Exposure Therapy Mistakes
Exposure therapy is a method to reduce your fears by facing and getting used to them in a systematic, manageable way. Going through it isn't always easy or comfortable, but there's a lot of research that shows it's effective.
Though while exposure therapy works in theory, you'll often see accounts online of people who said they've tried it and that it didn't work. Often when you learn more about how they did their exposures it's clear they made one or more common mistakes. This longer article will go over the errors people often make when doing exposure therapy, with an emphasis on trying to use the approach on your own.
Here I'll assume you're already familiar with the basics of exposure therapy, but if you want to learn more about it, you can check out these links:Why It's Essential To Face Your Social Fears
How To Face Your Bigger Social Fears Gradually
There are lots of things people can be afraid of, and they all have their nuances for how they need to be tackled, so I can't cover every last way someone may go awry in facing a fear. Also, I'll focus on how exposure therapy is used or misused to handle simple phobias, social anxiety, and panic disorder / agoraphobia-related fears. Obsessive-compulsive disorder and upsetting traumatic memories can also be treated through exposure, but those methods are somewhat different. Some of the points in this piece apply to them, but not all.
Even though there are plenty of ways exposure therapy principles can applied incorrectly, this article is not trying to say, "Exposure therapy always works. If it doesn't for you, then you did it wrong." The treatment has a lot of evidence supporting it, but no approach is successful for everyone. Some people try it, and do everything by the book, but it doesn't take for whatever reason. Maybe it will go better if they attempt it again years down the road. Maybe another treatment is a better fit.
Below I'll divide up the mistakes into rough categories, but before all that, here's one big way people can have the wrong idea about exposure therapy:
Thinking of randomly coming up against your fears as you go about your life as doing Exposure Therapy
Exposure therapy is a structured process. It doesn't mean to live your life and happen to run into your feared situations whenever they'd naturally appear. If you're terrified of public speaking, are forced to give a last-minute presentation at the office, and it goes poorly, you can't walk away concluding "Exposure therapy doesn't work".
Coming up against a feared situation is exposing yourself to it, but it's not proper, systematic Exposure Therapy. When you haphazardly run into your fears without a proper approach for dealing with them, you probably aren't going to change much, and can even make things worse. If going about your life and randomly encountering your fears worked, you'd already be over your problems.
Mistakes while preparing for or starting exposure therapy
Not addressing other mental health conditions that may interfere with a course of exposure therapy
For example, if someone is severely depressed, they probably won't have the energy or motivation to face their fears several days a week. They should take some time to work on their depression first. If someone's anxiety comes from substance abuse, or unresolved trauma, they may also want to make those issues a priority.
Not being motivated to do exposure therapy at this point in your life
Exposure therapy is hard work. You have to repeatedly face your fears, and the anxious feelings that causes. Its structure makes the process as easy as it can be, but it's still difficult at times. If you're not that motivated it's tough to stick with it. Your family or partner may want you to change, but if you don't want it for yourself, it's unlikely to happen.
One way people can be unmotivated is if they're trying to get over a fear they don't actually care about beating. Like someone may think they want to get over their dread of public speaking, because they believe that's what they should want as someone with their job. But deep down they aren't interested in giving a bunch of presentations, and don't mind if it limits their career. Another way to lack motivation is if you gain things from your anxiety, like not having to work because your parents let you live with them. I'm not trying to claim everyone with anxiety is secretly a greedy, lazy mooch. Just that if we get benefits from an otherwise crappy condition, we're only human and that will factor into our decisions.
Starting exposure therapy when you've got too many other things going on in your life
Exposure therapy often succeeds, but as I've said, it can be mentally challenging. It also takes time out of your schedule. If you're really busy with other responsibilities, or are under a ton of stress for another reason, then taking on a big, intense therapy project may not be the best move. You won't have enough time to devote to your exposure tasks, or the extra stress they cause could be too much. Though that isn't to say you can only do exposure therapy when every other facet of your life is orderly and serene. That's not realistic, and waiting for that time can be a way to procrastinate. It's just that if things are ultra-hectic, then it may not be the best idea to add more to the pile.
