Imaginary exposure follows just a few basic steps:
1. Before you start, try getting more comfortable by using one of the brief relaxation strategies we describe earlier in this chapter.
See the section "Getting ready by relaxing."
2. Choose the lowest step from your staircase of fear.
3. Picture yourself as though you're actually confronting your fear.
Leeann's was visiting the airport without any intention of flying.
4. Imagine as many details about your fear step as you can — the sights, sounds, smells, and anything else that brings your imaginary experience to life.
If you have difficulty picturing the experience, see Chapter 12 for ideas on how to sharpen your mind's eye.
5. After you have a good picture in your mind of what being exposed to your fear would be like, rate your anxiety on a scale of 0 to 100.
6. Keep the picture in your mind until you feel your anxiety drop significantly.
Waiting until your rating decreases by around half or more is best. It will come down that much as long as you stay with the imaginary exposure long enough. For example, if you experience anxiety at a level of 60, keep thinking about the exposure until it drops to around 30.
7. Finish the session with a brief relaxation technique (see Step 1).
8. If the imaginary experience went easily, you may want to try the next step up in your staircase of fear, and perhaps another one after that. Continue daily practice.
Always start with the last step that you completed successfully (in other words, one where your anxiety level dropped by half or more).
Facing your fears (gulp)
Although we usually recommend starting exposure in the imagination, the most effective type of exposure happens in real life. The strategy works in much the same way as imaginary exposure; you break your fears down into small steps and arrange them into a staircase of fear from the least problematic to the most intensely feared. It's just that these steps all happen through action, not in your imagination as in the previous section. Now, it's time to face your fears head-on. Gulp.
1. Start with a brief relaxation procedure, such as the ones we describe in the earlier section, "Getting ready by relaxing."
2. Select a fear or a group of worries with a similar theme.
For example, fear of rejection is a theme that involves lots of worries about criticism and evaluation by others. Similarly, anxiety about personal injury is a theme that involves a variety of fears about safety.
3. Break the fear into a number of sequential steps, with each step being slightly more difficult than the prior step.
4. Take one step at a time, and keep working on each step until your anxiety drops, generally by at least 50 percent.
If your anxiety starts to rise to an unmanageable level, try using one of the brief relaxation techniques from Step 1.
The following hints can help you get through the exposure process:
Enlist the help of an exposure buddy, but only if you have someone you really trust. This person can give you encouragement and support.
If you must, back off your step just a little. Don't make a complete retreat unless you feel absolutely out of control.
Your mind will tell you, "Stop! You can't do this. It won't work anyway." Don't listen to this chatter. Simply study your body's reactions and realize that they won't harm you.
Find a way to reward yourself for each successful step you take. Perhaps indulge in a desired purchase or treat yourself in some other way. For example, you could put a few bucks in a shoebox each time you complete a step with a goal of rewarding yourself with a larger treat after you've made substantial progress.
Use a little positive self-talk to help quell rising anxiety, if you need to. See Chapter 5 for ideas.
Understand that at times, you will feel uncomfortable. View that discomfort as progress; it's part of how you overcome your fears.
Practice, practice, practice.
Don't forget to practice brief relaxation before and during the exposure.
Remember to stay with each step until your anxiety drops. Realize that your body can't maintain anxiety forever. It will come down if you give it enough time.
Don't expect an instant cure. Proceed at a reasonable pace. Keep moving forward, but don't expect to conquer your fear in a few days. Even with daily practice, exposure can take a number of months.
Remember to set realistic goals. For example, say you're afraid of spiders — so much so that you can't enter a room without an exhaustive search for hidden horrors. You don't have to perform exposure exercises to the point where you let tarantulas crawl up and down your arms. Let yourself feel satisfied with the ability to enter rooms without unnecessary checking.
Try to avoid using crutches to avoid fully exposing yourself to the steps in your staircase of fear. Some of the popular crutches that people use include the following:
Drinking alcohol
Taking tranquilizers, especially the benzodiazepines we discuss in Chapter 9
Distracting themselves with rituals, song lyrics, or chants
Holding onto something to keep from fainting
Asking someone else to reassure you that everything will be okay if you carry out a step on your staircase
All of these crutches actually interfere with the effectiveness of exposure. But if you absolutely feel the need to use one of these crutches, use as little as you can. Sometimes a reasonable in-between step is to use lyrics or chants at first, and then make the next step in your staircase of fear the same activity without the chants.
