part0022

N ow that we’ve learned the mindfulness skills of defusion, expansion, and engagement, it’s time to put them into practice. This isn’t going to be easy, but it is possible and often life changing. When we see anxiety-inducing situations as opportunities to learn, improve and grow, we adopt a mindset of courage and optimism. Initial successes will boost our confidence and future challenges won’t seem so insurmountable.

Taking practical steps to overcome social anxiety can be demanding at first. This is because once certain social anxiety triggers are established and a neural pattern has been formed, it’s difficult to stop the amygdala flooding us with anxiety. However, with practise, we can retrain the brain’s response to anxiety and develop new pathways that compete with and overpower the original anxiety response. To do this, we need to expose ourselves to those very situations that trigger our anxiety and then counter the association between the trigger and negative social event or situation.

The defusion and expansion skills will help us to effectively manage our unhelpful thoughts and feelings when we confront our anxiety, and engagement will help to keep us present in the situation. This will allow our amygdala to learn from the new experience and make new connections in response to it.

In our everyday lives there are many examples of people confronting and overcoming their anxiety in this way, and you’ve probably done it in other areas of your life before too. Learning to drive and swim requires us to overcome some initial anxiety, and ask anyone who’s skied or parachuted if they had any anxiety when they first attempted it. We take many of these situations for granted and forget that we ever felt anxious, but we can overcome unnecessary anxiety that stops us from living life fully in almost any situation and at any age.

By repeated exposure to an anxious situation - without anything negative happening - we can demonstrate to the amygdala that it doesn’t require a fear response. We can teach our amygdala to feel safe.

You may remember that we discussed exposure treatment earlier in Chapter 6, when we described how psychologists normally treat Escape Avoidance Learning (the tendency to escape from anxious situations). It’s been used to successfully treat panic attacks, obsessive-compulsive disorder (OCD), various phobias, and many anxiety related disorders. Exposure treatment involves people being exposed to situations that make them fearful or anxious, sometimes in gradual stages (like the example we used of the people treated for snake phobias) or sometimes abruptly.56

The treatment requires people to be exposed to the threatening situation, often causing their anxiety to rise to uncomfortable levels, until eventually subsiding without them leaving the situation. It’s important to allow the anxiety response to run its course without the person escaping, as it is this that teaches the amygdala that similar situations are safe and shouldn’t be feared.

In order for exposure treatment to work, we have to give the amygdala the opportunity to make new connections in the social situations that set off the anxiety response. This involves confronting our fears, which is why it requires courage and determination. We need to provoke the anxiety response, as only this activates the memory circuits that relate to that particular threatening situation, allowing new connections to be made and the amygdala to respond differently. This is why it is key to adopt the mindset that threats are an opportunity to learn and implement positive change. Exposure treatment isn’t easy because it involves deliberately engaging in situations that we find anxiety inducing.

The gradual approach is called Systematic Desensitization and involves experiencing feared situations or objects in a gradual manner. The treatment for snake phobias we discussed earlier in the book is a good example of the gradual approach. You may remember that the snake was introduced in a slow but steady way, moving closer and closer, firstly from room to room and then within the room itself, allowing the person’s anxiety to rise and fall before going onto the next stage.

The more abrupt version of the exposure treatment is called Flooding , and while it is a far more intense approach, it tends to provide relief from anxiety much more quickly. Rather than gradually building up to the fearful situation or object, people are thrown straight into the most anxiety-inducing situation and asked to stay with it until the anxiety subsides.

If flooding is used for treating snake phobias, the person is immediately given the snake to handle, with no other preceding stages, and asked not to escape the situation, but to stay holding it until their anxiety goes away. Flooding can sometimes last hours, but is generally a quicker version of the treatment as there is no gradual build up .

Whether gradual or abrupt treatment is used, before being exposed to the fearful situation or object, the person would normally practise visualisation. This involves them imagining themselves in the feared situation. While visualisation is not enough on its own - any mental rehearsal must be followed by a real and direct situation - it is an effective first step in the exposure process.

