Almost everyone I know has something they’re afraid of, and the reality is that most of us have many situations we fear, not just one. Who doesn’t feel afraid? Who doesn’t feel anxious?  Our fears are living entities that evolve, morph, and transform. To handle them effectively, they require we pay attention to them on a regular basis.

When feeling scared, we do all types of things to manage the discomfort that comes our way. Most of the time, we avoid what we’re afraid of. As species, we are hardwired to avoid, control, and escape the stuff that makes us uncomfortable, that’s natural and that’s expected. To avoid is to be human. 

But, what happens when we avoid things that we care about because they are uncomfortable? What happens when we disconnect from the stuff that matters to us because we’re trying to control what we feel? What’s the long-term outcome of those avoidant behaviors in our lives?

The most well-established way to tackle those fears is called exposure; some people refer to it as exposure-response prevention exposure therapy. Either way, they’re referring to the same process of approaching, facing, and confronting fears.

What is in this series?:

Part 1: What are exposure exercises?

Part 2: How to create your values-based exposure menu? 

Part 3: What are the different types of exposure exercises? 

Part 4: Where do you start? 

Part 5: What to do when doing an exposure exercise?

PART 1: From the habituation model to the inhibitory learning model, and to a process-based approach to exposure 

Over the years, most exposure treatments and books have been based on the habituation model, which encourages you to face your fears gradually and to stay in a triggering situation until your anxiety level decreases. The habituation model posits that, for exposure to work and for it to be successful, a person’s level of anxiety needs to decrease within an exposure session and between sessions. For example, a person scared of taking an elevator would do an exposure whereby they stay in an elevator and take it back and forth until their anxiety levels are reduced to 40 percent of what they were when they started. However, despite this model’s success, a significant number of people don’t respond to it, relapse, and drop out of treatment prematurely (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).

Craske (2013) studied in detail what drives change—mechanisms of change—when exposure exercises are practiced.

Her studies led her to three key findings:

(1) a person feeling less anxious is not what makes exposure effective,

(2) a person feeling less anxious between each exposure exercise is not what makes exposure impactful,

(3) a person approaching their fears hierarchically and progressively is not what makes exposure work.

Based on these results, Craske proposed a new model, called the inhibitory learning model (ILM) as a frame to understand how exposure exercises actually work. The ILM reconciled the fact that our brain doesn’t work by subtraction of experiences but by the addition of them. So, when a person experiences an anxious response to a particular situation, it’s because they have learned a threat-based association between an aversive stimulus and a particular response.

According to the ILM for exposure treatment to be effective, it’s not about how much or how little anxiety a person experiences when approaching that aversive situation; it’s more about how a person approaches that stimulus. When a person approaches what he’s afraid of by noticing the emotion, removing safety crutches, and mixing the ways of approaching, that process will lead to the formation of a new relationship called a new safe-association. With multiple experiences in different locations and in different ways, that new safe-association blocks the activation of the old learning, which is how exposure works, and that’s the reason for the name of this model as the inhibitory model (in which the new association inhibits the old association).

Based on the current findings on exposure theory, a new approach has emerged, which I refer to as process-based exposure. Acceptance and Commitment Therapy (ACT), at a general level, is already an exposure treatment because it invites us to get in contact with our internal struggles as they are and without running away from them, which naturally, requires exposure.

When targeting fear-based reactions in particular ACT capitalizes the findings from the inhibitory learning model and infuses elements of willingness, defusion, values, and acceptance in every single step you take to face what you’re afraid of, from the moment you make a decision to approach your fears, during the exposure exercises, and as you move forward in your day-to-day life. Within ACT, you are invited to approach what you have been avoiding in the service of your values and, instead of keeping track of the levels of anxiety, you’re invited to check your willingness to make room, accept, and learn to have the yucky stuff that shows up when doing what matters.

The way that I think of process-based exposure, based on ACT, is that you’re invited to developed a new relationship with your thinking and a new relationship with your fears as they come and go in life. To be scared, is to be human, and as we all know, it’s not a one time thing, but an ongoing process.

Facing our fears is really hard work, but when we do it because it matters to us, that’s a different story.Click To Tweet

PART 2: How to create your values-based exposure menu?