Trying to do exposure therapy on your own when your anxiety is severe
I swear I'm not trying to have this point be an infomercial for hiring a therapist. I think it's perfectly reasonable for many people to do some research on exposure therapy and gradually face their fears on their own. However, if your anxiety is severe, like you constantly have panic attacks, can barely leave the house, or haven't worked in years, that's a different story. It's best if an experienced mental health professional helps you through the process. I'm sure some severely anxious people can successfully learn about and do exposure therapy by themselves if they're extremely motivated and hardworking, and have a good mind for psychology concepts, but that's a lot to ask. There's no shame in knowing your problems are beyond you and getting some outside support.
Starting or adjusting medication while doing exposure therapy
You can do exposure therapy while on psychiatric medication. If your anxiety's really bad, you may not feel well enough to start the process otherwise. But ideally you'll have been on a steady dose for a while. That way you have a stable baseline, and you can chalk up any lowered anxiety to the exposures you're doing. If you begin a new medication or adjust your dose while doing exposure therapy, your mind can attribute any progress to the drugs. If you stop taking them down the road your fears may come back, because you don't believe you learned to handle them on your own.
Not spending some time beforehand addressing the counterproductive beliefs and thought patterns that influence your fears
Many fears have a web of maladaptive beliefs and distorted thought patterns behind them. For example, people with social anxiety have worries about how mean and judgmental others are, and how even tiny social gaffes could lead to humiliation and rejection. They generally believe they're flawed and unlikable. They may walk by a group on the street and "know" everyone thinks badly of them. After getting home from work they may go over their day and remember all the ways they "know" they were awkward and irritated their co-workers.
If you try to face your fears without working on the underlying beliefs and thought patterns you often won't make great progress. First, your beliefs will make facing the fear that much more scary and unpleasant. Like, if you're afraid of having a panic attack, that fear is going to be way worse if you genuinely believe panicking could make you die or go crazy vs. if you knew panic is very uncomfortable, but it won't cause you to drop dead or mentally snap. Second, after you've exposed yourself to your fear, your counterproductive thinking can cause you to take all the wrong lessons from the experience, leaving you even more nervous and discouraged (e.g., "When I stammered while telling that story everyone thought I was a loser for sure. How can I see them again knowing they hate me now? I'll never be comfortable around people. I should give up. ")
Not taking some time beforehand to learn the proper mindset or techniques to handle the anxiety that comes up during exposures
The idea of exposure therapy is to put yourself in situations that make you nervous. But you have to have the right mindset toward your anxiety. You won't get far if you see it as this terrible, intolerable thing that you must avoid at all costs. Instead you have to view it as a state that can be very unpleasant, but which won't kill you, and which you can function in spite of. You have to accept it when it comes, and sometimes be willing to ride it out, rather than fight it.
Aside from getting your mentality in order, it's also useful to know some practical techniques to calm down, such as deep breathing or progressive muscle relaxation. As I'll get into later, whether you should use these calming techniques during exposures depends on your goals.
Not clarifying exactly what fear you're trying to reduce
Three people could fear the same situation for different reasons. For example, if they were afraid of driving on the highway, one could be scared of getting into an accident because they don't feel experienced behind the wheel. The second could be afraid of other drivers looking down on them for driving poorly. The third could fear they'll have an horrible-feeling panic attack while they're trapped in a traffic jam.
While all three need to face their fear of being on the freeway, they need to focus on more specific things to really cut down their anxiety. The person who feels inexperienced may simply need to put in more time on the highway until they get used to it and feel more confident in that setting.
For the other two, just being on the freeway won't cut it. It might help a bit, but the anxiety may seem to stubbornly linger. The person with fears of being judged may have to deliberately make some minor mistakes, like driving too slow in the passing lane, to realize they can handle it if other drivers get annoyed at them. The person with a fear of panicking has to drive until they do get panicky, and then learn firsthand they can get through it.
At times someone won't figure out what their true fear is until they've done some exposure therapy, aren't getting the results they expected, and have to reflect on why. They then realize they weren't tackling their core fear, just a few situations connected to it.
Fearing a situation vs fearing your anxiety symptoms
It's not always a tidy distinction, but the two main ways people can be scared of something is when they're worried about an external threat vs. when they're afraid of their own anxiety symptoms that may arise in a situation. For example, one person may be afraid of nightclubs because they're worried about being judged or getting into a fight. Another may worry they'll feel trapped and overheated in the crowd, which will cause them to get so anxious they'll be nauseous.