In your later steps, it's good to drop even relaxation and self-talk as ways to completely master your fear.
Conquering All Types of Fears
Confronting your fears directly is one of the most powerful ways of overcoming them. But your exposure plan can look different, depending on the particular type of anxiety you have. This section lays out example plans for seven types of anxiety. You'll no doubt need to individualize these for dealing with your problem. However, they should help you get started.
You may want to review the descriptions of the seven major types of anxiety in detail in Chapter 2. The list that follows offers a brief synopsis of each anxiety category for which we suggest the use of real-life exposure:
Generalized anxiety disorder (GAD): A chronic, long-lasting state of tension and worry.
Social phobia: A fear of rejection, humiliation, or negative judgment from others.
Specific phobia: An exaggerated, intense fear of some specific object, an animal, spiders, needles, or a situation, such as being high off the ground (acrophobia).
Panic disorder: A fear of experiencing repeated panic attacks in which you feel a variety of physical symptoms, such as lightheadedness, racing heartbeat, or nausea. You may also fear losing control, dying, or going crazy.
Agoraphobia: This problem often, but not always, accompanies panic disorder. You worry about leaving home, which leaves you feeling trapped or unable to get help if you should need it. People with agoraphobia often avoid crowds, traffic, and even leaving the house.
Post-traumatic stress disorder: This problem occurs after experiencing a highly threatening, traumatic event. Symptoms usually include recurrent flashbacks, a sense of re-experiencing the trauma, and avoidance of reminders of the event.
Obsessive-compulsive disorder: Repetitive, unwanted thoughts jump into your mind and disturb you. It can also involve various actions or rituals that you do repeatedly as a way to prevent something bad from happening. However, these actions don't make much sense.
Waging war on worry: GAD
People with generalized anxiety disorder worry about most everything. As a result of that worry, they usually end up avoiding a variety of opportunities and other tasks of everyday life. These worries can rob their victims of pleasure and enjoyment.
Maureen's story shows you how someone with GAD tackles her worries with a staircase of fear.
Maureen's friends call her a worrywart, and her children call her "the prison guard." Maureen frets constantly, but her biggest worry is the safety of her 16-year-old twin boys. Unfortunately, Maureen's worry causes her to restrict her kids' activities far more than most parents do. She doesn't allow them out of the house after dark, so they can't participate in extracurricular activities. Maureen interrogates them about every new friend. As the kids get older, they rebel. Squabbles and fights dominate dinner, but the biggest bone of contention revolves around learning to drive. Although both are eligible to take driver's education, Maureen declares that they can't drive until they're at least 18 years old.
Maureen is surprised when the school counselor calls her to discuss her sons' concerns. He meets with her for a few sessions and helps Maureen to realize that her worries are overblown. She knows she has a problem and decides to tackle it head-on.
After helping her understand that her worries are over the top, the counselor suggests that Maureen talk to other parents at her church to get a reality check. She finds out that most parents allow their 16-year-old kids to attend supervised evening activities, to take driver's education, and even drive if they maintain good grades.
Maureen constructs her staircase of fear, stacking the steps from the least fearful to the most terrifying (see Figure 8-2). She rates the anxiety that each step causes her on a 1-to-100-point scale. Then she rates her anxiety again with repeated exposures. She doesn't go to the next step until her anxiety comes down about 50 percent.
Figure 8-2: Maureen's staircase of fear, with the most fearful situations at the top.
Although we only show six steps, Maureen's entire staircase of fear actually consists of 20 steps. She tries to make sure that each step is within five to ten anxiety points of the previous one.
If you have GAD, pick one of your various worries. Then construct your personal staircase of fear to address that particular worry.
Construct your staircase with enough steps so that the steps are small. If you find one step insurmountable, try coming up with an in-between step. If you can't do that, try taking the tough step through repeated imaginary exposures before tackling it in real life.
Fighting specific and social phobias
You fight both specific and social phobias in pretty much the same way. Take the feared situation, object, animal, or whatever, and approach it in graduated steps. Again, you construct a staircase of fear consisting of a series of small steps. Ruben's story is a good example of how the staircase of fear can help someone with a specific phobia — a fear of heights.
Ruben meets Diane through a dating Web site. They text back and forth for several weeks. Finally, they decide to meet for coffee. Several hours pass in what seems like minutes to both of them, and Ruben offers to walk Diane home.
