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Tools, Not Schools, of Therapy
Part 3: The Exposure Model

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Copyright © 2008 by David D. Burns, M.D. Any reproduction, electronic or otherwise, is strictly prohibited without expression written permission of the author.

By David Burns, M.D.

In this newsletter, I’ll focus on the Exposure Model. Exposure therapy is arguably the most researched and validated psychotherapy technique that has ever been developed for the treatment of anxiety. If someone is suffering from any type of anxiety, some form of exposure will almost definitely have to be included in the treatment package in order to get optimal results. However, exposure is only one of three powerful treatment models I use in the treatment of anxiety. The two are the Cognitive Model and the Hidden Emotion Model. I integrate all three models in my treatment of every person suffering from any type of anxiety. My goal with my patients is not simply improvement, but rather a complete elimination of the anxiety.

In spite of the overwhelming evidence in favor of exposure, most therapists do not use this technique. In my experience at anxiety workshops, I ask for a show of hands of therapists who routinely use exposure in the treating of anxiety disorders, and only about 20% of the participants raise their hands. It appears that most therapists fear exposure as much as their patients. Sometimes our patients hypnotize us and we start believing things that are not true. For example, the person who suffers from depression can “hypnotize” us into believing they are hopeless and worthless, when in fact, they are not. The person who suffers from anxiety casts a different spell on us. They can hypnotize us into believing that their fears really are dangerous and must be avoided. While there may be cases, or points in therapy, where the use of exposure is not indicated, in most instances this fear of exposure will prevent the treatment from being maximally effective. So to treat anxiety effectively, we may have to confront our own fears.

There be monsters

I believe that Exposure Therapy is based on the teachings in the ancient Tibetan Book of the Dead. According to this book, after you die, you will wake up again in a dark place. Out of the darkness, a terrifying monster will suddenly appear. The monster will represent all the worst fears you’ve ever had. For each person, the monster will be different, since we all have different fears and vulnerabilities.

When the monster appears, you’ll be gripped with terror, and you’ll have two choices. You can run and try to get away from the monster, or you can surrender to it. If you run, you will escape – but just barely – and soon, you’ll find yourself in a dark place again.

Out of the darkness, a second monster will suddenly emerge. This one will be almost as terrifying as the first, but not quite. Once again, you have two choices—run or surrender. If you run and try to get away, you will just barely escape, but then you’ll find yourself in total darkness again.

Suddenly a third monster will appear, and then a fourth. Every time you try to escape, you will get away, but then another monster will suddenly appear. However, each monster will be slightly less terrifying than the one before, but overwhelmingly terrifying.

According to the legend, this process will repeat itself over and over. The number of monsters you will confront depends on the number of days in the month when you died. If you died in January, for example, there will be a total of 31 monsters.
If you try to escape from all the monsters, you will be reincarnated as something very lowly, like a worm. Or even worse, a psychologist in the era of managed care. (That joke maybe only works in the US where most mental health professionals understandably feel deluged with excessive paper work and deprivation.) In contrast, if you surrender to any of the monsters, you will be reincarnated at a higher level. The scarier the monster you surrender to, the greater your status in your next life will be.

In the event that you surrendered to the first and most terrifying monster of all, two things would have happened. First, you’d suddenly discover that the monster was not actually real, but an illusion, or a gigantic cosmic joke, and that you never had anything to be afraid of in the first place. You would suddenly see that the monster had no teeth and cannot hurt you. This, of course, would be an incredible triumph for you, and you may suddenly break into uncontrollable laughter. The Buddhists call this “laughing enlightenment.”

Second, you wouldn't have to go through the life-death cycle any more. Instead of being reincarnated, you would be transported to a higher plane of existence, perhaps like the Buddhist concept of heaven or Nirvana.

Of course, a legend is just a legend, but this one contains a profound truth, especially if you've ever suffered from anxiety. You will have to confront the monster that you fear the most in order to gain complete and total liberation from your fears. But most of us avoid what we fear the most, so we never achieve enlightenment. We just keep running from our fears.
There are three categories of exposure, including classical, cognitive, and interpersonal exposure techniques. All can be administered using gradual exposure or flooding, and both approaches can be effective.