If you're scared of your anxiety itself then just being in the situation isn't enough. If you go and don't get particularly anxious, you can always think, "But maybe next time I'll get really nervous." You have to let your symptoms come on in that setting, then ride them out. You have to learn you can tolerate the feelings until they fade. In some cases you may have to experience it's not as bad as you feared if your physical symptoms do get the best of you. (E.g., you have to excuse yourself to go throw up in the bathroom. In your mind you ran off puking while everyone laughed at you. In reality you looked a little green, walked to the restroom, and returned to explain what happened to your understanding friends.)
Unrealistic expectations for exposure therapy
Expecting your fears to be erased after a handful of exposures
Occasionally you can extinguish a fear after facing it a few times, but usually it takes longer for the lesson to sink in. Don't think exposure therapy doesn't work just because it doesn't cure you after a week or two.
Expecting exposure therapy to completely eliminate all your fears
Some fears totally go away after exposure therapy. Others remain, but they're much more manageable. There are things most people never fully get used to, like dating and public speaking. Some people's more idiosyncratic fears don't totally go away either. Though again, they become less intense and don't interfere with daily life as much.
Expecting to make nothing but smooth, steady progress as you do exposure therapy
Like with learning anything, you'll have more-successful and less-successful periods while doing exposure therapy.
- Sometimes your anxiety or motivation levels will randomly fluctuate, and you'll have trouble with a situation you easily faced a week ago.
- Sometimes you'll hit a snag when you realize you got the design of your exposures wrong. Maybe there was too big a gap between two items on your fear-facing hierarchy and you need to come up with an intermediate task as a bridge.
- You may also find that moving up your hierarchy reveals bigger fears you didn't know you had. For example, someone with social anxiety doesn't realize they're terrified of opening up to their friends. They have a relatively easy time with the early steps in their hierarchy, when they're trying to meet new people and have some surface-level conversations. Later, as they get to know some of those folks better, they suddenly find they're much more anxious, even though they're doing similar tasks as before. It's not that they're backsliding for no reason. It's that they unconsciously know soon they'll have to share more about themselves to their new friends.
Either way, unsteady progress doesn't mean exposure therapy is useless. Once you identify your sticking points, you can keep moving forward.
Mistakes while doing exposure therapy
Not having a longer-term plan for your exposures
Exposure therapy is structured and goal-oriented. You don't just face your fears here and there when you feel like it. The classic exposure therapy structure is to make a hierarchy of your least to most-feared situations, then work your way up it. You don't necessarily have to do the items 100% in order, but overall you're starting with what you can handle, then building from there. When you face your fears haphazardly you risk biting off more than you can chew.
Only doing exposures occasionally
You need to do most exposures at least a few times a week. The consistency drives home to your mind that the thing you're afraid of really isn't that dangerous or unmanageable. It also allows you to build momentum. If you only do exposures every now and then your fear will regroup in between them. It's like trying to get in shape, but only going to the gym once every three weeks.
Only doing exposures when you have spare time that day
So you have to do your exposures consistently. That means making them a priority in your schedule. You may have to temporarily put other aspects of your life on the backburner. You can't have an exposure to do that day, but think, "I got busier than I expected at work. I'll see how I feel when I get home. I'll do it if dinner doesn't take too long to make." Of course, the odd emergency is unavoidable, but you can't face many fears only once a week when you have a spare moment and expect good results.
Only doing exposures when you're having a good, low-anxiety day
Obviously exposures are easier and more comfortable to do when your anxiety is low. However, if you only do them when you're calm you're teaching yourself "The situation is still a threat. I can only cope and function in it if I'm in the right mood. I'm too fragile otherwise." The point of exposure is to directly learn that you can handle your fears, even if you're feeling pretty anxious at that moment.
Doing exposures that are too easy
Exposure therapy typically has you start with things you can handle. Though even the earlier tasks should push your comfort zone a little. When you never move beyond easy exposures you're not teaching yourself that you can handle scarier situations.
Some people are afraid to do tougher exposures, so they unconsciously pick tasks that are too easy, and then practice doing them for weeks and weeks. They feel like they're diligently doing their exposure homework and making progress, but get knocked back and feel deflated if they find themselves in more-frightening circumstances. Others pick some easy exposures, and feel a surge of confidence as they successfully face them. However, they mistakenly expect their newfound courage in simple situations will now let them effortlessly tackle their biggest fears. When that doesn't happen they want to throw in the towel.