The treatment normally has to be repeated if we are to overcome our fear completely and rewire the memory circuits of the amygdala. So one session of exposure, using the abrupt or gradual approach, would not typically be enough to eliminate the fear and change the response of the amygdala, but would have to be repeated until the shift has been made.57

Evidence suggests that, in theory, the flooding approach — in which people are exposed to their fear in an extended and rapid way — is the more powerful and quicker method. However, for any treatment to work, people must be willing and able to do it, and therefore anxious people often prefer the more gradual approach. While this approach may take longer, it is often more effective as people are able to start and continue with the treatment. Just as with diet and physical exercise programmes, the most direct ways to lose weight or become physically fitter aren’t always the best ways, as people are often unable to keep up with extreme diets or fitness regimes, but give up soon after they have started.

We need to keep the following points in mind when creating an action plan for exposure treatment :

Prepare For Pain - It should now be clear that to overcome our anxiety we have to expose ourselves to our fears. As Jane Fonda said in her 1980s aerobics videos, ‘No pain, no gain.’ The most effective way to rewire our anxiety response is to excite the neurons that activate the specific neural pathway holding the memories we want to change. So we need to experience the situations and stimuli that create the anxiety. This will allow us to create new neural connections and pathways, changing the response of the amygdala, reducing the anxiety response, and altering our limiting behaviour.

Discomfort is the price of admission to a meaningful life, but the courage to do difficult actions can be made easier if they are aligned with our values. Courage is not the absence of fear, courage is fear walking. If we’re not prepared to accept pain or discomfort, we are pursuing dead people’s goals. Dead people never get rejected, never fail, and never feel stressed. We don’t want dead people to be our role models.

Be Confident You Can Complete the Plan Before You Start - Confronting our anxiety in this way is difficult. We rarely go out of our way to seek discomfort and distress, so it’s important for us to consider what we are taking on before we go ahead. It’s essential to be confident and determined that we can go through with each stage of the action plan. When facing situations that threaten us, the desire to escape can sometimes be overwhelming or unbearable. If we find it too much and leave the situation before the anxiety reduces, we can strengthen the anxiety response. This will teach our amygdala that escaping an anxious situation is the best behaviour to follow in similar situations in the future. So don’t leave the situation when the fear is high. Keep this in mind when designing each stage of the action plan, make sure it is doable for you. It’s essential that the outcome of the exposure is positive or neutral, otherwise it can be detrimental. Of course, it won’t be anxiety free, and courage will be required, but we should ensure, as much as we can, that nothing bad will happen. Although this sounds distressing, the exposure won’t be distressing in every moment of the treatment. You will find your experience of anxiety changing quickly, making it easier each time.

Use the ACT Mindfulness Skills Throughout the Process - During the exposure treatment it’s likely you will have some unhelpful thoughts and uncomfortable feelings or sensations. Remember, we need to defuse from unhelpful thoughts, and make room for any uncomfortable feelings that come up, and then engage with the present. Accept, welcome, and allow the fear to be there until it subsides on its own.

You may also benefit from changing the way you interpret the symptoms of fear. We talked about how important mindset is earlier in the book. Adding to that evidence is some new research suggesting that if we interpret our fear as ‘excitement’, we’re more likely to use it to take action that will result in more positive behaviour. This is because excitement, like fear, is a high arousal state. Eliminating a high arousal state is almost impossible, but reinterpreting it is relatively easy. The research demonstrated that re-framing fear as excitement increased performance in a number of tasks, particularly those involving social evaluation.58 So accept fear, welcome it as a friend, and when possible, use it to your benefit.

Practise Exercises That Desensitise You to the Uncomfortable Physical Symptoms - If you find the physical symptoms of anxiety particularly uncomfortable, practise exercises that simulate these symptoms before you do the exposure. For example, do intense physical exercise to accustom you to a racing heart; spin around in a circle to simulate dizziness and lightheadedness. This will allow you to become familiar with these feelings and sensations, making it easier to accept and handle them in threatening situations.

Repetition is Your Friend - The more we repeat our exposure to the feared situations, the more we activate the specific circuitry and the stronger the new pathway gets. Both gradual and abrupt exposure requires repeated behaviour. So, for example, if you fear walking down a busy street in front of others, walk down multiple busy streets, in different areas, on different days, and at different times.