Classical exposure techniques

Classical exposure techniques have been around for decades. Much of the creative new work has been in the area of interpersonal and cognitive exposure techniques available, with many powerful and innovative techniques such as the Feared Fantasy, Acceptance Paradox, Cognitive Hypnosis, Time Travel, Memory Rescripting, Cognitive Hypnosis, Shame-Attacking Exercises, and a host of others.

Classical exposure is straightforward. If you have the fear of heights, you could stand on the top of a tall ladder until the fear disappears. That’s called flooding. Or you could do it little by little over a period of time, working your way up a hierarchy of increasingly fear situations until the anxiety disappears at each level. That’s called gradual exposure. Both are effective, but I prefer flooding. I’ve experienced and defeated fourteen different types of fears and phobias during my life, so I’m very familiar with flooding.

For example, I used this technique in high school, with the help of one of my teachers, to overcome my fear of heights, because I wanted to work on the stage crew when the school put on the play, “Brigadoon.” The teacher said I would have to overcome my fear of heights if I wanted to be on the stage crew, since you had to work up near the ceiling, with the lights and curtains and such. It took about 20 minutes of standing at the top of a tall later, while my teacher stood patiently waiting on the ground, to overcome this fear. During the flooding, my fear was intense. Suddenly, it disappeared, and I was “cured.” After that, I LOVED working at heights and could not comprehend why or how I had previously been so terrified.

Some patients cannot use classic exposure techniques because the thing they fear does not exist, or cannot be confronted, in reality. This is why a great number of cognitive exposure techniques, such as Cognitive Flooding, have been developed. When patients use Cognitive Flooding, they intentionally flood themselves with the painful memories or frightening fantasies they've been trying to avoid. They can try to make themselves as anxious and upset as possible, and simply endure the anxiety without fighting it. After a period of time, the anxiety will usually burn itself out and the images will lose their power to upset the patient. You can also change the images during the intense period of anxiety, to provide the patient with relief.

This is called Image Substitution.

Sometimes change happens rapidly during cognitive flooding. A therapist named Melinda told me about her fear of flying at one of my workshops, during the afternoon break. Melinda was upset because she and her fiancé planned to get married at his parents' home in France, which meant that she'd have to endure a long airplane flight across the ocean, and she was terrified.

I asked Melinda to close her eyes and visualize what she was the most afraid of. She imagined the airplane shaking violently in bad weather. Her anxiety shot up to 90%. I told her to try to push it up to 100%, by making the fantasies as horrible as possible. Then she fantasized the plane crashing toward the earth while all the passengers were screaming in terror. At this point, her anxiety was 95%. I told her it was quite high enough, and to try to push it to 100%. For example, she could imagine the plane hitting the ocean, exploding, arms and legs being ripped off, that type of thing.

She apologized and said she was having a problem, and that her anxiety had dropped to 40%. I told her to try hard to push it up to 100%, and to try to freak out, because I wanted to illustrate Image Substitution. She opened her eyes and said, “Dr. Burns, I really have to apologize. My anxiety just dropped to zero. I’m not afraid of flying any more!” Usually, recovery is not nearly that fast, and I was not even attempting to treat her, just to illustrate how the method worked so she could practice with her therapist over a period of time.

As an aside, this intervention incorporated several techniques, or dimensions: 1. Empathy—she appeared to trust me, and was willing to take a chance and do something she feared with my help. 2. Flooding—confronting her worst fear head on. 3. Paradox—rather than helping her control or avoid the anxiety, I pushed her to intensify it and freak out. This conveyed the message, “I am not afraid, and there is really nothing to fear. So stop trying to control and let’s see how bad you can make it.” Paradoxically, her anxiety suddenly disappeared.

Desensitization can be a long process

Often, the desensitization to the feared fantasies can take much longer. In my recent book, When Panic Attacks, I described a woman named Theresa who developed an anxiety-producing obsession shortly after her son was born. She began to worry that her baby might have been switched with another baby at the hospital, and that she'd ended up with the wrong one. Rationally, she realized that this was extremely unlikely, but couldn't seem to shake the obsession from her mind.
Theresa's son had been born in San Francisco via Caesarian section. While she was in the recovery room, the doctor explained that he'd accidentally nicked the baby's bottom with his scalpel during the delivery. He reassured her that the cut wasn't serious and would heal up nicely without a scar. Aside from that, everything had gone smoothly. When Theresa held her son for the first time, she immediately examined his bottom. Sure enough, he had a small cut on his bottom in the exact spot the doctor had described. Theresa was flooded with feelings of joy and relief.

