’. What happens is his brain lessens the phobic reaction when it becomes clear that the man is not going to react and leave. This makes sense because the brain is not comfortable with maintaining anxiety at such high levels for long periods. However, the brain won’t change the safety connection just because of this one-off exposure. It simply makes a temporary adjustment to avoid prolonged disruption.
With this ‘in trial habituation’, or you could call it ‘in trial desensitisation’, the critical thing to remember is ideally we have to stay in the supermarket until the anxiety begins to diminish in order to get the best results. This is when the brain learns the most regarding the exposure to the perceived danger. However, although this one-off exposure will have a positive effect on the brain, it won’t count for much unless it is repeated. This brings us to ‘between trial habituation’.
‘Between trial habituation’ refers to what happens in the brain when the exposure is repeated over and over again. This is central to understanding how Exposure Therapy works. Think of it this way: a phobic reaction is quite disruptive on the body, but the brain is quite prepared to induce this if it serves the purpose of removing the person from the danger. However, when the exposure is repeated over and over again, the brain is not quite so prepared to put up with this. This is what causes the brain to reconsider matters and change the danger connection. What this means in practice, is the person would have to visit the supermarket several times each week in order to encourage the brain to become desensitised. In fact, if we were to call this ‘repeated trial desensitisation’ that might better reflect what happens.
With this type of straightforward phobia, there is another crucial point to note. It doesn’t matter what’s going on in the sufferer’s head while in the supermarket. Just like with the animals in the jungle, who are not inwardly agonising over the pros and cons of being around humans, the desensitisation process happens purely with the passing of time. This is an example of a simple phobia and there is little or no psychological dimension to it. Our sense of reason more or less tells us that supermarkets do not pose a danger, and therefore we can be quite sure that the fear is wholly irrational. Where there is a psychological dimension to the phobia, say for example if the man had been trapped in a supermarket fire, then this element would have to be dealt with as part of the recovery process.
Exposure therapy then, in the narrowest sense, is about placing the phobic person in the dangerous situation repeatedly, and this is done to encourage the brain to reassess matters. In the broadest possible sense, exposure therapy can be seen as any endeavour, behavioural or otherwise, which encourages the brain to make the necessary changes. When phobias are complicated, Exposure Therapy can work alongside Cognitive Therapy which can help deal with any psychological or emotional elements.