I received an email from someone recently who asked a great question about anxiety treatment:
(Paraphrasing) How do I do exposure therapy when my anxiety is triggered very infrequently (but very intensely)? How do I practice facing a fear when I rarely come into contact with the object of my fear?
When you have an irrational fear of something your brain screams danger in a reasonably safe situation. If you wish to someday reduce this fear, the goal is to teach your brain that what you fear is safe. If you have a phobia of dogs, for example, you could choose to hang-out with your friend’s and family’s pets, go to the local pet store, and even hang out at a dog park. You could arrange your schedule to be literally surrounded by dogs twenty-four seven.
Or perhaps you are phobic of driving a car. You could choose to spend many an hour just circling around your block and then gradually expanding your circle outward. If heights are your tallest challenge. You could spend time at the top of parking structures, hillsides, or even a ladder against your own home. These can certainly be difficult challenges if you are phobic, but arranging opportunities to face these fears are not. The reality is that some fears are just more convenient to face than others.
Other phobias, however, are more challenging, expensive, or inconvenient to face directly. I have had clients whose anxiety was only triggered when they were one-thousand miles or more from their home. I myself have dealt with the inconvenient fear of flying through turbulence. Sure, if you are a business traveler whose company shells out the big dollars for you to fly on a weekly basis then you have a wonderful opportunity to practice facing your fear. For the rest of us, it costs hundreds of dollars per flight and is very time-intensive—and even then, there is no guarantee of turbulence.
Still, others have fears that they will never be able to directly expose themselves to. For example, people who are phobic about their home being haunted or about rare diseases or their spouses cheating on them are not going to be directly facing their fears anytime soon (hopefully).
Here are some strategies for dealing with fears that are infrequent (or impossible) to face directly:
Focus on facing your internal fears
Facing a fear in real life is just one way to do exposure therapy. People also face fears using other means such as:
Imaginal: Very often, at least to some degree, when you imagine facing a fear your anxiety believes it to be a real threat and will release the adrenalin it thinks is required to help keep you safe. Imaginal exposure involves setting aside time to face your fears in your imagination. Sit down, close your eyes, and allow the Stephen King version of your fear to play out. Resist the urge to white-knuckle, hold your breath, or distract yourself, or get certainty about the content of the thoughts. Sit with the images and the anxiety and uncertainty they bring repeatedly—time and time again. You might find that even the most terrifying of thoughts can feel boring after a while.
Interoceptive: Sometimes the fear you might have is of the fear itself (I can’t tolerate feeling anxious!!). Interoceptive cue exposure is designed to help you face the actual feelings of anxiety and learn that you can tolerate them without catastrophe ensuing. By doing this you can build up your anxiety-tolerance muscles. Examples of interoceptive exposures include:
- Wearing constricting clothing or snug scarf or tie
- Breathing through a narrow straw
- Holding your breath
- Drinking caffeinated beverage
- Cardio exercise
- Holding the “plank” position
- Sit in a warm/stuffy room
The idea is to do something that triggers similar physical sensations that you experience when you are anxious. After spending significant time teaching your brain that these feelings are not emergencies, they may feel seem less powerful when they naturally occur.
Face your fears virtually
If you have access to virtual reality equipment, many fears can be simulated in the privacy of virtual worlds and experiences. Your anxiety often has great difficulty telling the difference between real and virtual and therefore you can practice facing digitally rendered fear triggers. This won’t be applicable to all fears, but many common and even uncommon fears can be found in commercially available VR applications.
Face related triggers
If you fear, for example, being seen as anxious by a potential love interest you don’t have to wait until you are in a relationship. You can start out by intentionally coming across as anxious in other situations so you can teach your anxiety that this doesn’t lead to the catastrophic outcome that it believes.
If you fear people will see you blush, you could eat spicy food or exercise intensely to take on the appearance of blushing on purpose and then spend time around a range of people and take note that nothing threatening occurred.
Similarly, you can create shaking, sweating, and losing your train of thought in front of others and see that it is tolerable and that the other people don’t react in a threatening manner.
The more you teach your anxiety that something is not a threat the less it will vigorously try to protect you by cranking the dread and adrenalin. Then, when you are in the rare, but very triggering situations you’ll have a head start on teaching your anxiety that those situations are safe.
Greet those rare anxiety triggering situations as golden opportunities
So now the time has finally arrived. You are on your way to take that flight, give the big speech, or are on a date with the person of your dreams. Your anxiety is roaring, trying to protect you by convincing you to cancel your trip, call in sick to work, or avoid the big date. You may be tempted to give in to this. You may find yourself fighting, hating, and struggling to just make your anxiety STOP!
When I dealt with an extreme phobia of flying, heavy turbulence during a flight was not something I could order up along with my inflight meal. Heavy turbulence happens, but rarely and unpredictably. Even those without a phobia of flying tend to dislike heavy turbulence, but for me it is an AFGO (Another Freeing Growth Opportunity). I don’t have to like it to realize that it is an opportunity to further train my anxiety that I am safe and that I can tolerate (even if I find it aversive) the discomfort that may show up.
If these rare occurrences happened with great frequency, then we can habituate (get more comfortable with) more quickly. However, habituation is not necessary in order to live a good life. I don’t have to be comfortable with heavy turbulence, I just wanted to teach my brain that it is not catastrophic, and it is tolerable, despite being unpleasant.
Here are some tips for when these rare situations present themselves:
- Rather than curse your fate, thank your lucky stars for having the opportunity to give your anxiety a teachable moment.
- Don’t avoid or demonize these situations when they arise—embrace them as cherished teachers.
- Rather than tighten up and white knuckle through the experience, soften, breathe, and open-up to the thoughts and feelings that emerge.
- Rather than getting hooked by catastrophic thoughts, notice, accept and defuse from them. When your anxiety shouts “The plane’s going down!!!” rather than get into an argument with it or take the thought as fact, unhook from it—I am having the thought that the plane is going down. Or perhaps, “My inner bodyguard is trying to protect me right now—thanks for trying, but I’ve got this.”
- Rather than being a harsh critic to yourself (What a loser I am for feeling this way—no one else does!!!) think about the helpful attitude you would have towards a cherished loved one who had that fear in the moment. Think about the kind and compassionate tone you would take. Aren’t you equally worthy of this? Direct the kind and compassionate tone inward and be your very own “good coach” that gently motivates and encourages you.
- Don’t over-rely on safety behaviors to “survive” a reasonably safe experience. These might include having a few drinks to numb the anxiety, gripping the armrests for support, asking for reassurance repeatedly, and so on.
Most importantly, keep your eye on the prize—being free to live a life of value without artificial constraints imposed by the whims of a glitchy emotion. The reality is that life does hurt sometimes. If you go to school rather than staying home and playing video games, that is you choosing meaning over comfort. If you get up and go to work, you are choosing meaning over comfort. If you raise children, you are choosing meaning over comfort. And, if you brave the awkwardness of meeting a stranger for a coffee date, you are choosing meaning over comfort.
And wouldn’t you rather opt for the depth and richness of a meaningful life over the temporary relief of escape and avoidance?
Eric Goodman, Ph.D.