Facing Your Fears Through Exposure
In order to habituate to an anxiety-provoking situation or trigger, it is necessary to place yourself in that situation or expose yourself to the trigger frequently, for increasingly longer periods of time, until habituation occurs. Exposure must take place without engaging in any compulsive, ritual, or avoidance behavior. Even though we take small steps, this is hard work.
When we ask clients to rate their SUDs, we say that a rating of one is almost no discomfort, and a ten represents the equivalent feeling of facing a bear alone in the woods. Imagine facing that bear in the woods because you choose to! Not only that, but you have to stay with that bear for at least ninety minutes or until your fear subsides by at least 50%. And then tomorrow, you will repeat the process, and continue repeating it for the next fifteen days.
Anxiety clients must be highly motivated to follow through. We ask clients to resist any compulsions that they’ve used in the past to reduce their anxiety; we call this response prevention. Fortunately, we can design an approach to exposure that allows clients to take small steps, or we can create conditions that make exposure more tolerable. Make no mistake—this is challenging work. It will not be easy to do.
Exposure may be accomplished by having the client face the actual feared situation in real life (in vivo exposure) or in a contrived or imagined situation (imaginal exposure). For a person with a fear of heights, for example, in vivo exposure might include gradually climbing and staying at specified heights until his fear subsides. Imaginal exposure could include his counselor asking him to imagine standing and looking off a balcony or cliff repeatedly until he habituates. Likewise, a person with a fear of contamination may be asked to touch a wet toilet seat and not wash his hands (in vivo exposure) or imagine touching a wet toilet seat and not washing his hands (imaginal exposure). Today, video exposure can be an option, too; you can find just about anything you can imagine on www.youtube.com.
Benefits of Working With a Therapist at Home and Elsewhere
There are many benefits to in vivo exposure at home or in another environment where anxiety occurs, under the guidance of a therapist. A therapist’s office can be a neutral or even a comforting environment; doing the work where the anxiety occurs can maximize exposure to triggers in the environment. It can provide real-time accountability for the exposures. Sometimes anxiety can become so strong that it is very tempting for the client to quit before they have had a chance to calm down, which can actually make the anxiety worse in the future and make exposure therapy more difficult. Having a therapist at hand can help the individual calm down enough that they are able to follow through with the exposure and get the most out of it. When a person can succeed in going through the anxiety without avoidance behaviors or rituals to make it go away, it can bolster their confidence to keep doing exposures in real-time settings and give them a better view of the situation. It provides the therapist with more insight into the situation as well, as they can add their own observations to the self-reporting of the client.
Exercise: What fears have you overcome?
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See how natural exposure has worked in your life. This may encourage you to take the matter of exposure and habituation into your own hands. Most of us can remember a time in our lives when we fretted, worried, or had anxiety about different circumstances. You may have had a fear that something was lurking in your closet or under your bed. Take a few minutes and write down any fears that you may have had but no longer harbor. See if you can identify what may have happened in your thinking or experience that helped you “get over” that fear or worry.
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Intrusive Thoughts, Urges, and Anxiety Triggers
Understanding Intrusive Thoughts
Most people are surprised to learn that almost everyone experiences random, distressing, or unusual thoughts or images that suddenly enter their minds. We refer to these as intrusive thoughts. When clinicians and researchers discuss intrusive thoughts, they generally mean thoughts or images that:
- Appear to enter the mind out of nowhere
- Are unwanted and occur against one's will
- Interrupt current activities or lines of thinking
- Feel negative, repugnant, or not fitting one's personality
- Are difficult to dismiss once they occur
Essentially, an intrusive thought is a mental "pop-up" that barges in, demands your focus, and is incongruent with your present situation. Here is the first key concept I want you to understand: Individuals without anxiety disorders or OCD also experience intrusive thoughts, including content that may be bizarre, aggressive, or blasphemous. The distinction is that they typically recognize the thought as senseless and move on without much difficulty. Studies indicate that 80-90 percent of people in non-clinical groups report intrusive thoughts at some point (Radomsky et al., 2014). Feeling distressed or ashamed by these thoughts does not mean you are dangerous or broken. It simply suggests your internal alarm system is highly sensitive and producing "false alarms."
