How To Deal With Fears, Phobias and Intrusive Thoughts: Exposure Therapy

Friday, May 09, 2014 by Meg   •   Filed under Treatment Techniques

This is my mother's all-time favorite joke:

Q: "Why don't cannibals eat clowns?"
A: "Because they taste funny!" 

Here's how it would go for someone with coulrophobia:
Q: "Why don't cannibals eat clowns?"
A: "Because clowns are fucking terrifying!" 

Clowns are one of the more common phobias, and it's easy to see why.

Those giant noses, ridiculous feet and seriously creepy belt buckles...how do they sleep at night with that shit hanging in their closet?  

Thanks a lot, Stephen King. After It, clowns will never be the same. Just picturing the book jacket creeps me out.

So, if you happen to be clown-phobic, it's all well and good if you avoid the circus...and the bookstore. However, what if a coulrophobic found themselves on a deserted island where the only way to survive was to work with Bozo? They may want to rethink their clown-avoiding approach to life. 

Or maybe they just want to take their kids to the circus, or Sea World or something. 

Either way, what now?

Types Of Exposure Therapy

The premise of exposure therapy is simple. Avoiding the object of the fear leads the brain to fear it more because the only information it gets are the thoughts about killer clowns, biting tarantulas or crashing elevators without any information to dispute it. Exposure disputes the idea that something is dangerous or scary by providing a concrete situation where it isn't. The more often you are exposed to something and nothing bad happens, the less likely you are to hold on to an unfounded fear.

And there are a bunch of different ways to expose yourself. (Some of them are even legal.) 

Cognitive Exposure

Mental, or cognitive, exposure is essentially focusing on the object of your fear inside your head. This tends to work better with less tangible types of fears, or things you can't experience to get over, like the fear of going crazy or the fear of having a heart attack. However, some do use cognitive exposure as a warm-up to physical exposure techniques. 

The premise with cognitive exposure is that by allowing yourself to focus on a scary thought, and experience the feelings that go along with that, the body will eventually burn out the response to it. In The Mindfulness Solution, Dr. Ronald Siegel encourages sitting and thinking about the fearful thought and trying to gain the highest level of arousal you can, until the fear begins to decrease2. This works because the body will often respond less ferociously to the same stimuli with time, particularly once it senses that are no negative events occurring because of it. 

If purposely increasing your anxiety while thinking about going crazy didn't actually make it happen, maybe it won't actually happen at all. Until someone leaves a Lego on the floor for you to step on in the middle of the night. Then all bets are off.  

While some are able to burn out a response in a few intense cognitive exposure sessions, most require multiple exposures. One technique, discussed by Lucinda Bassett in From Panic to Power, involves writing down the scary thought, and reading it aloud multiple times a day2. Most find that over time, the panic associated with the thought lessens and eventually fails to trigger anxiety at all. 

Cognitive Exposure During Sleep?

Additional research may provide yet another approach to exposure by pairing a scent with the fearful thought and exposing yourself during sleep3. In one study, published in "Nature Neuroscience", participants were conditioned to be fearful of electric shocks that were paired with a particular scent. At night, the participants were exposed to the scent alone and found that this led to a reduction in fear of shocks during the day.

Scientists get to do all kinds of fun things. "Hey Harry, come over here so I can zap you with this cattle prod. Don't be scared, I'll let you smell this orange, and then you can take a nap."

This may work because the primary drive (sleep) overrides the fear response at that time (much like how pain may override the drive to eat). Having sleep as the primary drive may allow for more effective exposure therapy in some cases.

If you take your cues from these researchers, this would involve exposing yourself to the fearful thoughts using the cognitive exposure technique discussed above while smelling something specific, say a type of essential oil. Over several sessions of exposure, the smell itself should be associated with the memory or thought in question. Then you can smell the oil before bed or spray it on your pillow before drifting off for a subtle exposure during rest. Over a few weeks, the fear may lessen, though I would start with a smaller nagging thought as opposed to a traumatic one. 

This should probably not be your only form of intervention, and additional research still needs to be conducted in this area. But if you are already engaging in cognitive exposure, there is not much downside to adding an additional layer. However, I would recommend using a scent you are not particularly attached to, and one you are unlikely to be exposed to accidentally. Nothing says, "Happy holidays!" like getting anxious smelling aunt Helen's perfume, or wanting to punch the grocery clerk for bringing out the lemons.

Disclaimer: Grocery clerk punching is for dicks. Don't do it.  

Physical Exposure, From Gradual Exposure to Flooding
   

Physical exposure works well with phobias or in cases where the fear is something tangible and unlikely to actually cause harm. A fear of leaving the house is often treated by forcing one to gradually travel further and further from their home. A fear of elevators can be dealt with by riding up and down, a fear of snakes can be overcome by handling them, a fear of clowns can be decreased by (gasp) letting them shoot you with their freaky water-squirting flowers. 

These exposure techniques can be either gradual or all at once. Gradual Exposure for clowns may be first watching a clown on television, then sitting outside a circus, then walking around the building, then seeing a circus from near the door, then moving up be a few rows each time you go until you watch from the front row. The next steps may be talking to a clown, touching a clown, hugging a clown, etc. until the fear subsides.

While you are waiting to get used to Bozo, you could even learn to juggle, a completely legitimate treatment option for reducing anxious symptoms4. You can't make this shit up.

Flooding (or immediate exposure) is quick and dirty. If a person is able to stick around and deal with the fear response, they can usually overcome the fear in a much shorter time frame, sometimes that day. Clown "flooding"--which inadvertently sounds dirty somehow--would involve being put immediately into a room with Mr. Big Shoes himself and interacting with him until the fear goes away. 

Flooding would probably be the only way to go on a clown-populated, food-sparse desert island. For now, I will chalk that image up to the stuff of nightmares. 

Have you ever gone through exposure therapy? Do you like clowns?

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Citations
  1. http://www.amazon.com/Mindfulness-Solution-Everyday-Practices-Problems/dp/1606232940/
  2. http://www.amazon.com/From-Panic-Power-Techniques-Anxieties/dp/0060927585
  3. http://www.nature.com/neuro/journal/v16/n11/abs/nn.3527.html
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876467/



Topic-Relevant Resources

The Mindfulness Solution
Meditative and cognitive techniques for everyday use

When Panic Attacks
Detailed overview of cognitive behavioral techniques for changing negative thought patterns

Brain Lock: Free Yourself from Obsessive-Compulsive Behavior
Useful information and tools for addressing obsessive or scary thoughts and the behaviors that go with them.

Mindsight: The New Science of Personal Transformation
New techniques for mindfully altering the wiring of your own brain, leading to increased happiness.

From Panic to Power: Proven Techniques to Calm Your Anxieties, Conquer Your Fears, and Put You in Control of Your Life
Techniques for reducing anxiety and living a happier, healthier life.



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