In part 1 of this series, facing your fears, you learned that the most research-based approach to face your fears is named exposure, how it has evolved up to the present time, and how Acceptance and Commitment Therapy capitalizes the current research on exposure.

Now, you’re going to read about the first step to confront those fears that are keeping you stuck so you can move forward spending your time, energy, and efforts on doing what you care about.

To start, you need to do an inventory of all the situations you’re avoiding as a starting point. Next, you will use that inventory as a guide to developing your values-based exposure menu. And yep, you read the word “menu” correctly. The goal is for you to decide what situation to face, when to face it, and how to do it, and to always do it in the service of your values.

Behind every situation you’re avoiding, there is something you care about. Click To Tweet

Creating a values-based exposure menu

Grab a paper and a pen, and jot down all those situations. Don’t worry about the order in which you list them, or how big or small they are, just write them down.

This inventory is a guide designed to build your values-based exposure menu. 

Because facing your fears is hard work, it’s important that you do your best to figure out what you care about – what makes the work worth it – when you approach these scary situations.

Here are two questions to help you figure out your personal values behind these exposure exercises when facing your fears:

(1) Which situations matter enough to you that you’re willing to face them and sit with the discomfort that comes with approaching them? Click To Tweet

(2) Which values are you open to moving toward that make it worthwhile for you to do the challenging work of facing those fearful situations? Click To Tweet

Next, based on the inventory you wrote and your personal values, jot down all the situations that are really important to you, that you are willing to approach and get better at handling in the face of overwhelming fear-based reactions. Each situation is an exposure exercise in your exposure menu, and it all starts with things that you’re struggling with in your day-to-day life.

Your values-based exposure menu is your road map for tackling those triggering situations in an organized and planned manner. You can always go back to it, change it, modify it, and adjust it as needed. Your values-based exposure menu is not a menu set in stone but a flexible one that will guide you to decreasing habitual safety-seeking behaviors.

If some of those activities are extremely hard,  you can add other exposure exercises to make things more doable for you. You don’t have to approach a feared situation cold turkey. You can always modify it. Try considering the following variables:

• Spatial proximity: How close are you going to be to the feared situation? 
• Temporal proximity: For how long are you to be in contact with the feared situation?
• Degree of threat: How difficult is the feared situation?
• Degree of support: Is there someone who can be your support person when facing this feared situation?

For example, Chris, a website developer, is afraid of public speaking and dogs. When he is expected to speak at weekly meetings, his anxiety is prominent: he feels his heart beating fast, sweaty hands, butterflies in his stomach. Similar reactions happen when seeing, hearing, or being around dogs. When Chris was a teenager, he was attacked by a dog, and since then he has been struggling with a dog phobia. Chris wants to be promoted to a new position in his company, but he’s extremely concerned about his fear of public speaking since the new position will require him to run multiple meetings during the week at an executive level. Chris has been successful at avoiding dogs for years: asking his friends to keep their dog in a separate room, not going to parks where he anticipates dogs could be unleashed, not leaving his car in a new neighborhood until he is sure that no dogs are around. But Chris has fallen in love with someone who’s a dog sitter; he knows it’s time for him to overcome his phobia.

When Chris answered those questions from above, he came up with the following values:

Romantic relationships:
Being open to new experiences with my partner.

Personal growth:
Being flexible with unpredictability, the unknown, and uncertainty as it comes up in my day-to-day life.

Relationships
Being authentic when connecting with others.

After gaining a sense of his personal values, Chris came up with this values-based exposure menu based on how his day-to-day activities are impacted by his fear of social performance and dog phobia.

• Asking a question in a meeting, so I can practice sitting with the discomfort that comes with not knowing how people see me.
• Going to a new neighborhood with my girlfriend without asking if she sees a dog around,  so I can practice being open to new situations.
• Asking a friend that owns a dog to go on a 10-minute stroll with me and with the dog leashed at all times.
• Making three brief comments in each meeting, so I can learn to be with the struggle of being the center of attention.
• Inviting a manager of a higher level to go out for lunch, so I can get better at connecting with others.
• Being next to a leashed dog for five minutes without asking the owner if the dog is aggressive.
• Smile and ask a question about a product to a stranger in a grocery store, so I can get better at connecting with others.
• Driving next to a dog park and staying in the car for 10 minutes while watching the dogs playing, so I can learn to try new experiences.
• Inviting people to my place for dinner, so I can learn to have authentic conversations with others.
• Write down a brief update on my department and read it during a meeting, so I learn to be flexible with my fears about giving a public presentation.
• Interviewing my girlfriend about the challenging moments she has had with dogs as a dog sitter, so I can be flexible with thought-triggering moments.