An intrusive thought becomes a significant problem based on what you believe about it and how you react to it—the specific meaning you attach to it and the compulsions or avoidance behaviors that follow. This is the process where anxiety and OCD become reinforced and strengthened.
Distinguishing Intrusive Thoughts from Worry, Rumination, and Obsessions
Use this table as a guide:
| Kind of thought | Sensation | Form/Duration | Consequence |
|---|---|---|---|
| Intrusive Thought | Sudden, unwanted 'pop-up' thought or image that feels out of character. | Brief image or phrase; usually short-lived. | Alarm, shame, drives neutralization, avoidance, or checking. |
| Worry | Stream of 'what if...' thoughts about the future. | Mostly words/sentences; lasts minutes or hours. | Apparent problem-solving that is circular and maintains anxiety. |
| Rumination | Mentally replaying past events, losses, or failures. | Mostly words, sometimes images; lasts minutes or hours. | Keeps focus on 'Why did this happen?' or 'What is wrong with me?'; worsens mood. |
| Obsession | Intrusive thought/image that feels very important, dangerous, or meaningful. | Often repeats; feels urgent and 'sticky.' | Drives compulsions, reassurance, or rituals for safety/certainty. |
In this workbook, we are primarily focused on those distressing intrusive thoughts that become obsessions and drive the urge toward compulsions or avoidance behaviors. As you move into the following section, we will illustrate this process using real-life examples, such as the agonizing thought, “What if I hurt my children?” You will learn how we utilize exposure and response prevention to help you develop a more functional way of responding.
In vivo exposure becomes challenging when the fear attaches to an intrusive thought, such as “My children will become failures because I’m not a good mother. I don’t play with them or hug them enough.” Everybody has intrusive, irrational thoughts like “I should smack your face!” However, without an anxiety disorder, these thoughts don’t elicit self-recriminating thinking or compulsive rituals. “I should smack your face!” isn't acted out and doesn’t elicit a high level of anxiety. People without anxiety disorders recognize the irrational thought and simply move on.
Examples of random, intrusive thoughts that clients with anxiety disorders have shared:
- “Damn!” An intrusive curse like this may be followed by a compulsive prayer or another mental ritual. Sometimes the prayer must be said over until the person feels better or must be repeated if it’s not said exactly right. Content like this may follow: “Please, Lord, forgive me for saying that word. I must be a bad person to have that word just come into my head. I could go to hell. Please forgive me for saying…the opposite of heaven…I really don’t know why I have those thoughts. I’m trying to do better. Please help me. Amen.”
- “What if I picked up a knife and stabbed my children. What is wrong with me that I have these terrible thoughts? I must be a horrible person. What if I sleepwalk in the night and get a knife out of the drawer and hurt my children? I’ve got to hide these knives so that I can’t find them if I sleepwalk.” Intrusive thoughts such as this may be followed by hiding the kitchen knives and locking doors to make it difficult to get to the knives.
- A siren sounds (a trigger). “What if my husband has been in a wreck? It’s about time for him to come home. I need to call and check on him and make sure he is okay. Oh! I got his voicemail. He may be hurt and can’t answer the phone. I have to keep calling until I get him. I’ll call his office and see if he has left yet.” Repeated calling and checking (compulsions) may follow. The departure of loved ones for work or school (triggers) may be preceded by compulsive questioning and the superstitious (magical thinking) behavior of telling the person to be careful (compulsion). Failure to remind loved ones to be careful could result in something bad happening to them.
- Social anxiety triggers: “She’s looking at me. I wonder if she’s mad at me. Did I say something to hurt her feelings? I think I haven’t told her I love her today. She probably thinks I don’t care. I need to ask her if she’s upset with me. What if I die with her being upset with me?” These thoughts may elicit the behavior of repeatedly seeking reassurance or apologizing for any perceived nuance of unkindness.
