At the heart of Cognitive-Behavioral Therapy for OCD and related anxiety disorders is the process of “exposure therapy”, during which we help clients repeatedly do the very thing that most terrifies them. For a client with OCD, this might mean purposely touching doorknobs without then washing. For someone with Pure Obsessional OCD (Pure O), this could mean purposely thinking about being a pedophile or a murderer. A client with Body Dysmorphic Disorder (BDD) may be asked to go out for a walk without the hat they usually wear to hide their face or to go to a brightly-lit restaurant with a group of friends. For someone with Panic Disorder, exposure might mean driving on the freeway or taking a plane flight. And an individual with Social Anxiety may be urged to go to the mall to initiate conversations with strangers.
As a treatment center specializing in Cognitive-Behavioral Therapy (CBT) for OCD and related anxiety conditions, we regularly do exposure therapy with our clients. When we first broach the subject, it is not unusual for a client to be taken aback by our suggestion that they directly face their fear. Some variation of “why on earth would I want to do that” is not an uncommon reply.
When beginning therapy with these clients, we explain that the basic principle of exposure therapy is that one will become less afraid of just about anything if they are exposed to it frequently and regularly. So if a young boy has a phobia of dogs, the exposure would be to purposely, repeatedly spend time with dogs until such time that the fear is reduced to a minimal level.
The question then often arises how this works. So here is a simple, non-clinical way to understand how exposure helps to diminish anxiety.
First, by doing exposures, one often discovers that the feared event never occurs. The client who touches doorknobs without washing afterward discovers over time that they don’t get sick and die. The client with Social Anxiety learns that people at the mall don’t respond as if he is an idiot or a freak. The woman with BDD discovers that nobody points at her in horror. And the boy afraid of dogs learns that he doesn’t get bitten.
The second benefit of exposure is that the client learns that, if they don’t do their customary compulsive or avoidant behavior, the anxiety almost always go down all by itself. If the person who is afraid of germs touches some doorknobs and then doesn’t wash, they will at first experience some anxiety. But that anxiety eventually goes away – and often more quickly than if they had washed their hands. Likewise, if a person with BDD goes out without their usual camouflage of a big hat, their initial anxiety will diminish over time – again, often more quickly than if they had worn the hat.
The third way in which exposure works is by helping clients see that even if a feared thing does come to pass, it is not necessarily catastrophic. People do get sick or experience panic attacks, others do sometimes evaluate us negatively, and dogs do occasionally bite. But if by chance these events do occur, the client has an opportunity to learn that it isn’t so bad after all. I personally have been sick more times than I can count, have had panic attacks, have been evaluated negatively on numerous occasions, and have been bitten by a dog. I have never liked these experiences, but they were not catastrophic.
The fourth, and perhaps most important benefit of doing exposures, is that the client learns an incredibly valuable lesson – that they are capable of tolerating the anxiety that they have avoided for so long. Clients often spend years doing compulsions and avoidant behaviors in an effort to avoid the feeling state of anxiety. In fact, the fear of the feeling of anxiety is the single thing that relates all anxiety-based conditions. And when one does repeated exposures, they learn that, lo and behold, they are far more able to tolerate this feeling than they realized. What they thought would be unbearable turns out to quite bearable after all. Less than ideal perhaps, but hardly unbearable.
People who don’t have anxiety disorders cannot fathom just how terrifying the prospect of exposures can be to someone who has spent years avoiding the very thing we are asking them to face. But to those with anxiety disorders, this fear can control and drastically diminish their life. In facing their fears head on, they learn these four valuable lessons which help them change their life from one of anxiety, avoidance, and dread, to one in which they can choose to live as they have always dreamed.
•Tom Corboy, MFT, is the executive director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.