A couple of observations on this values-based exposure menu

• As you notice in Chris’s values-based exposure menu, there is a mixture of exposure exercises related to both of his fearful situations. So, if you’re dealing with different fearful situations, you don’t need to have a separate values-based exposure menu for each one of those fears, just a single one, like in Chris’s case.
• Chris’s exposure activities are related to his day-to-day life. This is the best starting point for approaching your fears. Exposure exercises are not about counting how many times you face your obsessions or power through them. They are about making sure that facing a particular situation, person, activity, or object gets you closer to being the person you want to be and showing up how you really want to show up at that moment.
  
  
• Some of the exposure exercises also include the safety crutch that Chris is trying to discontinue during his exposure. This is important since the purpose of approaching your fears is to get in contact with, to the best of your ability, the emotional experience that shows up at the moment.

PART 3: What are the different types of exposure exercises?

This is part 3 of the series facing your fears. In part 1, you learned about the current research on approaches to facing your fears; in part 2 you learned how to face your fears in the service of your values by creating a values-based exposure menu. 

Now, as you take steps to approach situations, activities, objects, thoughts, or images you’re afraid of, let’s consider the many ways you can practice your values-guided exposures.

Basically, you can use a situation, your imagination, or your body when facing your fears; academically speaking, those types of exposures are called situational, imaginal, and interoceptive exposure respectively. In this post, you will learn in detail about each one of them and how to connect them with your values. You can definitely mix them up in any way when working through your values-based exposure menu. Let’s learn more about them!

“We are more often frightened than hurt, and we suffer more from imagination than from reality.”

Seneca

Using a situation: Situational exposure

This type of exposure means physically approaching an activity, situation,  person, or object and getting in contact with all the discomfort that comes with it.

Example:

Rose has been avoiding driving on the freeway for years, and she manages this phobia by asking everyone in her house to give her a ride wherever she needs to go: to school, her girlfriend’s apartment, work, and basketball games. When she cannot find a ride, she plans ahead for the extra time it will take her to use public transportation, or she checks if she can afford a taxi. His exposure menu looks like this:

• Sitting in a parked car on a side street watching the freeway
• Riding on a freeway with someone else driving and me sitting in the back seat
• Riding on a freeway with someone else driving and me  sitting in the passenger’s seat
• Driving for 5 minutes with a person sitting in the passenger’s seat
• Driving for one exit with a person sitting in the passenger’s seat 
• Driving for 10 minutes with a person sitting in the passenger’s seat
• Driving for two exits with a person sitting in the passenger’s seat
• Driving for 10 minutes with a person sitting in the passenger’s seat during heavy traffic
• Driving for 10 minutes alone during heavy traffic
• Driving for 10 minutes alone with the radio on during heavy traffic

Using your imagination: Imaginal exposures

Another way to do exposure exercises is by using your imagination, based on a script you develop for that purpose. You can practice values-guided imaginal exposure if one of the following situations is happening:

1. You are dealing with triggering situations that you cannot approach as a  situational exposure.
   (for example, obsessions about stabbing your loved ones, contracting AIDS, exposing your private parts, or molesting your child).
2. You have tried a values-guided situational exposure first, and even though you tried to tune it up, you’re feeling terribly anxious, terrified, and fearful about that particular situation.

Here are the key elements to writing a script for a values-based imaginal exposure:

1. Write the script in the present tense, as if it’s happening right now.
2. Write the script in the first person, using “I” as a pronoun.
3. Write the script using as many details as possible that involve the five senses (describe what you see, hear, feel, sense, and smell).
4. Write the script describing your private experiences when having those obsessions. (for example, “I feel…,” “My body will…,” “I’m thinking…”.
5. Write down the script, including the worst-case scenario.
6. Do not include reassurance statements (for example, “Everything was okay, I was fine,” “They were fine,” “This would never happen,” “This will end soon”).
7. Do not engage in mental rituals (such as counting, praying, saying special words, etc.).
8. Don’t worry about the length of the script, it doesn’t matter. It’s more important to have a script that has the elements described in points 1 through 6.
   

