Please note: this is Part III of a series of posts on exposure therapy. You may benefit from reading Part I (Understanding Phobias: How Neutral Stimuli Become Scary) and Part II (Exposure Therapy: How Scary Stimuli Become Neutral) before continuing with this post.
Some clients are quick to accept the model of exposure explained in parts I and II. They've been avoiding situations that make them anxious, and report that the avoidance has only made things worse in the long run. Other people object to the model of exposure, because they've been encountering their feared situation repeatedly, and their anxiety never improves. They typically say something like, "exposure won't solve my problem; I've been exposed to my fear hundreds of times, and it never gets any better. In fact, it seems that the more I face it, the worse it gets."
If you're one of the people who has been exposed to your fears repeatedly and the anxiety hasn't gotten any better, there are two probable explanations.
The first explanation is that you haven't stayed in the anxiety-provoking situation long enough for your anxiety to reduce. As we discussed in part II, it can often take more than 30 minutes for anxiety to reduce during an exposure. So if you've repeatedly exposed yourself to an anxiety provoking situation but you left the exposure within seconds or a few minutes, it probably wasn't long enough for your anxiety to go down and as a result you didn't see any benefit from those exposures.
The second explanation is that a safety behavior has interfered with the benefits of an exposure. If you've faced your fears repeatedly for prolonged periods without benefit, a safety behavior is very likely the problem. Safety behaviors are actions that we take to make ourselves feel safe, or less anxious. Safety behaviors often seem helpful in the moment, but ultimately render exposures ineffective.
To better understand this, let's consider an example. Let's pretend that your child has a fear of vomiting at school. He's so anxious about throwing up there that he wakes up every morning feeling nervous about going to school. In an effort to help him, you did some research and learned that ginger can be very effective for settling an upset stomach. So you both decided that he'll carry a little ginger candy with him every single day. If he's at school and he notices any feeling of nausea, he eats a ginger candy right away.
Remember that safety behaviors are actions that we take to make ourselves feel less anxious. Therefore, eating the ginger candy is a safety behavior, and it will help in the short-term. (Before we explain why this is problematic, let me first acknowledge that if your child is protesting school, you'll do just about anything to get him to go. The ginger candy solution gets him to school, and that is a major victory! Unfortunately, it will also have the unintended consequence of prolonging his fears.)
To help clarify this point, let's review the situation and pay special attention to the child's beliefs about vomiting in school.
Before exposure: Child believes "I am likely to vomit at school."
Child goes to school repeatedly for prolonged periods (exposure). Every day, he brings a ginger candy and eats one at the first sign of upset stomach (safety behavior).
After exposure (with a safety behavior): He believes that "the reason I haven't vomited so far is because I ate those ginger candies." Thus, the child continues to believe "I am likely to vomit at school."
Thus, because of the safety behavior, the belief that he is likely to vomit in school remains unchanged. The safety behavior has rendered the repeated exposures ineffective.
This happens with all sorts of safety behaviors and is not unique to a fear of vomiting; the individual attributes their continued safety to the safety behavior rather than learning that the situation is objectively safe. In the above example, the core maladaptive belief "I'm likely to vomit at school" remains unchanged, and therefore the fear remains despite repeated prolonged exposures.
It's tempting to believe that a simple explanation would reverse this process. One can imagine saying to the child, "you only think the ginger candy kept you from vomiting, but you wouldn't have vomited anyways. So you see, there's nothing to fear!" Sadly, this explanation won't be helpful because anxiety responds to experience, not explanation. In fact, this is a source of constant frustration for many families. During my initial intakes with families, parents frequently say, "I told him a million times that he'll be fine, and sometimes he'll believe me for a second or two, but it never lasts."
So, if you've exposed yourself (or your child) to a feared situation repeatedly and it's never gotten any easier, chances are a safety behavior is interfering with exposure. Instead of a fear lasting a few days or weeks and then going away, safety behaviors can prolong fears for months of even years. Thus, it is critical to identify and eliminate safety behaviors when doing exposure therapy.