Starting with exposures that are too scary
It can work to face your biggest fears right away. However, most people find that too stressful and overwhelming, if they have the willpower to do it in the first place. Starting with something too scary can be such a negative experience that it sets you back.
Not doing any basic preparation for the situations you'll be in
If someone is afraid of cats, it's reasonable that before deliberately being around them, they learn a bit about feline behavior and body language. They don't need to become experts, but it's sensible to be able to recognize when a cat is mellow and friendly vs. cautious and agitated. No point in accidentally creating a bad experience because they couldn't tell their friend's kitten was getting too feisty and about to nip them.
Some quick, basic preparation is one thing. You don't want to over-prepare to the point where you exaggerate the risks of the situation or downplay your ability to cope. Like, if you're meeting someone for coffee, you don't have to pre-plan an answer to every question they could possibly ask you. If you're going to a crowded concert you don't need to look up the venue's layout and memorize every exit.
Feeling you've failed an exposure if you get anxious
The short-term aim of an exposure is not to show up and feel no nervousness at all. Reduced anxiety is the longer-term goal. Your objective in that moment is to learn you can be in that situation, and even be anxious in it, and survive. If you're afraid of your anxious symptoms, you actually want to get nervous during an exposure, as masochistic as that sounds. You're not exposing yourself to your anxiety, and learning to tolerate it, otherwise. (That said, it does feel great when you show up ready to confront a big fear and realize you're way calmer than you anticipated, because you've diligently been plugging away at the therapy.)
Exposing yourself to your fear, but fleeing as soon as you start to feel anxious
If you escape as soon as the nerves kick in you're just reinforcing your fear. The lesson your brain takes away is, "That scenario was legitimately dangerous. It was a good move to get out of there." For exposure to work you need to be in a scary situation, let the anxiety come, and get through it. Ideally your nerves will dissipate completely, or go down significantly, but even if they don't, you're still experiencing firsthand that you're okay. You may feel jittery and gross, but you're okay.
However, it is sometimes the right move to strategically back off if you're doing an exposure and get an intense, unexpected hit of anxiety. Like if you plan to confront a fear you figure will make you 5/10 anxious, and once you're there your nerves instantly hit 9/10, that's a sign you may need to return to the drawing board. Maybe you designed your exposure hierarchy wrong, or this one situation is setting off a second fear you weren't aware of. Though if you go into a situation knowing it will trigger 9/10 anxiety for the first minute, and that's exactly what happens, then you should stick it out.
Facing a scary situation, but rushing through it and leaving while you're still quite anxious
If you're afraid of a specific task like making a phone call or shopping at a particular store, it's possible to face the fear, but get it over with as fast as possible, rather than go at a normal pace, or repeat it a few times. This also sends your brain the message that the situation is threatening, and you can only survive if you wrap it up as quickly as you can.
Rushing a task can still have some use, because on another level you're still getting a bit of real-world feedback that you can be in that situation without something instantly going wrong. A series of rushed freeway trips could help you realize those roads aren't wall-to-wall accidents. Overall though, it's best if you can also allow enough time for your anxiety to settle, so you can learn from the exposure in that way as well.
Only exposing yourself to your fear in one or a handful of contexts
For example, you're nervous about meeting new people and join a dance class where a lot of one-time students drop in. You get more comfortable making conversation there, and that's an accomplishment, but your confidence may not transfer to all social situations. Instead you can unconsciously conclude, "I've gotten the hang of chatting to people in my safe, predictable class, but every other setting is still a scary unknown." You want to face your general fear in a variety of ways, so your mind learns "The whole category of X is okay" not "This handful of places are the exception, but X is still a threat."