Imaginal exposures have two steps:

Step 1: Recording your imaginal script
When conducting your imaginal exposures, you’ll need a device to record your voice. Sit in a comfortable position, with your recorder and written script handy, take a deep breath, and start the recording of your imaginal script.

When recording your imaginal script, you may experience some degree of discomfort and urges to neutralize your reactions. Do your best to continue the recording, keep talking, keep recording, until you complete recording your full imaginal script.

Step 2: Listening to your imaginal script

Find a comfortable place to listen to your recording, and then play it for at least 30 minutes a day. If you can, set the replay option on your device; if not, do so manually. After writing your script, you can put into action your imaginal exposure by reading it, recording it, and listening to it.

Example:

Let’s think for a moment of Jason, a very religious person of faith experiencing blasphemous obsessions, such as, Does God really exist? Is the Bible a trustworthy resource? When having these obsessions, Jason feels guilty and ashamed. He spends hours praying as proof of his faith. When considering the consequence of his fear, Jason knows that he is afraid of losing his faith. So he writes an imaginal script about it.

“I’m walking in the street, wandering around and feeling a strong sense of emptiness. God has left me. He’s not protecting me any longer. I’m sad, feeling abandoned, and upset that He’s not watching over me. No one is watching over me. I keep walking in the street feeling a strong hollow sensation and pain in my chest. My sense of loneliness is bigger than my existence. I cry quietly while walking in the street; no one notices anything. As I walk, I see so many homeless people, smell bad smells, watch people driving pretentious cars in a rush. Everyone is doing their own thing, nobody cares about anybody. This is evidence that God doesn’t exist, that I cannot trust the Bible, and that He’s not in charge. I know that I lost my faith. There is no God, there are only humans existing on their own.”

Using your body: Somatic or interoceptive exposures

Sometimes the triggers of a habitual safety-seeking behavior are physical sensations—breathing, swallowing, not feeling full after eating, to name a few—that act as a barrier in a person’s life. So an exposure focusing on these physical sensations is handy to expand your life. These types of exposures are called somatic or interoceptive.

For this type of values-guided exposure, you need to identify those specific physical sensations that are related to your triggering episodes. Then do two things:

1. Think about regular physical activities that are part of your day-to-day life that may trigger some of those bodily sensations (for example, if your heart beating fast is a trigger for your fear of having a heart attack, one exposure exercise could be going for a run for 30 minutes).
2. Practice interoceptive exercises that mimic or activate that particular physical sensation. 

Here are the most common interoceptive exercises you can start with: holding your breath, swallowing fast, jumping up and down in the same place, breathing through a straw, staring in a mirror, drinking water really fast, running up and down the stairs, staring at a light, smelling strong smells, wearing a scarf around your neck a bit tight, shaking your head from side to another, stretching muscles for long periods of time so you experience a tingling sensation, or doing ab workouts with books on your stomach.

Facing your fears is not a robotic, mechanical, or linear process. It actually requires creativity, flexibility, and variability. Click To Tweet

Now that you’re familiar with three different types of exposure exercises, you can play with them in your values-based exposure menu so you have a broad range of activities to engage with all the stuff you have been avoiding because of anxieties, fears, worries, obsessions, and panic.

PART 4: Where do you start?

You have brains in your head.
You have feet in your shoes.
You can steer yourself
any direction you choose.
You’re on your own. And you know what you know.
And YOU are the guy who’ll decide where to go.

Oh, the Places You’ll Go

Dr. Seuss

Now that you have an idea of how your values-based exposure menu looks like when approaching a situation that you have been avoiding, and you’re familiar with the different types of exposure exercises,  you may wonder, where do I start?

Here is my response:

Start your exposure exercises with an activity that truly matters to you, that you’re committed to, and for which you’re willing to face all the yucky discomfort that comes with it. Click To Tweet

If the exposure exercise gets so challenging that it becomes unbearable, you can always adjust it and make some changes that you will learn in the next chapter (e.g., doing it for less time, creating more distance, or using imaginal exposure first).

