People often ask me what a typical workday is like for an exposure therapist. Here is a typical Tuesday:
7AM: The chimes on my alarm kicks off the morning dash. Shower, dress, and then breakfasts are thrown together and wolfed down by ravenous children. I’m out the door for the cool morning sprint to the school bus stop. Then, back home for coffee with my spouse and a review of the day’s schedule. Fueled up, I’m off to the office.
8:30AM: Phone calls are returned, today’s charts are pulled, and miscellaneous paperwork is either completed or neglected. I bang on my old printer to get it working and print out the various forms that will be used today. Now, what props will I need for today’s exposures? I gather them as my 9AM arrives.
9AM: Fifteen year-old “Amy” comes into the room, accompanied by her mom, who is serving as her “exposure-coach” between sessions. Amy has a severe fear of vomiting (emetophobia). She avoids touching things in public places, which makes high school hell for her.
We spend the session watching Youtube videos of people vomiting, while practicing coping with her body’s natural disgust reaction. Her anxiety comes down very slowly and, eventually, we share a queasy laugh as we repeatedly watch the horrified expression of a reporter whose interviewee awkwardly unloads on her desk while on live TV. Amy leaves with the promise to watch videos daily and I nauseously write my progress note, regretting the greasy breakfast eaten before this session’s barf-fest.
10AM: “Nick” is a 21 year-old college student who recently accepted an internship with a company twenty miles north of here. The problem is that he is terrified to drive on the highway! To get to his internship he will not only need to drive on the highway, but also up and down a very steep mountain route (AKA “the Grade”).
I spend the next 40 minutes riding with Nick in his truck as he nervously drives up and down the Grade. I enjoy the sweeping scenic vistas while encouraging him to loosen up his death grip on the steering wheel and decrease his attempts at distraction. (The radio stays off and chatting is minimized.) Next time we will need to repeat the exposure, but with him driving in the lane next to the mountain ledge. He drops me off at the office barely in time for my next client.
11AM: Another young college student, “Mark” and I quickly set some goals and then we are out the door and into the heart of downtown. Mark’s OCD has recently caused him to withdraw from friends, family, and cherished activities (and nearly drop out of college) in order to avoid “catastrophic” consequences of touching germs.
We touch the inside of all of the garbage cans we find on our way to his most challenging exposure site, “Bubble-Gum Alley” (a sticky and disgusting San Luis Obispo institution!). After watching me touch the wall (Yuck!), he places his hands on the wall and I set a timer for five minutes. We get a few curious glances from tourists and one horrified expression that Mark and I will laugh about at a later session.
On the way back to the office, we stop by a local candy store, Rocket Fizz, where I reward him with his favorite drink, an ice-cold bottle of Sarsaparilla, which he triumphantly sips… moments after he contaminates it with his sticky hands.
Back at the office, I munch on half a protein bar while writing my progress note.
12PM: “Michelle” is a 30 year-old woman with OCD who is plagued by unwanted intrusive thoughts that she will snap at any moment and stab her spouse (whom she loves dearly). She is now either avoiding her spouse or barraging him with requests for reassurance, which is straining the relationship. She has removed the steak knives from her house and won’t sleep in the room with her spouse. At the worst times, she contemplates taking her own life (so she can be certain that she won’t harm him). She has been despondent and debilitated for the past six months, unable to work or find even brief enjoyment in her life.
Michelle would like to have one-hundred percent certainty that she is not a killer deep inside. Unfortunately, such certainty is not possible and to demonstrate that uncertainty does not mean that her worst fear will come true, we do exposure therapy with a large serrated knife that I keep at the office. I instruct her to hold the knife close to my neck as if she were going to slit my throat. (Kids: don’t try this at home without a relevant graduate degree, sufficient training, and appropriate clinical supervision!) Hesitantly, she follows through with the exposure, her anxiety initially quite high. “Slice my neck!” I add, just to further challenge her.
We wait…Forty minutes later I am sleepy, but still alive. She realizes that her psyche is not so fragile and her scary thoughts seem much less threatening and quiet down when she stops running from them. She leaves smiling for the first time since I met her.
I finish the chalky protein bar while prepping for my next client.
1PM: “Sara” is a 20 year-old who is on medical leave from college. She lives in constant fear of panic attacks and has become so agoraphobic that she rarely leaves home. Her mom has moved in to take care of her and brings her for therapy. Ideally, they would like for her to relax her panic away, but that’s not how it works. To get better, she has to face the physical sensations and catastrophic thinking that cause her to panic.
Today, she will practice bringing on her feared physical sensations by running in place until heart rate increases and shortness of breath occurs, twirling around until dizzy, and then she’ll sit in a giant, dark, enclosed box until her anxiety habituates. She has one panic attack following the twirling, but copes admirably and her panic quickly subsides. She leaves exhausted, but with growing confidence that she can deal with whatever anxiety throws her way!
Next week, we plan to add a strobe light to the inside of the box (in order to create a surreal experience that is a major trigger for many people with panic disorder). She nervously jokes that this will make it the disco box from hell! I make a note to write that on the front of the box.
2PM: I return some phone calls, one from a new client who is in the midst of a crushing panic attack and one from an individual desperate for treatment for his severe phobia of flying—his flight is tomorrow morning. I deal with other administrative chores and prep for tonight’s workshop, then rush home to meet my kids at the bus stop.
3PM: My kids pile into the car and I shuttle them to Karate class while I grab a workout at the gym. I make it back in time to enjoy the ninja’s sparring free-for-all. Then we head back home for homework, dinner, and some family leisure time. My watch alerts me that it’s time to get back to the office.
6:30PM: The Social Anxiety Workshop co-leader and I review tonight’s goals and attendees begin to file in by 6:45pm. We engage them in casual small talk (which is one of their greatest fears!).
7PM: The rest of the attendees arrive and we check-in with each of them regarding the goals they set last week. Then the co-leader and I strategically divide the attendees into two groups and we head into the heart of downtown for behavioral experiments.
One person in my group is a middle-aged gentleman who is terrified of inconveniencing others. He agrees to enter the busy candy store and purchase a single jelly bean. He predicts that social catastrophe will ensue and is very pleasantly surprised to see that the person at the cash register simply rings up his order politely.
Next, a female college student who feels very frightened and intimated around attractive men is encouraged to ask directions from and give a compliment to a young man standing outside a shop. We watch from a distance as they have a three-minute conversation and she returns with a big smile on her face.
The third person in my group is a painfully shy 18 year-old man who fears appearing foolish, especially to young women. He is sent into Victoria’s Secret to ask an attractive young woman for directions to the coffee shop that happens to be right next door. He shakes slightly as he enters, but upon leaving he reports, “I can’t believe how nice she was!”
They each engage in two more experiments each and then we return to the office to meet up with the other group and swap success stories. Each attendee in turn stands up in front and gives a two-minute speech on what they learned from tonight’s experiments. They leave with a new sense of courage and the promise to complete more experiments on their own the following week.
The co-leader and I debrief and then I’m headed home.
10PM: My wife and I unwind in front of the TV and I quickly nod off.
This is a typical Tuesday. Even though I am working with a diverse bunch of fears, they are treated using the same process. People learn to come face to face with their fears without running, fighting, or compulsing. They learn to accept uncertainty and take reasonable (if sometimes yucky) risks.
Eric Goodman, Ph.D.