Exposure to the fear

 There are two ideas involved. First is the idea that irrational fears grow stronger whenever we run away from the scary-but-not-dangerous situation. Second is the idea that we can change our attitude from, "I can't stand the stress" to "I can stand it." Putting these ideas together, the method is to gradually approach the frightening situation with a strong determination to take all the fear it can generate.

The most thorough description of this method and its application is by Jeffers (1987).



STEP ONE: Arrange for plenty of time and a supportive friend, if needed, to help you

 You should have at least two hours, perhaps all day. Select a friend who is sympathetic and encouraging, who can cheer you on and give advice like a coach. Besides, if the fears should become extremely intense, you need a dependable friend there in case you start to feel overwhelmed (not likely but be prepared).

STEP TWO: Expose yourself to the scary situation

 Approach the scary situation. If you can go all the way at first, then do it and stay in the situation until the fear declines. If you can't stand to go all the way at first, get as close as you can stand, wait until the fear declines at that point, and then advance a little further as you can tolerate it. Example: if you are afraid of elevators, perhaps you can just get on and ride all day until the fear subsides. If you can't get on it and ride immediately, you can stand outside it, then stand on it without going up or down, then go only one floor, etc.

STEP THREE: Experience the fear completely until it loses its strength

 The use of this method has gone different directions over the years. In this step I used to say: If needed hold your friend's hand, but approach the frightening situation so that the fear is intense. Don't try to reduce the fear, rather try to experience the fear fully. Tell yourself you want to feel it, not run away. Focus on the fear, not on the situation and not on your urge to run. Concentrate on your physical reactions (shaking, sweating, rapid heart beat, etc.) and on your thoughts about all the awful things that might happen. Recognize how unrealistic the thoughts and fears are.

 Try to arouse the fear to its full fury, study it (telling yourself you can stand more), and challenge it to become even more intense. Welcome it. Be determined to stay right there as long as it takes to overpower and shrink the fear response. The fear will decline after some time, maybe after a couple hours or maybe after 6 or 8 hours (probably not that long).

 Today, exposure has become a much more common approach because it is a very simple and effective way to reduce certain fears. But there is less emphasis on the need in most cases to arouse extreme fear. Just getting people to gradually expose themselves to heights or bugs or large (friendly) dogs or asking questions in meetings or public speaking may be all one needs to do. One reason for this change in approach is because commercial airlines and other businesses would like to help people get more comfortable using their products. In those cases arousing intense fear and having horrible fantasies are not desirable or acceptable. Some airlines provide a instructional/informational approach giving explanations of the physics of flying, the causes and consequences of turbulence, the reasons for certain flight instructions and noises, the facts about airline safety, etc. All of which arouse many fantasies of flying. Other approaches simply expose potential flying customers over and over to various scenes (sights and sounds) they will encounter in flight. There are several impressive efforts to use computer-assisted instruction and videos to expose flight phobic people to scary situations until the anxiety responses are acceptable (Bornas, Tortella-Feliu, Llabrs & Fullana, 2001).

 Many fears may involve situations you can not create, so you will need to use your imagination. Examples: speaking to large crowds or auto accidents or fires or a death. Pictures can be used to augment your fantasy. You have a choice to make the fantasies as scary as possible (as mentioned above and in implosive therapy--see method #10) or you can simply confront (in reality or in fantasy) the situations that make you uncomfortable until you are fairly comfortable. However, it seems clear to most of us that viewing a picture of the inside of a plane or of a street far below the balcony railing is not the same as being there. Likewise, imagining giving a speech is not the same as doing it. So your fantasies may need to approach reality fairly closely. This is the rationale for including scary scenes and distressing consequences, like a speaker being rejected by the audience, losing esteem in the eyes of the listeners, being rejected, questioned, and walked out on. Continue the fantasies until the anxiety is lowered to tolerable levels. The alternative would be to imagine over and over giving the speach and doing fairly well. I don't think we know which approach works best or when. In either case, when appropriate (and fairly promptly), you have to expose yourself to the real-but-not-dangerous situation until you can conquer the fear in real life.

