Real-Life Exposures
If I had to pick just one Cognitive Behavioral Therapy technique for treating anxiety, this would be the one. It is the only technique that, all by itself, has been able to completely treat some of my patients.
Just to introduce the topic of “exposures”, all of us have a comfort zone. We all have certain people, places, and situations that are inside of our comfort zone, and we all have people, places, and situations that are outside of our comfort zone. For example, I used to be very shy, so I had a small social comfort zone. Just family and one or two close friends inside of it, everyone else outside of it. With treatment, my comfort zone is now bigger than average, but there’s still plenty of things outside of it. For example, if I went to a large party where I didn’t know anyone, I’d feel awkward. If you got me to give a lecture to a bunch of other doctors without any practice, I’d be nervous. So, there are still plenty of things inside and outside my comfort zone. That is actually always going to be the case.
When we are going through a period of anxiety, our comfort zone actually shrinks. We have a strong urge to hibernate. When it gets bad, we don’t want to leave the house. When it gets really bad, we don’t even want to get out of bed. It’s a strange instinct because it always makes anxiety worse (which can then lead to depression). Getting better always involves pushing ourselves outside our comfort zone and fighting back against hibernation.
What I want you to do is, for the next few weeks, on a regular bases, do something that is just outside your comfort zone.
Things that count are usually pretty small. Getting out of bed, getting dressed, walking around the block. Depending on your comfort zone, these activities might count. Other activities that might count as mild include reaching out to friends, doing just an hour of work, or exercising for just 5 minutes. Wherever your comfort zone happens to be, step just outside of it.
Whenever you do a Real-Life Exposure, it’s like taking a stick and poking your comfort zone out a little bit in this direction and that direction, gradually expanding your comfort zone.
How do I know if a Real-Life Exposure was helpful?
A good exposure is judged by how it goes into your memory.
It takes five to ten good memories to cover over one bad memory. That’s why avoidance doesn’t work. Even if you avoid something for several years, the last memory standing is still a bad one, so the anxiety will still be there when you return. The point of a Real-Life Exposure is to get five to ten good memories in a row so that you can expand (or re-expand) your comfort zone.
After an exposure, if you remember the activity as being fun or you are proud of yourself, then it is going into your mind as a good memory. That will help you. If, after an activity, you are putting yourself down (“I can’t believe I got so anxious/couldn’t do it.”), then it is going into your mind as a bad memory. It’s not the end of the world, but it means you have to start over collecting good memories.
Try to biased yourself towards having a good memory by encouraging yourself. If, after an exposure, you are putting yourself down because you got anxious or couldn’t do an activity, push yourself to feel proud instead (“Good job, you are trying to push your comfort zone”, “Keep at it, this is the way to get better”).
The best way to ensure that an exposure is helpful is to pick an activity that is mild to begin with. Because we are trying to collect five to ten good memories in a row, doing a high frequency of low-intensity exposures is the most reliable way to expand your comfort zone.
What is the best Real-Life Exposure to start with?
The best activities to start with are the ones that you miss the most and/or the ones that are interfering with your life goals the most.
My favorite exposures (and the ones I still do now) are pushing myself to do things a little more or a little longer, and then stopping. For example, talking a little more, staying out a little more, exercising just a little more than I feel comfortable. This is the most naturalistic way to do exposures.
If you are having trouble coming up with ideas for exposures, try the “Exposure Hierarchies” section on the Berserker Style page.