Example: Harry’s Fine-Tuning
Harry struggled with the fear of panicking in public places. When he got to this stage in his treatment of his panic disorder, his exposure inventory was a little skimpy. It looked like this:
The anxiety solution can be summarized as a deceptively simple two-step process:
Or in psychology jargon:
Or even more simply, in cowboy lingo:
If only it were that simple! Just to get ready, you’ve already had to do a lot of reading, a lot of intense pen and paper work that is scary in itself, a lot of learning, preparing, motivating, analyzing, ranking distress and values, and so on. And you have yet to actually put one of your plans into action.
But now all your work is going to pay off. In this chapter you will finally face and overcome your anxiety, turning off your old false alarms.
It’s hard to face something you believe is very likely to harm you. And that’s exactly what this treatment program is asking you to do. It would be understandable if you were thinking seriously about stopping right here, hoping to find some other way. But here’s the problem: exposing yourself to what you fear is the only way to permanently surmount anxiety. And the exposure process offered here—though challenging—is faster and more effective than earlier therapies.
Other solutions don’t work. Anxiety drugs are rarely a good option. They help only as long as you take them, and many cause chemical dependence. When you stop the drugs, the withdrawal or discontinuation syndrome can leave you feeling worse than before. Waiting and hoping sometimes seems like a solution because anxiety can spontaneously wax and wane. But the long-term trajectory for untreated anxiety disorders is that they usually get worse. Avoidance begets increased avoidance, and life becomes ever more restricted and closed in by fear. Another strategy, trying to get people to help you, reassure you, or protect you, also makes anxiety worse in the long run. Everything you do to feel safer brings momentary calm at best, before you get caught in the next round of anxiety.
Your belief that certain things will harm you cannot change without disconfirming experiences. When it comes to fear, everyone is from Missouri—we have to be shown. We have to experience directly the feared situation and see that we are unscathed by it. That’s what will happen in this treatment program. It’s hard, it requires courage, but it will set you free.
Get out your Exposure Inventory Worksheet from the previous chapter. Before you put your various plans into action, you’ll want to do some fine-tuning to guarantee maximum results.
Effective exposure depends on the maximum discrepancy between your predictions of harm and actual outcomes. Therefore, you should make sure that all your exposure items have probability percentages of over 60 percent. That way you will have maximum learning potential and the best opportunity to disconfirm your fears.
If an exposure item has less than a 60 percent probability of harm, extend the time spent in the exposure, plan to move closer to the feared situation, or combine it with another feared situation until the probability exceeds 60 percent.
Make sure that the exposure items on your inventory cover the full range of probability percentages, from 60 to 100 percent. Avoid large gaps of more than 10 percent—for example, where you have items at 60 percent and the next highest item is 80 percent. If need be, fill in these gaps with additional exposure items.
Make sure that the plans you make for exposure to things you avoid meet these criteria:
Situational exposure, which involves being in or near something you expect to harm you, is not the only form of exposure. Imagery exposure is used to visualize frightening events from the past, to relive traumatic memories, or to “expose” yourself to situations that are not easily reproduced in real life. For example, it is not safe or practical to plan to encounter a real traffic accident or a poisonous spider, so you do it in your imagination.
Imagery exposures can also be attached to situational exposures in order to increase the expectation of a feared outcome, thus strengthening the disconfirming power of the exposure. In other words, when you deeply believe something bad will happen, and it doesn’t, you start to disconnect the exposure experience from the idea that you’ll be harmed. For example, you might precede a freeway driving exposure with an image of a traffic accident, thus increasing your expectation of harm.
Reading about scary things related to a feared situation, just before an exposure, can also make the exposure more effective. By intensifying the expectation of harm, an outcome in which no harm comes to you helps you learn that the exposure stimulus isn’t dangerous.
This is exposure to physical sensations that you identify with fear and danger, such as being out of breath, being hot, having an elevated heart rate, having shaky muscles, and so on. Interoceptive exposure was covered in the previous chapter, under panic disorder. There’s also more information in appendix IV at the end of this book.