As he holds the restaurant door open for her, her body brushes against him. Their eyes meet, and Ruben almost kisses her right there in the doorway. As they walk toward her apartment building, she asks, "Do you believe in love at first sight?" Ruben doesn't hesitate, "Yes," he answers, wrapping her in his arms. The kiss is so intense that Ruben thinks he might collapse on the spot.
"I've never done this before on a first date, but I think I'd like you to come up to my place," Diane says, as she strokes his arm. "I have a wonderful view of the entire city from my penthouse apartment."
Ruben looks up at the 25-story apartment building. His desire shrinks. "Ah, well, I've got to pick up Mom, I mean the cat at the vet," he stammers. Diane, obviously hurt and surprised, snaps, "Fine. I've really got to wash my socks."
Ruben decides to fight his phobia. He constructs a staircase of fear (see Figure 8-3) out of steps that start at the bottom and go all the way to the most fearful step at the top.
Figure 8-3: Ruben constructs a staircase of fear to overcome his fear of heights.
Confessing his problem to Diane is a step that may appear unrelated to Ruben's fear. However, not admitting to his fear is avoidance, which only fuels fear. Including any step that's connected to your fear is good. Ruben also included steps in his staircase that required him to use his imagination to face his fear. It's fine to do that. Sometimes, imaginary steps can help you take the next behavioral step.
Imagining the real-life steps before actually doing them doesn't hurt and will likely help prepare you for the real thing.
Pushing through panic and agoraphobia
Some people have panic disorder without agoraphobia, others have both, and still others have agoraphobia without a history of panic disorder. Whether you have one or both of these problems, you can approach them in much the same way. That's because both panic attacks and agoraphobia usually have predictable triggers. Those triggers can form the basis for your staircase of fear. Tanya's story depicts how someone who has panic disorder with agoraphobia builds a staircase of fear.
Tanya experiences her first panic attack shortly after the birth of her baby. Always somewhat shy, she begins to worry about something happening to herself when she takes the baby out. She fears that she might faint or lose control, leaving the baby vulnerable to harm.
Her panic attacks start with a feeling of nervousness and sweaty palms, and then progress to shallow, rapid breathing, a racing heartbeat, lightheadedness, and a sense of dread and doom. Trips away from the house trigger her attacks, and the more crowded the destination, the more likely she is to experience panic. By six months after her first attack, she rarely leaves the house without her husband.
One day, Tanya's baby girl develops a serious fever, and she needs to take her to the emergency room. Panic overtakes her; she frantically calls her husband, but he's out on a business call. Desperate, she calls 911 to send an ambulance, which she and her husband can't afford on their limited budget.
Tanya knows that she must do something about her panic disorder and its companion, agoraphobia. She constructs a staircase of fear (see Figure 8-4) out of a set of steps, starting with the least problematic and progressing to the most difficult goal.
Notice that Tanya's staircase of fear contains quite a few steps between 80 and her top item of 98. That's because she needs to make each step very gradual to have the courage to proceed. She could make the steps even smaller, if necessary.
Figure 8-4: Tanya's staircase of fear focuses on her panic disorder and agora-phobia.
You can break your staircase of fear down into as many small steps as you need to avoid feeling overwhelmed by taking any single step.
Another type of exposure that aims specifically at panic attacks involves experiencing the sensations of the attacks themselves. How do you do that? You repeatedly and intentionally bring them on through a number of strategies, as follows:
Running in place: This accelerates your heartbeat, just as many panic attacks do. Run for at least three to five minutes.
Spinning yourself around until you feel dizzy: Panic attacks often include sensations of dizziness and lightheadedness.
Breathing through a small cocktail straw: This strategy induces sensations of not getting enough air, which also mimics panic. Try this for a good 60 seconds at a time.
Putting your head between your knees and rising up suddenly: You may feel lightheaded or dizzy.
After you experience these physical sensations repeatedly, you discover that they don't harm you. You won't go crazy, have a heart attack, or lose control. Frequent, prolonged exposures tell your mind that sensations are just sensations.
Don't bring on these physical sensations if you have a serious heart condition or any other physical problem that could be exacerbated by the exercise. For example, if you have asthma or a back injury, some of these strategies are ill-advised. Check with your doctor if you have any questions or concerns.
Overcoming Anxiety For Dummies, 2nd Edtion Page 17