STEP FOUR: Continue the exposure continuously until the fear is conquered

 Don't give up. Don't be intimidated by the fear. Repeatedly have the experience if a few exposures are not enough (don't forget you may need new skills to become comfortable--relaxed dancers must learn how to dance; confident speakers must know what to say). Also, continue to have the experience occasionally, otherwise the fear may return.

Time involved

 Possibly a total of 10 to 15 hours. It will take an hour or two for the fear to subside the first time, maybe much longer. Then the experience needs to be repeated.

Common problems

 The most common problem is that people do not want to suffer the stress, in which case they could use desensitization. This method is only appropriate when there is a specific and available scary situation. Vague generalized anxiety doesn't involve a specific scary situation to confront.

Effectiveness, advantages and dangers

 Several researchers (Gelder, 1976; MacLean and Graff, 1970; Olson, 1975) have found this method to be generally effective--also see references above and under fear and panic in chapter 5. The major advantage of the method is its speed. Another possible advantage is the self-esteem, the feeling of strength, one might gain during the process. The major danger is, if during the exposure, the stress becomes too great and you give up. If the fear over-whelms you, you will be strengthening the fear response and weakening your self-confidence. There are probably some mild risks in the opposite direction, namely, of exposing yourself to various mildly scary scenes but never getting to the point of extinguishing the unwanted intense fear responses. This could actually strengthen your fear somewhat. Another danger is using the method where real dangers exist, like jumping into water over your head or confronting a bully or a vindictive boss. Don't do these things. We are only reducing unrealistic fears. Be careful, take no real risks.

Additional readings

Stress-inoculation: Self-instructions and coping imagery

 Stress-inoculation involves gaining awareness of why we get upset. Then we learn ways to control our emotions, e.g. through self-instructions and rational thinking and by changing our attitudes and expectations. Finally, by imagining being in the stressful situation over and over, we can practice calming ourselves down with these self-help methods. Later, we use these same self-instructions and techniques to stay calm in the real situation. In short, we use our reasoning power and imagination to reduce our unwanted emotional responses.

 This method combines several cognitive techniques into a complex treatment program which is useful with several emotions in many situations. Meichenbaum (1985) is the originator and principle advocate.



STEP ONE: Plan how to reduce the unwanted emotion by using thoughts, imagination, and self-instructions

 This first step is an educational process: learning a variety of mental processes that can influence emotions. Cognitive theory emphasizes that emotions reflect how we appraise the situation, our expectations, our beliefs about others' motives and our interpretation of our physiological reactions, i.e. our thoughts determine our feelings. We need to understand this in detail.

 Learn about Rational-Emotive Therapy (RET) and challenging irrational ideas (see method #3 in chapter 14). Ideas can produce emotions; changing our thinking (these ideas) can change our emotions. Consider these examples of how our ideas, automatic thoughts, attributions, conclusions, judgments, beliefs and self-statements can create anger within us: (remember these are not examples of things really said to another person; they are thoughts you might have about another person.)

 Many of our irrational emotion-causing thoughts are "shoulds"--"I should do better," "They should be better," "They should not treat me that way," "Things should not be this way," "They should be punished," and so on. These ideas reflect our own unfulfilled expectations, often they are our dreams or hopes that were never reasonable or carefully cultivated. Irrational ideas can be changed to be reasonable (see method #3 in chapter 14).

 Learn to think logically. Our thinking is distorted in many ways (see method #8 in chapter 14). We often draw false conclusions about ourselves or others. We misunderstand the implications of someone's behavior; we misinterpret other peoples' comments; we make false assumptions about what people are thinking and feeling. Examples: Someone turns us down for a date and we conclude that most people would not want to go out with us. We are used and deceived by someone of the opposite sex and we conclude that all men/women are self-serving creeps. We are turned down after interviewing for seven different jobs and we conclude that there are no jobs to be had, that employers are prejudiced against us, or that there is nothing we can do to improve our chances of being selected. Our spouse hasn't been affectionate and we conclude that he/she is interested in someone else. In short, when we have negative expectations, we should ask ourselves "What is the evidence?" and "Is there another way to interpret that data?" As we saw in chapter 9, the best way to check our assumptions about how others are feeling and thinking is to ask them!