Example: Harry’s Fine-Tuning
Harry struggled with the fear of panicking in public places. When he got to this stage in his treatment of his panic disorder, his exposure inventory was a little skimpy. It looked like this:
| Fearedsituation | Safetybehaviors | Plan to stop safety behavior and to expose | SUDS 1–100 | Value 1–5 | Predicted worst-case outcome | Percent probability |
|---|---|---|---|---|---|---|
|
Eating out |
Avoid |
Order tea in diner |
50 |
2 |
Will have a panic attack, have to leave, be incapacitated for hours |
45 |
|
Eat lunch at nice restaurant with a friend |
85 |
4 |
All of the above, plus friend will be angry |
90 |
||
|
Take girlfriend out to eat |
75 |
5 |
All of the above, plus she will be angry for days |
80 |
||
|
Being outside, away from home |
Avoid, check and recheck for phone and keys, Take own car |
Take 1-mile walk along river |
60 |
4 |
Will panic, feel weak, barely make it home |
50 |
|
Take bus to work |
80 |
4 |
Will panic, have to call a friend to take me home |
80 |
||
|
Having elevated heart rate, feeling hot and out of breath |
Have stopped going to gym |
30 minutes in gym, getting hot, sweaty |
80 |
4 |
Have to leave, feel incapacitated all day |
80 |
Harry looked at his probability percentages and realized that ordering tea in the diner and taking a one-mile walk were under 60 percent. So he planned to also order a sandwich and increased the walk to two miles, raising the probability percentages to 60 and 65 percent respectively.
He also noticed that he didn’t have a really challenging situation in which the probability percentage reached 100 percent, so he added a weekend trip that his girlfriend had always wanted to take. He also added a couple of mid-range exposures to different feared situations to flesh out his inventory. One of them, going to popular movies, was something he really used to like to do, a high-value exposure.
Harry added a visualization of being lost in a strange city, late at night, and running out of gas. It was a situation he greatly feared, but he couldn’t figure out how to arrange it in real life. He also added some imagery exposure to his plan to take a two-mile walk along the river. While walking, he would visualize the time he had his first panic attack, on a hike with a former girlfriend.
Harry beefed up his plan to experience his panic sensations at the gym by adding a heavy sweatshirt and a visit to the sauna to address his fear of feeling hot. He also increased the time exercising in order to experience longer elevations of his heart and breath rate.
The final version of Harry’s inventory looked like this:
| Fearedsituation | Safetybehaviors | Plan to stop safety behavior and to expose | SUDS 1–100 | Value 1–5 | Predicted worst-case outcome | Percent probability |
|---|---|---|---|---|---|---|
|
Eating out in a restaurant |
Avoid, eat at home, call for delivery |
Order tea and sandwich in diner, stay 30 minutes |
50 |
3 |
Will have a panic attack, have to leave, be incapacitated for hours |
60 |
|
Eat lunch at nice restaurant with a friend |
85 |
4 |
All of the above, plus friend will be angry |
90 |
||
|
Take girlfriend out to eat |
75 |
5 |
All of the above, plus she will be angry for days |
80 |
||
|
Going to movies |
Just don’t do it anymore |
Go to crowded movie with girlfriend, sit in the middle of a row |
70 |
3 |
Will feel so claustrophobic that I’ll have to leave early |
85 |
|
Remembering first panic attack |
Distraction |
Visualize first panic attack for 1 min., then 2, then 3 min. |
60 |
2 |
Won’t last, will have to stop visualization |
85 |
These guidelines will help you solve your anxiety problem as quickly and thoroughly as possible. When you begin to experience your exposure situations in real life, review this section to make sure you are maximizing your chances of success.
Start small. Make your first exposure an item that has the lowest SUDS in your inventory. It’s best to start with something that doesn’t push your fear all the way to the top. Later you can randomize exposures, but let this first one be relatively easy.
Until recently, gradual or hierarchical exposure has been the gold standard for treating anxiety. You face your fear in small, graduated steps, a hierarchy from the least to the most feared item. This standard was based on the concept of habituation: you experience a low-level anxiety stimulus and stay in the situation until there is full desensitization and you feel no more fear. For example, people afraid of freeways might stand on the side of the road and watch an on ramp for half an hour. Then they would move up to being a passenger in the slow lane for a quarter mile. Eventually they’d work up to driving for real on the freeway. It took a long time and sometimes there were significant setbacks, when anxiety would suddenly flair up and they would have to break the exposure into smaller steps.
