Working with Phobias and Trauma

Exposure Therapy

Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, with the aim of reducing a fearful reaction. It is a specific type of cognitive-behavioral psychotherapy technique that is often used in the treatment of post-traumatic stress disorder (PTSD) and phobia.

Post-Traumatic Stress Disorder & Phobias:

In PTSD, exposure therapy is intended to help the client face and gain control of the fear and distress that was overwhelming in the trauma, and needs to be done very carefully, so as they’re not re-traumatized. After a traumatic event, many individuals experience distress and symptoms of PTSD & this distress may be highest when dealing with memories, thoughts, feelings, and situations that are related to the trauma.

When treating phobias, exposure therapy is used, together with relaxation exercises and/or imagery/visualisation. As well as learning how to consciously bring about a relaxed state ‘at-will’, this therapeutic technique gradually exposes clients to the object, memory or place which frightens them; it helps them cope with their fears.

Exposure therapy is any treatment that encourages the regular contact of a feared stimulus. External phobias include feared objects, activities and/or situations; internal phobias include worrying thoughts, traumatic memories & aversive or hostile thoughts.  Many exposure therapists use a graded approach, developing a hierarchy of the feared stimuli & ranking them accordingly, e.g. the most fearful ranked as 10 on a scale of 1 – 10 & the least fear-evoking ranked as 1. Typically, higher-level exposures are not attempted until the client’s fear subsides for the lower-level exposure.

People with anxiety disorders tend to underestimate their capacity to cope with fear. Those who face their fear and successfully tolerate it, without avoiding or withdrawing from it, begin to realize they are more capable and resilient than previously believed.  Repeating this practice they become more willing to face their fears in different contexts, thereby generalizing treatment effects.

How Exposure Therapy Works – Fight or Flight & the Amygdala:

Exposure Therapy has been shown to be the most effective treatment for people with varying anxiety issues. It is a form of therapy that helps reduce distress about the trauma & it works by helping the client approach trauma-related thoughts, feelings, and situations they have been avoiding.  Repeated exposure to these thoughts, feelings, and situations helps reduce their negative power.

Exposure Therapy helps to retrain the brain to let go of phobias, anxiety attacks, and other forms of anxiety disorders.  It’s not just about “getting used to” the fear; it’s about retraining the brain to stop sending the fear signal when there isn’t any danger. People really struggle with anxiety attacks and phobias, simply because they realize these fears are exaggerated and illogical. They try hard to talk themselves out of the fear, though that doesn’t work, so they then avoid the fear, & this simply strengthens its hold on the client.

What Happens When Facing Danger?

The part of the brain that handles Fight or Flight response is called the Amygdala.  When the brain gets a signal of danger, it triggers an immediate response, the familiar Fight or Flight response. That’s a good thing, because when we face danger, we need to react quickly and powerfully. The Amygdala doesn’t care how often it’s activated; it will react to actual and perceived fears, whether real or imagined as its purpose is to keep us safe.

The Amygdala is always alert to any sign of danger & when it sees it, true or false; it presses the “fight or flight” button and fills you with fear. When the danger is real, that’s a good thing; however, the Amygdala works automatically and will frequently make the mistake of seeing danger when none is present. Once the danger is overcome or avoided the Amygdala reverts to its passive mode of simply watching out for danger. The Amygdala learns by association; it associates the thing that causes you to feel fear, e.g. entering a crowded shop; seeing a dog; hearing the phone ring; as a source of danger. It doesn’t learn by conscious thought, which is why it’s not possible to talk yourself out of a phobia or anxiety attack. The fear memory is stored as a conditioned fear, and can only be relieved by more conditioning, not discussion or reason.

The Amygdala only learns when it’s fully activated, when it spots something it considers dangerous. It only forms new memories and associations, new lessons, when we’ve become afraid. The rest of the time it’s on autopilot, passively watching. So in essence, avoiding the feared object or activity, allows the Amygdala to continue “believing” the same old mistakes, without a chance to learn anything new. Equally, if we flee the scene every time we have an anxiety attack, the Amygdala learns that this action is what’s needed to keep us safe.

How to Retrain the Amygdala:

Firstly, the Amygdala has to be activated by being exposed to the trigger that is fear inducing. This allows the Amygdala an opportunity to learn that the feared object and/or place are not dangerous or threatening as it had been conditioned to believe. With repeated exposures the Amygdala will develop a new memory, one that lets us get on with our lives, without being disrupted by phobias and/or anxiety attacks. Key to successful exposure therapy is to gradually & continually arrange to activate the Amygdala by exposing ourselves to what we fear, and then staying in place, making sure that the fear leaves before we do.

In conclusion, exposure therapy is considered the gold-standard treatment for individuals with PTSD and/or phobia. This technique firstly requires education by the therapist about this type of treatment, enabling the person to learn more about their symptoms. The next step is breathing retraining as a way of inducing relaxation. Most people, when scared or anxious, do not breathe properly; learning how to control breathing can lessen immediate distress. The individual works with the therapist to approach trauma-related situations and memories at a comfortable pace, usually, starting with things that are less distressing and moving towards things that are more distressing. With time and practice, they will be able to see that they can master stressful situations, objects or memories that are fear-evoking; the goal being that they, and not the memories, object or situation, can take back control of their life & of how they feel.

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