But soon, she began to wonder if the cut was in the right location on his bottom. If not, it would mean she had another baby with a cut on his bottom, and not her own baby. Although she realized that this idea was absurd, she couldn't shake the obsession from her mind. She began checking her baby's bottom 20 – 30 times a day in an attempt to reassure herself that she had the right baby.

Theresa had developed full-blown Obsessive-Compulsive Disorder. The obsessive thought was, "I might have the wrong baby," and the compulsion was the overwhelming urge to keep checking his bottom.

I tried more than 30 techniques to help Theresa overcome this fear, but none of them helped at all. I wondered if she had mixed feelings about being a mother that she hadn't owned up to, since I she had a successful career as a corporate executive at the time she became pregnant. I explored this possibility with her, but the idea didn't seem to be on target.

One day, I used the What-If Technique to see if I could find out why Theresa was so worried. Suppose she did have the wrong baby—what then? What frightening fantasy was at the root of her fears? Our dialogue went like this:

David: Theresa, we know rationally that this is your baby. But suppose it turned out that he wasn't your baby, but someone else's. Obviously, no one would want the wrong baby, but I'm wondering what this would mean to you. What if you did have someone else's baby? Why would that be upsetting to you?
Theresa: It would mean that someone else has my baby.
David: Okay. Let's assume that someone else does have your baby. Why would that be upsetting to you? What are you the most afraid of?
Theresa: Well, maybe the people with my baby are kidnappers, or bad people who abuse children.
David: That sounds truly awful. But let's suppose that happened. What are you the most afraid of? What do you picture in your mind's eye?

Theresa reluctantly described a horrible scenario. In her fantasy, sadistic kidnappers have taken her little boy to a cabin in the desert in Mexico. She told me that she could see one of the kidnappers holding her baby by his feet and swinging him through the air, smashing his head against the wall. Then they throw him down the stairs and kick him around, like a basketball. Finally, they lock his broken and bleeding body in a dark closet where he slowly dies, crying and alone.

Theresa sobbed as she described the fantasy. On a scale from 0% –100%, she said she felt 100% anxious and upset, the absolute worst. I was concerned that I was hurting her, and wondered if I should back off. At the same time, it seemed like we'd finally gotten to the bottom of her fears. I reminded myself that patients have to confront the monster they fear the most if they want to recover. If they turn away, the problem intensifies.

I encouraged Theresa to stick with the fantasy and endure the anxiety for as long as possible, but told her I would back off if it was too much for her. She courageously pushed ahead, but her anxiety stayed at 100% and didn't decrease during the session. I told Theresa that I felt badly about making her so miserable, and reminded her about the rationale for Cognitive Flooding. I encouraged her to continue using this technique, but reassured her that we could use some other method if it seemed too overwhelming.

Theresa bravely said that she'd try, and agreed to practice at home for 15 minutes each day. I told her not to do anything to try to make her anxiety go away, and explained that if she felt extremely anxious, it meant that we were probably on the right track.

At the next session, Theresa explained that she hadn't done any Cognitive Flooding on her own because it seemed too upsetting. However, she was willing to try it again in the office with my support. We spent the entire session with the same horrible fantasies, but Theresa's anxiety did not diminish.

I reemphasized the importance of practice at home, since it can take time to get over these kinds of fears. Theresa made a firm commitment to practice for at least 15 minutes every day, no matter how upsetting it was.

The next week, Theresa reported that the first few times she'd tried the flooding at home, she'd gotten intensely upset, but on her fourth try, the fantasies began to seem unrealistic and her anxiety diminished. The fifth time she tried it, the fantasies seemed totally absurd, and her anxiety disappeared completely.
Theresa suddenly had no doubts at all that this was her son, and no more urges to check the cut on his bottom. Her anxiety vanished, and she felt excited to be mother. She terminated therapy the following week.