A better way to do exposure has since been discovered (Craske et al., 2014) that takes less time and produces more lasting results, fewer relapses, and a profoundly positive change in your relationship to anxiety. It is called inhibitory learning. Instead of relying exclusively on habituation, which can so easily unravel and reverse, inhibitory learning helps you learn that the things you fear will not happen. This shift in your catastrophic beliefs—that terrible things will occur if you get on an elevator, touch a bathroom doorknob, say hello to a stranger, go far from home, or whatnot—is a game changer that can permanently liberate you from a life of anxiety. Instead of believing that the worst will happen, you will have learned that there is no relationship between the old feared stimulus and disaster.
That’s why exposures in this program always include a worst-case prediction and your estimate of the percent probability of the prediction coming true. After each exposure, you get a chance to learn about the actual dangerousness of things you fear.
The inhibitory learning model breaks with exposure traditions in other ways. It replaces the old hierarchical exposure approach with random exposures. Instead of using a hierarchy in which you expose yourself stepwise up a ladder of increasingly fearful situations, you do exposures in a deliberately random order, mixing situations that cause you varying levels of distress (SUDS). This is a faster way to learn that your predictions of catastrophe will not come true.
So, after starting with your lowest SUDS item, jump to one with significantly higher SUDS, and a higher percent probability of harm. As you expose yourself to items with different SUDS levels—some lower, some higher—it serves to better disconfirm your expectation that bad things will happen. Keep jumping around your inventory by asking the questions “What do I need to learn next?” and “What avoided experience do I need to face next?”
Special note: Randomizing exposures instead of gradually progressing from lower to higher fear-evoking items is challenging. We strongly suggest you do this because treatment results are more rapid and complete. However, some people find that random exposures present a level of fear and difficulty that is too challenging to face. If, after attempting random exposures, you feel too anxious to go on, we suggest you reorder your inventory as a hierarchy, with items arranged from the lowest to highest SUDS rating. Work up the hierarchy gradually, attempting an exposure to the next-highest item only after learning to face the one below it.
Here are the other general rules to keep in mind as you create your inventory:
When taking on higher SUDS items with more challenging fear levels, initially select exposures that also have higher value ratings. So while the exposure may be more scary, it is also something you want to do—it really matters to you. If you think back to Harry’s inventory, for example, high-value items like going to the gym were also quite frightening (high SUDS).
This means, in Harry’s case, that if he does an exercise exposure in the gym, the next exposure should be in a different setting—a brisk walk by the river, or on the crowded streets downtown. Keep altering where, how, and with whom you do certain exposures so you’ll learn to face the fear in multiple contexts.
During exposure, fully observe your emotions, body sensations, and thoughts. Notice the full range of your experience. In your mind, try to name the feelings you have, and watch as they may shift and change during the exposure. Do nothing to avoid or numb your feelings. Don’t try to reassure yourself, use coping thoughts, or try to control your fear in any way. In other words, do nothing to feel safer.
Stay aware of the exposure experience itself. For example, if you are exposing to heights, you might try to focus on objects below you, noticing how far away they seem. If you are exposing to a social anxiety, it would be helpful to observe people’s tone of voice and facial expressions as they speak to you.
Long enough means the full length of time you planned. Anything less won’t fully disconfirm your prediction of the worst-case outcome. If you can’t last the whole time, you’ll have to break up the exposure into two or more sessions in which you can stay for the whole time. Alter your inventory accordingly as you go along.
Try to stay in the exposure or repeat it until your expectation (percent probability) that the feared outcome will occur has dropped significantly. It doesn’t matter whether your actual fear level has gone down—only that your expectation of harm has decreased. If you thought you’d need to expose yourself to a scary situation for an hour, but your expectation of disaster drops to 10 percent after fifteen minutes, you’ve accomplished your goal and you can stop.
Once you have some successful exposures under your belt, you can try combining exposures. You can combine two situational exposures, or pair a situational exposure with imagery or interoceptive exposure. Combined exposures result in something called deepened extinction—a more profound violation of your expectation of harm, and something associated with better treatment outcomes. But when you combine situational exposures, make sure you have already done at least one of them already.