 Learn to think like a determinist. So far as anyone knows, everything has its causes. Just as the laws of physics and chemistry describe the physical world, the laws of behavior describe the animal world. Every action, every feeling, every thought, so far as we know, has a cause--it is lawfully determined, even our "free will" and our "free choices." We can learn to accept our and others' behavior as being lawful, i.e. the natural, inevitable outcome of earlier events (see method 4 in chapter 14). We can't change the causes of the past and present; "it's water over the dam;" we may be able to change the causes of future events. It is on these logical grounds that a person can come to accept him/herself and others, to be tolerant of the past and hopeful to improve in the future.

 Learn to be a hopeful self-helper. Believe you can change the unwanted emotions. Avoid defeatism. Avoid catastrophizing--ask yourself, "What is the worst that could happen? Would that be the end of the world?" Be optimistic--ask yourself, "Life is a lemon right now, how can I make lemonade out of it?" or "What would a super well adjusted person in my situation say to themselves and do?" Think big. Think positive. Use your problem-solving and assertiveness skills (chapters 2 and 13) to plan several ways of changing the unwanted emotions.

 Learn to give self-instructions to control your own behavior and emotions. This includes self-directions and advice about how to accomplish the task at hand (see method 2 in chapter 11). It also includes self-help techniques for relaxing and controlling other unwanted emotions (see methods in this chapter). For example, as our body tenses up, if we interpret this reaction as anger or fear, we will "feel" these emotions immediately and more intensely. On the other hand, if we learn (by practicing over and over) to interpret tension as simply a signal to relax, we can avoid unnecessary anger and excessive fear.

 Many of us feel bad because we say negative statements to ourselves: "I'm going to mess it will never work out...he/she won't like me...he/she is so selfish...they make me furious...I can't stand...." These thoughts are our negative interpretations of other peoples' behavior and intentions, of sensations inside our own body, of our own behavior and situation. Our thoughts could be positive instead and relax us, energize us, lead us wisely, give us hope, etc. Several Cognitive-Behavioral therapists have listed many coping self-statements:

 Make up your own list of coping statements. Repeat them over and over to yourself and say them with feeling, so they do not seem foreign to you when you use them under stress.

 The essence of this "stress inoculation" method is the development of self-instructions that we can use in stressful situations to calm us down and make us more effective. The above methods and attitudes--RET, logical reasoning, determinism, optimism, self-instructions, and anything else that will work--can be utilized in the coping self-instructions developed by you for your specific situation in step three. But, first, you must be aware of your specific feelings in specific situations and your thoughts and attitudes that contribute to those feelings.

STEP TWO: Run a mental movie of the emotion-arousing situation(s). What are your feelings? What are your thoughts?

 In fantasy, re-live the stressful experience(s). Do this over and over, if needed. First, focus on your feelings and try to identify all the emotions you are having. There's probably more than one. What are the first signs of the unwanted emotion? (Use these as signals to relax.) Then, see if you can discover the ideas, automatic thoughts or beliefs you have that create or intensify your unwanted feelings. Ask yourself if you have possibly drawn false conclusions. Check to see if your attitudes are non-accepting of others or of yourself. Did you label other people as bad? Are you pessimistic and/or overly quick to conclude that there is nothing you can do about the situation?

 The general idea is to understand the causes and sources of your feelings (not the external causes but your own thoughts and attitudes and false conclusions that cause or intensify emotions).

 If you need to reduce your anxiety or anger, you should, at this point, make up a hierarchy of common situations you encounter that are associated with these emotions. See desensitization (method # 4) for instructions about how to rate these scenes. If you are dealing with only one situation, go on to step three.

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