You might be thinking that the treatment was just too gruesome, and that there had to be a better way. That was exactly my thinking as well. But I'd already tried many techniques that hadn't been helpful. I believe the results were well worth the discomfort we both had to endure.

A strong therapeutic alliance needed

Some therapists are concerned that Cognitive Flooding might re-traumatize a patient who's endured a terrible ordeal in the past, and victimize them once again. One of my greatest problems as a teacher is that therapists sometimes think about applying techniques in a vacuum, without looking at the larger therapeutic context. You'll need a strong therapeutic alliance and a motivated patient before you can use any technique. If you try to impose a technique on a reluctant patient, you'll be asking for trouble. The patient will resist and may act out in order to punish you. Then you might conclude that the technique was ineffective or inappropriate, when the real cause of the failure was a lack of trust and collaboration.

Theresa and I had a positive therapeutic alliance, and I'd routinely received perfect scores from her on my Therapeutic Empathy scale at the end of every session. In addition, she was highly motivated and determined to beat the problem that was plaguing her.

Although exposure techniques are in some way simple and straightforward, their successful use requires a high degree of skill. That’s because most patients will intensely resist using these techniques. In fact, when working with any form of anxiety, two common categories of resistance need to be considered. They include Outcome Resistance and Process Resistance. The Outcome Resistance usually involves the concept of magical thinking—it’s the idea that my anxiety is somehow protective and necessary, and that something awful will happen if I am not anxious.. In Theresa’s case, she felt that she needed her anxiety, since if she gave it up, she might end up with the wrong baby. Outcome Resistance is perhaps evolutionary, since some healthy fear does have survival advantages. Of course, it can sometimes get out of hand. Too much of a good thing, like fear, can hold us back and make us miserable.

Process Resistance has to do with the natural reluctance we all feel to use exposure techniques to confront the anxiety. The anxiety can be so intensely uncomfortable that one keeps hoping that there’s another way to get around it. Therapists and patients alike fear exposure in many cases. But the behaviorist therapists believe that avoidance actually intensifies the anxiety in most if not all cases, and that exposure is usually the most powerful treatment tool. There are actually many powerful treatment tools, however, and no rule is absolute.

The importance of empathy

And that brings us to the last important point about the treatment of anxiety, which I alluded to earlier. Empathy will be crucial to your success. I believe that every person suffering from anxiety can make remarkable progress, and in many cases will be able to eliminate the anxiety entirely (although it may return at times and require brief therapeutic tune-ups). In order to achieve optimal results, tremendous trust and teamwork are necessary between patient and therapist. So if you experience an alliance failure, or an empathy failure, that rupture must be repaired in order for the therapy to continue productively. These failures are not bad; in fact, they are often good, leading to a deeper and better therapeutic relationship, to say nothing of the enhanced understanding. But they don’t feel good at the time. They can seem jarring, or even shameful to the therapist and patient alike.

The successful treatment of anxiety means going to the gates of hell with your patient. This cannot occur effectively if you have drifted out of a state of warmth and trust, so that the patient no longer feels safe or accepted. This should be fairly obvious, but not necessarily since some therapists believe you can treat patients with techniques, without much regard for the quality of the relationship. This is not valid. But once you repair the rupture of trust, then you can continue together, with deeper understanding.
Most of what I have written about in this newsletter is just common sense, but I hoped that it might have some modest value to you in thinking about how to approach a patient who is struggling with mild or severe anxiety.
Finally, when treating anxiety, remember that exposure is just one of three powerful treatment models. In addition, with most patients, you will have several tasks, all of which are important:

1. Reducing or eliminating the anxiety per se.
2. Addressing the shame which nearly always accompanies anxiety.
3. Treating related feelings, such as depression or inferiority, which often go hand-in-hand with anxiety.
4. Dealing with personal relationship problems and conflicts that sometimes co-exist with anxiety disorders. Sometimes these conflicts are obvious, but often they’re hidden.
5. Treating any co-morbid addictions. For example, some studies indicate that 50% of individuals with social anxiety disorder tend to abuse alcohol or drugs as a “treatment” for the intense discomfort they feel in social situations.