After each exposure, fill out one of the Results Tracker worksheets provided later in the chapter. It gives you plenty of room to answer four important questions:
You are ready. Grab your fine-tuned Exposure Inventory Worksheet, pick out your first exposure experience, and go out and do it. Work through your list of exposures systematically, following the guidelines and evaluating each exposure upon completion.
Example: Harry’s Exposure Process
Harry’s first exposure was to his inventory item with the lowest SUDS—going to the diner to order tea and a sandwich. He had no panic attack and stayed for 40 minutes, finishing every crumb and drop. Twenty minutes into the experience he realized that his expectation of a disastrous attack had declined to nearly zero percent. While he finished his meal he pulled out his Results Tracker and wrote up his experience, rating the probability of his worst-case outcome happening as 4 percent.
Harry didn’t decide on the order of his exposures in advance. Instead, he kept asking these questions: (1) “What do I need to learn next?” (2) “What avoided experience do I need to face next?” (3) “How can I achieve maximum violation of my predicted outcomes (percent probability that what I fear will actually happen)?”
For his second exposure, Harry skipped eating out with a friend and jumped right to having dinner with his girlfriend at her favorite restaurant. He was combining a high-fear with a high-value experience. Though a slow, sit-down meal was scary (he rated an 80 percent chance of panic), showing his girlfriend a good time was very important to him. They spent most of their nights at home, and she chafed at the ways his life had become constricted.
While they waited to give their order, Harry’s heart started to pound. He felt hot and his breath rate climbed. Harry just observed his experience moment by moment, feeling his heart and breath, having the thought, Here we go, meaning a panic was imminent. He looked at the waiters with their trays; he listened to the murmur of conversation. Despite the fear, he was determined to stay for the full meal, and he did. Later that night, Harry wrote in his Results Tracker that he had panicked, but it lasted only a minute or two. He didn’t have to run home, and his girlfriend—best of all—had a good time on their dinner date. When he re-rated the percent probability that he would panic and have to leave a restaurant, it was down to 20 percent.
Harry decided to take on something very different for his next exposure item. He went to the gym for 30 minutes of sauna and treadmill. He had rated the likelihood of panic at 80 percent, and assumed he’d be forced to leave before the allotted time. To his surprise, Harry discovered that his heart could race and he could perspire and be out of breath, and yet not panic. He was actually starting to get used to these sensations. The next day he went to the gym to work out like he used to.
Harry asked the question, “What do I need to do next?” and scanned his inventory. Intuitively, it occurred to him that he needed to face the fear associated with his original panic attack. So he visualized the scene on the hiking trail for 1, then 2, then 3 minutes. Though he expected an 85 percent chance of panic, his heart raced without further symptoms, and the percent probability went down to 5 percent on his testing worksheet.
Next, Harry visualized his first panic just before a hike by the river, and later combined the same visualization with a movie date with his girlfriend. Though Harry sometimes had brief panic symptoms, none of them incapacitated him or forced a return home. He was beginning to believe no great harm would come to him for the items he’d already tested.
Harry tried other exposure contexts—walking briskly on the crowded downtown streets, and hiking with his girlfriend in Muir Woods. He continued to vary items in terms of fear intensity and expectation of harm. Whenever possible, he combined high SUDS items with things he wanted to do and greatly valued. While these high SUDS items were scary, they were also experiences he felt very motivated to face.
During each exposure, Harry observed both his internal feelings and the external sensations. He watched all that went on without resisting, coping, or distracting from the exposure. And, with each successful exposure, he felt more and more convinced that the things he’d avoided for so long would not hurt him.
Harry got to where he could “freestyle” exposures that were not planned out on his inventory. He started taking the subway to work sometimes, or taking the bus partway and walking the rest. He also chose to walk for various periods on the beach, in an empty area of a big park, and on several new hiking trails. He even decided to take a two-hour hike with a group of outdoor enthusiasts at work. His girlfriend pointed out to him that what he called “freestyling” other people called “living your life.”
Here is the worksheet for tracking your results after each exposure, followed by an explanation of how to answer each of the four questions, and examples of how others have used the Results Tracker. (This worksheet is also available for download at http://www.newharbinger.com/34749.)
|
Exposure: |
|
Predicted worst-case outcome: |
|
1. Did the worst-case outcome happen? Yes No |
|
2. What happened instead? |
|
3. Percent probability: Before: After: |
|
4. What did you learn from the exposure? |
|
5. SUDS 1–100: Before: After: |
Write out what you did in detail and how you followed your plan for exposing yourself to the feared situation without using any of your preferred safety behaviors.