Choose Your Battles Carefully - We should use exposure on the situations that have the most impact on our lives, and only when it’s necessary. It’s reasonable to withdraw from a situation, or avoid it altogether, if the anxiety doesn’t present much of a problem or has little consequence for us. If we don’t enjoy riding large roller coasters and it overwhelms us with anxiety, it won’t hold us back in life if we never bother to ride them. If we are afraid of public speaking, but have no desire to speak in public and are never required to do so, then the fear won’t impact on our lives. However, when our anxiety is holding us back from doing something we value or want to do; or causes us extreme distress and arises frequently; then we need to work on tackling and overcoming it.

Avoid Using Safety Behaviours - In Chapter 3 we made a list of the ‘hiding behaviours’ we often use to minimise our anxious symptoms. The behaviours vary between individuals but common ones include; using smartphones, tablets or sunglasses as props to hide behind; sticking with a safe person at a social event; arriving early at social gatherings to avoid interacting with others. Using safety behaviours such as these in exposure treatment can lead to partial results and are often far less effective.

All exposure treatment plans are individual as the experience of social anxiety differs from person to person. Only you will know the specifics of your social anxiety. Professional help with designing exposure treatment is beneficial but this option won’t accessible to everyone. If you’re unable to design a plan with a therapist or medical professional, carefully use the following steps. It shouldn’t be rushed or done on impulse, as an inappropriate plan can worsen anxiety. In the next chapter, after you’ve designed your exposure treatment plan, we’ll embed it into a safe structure to make it as beneficial and effective as possible.

First of all you need to decide which specific area of your social anxiety you want to focus on. Remember, focus on the situations that most impact your life; the ones that are holding you back from properly living. The situation should be very specific and relate closely to your real life experiences. For example, fear of going to a shop to make a purchase will differ depending on type of shop (small corner store or department store), type of purchase (new clothes or bottle of water), type of environment (hometown or unfamiliar city) etc.

Next, you need to decide whether you want to ‘jump in the deep end’ with flooding, or use the more gradual, ‘easy goes it’ approach of systematic desensitization. The gradual approach should be a step-by-step plan that sees you working up to the most challenging part of the social situation over time, while the abrupt flooding approach involves you starting with the most difficult part of the situation. We’ll make a plan for the gradual approach, but if you want to use flooding, start at the most challenging point.

Creating an exposure hierarchy involves breaking down the challenging social situation into a list of steps, in rank order, starting with those that cause the least anxiety, progressing to the most challenging steps. When you start the exposure treatment, you will go through the steps one-by-one in sequential order.

We start creating this list of steps by firstly identifying the components of the social situation that provoke the most and least anxiety. We use these two components as the extremes and then identify at least five steps in the middle. For example, a person who fears going to cafe for a drink, may say that the most stressful part of the situation is talking to the person behind the counter to order their drink, and the least anxiety provoking part of the process is walking along the street towards the cafe.

Now we need to make a list of the challenging components that fall into the middle of the two extremes. The list of challenging intermediate components in our example may include:

Next we make a numbered list, sorting the components of the challenging situation from least to most threatening, rating them between 1 to 100, where 1 = not at all anxious and 100 = highest possible anxiety.

The goal of the exposure therapy is now to complete each step until the anxiety reduces. In our example, this means starting by walking on the street towards the cafe a number of times, before going onto the next step. This can be done over a period of time. When using the gradual method you don’t have to complete all the steps immediately. It’s important to remember that you must stay in the situation until your anxiety reduces or you could make the anxiety worse. If you rated the anxiety level of a step as 70, I’d suggest that you need to make sure that the anxiety has fallen to least half of that (35) before you leave the situation. Your amygdala needs to learn by experience that escape isn’t necessary, that these situations will not harm you, and it need not initiate the fight-or-flight response.

Use the ACT mindfulness skills of defusion, expansion, and engagement to help you stay with the anxiety. Each step should be done repeatedly. The more anxious you feel about the step the more practise you need. It normally gets easier with each repetition, but as we don’t have control over every situation, this may not always be the case. There will be ups and downs and this should not throw you off course. Overall, the experience will get better.