Keep in mind that doing what matters, and facing those distressing feelings that drive your go-to safety-seeking behaviors, is challenging and is going to be distressing. But that’s not a reason to pull back all the way from your… Click To Tweet

How difficult or easy it is, or how much or how little fear you have, to approach that particular situation shouldn’t be your criteria in choosing what to approach what you have been avoiding. Your main criteria is how important… Click To Tweet

“Do. Or do not. There is no try.”

Yoda

PART 5: What to do when doing an exposure exercise?

After developing your values-based exposure menu, and choosing a starting point for your exposure-exercises, you may be wondering,

What do I do when facing a situation I’ve been avoiding?

Here are key recommendations for you to keep in mind when approaching your exposure exercises.

Don’t escape by distracting, performing relaxation exercises, or doing calming mental rituals

It’s natural that you may have urges to distract, escape, or minimize the reaction you have when facing triggering situations —it makes sense. And yet, to fully unhook and liberate yourself from those fears, worries, anxieties, and obsessions, it’s important that you approach those fearful situations exactly as you experience them.

Keep doing your exposure practice as your feelings change

All the feelings of anxiety, fear, discomfort, and distress that come with your exposure practices may go up, down, left, or right. This is very natural—you’re not losing your mind. When practicing exposure exercises, as it happens every time we do anything we care about — from cooking our favorite recipe to raising our kids, and from applying for our dream job to going on a date—our emotions move in all directions. As uncomfortable, annoying, and overwhelming all those feelings that come along in your exposure practice are,  remember that you, I, and everyone around us don’t have control over what we feel, think, or sense. Our minds, bodies, and emotions have a life of their own. We don’t have a switch to turn our feelings on and off, but we do have the power to choose how to respond to them.

Use acceptance prompts when feeling emotionally overwhelmed

If you feel emotionally overwhelmed when practicing any exposure exercise, you can use acceptance prompts. An acceptance prompt is a gentle way to coach yourself to make room for those fears, anxieties, worries, and any other overwhelming reaction that shows up when you practice your exposure exercise, without fighting against them. The idea is to really open up to them so you can expand your day-to-day living. Acceptance moves can include short acceptance prompts that you tell yourself, such as:

o   I want to give my best at this moment to ride this wave of emotion.
o   I want to do what I can to let this obsession come and go.
o   Fighting this wave makes it worse.
o   I’m going to let this one go.
o   I want to get through this without fighting.

Here is what I find fascinating about acceptance skills at a brain level (apologies for my nerdiness):

Neuroaffective science of emotions has demonstrated that the skill of observing or detaching from the meaning of our stress-based responses – in plain terms, the skill of watching an overwhelming experience – is extremely handy and even faster than other skills in reducing the activation of our nervous system.”

Keep in mind that using an acceptance prompt is never with the purpose of eliminating an uncomfortable emotion you’re going through; it’s just a cue for you to check whether you’re fighting your experience instead of making room for it, and then letting it be. 

Approach exposures with flexibility and not in a mechanical way

While learning to practice exposure exercises is a skill that you will practice, rehearse, and get better and better at,I encourage you to focus more on the process of approaching a fearful situation, no matter how many times you do it or how big or small the actions are that you’re taking. Click To Tweet

Certainly, exposure exercises are all about helping you to get in contact with, move toward, and stay present with any fear-based reactions that come with a particular stimulus but,

Exposure exercises are also a personal decision you make to face that discomfort in the service of your values and a decision you make to sit with the yucky stuff that gets under your skin when doing what you care about. Click To Tweet

Be curious when practicing your exposure exercises

Being curious is not a technical principle but a matter of attitude and approach. The attitude of curiosity I’m referring to is not the cold and disconnected one but the one that doesn’t get attached to any particular outcome. This curiosity means that, when practicing exposure exercise, you practice also being interested in what shows up, how it shows up, and how often it shows up.

Following all these tips to practice your values-guided exposures  – and approaching fearful objects, situations, and people – will help you to maximize the steps you’re making, the effort you’re putting into it, and the courage you’re taking to build the full and meaningful life you deserve!