Write down the worse-case scenario of what you think will happen.
This is a simple “yes” or “no” evaluation of what happened. Either the harm you predicted occurred, or it did not. Put an “x” next to either yes or no on the Results Tracker. Because predictions should describe observable outcomes—either events or behaviors—the answer to this question should reflect actual events, rather than feelings or impressions.
Describe exactly what happened. What behaviors did you or others display, either during or right after the exposure? Did you follow your plan exactly, or were there differences? If the worst-case outcome you predicted didn’t occur, what events did you observe during the test? As much as possible, be a personal scientist and describe the exposure outcome objectively.
An example would be a man who feared germs. Unless he washed thoroughly for half an hour after touching a series of knobs in a bus station, he predicted, he would grow very ill within three days. Here’s how he described what happened: “A day after the doorknob test, I felt a little tired, not quite my usual energy. Day two I was okay, but I blew my nose a few times. Day three I was okay, no noticeable symptoms. I gave myself an extra day, but even on day four I felt pretty healthy. I don’t have any symptoms of illness.”
Write down the percent probability for the worst-case outcome that you had before the exposure, and the percent probability for the worst-case outcome now, after the exposure experiment.
This is the time to make sense of your experiment. How do you explain the outcomes? If the predicted harm didn’t occur—as is almost universally the case—what does that tell you about the dangerousness of this experience? Did anything surprise you? How likely does the predicted harm seem now—in terms of percent probability?
For example, a woman predicted having a panic attack and becoming incapacitated and unable to drive if she attempted to cross the Golden Gate Bridge. She wrote this summary of her learning on her Results Tracker: “I was anxious. My heart rate was way up. It was pounding. And I felt light-headed like I get. I was ‘panicky’ but not in full panic. I was able to drive okay, which surprised me. I was able to react appropriately to traffic, and even get out of the way of a car that was merging into my lane. I learned I can get anxious without having a panic attack, and I can drive okay even if my heart is racing. I stay functional. Percent probability that I won’t be able to drive and have to stop on the bridge: 40 percent.”
Record the SUDS from your Exposure Inventory Worksheet, and the SUDS you felt just as you ended the exposure. This is probably the least important information on the Results Tracker, because the object of exposure is not necessarily to reduce your SUDS. However, it can be interesting to compare post-exposure SUDS to the SUDS level you expected for this experience in your inventory.
Example: Obsessive-Compulsive Disorder
After reading about a child who ran into the street and was killed by a car, Aaron could hardly get the thought out of his mind, especially while driving. He imagined that small children could run out and fall under his wheels and he might not even know it. He began driving only short distances, retracing the whole route at least once to see if he hit anyone without noticing. He avoided driving anywhere near schools and playgrounds, and generally would not travel more than fifteen miles per hour. Here is one of his Result Trackers:
Aaron’s Results Tracker: Fear of Doing Harm
|
Exposure: Drive 22 miles to visit mother after Googling and reading articles about children being hit by cars. No retracing route. |
|
Predicted worst-case outcome: I will hit a child while I drive and read about it in the newspaper the next day. |
|
1. Did the worst-case outcome happen? Yes X No |
|
2. What happened instead? There were no newspaper reports of children who were victims of a hit and run. There was an accident where a child was hurt inside a car, but that’s all. I was also worried, I’ll admit it now, that I’d be so scared I’d have to retrace my route. But I forced myself to park and ring my mother’s bell. |
|
3. Percent probability: Before: 80 After: 60 |
|
4. What did you learn from the exposure? I learned that I can drive at a moderate speed and a moderate distance without hitting a child, at least this time. |
|
5. SUDS 1–100: Before: 95 After: 75 |
Example Panic Disorder
Beth’s first panic attack occurred while she was driving over a high suspension bridge. She had just left her father’s funeral and was on her way home. It was so horrible that she was determined never to let it happen again. Over the next few days she vigilantly watched for the first physiological signs—the feeling that she couldn’t catch her breath, dizziness, and a pounding heart. But despite her efforts, the panic returned in several settings—such as in a restaurant, on a bus, and walking to work. More and more she tried to avoid situations in which she’d previously panicked. But it didn’t work. The frequency of her attacks went from once a month to twice a week. Here are the results of her first exposure:
|
Exposure: Run in place for 2 minutes until I’m out of breath and my heart is pounding. |
|
Predicted worst-case outcome: I’ll get so panicked that I can’t stand it and will have to stop early. I’ll be too upset to do anything the rest of the day. |
|
1. Did the worst-case outcome happen? Yes X No |
|
2. What happened instead? I got winded and my heart was racing. But I made it through the full 2 minutes. I was able to do the bills after, and go over and visit Joan that night. I was anxious, but I got though the exercise and could still function. |
|
3. Percent probability: Before: 95 After: 60 |
|
4. What did you learn from the exposure? I learned that I could stand the feeling of being out of breath and having my heart pound. The feeling doesn’t incapacitate me. I can carry on with my life. |
|
5. SUDS 1–100: Before: 90 After: 50 |
Example: Specific Phobia
Janice was afraid of heights. It began at age eleven, when her brother encouraged her to climb a water tower, then left her up there, terrified to climb back down the ladder. While completing a degree in structural engineering, Janice landed an internship with a major construction firm. Part of her job was going to be inspecting construction sites, which often involved working in tall, partially completed buildings. Moving forward with her career required that Janice overcome her acrophobia.
Janice’s Results Tracker: Acrophobia
|
Exposure: Go with friend to third floor of building under construction. |
|
Predicted worst-case outcome: I will slide, fall, or jump off the edge of the open floor. Something will pull or compel me to fall. |
|
1. Did the worst-case outcome happen? Yes X No |
|
2. What happened instead? I’m alive and uninjured—I’d be dead if I’d fallen. I felt a little dizzy up there. I had a picture in my mind of the floor tilting and me sliding off. And then—like I’d seen in a movie—I imagined myself running full-out over the edge. But none of those things happened. |
|
3. Percent probability: Before: 70 After: 40 |
|
4. What did you learn from the exposure? That having pictures in my mind of horrible things doesn’t make them happen. That I’m not going to fall if I’m 10 feet from the edge, no matter what story I’m on. |
|
5. SUDS 1–100: Before: 80 After: 60 |
Example: Post-Traumatic Stress Disorder
Arturo was attacked at an ATM at night. Three men hit him, one with a wrench. While half-conscious, he felt them meticulously go through his pockets and take everything of value. Six months after the assault Arturo was experiencing flashbacks, mood swings, and nightmares. He had become extremely fearful of going out at night and walking near groups of men, even on safe, well-traveled streets.
Arturo’s Results Tracker: Fear of Assault
|
Exposure: Walk down Market Street between Sixth and New Montgomery (a busy commercial area) at 8 p.m. |
|
Predicted worst-case outcome: I’ll be attacked and beaten on the street. |
|
1. Did the worst-case outcome happen? Yes X No |
|
2. What happened instead? I got all the way to New Montgomery and nobody even seemed to notice me, let alone make a move toward me. I was nervous at first, although that got better. I did the visualization of my mugging in a coffee shop. I’d done it before, so it didn’t scare me as much as I thought. I felt like I could face the walk back, so I did. |
|
3. Percent probability: Before: 75 After: 50 |
|
4. What did you learn from the exposure? I learned that I can probably walk down Market Street without anyone bothering me and that expecting something to happen doesn’t mean it will. I have more ability to face things than I thought. |
|
5. SUDS 1–100: Before: 80 After: 50 |
After you have worked through your inventory, what happens when you encounter some of those same feared situations again? Your anxiety or subjective units of distress (SUDS) will be significantly reduced. The anxiety is unlikely to completely disappear, but that’s not the point of this treatment. The point of the treatment is to significantly reduce your anxiety, and the time when the formal exposure process ends is when you can do all the things you used to avoid.
No one’s life is free of anxiety. We all have fears. But the goal is to live life fully—free to do the things that matter to you—even if sometimes the alarm goes off.
Harry stopped planning exposures when he could do all the things in his inventory that mattered to him. Sometimes he felt twinges of the old anxiety, and there were situations in which the thought occurred to him that he might panic. But he had learned one thing: the old symptoms couldn’t hurt or incapacitate him. He could do everything he wanted to do.