Exposure and Response Prevention

Defined

Fear is one of our most basic and powerful emotions. It originates in the primal parts of our brain, and strongly influences our thoughts, emotions and behaviors. When we are afraid, we may project that fear onto an object, activity or situation in an effort to create distance between us and the fear. This helps us contain and remove the objectified fear from our daily life, and gives us a way to control our fear through avoidance (Fisher, 2012). 

While the act of avoidance may help to reduce our emotional burden in the short term, it can make us sensitive to memories, thoughts or experiences that remind us of our fear. Over time, this gives our fear power over us in ways that are unpleasant and unhelpful (CPGT-PTSD, 2017)

Exposure and response prevention (ERP) strategies help us understand our fear and what motivates it. While in the self-controlled ERP environment, we can more objectively re-evaluate the emotions and the intrusive thoughts that arise when we are experiencing fear (Craske, 2014). 

ERP promotes recognizing safety cues in order to build trust in our ability to keep ourselves safe. Thoughts of safety come to overshadow the original fear or trigger and we are better able to tolerate our responses (Abramowitz, 2018).

Over time, our efforts to engage, control and neutralize our fears reduces the intensity of the negative emotions that arise when we encounter our fear in real life. Instead of being triggered by an experience of fear, we are simply reminded of it. This allows us to experience less personal upset and reduce the need for future avoidance (HCSAT, 2011).

When approached from the perspective of inhibitory learning (focusing on feelings of safety over feelings of fear), we can apply the ERP healing strategy to compulsive thoughts (Abramowitz, 2018), anxiety disorders (Craske, 2014) post-traumatic stress disorder, social anxiety, and panic disorders (CPGT-PTSD, 2017). 

Getting Started

Because of the strong impact of fear, patience and caution are encouraged throughout this process. It is also important that we put in a meaningful effort to create a safe physical environment where ERP can be done in a measured, controllable way. This space should both physically and emotionally safe, meaning you are free to express whatever emotions come up without needing to engage the input or judgment of others. This safe healing environment allows us to more effectively identify the emotions that are motivating our unsafe feelings (CPGT-PTSD, 2017). 

Once safe, we will write out a list of our fears - including what triggers each fear and our expected outcome of interacting with the fear. Next, we'll rank the fears from most challenging to least (CPGT-PTSD, 2017). It helps to use as many details as possible. Describe any physical sensations experienced, acknowledge who or what causes the fear, and explore what influential factors are present during the feared situations.

Now let's consider our fear honestly and without judgment. We can do so by writing down all of the emotions that arise when we think about our fears, and take time to explore the origin stories of those emotions. Once we understand what emotions are behind our fear and avoidance, we can more quickly identify them when they come up in the future. For help with naming emotions, use the following graphic (Gottman, 2007):

Consider the following emotions list as well (Ackerman, 2019): Concern, despair, disappointment, disbelief, discouraged, disillusionment, dissatisfaction, doubt, emasculated, home sick, humbled, impatience, inadequate, indifference, insecurity, intimidated, irritation, loneliness, longing, moody, neglected, nervousness, annoyance, apprehension, conflicted, confusion, flustered, powerless, reluctance, remorse, skepticism, somberness, stunned, surprise, unappreciated, uncertainty, unease, vulnerable, wariness, wistful, worry, agitation, anguish, anxiety, appalled, betrayed, bitterness, contempt, defeat, defensiveness, defiant, denial, devastation, disgust, fear, envy, hatred, horror, hurt, panic, grief, guilt, dread, desperation, paranoia, pity, rage, regret, resentment, resignation, sadness, scorn, self-loathing, self-pity, shame, shock, smugness, terror, torment, vengeful, worthlessness, humiliation, obsessed, overwhelmed. 

Be sure to take a moment to explore these lists, and try to use the most specific emotional vocabulary possible when describing the emotions related to the fear. Understanding our emotions allows us to connect with the needs that are motivating them.

Within our safe environment, we make an effort to confront and explore, instead of avoiding, our emotions. We also benefit from withholding passing judgment on ourselves and others. While exploring what emotions come up, consider using physicality to help expel the excess stress hormones created by our fear.

It is important that we do not allow our fear emotions to take hold and grow in this moment. Instead we explore them as if we are a third party observer watching from the outside. Focus on maintaining an open-mindedness and curiosity toward the emotions that come up when confronting fear. This includes avoiding the desire to ‘overcome’ or ‘fix’ the emotions that arise (Abramowitz, 2018).

Engaging Fear and Building Tolerance

Let’s now decide on how we want to interact with our fear so we can practice our safety cues and tools. Revisit the list of fears, and decide if you want to work them from easiest to most difficult (graded exposure) or work on the hardest first (flooding). Consider combining exposure events with relaxation techniques to improve overall experiences and outcomes through systematic desensitization (CPGT-PTSD, 2017). For access to relaxation techniques, click here.

We must make an effort to ensure we engage this exposure technique in a safe, comfortable place. This involves reducing the number of distractions present, ensuring our basic needs are met prior to, and seeking out something soothing to drink or snack on. Be sure to factor in enough time for the experience and for the recovery afterwards. Leaving 24 hours time between these exercises and major events or decisions helps prevent misplaced harm from occurring.