Using safety behaviors
Safety behaviors are little things you can do cope with an anxiety-provoking situation. There are lots of them, but a few examples are:
- Always carrying fast-acting anti-anxiety medication with you
- Only doing things with a supportive, understanding companion
- Wearing earbuds and listening to a distracting podcast
- Only going shopping during non-busy hours
- Having a drink to calm down as soon as you arrive at a party
- Only driving on quiet side roads
- Being in a group conversation, but agreeing with everyone and not sharing any of your own opinions
If you use a safety behavior while doing an exposure you can come away unconsciously thinking, "I only got through that because of the safety behavior. I'd have been screwed otherwise." If you're doing exposure therapy there's some debate about whether you should try to drop your safety behaviors right from the get go, or if it's okay to use them at first, to ease yourself into tasks you wouldn't be able to do otherwise. I think the latter is fine, as long as you're working toward dropping them before long. Anxiety is tough to face, and sometimes we need a little boost, even if it's not the optimal thing to do in theory.
Sometimes you won't make the best progress with exposure therapy because you're using a few subtle safety behaviors you aren't even aware of. Having another set of eyes, like a therapist or supportive friend, can help you spot them.
If you're purposely exposing yourself to your anxious symptoms, trying to calm yourself down
There are plenty of ways people can try to calm their anxiety, like:
- Doing deep breathing
- Relaxing their muscles
- Trying to think thoughts like, "It's going to be okay. It's going to be okay."
- Asking someone for reassurance
- Listening to soothing music
- Distracting themselves with their phone
Whether trying to relax during an exposure is a good idea or not depends on the context. If you're trying to get used to a situation you see as externally threatening, then use some calming tools can help you stick around long enough to realize it's not as dangerous as you originally thought.
If it's not so much the situation you're scared of as the anxious symptoms it can trigger, then trying to relax can be counterproductive. You're sending the message to yourself that your anxiety is terrible and intolerable and you have to make it go away. I know it's much, much easier said than done, but you need to sit with your anxiety, not fight it, and allow it to run its course. If you have uncomfortable physical sensations, let them come and go. If you have frantic, scary thoughts, do your best to acknowledge them and let them pass without trying to debate them. That way you can eventually learn you can handle your anxiety.
Focusing on the outcome of the situation you're exposing yourself to
For example, you're trying to get used to making small talk with strangers. As far as the exposure therapy is concerned, it doesn't matter how well each conversation goes. That's partially out of your control anyway. The question is whether you faced your fear and stuck it out or not. Of course, you hope your anxiety from talking to people will drop over the longer-term, which will make your interactions go more smoothly, but that's not the goal for any one fear-facing session.
Only doing real-world exposures
The psychology jargon for real-life exposures is in vivo exposures. They're what most people think of when they think of exposure therapy, especially if they try a Do-It-Yourself approach. Other types of exposure can be very helpful, depending on what you're afraid of.
Imaginal exposure is imagining a scary scenario. This can be useful if you have a hypothetical fear that doesn't lend itself to real-life exposure. For example, someone worries they'll annoy their boss and lose their job. They obviously can't get themselves fired on purpose, but they can spend time vividly imagining themselves being terminated and dealing with being unemployed. At first these images may be upsetting, but with repeated exposure they can lose their power.
Imagery can also be a first step if someone is so anxious about something that even facing a mild variation of it in real life is too much. It can also just be a good add-on to in vivo exposure. Maybe someone can't face their real-life fear, like going to a party, every day, but they can still take time to imagine it.
Image and video exposures are when you look at pictures or videos related to your fear. It's another way to start small and easy, or to expose yourself to scenarios it would be hard to recreate in real life. For example, someone who's skeeved out by spiders could watch clips of them online.
Interoceptive exposure is for people who are afraid of their anxious physical symptoms. It involves doing things to purposely bring on those sensations. For example:
- Rapidly breathing to induce the physical effects of hyperventilation
- Running in place to elevate your heart rate
- Sitting with your head between your legs then standing up quickly, to feel lightheaded
- Staring at an odd photo for a few minutes, to create a vague feeling of unreality
You practice inducing your feared sensations then calmly sitting with them. With enough reps you realize a) you can tolerate the feelings, even though they're uncomfortable, and b) that they aren't the harbingers of imminent disaster you may have felt they were ("I thought if my limbs felt tingly it meant I was about to lose it, but it's just a side-effect of hyperventilation and goes away soon enough.")
Role plays let you practice and partially get used to nerve racking social situations in a lower-stakes setting. For example, if you're nervous about asserting yourself, you could role play several scenarios with a therapist, a support group, or your friends.
In the future virtual reality exposure may become more common. Some psychology researchers are experimenting with it. It's easy to imagine how it could be useful. For example, someone with social anxiety could put on their headset and go through a program where they mingle at a party.
