How do exposures work?
Face your fears is often a familiar statement that is used to described the theme underlying Exposure and Ritual Prevention (ERP), the gold standard for treatment of anxiety disorders based upon empirical research findings. ERP is the process of systematically confronting situations, behaviors, or thoughts that cause anxiety, while refraining from any types of behaviors, avoidances, or reassurances that might typically help you to feel better (i.e., rituals). Why would anyone purposefully do things that make them feel uncomfortable?
The logical behind ERP lies partially behind the concept of habituation, which typically happens while you are doing something that makes you feel anxious (i.e., exposures). Habituation occurs when you are in a situation long enough that you begin to feel less anxiety, even though you have done nothing to make yourself feel better.
Have you ever jumped in a cold pool at the beginning of summer? After entering the water, you probably find yourself shivering. If you left the water, then of course you would warm back up again. However, what happens when you stay in the water? Eventually, you stop shivering and the water might actually start to feel comfortable to you. Why? The water temperature does not change. It does not become hotter outside. Your body naturally adjusts to the temperature even though you have done nothing to cause this to happen.
In ERP, the same concept applies. Your body (and your mind) adjusts to the situation and the anxiety will begin to lessen. You learn that you can handle the situation, that it is manageable, and that anxiety will not harm you. If you never confront a situation head on, you will never learn these things nor will your body naturally adjust to the situation. You will continue to feel anxious, if not more anxious, if avoidances or other rituals are maintained.
There are two types of habituation – within trial habituation and between trial habituation. The trial just refers to each time that you complete an exposure. Within trial habituation means that your anxiety has decreased during the exposure. We often utilize the Subjective Units of Distress (SUDS) rating scale to measure this. Between trial habituation means that your anxiety has decreased from the first time you did the exposure, to the second, to the third, etc. The more you confront a situation, the less anxiety you typically experience. Let’s say that I am anxious about eating in front of people. The first time I do this, I might be really anxious to begin but less anxious by the time that I am done eating (i.e., within trial habituation). The next day and the day after that, I eat in front of people again. By the fifth day in the row of eating in front of others, this exposure doesn’t make me nearly as anxious as the first time that I ate in front of others (i.e., between trial habituation). This often provides some assurance, especially when first beginning treatment, that repeated exposures often do become easier over time (you get used to facing your fears!)
Dr. Shpancer’s article (“Overcoming fear: The only way out is through”) also provides additional information on habituation and some of the mechanisms underlying the efficacy of ERP.