We can chose to expose ourselves to the feared object, activity or situation in real life (in vivo), imagine the fear in great detail (imaginal exposure), or we may use technology to create an exposure situation (virtual reality exposure). It is also possible to re-create the sensations we experience when afraid, a rapid heart rate for example, in order to teach ourselves that these feelings are not inherently unsafe (interoceptive exposure) (CPGT-PTSD, 2017).

We can also write out the first time we experienced the fear (imaginational re-experiencing). Using first person, we tell the story in as much detail as possible and re-read it often to reduce the influence of the story over us over time (HCSAT, 2011).

In vivo exposure is often considered the most difficult approach to engaging with fear as it removes layers of distance and can overwhelm the senses. This can create a feeling of crisis, which may then serve to reinforce our body’s recall of fearful emotions and responses when presented with our fear in the future.

If we do choose this pathway, we should try to recruit a safe person who can help us process what emotions come up in the moment and who can help end the exposure to our fear if we are not able. We'll agree on an exit strategy ahead of time, and be patient with ourselves if we are not successful at overcoming our fear after the first few tries. This technique requires time, patience and compassion for self and others.

Imaginal exposure and imaginal re-experiencing are similar in that they use storytelling to describe the fear, the emotions behind the fear, and the outcome of the situations where we felt fear. The idea here is to create the fear-inducing situation in our mind’s eye, feeling it as if we were there and it was actually happening. While in this imagined fear-inducing situation, we identify the emotions that arise and reinforce the safety cues and tools available to us.

Virtual reality or video game worlds are an incredibly useful tool through which we can engage our fears. This may take the shape of an augmented reality headset that can place us right into the physical environment that we find triggering. Alternatively, we can visit online game hosting websites where we can enter a simulated environment to interact with fear-inducing triggers (steam.com and roblox.com offer some free and some paid experiences). The best part about virtual reality is that we can quit anytime we feel overwhelmed, and try again later. 

When using technology or our imagination to experience fear, we may trigger a reaction from our nervous system as it tries to activate the fight/flight/freeze/fawn response. It helps to try to allow these feelings to follow their natural course to resolution. We can remind ourselves that these emotions are occurring even though we are physically safe, and that they will pass with time. 

We benefit from trying to tolerate these feelings until they pass, but if this becomes overwhelming or impossible - we don’t force ourselves to suffer through them. We'll take a step back, regain our equilibrium, and try again another time.

Using Safety Cues and Safety Tools

Next, let's work to identify safety cues present that can help reduce the impact of the fear. A safety cue is a true statement that we can consciously identify, actively acknowledge, and then repeat when we feel overwhelmed by our fear (Abramowitz, 2018).

Think of it as a description of the safety-related facts surrounding the fear, or as an affirmation that we can use to refocus our attention to what is within our control. The goal here is to write down one safety cue for each of the fears we’ve placed on our list (Abramowitz, 2018). Consider the following safety cues to help get started:

  • Although my fear is triggered, I am capable of enhancing my personal safety. 
  • This experience will end. I will not feel this fear for much longer.
  • This experience is uncomfortable, but it will not result in my death. 
  • The last time this happened, I was able to survive. I will survive this time as well. 
  • That person is engaging what I fear, and they did not experience harm.
  • I have control over my breathing, my emotions and my reactions.

Now, we'll establish what safety tools we have available to us that mediate or reduce the feelings of fear we are experiencing. A safety tool is a coping strategy or action we can take to ensure that our fear does not overwhelm us (Abramowitz, 2018). Consider the examples below:

  • What I am afraid of is close to me, but I can maintain my distance.
  • I am able to walk away from this situation if I feel overwhelmed.
  • If what I fear contacts me, I can take action to prevent harm.
  • My friend/family member is present and they want me to be safe.
  • I have a strong mind and body, and I can use my strength to keep myself safe.
  • I know what triggers me, and I have prepared myself emotionally to withstand its influence. 

Each time our fear is triggered in the future, we will remind ourselves of our safety cues and tools until we feel safe or otherwise neutral regarding the fear (Abramowitz, 2018). 

Reflection on Exposure Events

In order to increase the value of our time spent working within ERP, we engage in self-reflection and reappraisal. Here we ask the following questions to better understand our emotions and reactions. Be sure to answer honestly and without passing judgment (Abramowitz, 2018):

  • What emotions did I expect to come up? 
    • What emotions did come up?
    • Was I able to tolerate and manage these emotions?
    • Was I able to tolerate the uncertainty of the situation?
  • Did the negative outcome I feared occur? 
    • If not, what prevented it?
    • If yes, was it as bad as I feared?
    • Were my expectations of the outcome reasonable or exaggerated?
  • When confronting my fear, did I act in a way that aligns with my morality and personal beliefs?
  • What safety cues did I identify?
  • What safety tools did I use?
  • Did I accurately assess my ability to keep myself safe?
  • What am I most proud of myself for?
  • What does my next exposure event look like?
  • In what ways can I increase the intensity, duration, or frequency of future exposure?
  • Can I change the environment of my exposure? Interpersonal context? Emotional conditions?
    • What new tools will I need if I do make these changes?
  • How can I make my exposure more safe? More tolerable?

Remember the importance of being kind and patient when engagin exposure and response prevention strategies. This process is difficult and takes time. Consider visiting the main strategies page to explore adaptive coping tools that can make the ERP process easier and more effective.