Only relying on passive habituation to reduce your fear
There are two ways exposure can reduce a fear. The first is through the automatic process of habituation. To put it simply, that's when we naturally get used to something the more we're around it. For example, if you move to a house near some train tracks. At first the sounds of a train rattling by distract or startle you, but soon enough your mind starts to filter it out. If you're afraid of heights and stand on a high balcony your fear will eventually diminish, even if you don't do anything else. It may not go away entirely, but it's not going to be as intense as it was at the beginning.
The second way exposure can reduce a fear is when it gives you information that challenges or disconfirms what you were afraid of. For example, you worry that if you share one of your insecurities you'll instantly be rejected and feel awful about it. You test your assumption on many people and find most actually react neutrally or positively. A few make a snarky comment, but it doesn't upset you as much as you thought it would. You come away from the exposures with an updated, more-helpful idea of how the world works.
When they do exposure therapy some people just put themselves around their fear then wait for their anxiety to drop on its own. And that alone can make a big difference. But you can wring even more value from your exposures if you actively try to challenge and disprove your anxiety-causing assumptions. Beforehand you can write down your predictions for what will happen when you face your fear, then compare them to what actually occurred ("I thought everyone would reject me for admitting I can be insecure, but most were fine with it"). Spend some time thinking about why there was a discrepancy. Really try to drive the lessons home ("I thought everyone was really mean and judgmental, but I guess they're not, etc etc..."). Of course, you need to have done some work on your thinking patterns first, so you can evaluate everything in a productive, levelheaded way.
Mistakes as you make progress in exposure therapy
Rushing through your exposure hierarchy
You don't want to dawdle on each step while moving up your exposure hierarchy, but you don't want to speed through the process either. You won't magically be cured as soon as you confront the top item on the list. You don't need to race to that point. If you rush you may have technically faced everything, and that is an accomplishment, but might not have really locked in your gains. It's better to spend a bit longer at each step, and become reasonably comfortable with each one, rather than white knuckle your way through everything for the sake of moving forward as fast as you can.
Not going far enough with your exposures to really extinguish your fear
Most hiccups people have with exposure therapy are early on, but this one can happen as you make more progress. You may reach a stage where you've mostly gotten past your fear, but not quite. That may allow you to function fine day to day, but leaves you open to a greater risk of relapsing.
What can help prevent that is to take your exposures beyond what you'd ever need to do in real life. Like if you're afraid of mice, you may let a pet mouse crawl all over you. There'd be no reason to do that if you just saw a mouse in your kitchen, but going far with your exposures really drills into your head that you can handle whatever the fear throws at you.
One way to you can take your exposures to the next level is to combine them. For example, someone's anxiety gets triggered when their stomach feels a bit off. It causes them to avoid a) eating so much that they feel full, b) drinking carbonated drinks, and c) being a car passenger. At first they expose themselves to these situations separately. Farther down the line they could eat a big meal, drink a can of soda, and then be driven somewhere.
It's not possible to do for every fear, but ideally you can use exposure to not just be able to tolerate an anxiety-causing situation, but to master it and feel totally confident in it (e.g., someone is around cats so much they feel totally at ease with them). Again, there are some fears you may never fully get used to, and tolerance is better than complete avoidance. However, it's always good to keep in mind that mastery may be a possibility. Don't stop too early.
Not doing the occasional maintenance exposure once you've gotten a fear under control
Even if you feel like you've utterly vanquished your fear, it's still a good idea to expose yourself to it every so often to maintain your progress. Without the odd reminder that you can handle the situation, your old doubts and worries can creep back in. Of course, if you were previously afraid of a routine task like driving, you may naturally maintain your progress as you now use your car in everyday life. Other fears, like public speaking, are things you may only have to do occasionally, and you'll have to put more effort into giving yourself booster sessions. The good news is that if an old fear comes back, if you act fast it's usually quicker and easier to get it back under control than it was to get comfortable with it for the first time.
I know I covered a lot of mistakes in this article, but I don't want to give the impression that exposure therapy is too complicated and intimidating to bother with. You can come up with a list of routine errors or misconceptions for any skill or procedure. It doesn't mean you should never try any of them. You prepare as best you can, give it a go, and if you mess up you make some adjustments and keep going.