Many of the clients I have had who were diagnosed with OCD questioned whether they were sane. For instance, one client was convinced that he was homicidal. He came in for three sessions with primary complaints of anxiety before I began to suspect OCD behavior and administered a screening. It was only after reading “I fear I might harm other people” and “I have violent or horrific images in my head” from the Yale-Brown Obsessive-Compulsive Scale that he told me he was terrified he might harm or even kill his wife. He told me about the “bloody scenes” in his mind, and that he had gone so far as to hide knives and remove weapons from his home. He never told his wife about this out of fear that she would leave him or call the police.
This client suffered from intrusive thoughts, and intrusive thoughts can be part and parcel of OCD. He was not homicidal at all. This concept was hard for him to understand. The difference is that individuals with intrusive thoughts such as this tend to be afraid of the thoughts. The ideas give them stress and anxiety, and they tend to obsess over them, asking themselves, “Why am I thinking this? I would never want to harm her!” These individuals are petrified that they will act on this thought or unwanted impulse, and are usually horrified by the images in their heads. Typically, someone who commits homicide would not experience this agony before their act. What I want you to understand is that if you experience these thoughts in this manner, it is characteristic of OCD. A trained and experienced professional will be able to discern the difference between intrusive thoughts and homicidal tendencies. It is important to be honest about the things you think and the way you feel about what you think, so that you can receive the right treatment.
Exercise: Identify intrusive thoughts
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As noted above, we all have intrusive thoughts from time to time. Write some of your intrusive thoughts. Some may be humorous and others anxiety-provoking. Are there situations that trigger intrusive thinking, e.g., socializing, being alone, or playing with kids?
| Intrusive Thoughts | Situations that Trigger Intrusive Thoughts |
|---|---|
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Exercise: Keep a stress log to increase awareness in the moment
Five steps and a four-column log, kept for at least a week. Type into it as the days go by and print or save the result, or print a blank log and carry it with you. Nothing you type is saved, sent, or stored.
Now that you have written about intrusive thoughts and common worries, the next step is to identify them as they arise. Those of us in the behavior-change business know that behavior change is hard. However, just as physical exercise builds strength and endurance, cognitive behavioral exercise does the same. As you now know, you can't change thinking, emotions, or behavior that you don't monitor. Therefore, the first step is to begin monitoring your cognitive behavior. In this exercise, notice when your stress increases, when you have an anxiety-provoking urge or anxiety trigger. For the next week, carry a pocket-sized notebook or write in your mobile device the following information (we call this a stress log):
- When you notice an increase in your feelings of stress or anxiety, estimate your stress level and enter a number on a scale from one to ten in the SUD Level column, where one represents very little stress, and ten represents as much stress as you could possibly stand.
- When you notice an increase in your stress or anxiety, write a brief description of the stressor under Trigger. You may experience a sudden increase in tension or anxiety but may not readily identify the trigger. In that case, describe what was happening at the time.
- Now, describe your emotional feeling and write this down in the Emotional Feeling column. I emphasize feeling because anxiety isn't just a cognitive experience; we feel it in our bodies. Your triggers may evoke feelings of nervousness, anxiety, disgust, hurt, anger, or dread; give the feeling a name. It will help you in your work to bring down your discomfort. Record them all—they don't have to be logical.
- In the next column, record the specific Thoughts that came to you as a result of the trigger. If you were not aware of any specific thoughts, write a description of what you now think, believe, or imagine when you reflect on the trigger. Don't clean up your internal language; write what you thought without editing.
- Keep your log for at least several days. If you are in counseling, take your log to the next counseling session. It will provide a good baseline assessment and highlight specific patterns.
| Trigger | Emotional Feeling | Thoughts | SUD Level |
|---|---|---|---|
The blank printed log carries sixteen rows across two pages, enough for a week. Nothing you type is kept — reloading or closing the page clears every row.
This page runs entirely in your browser. There is no account, no database, and nothing you type is saved, sent, or stored — not here and not on a server. Reloading or closing the page clears every field. Print it or save it as a PDF to keep it.