Facing Your Fears

January 6, 2025 • 5 min

Hi! I’d like to tell you everything I know about a treatment in CBT called exposure and habituation. It’s been a game changer for the treatment of common mental health difficulties, increases confidence, our ability to tolerate difficult emotions and is conducive to good mental health. 

Please note this was designed as a treatment for anxiety and is not a life hack for dangerous situations. We do not teach CBT techniques to manage any stress you might feel while outrunning a predator, for example. I’m assuming that when you feel anxious, there is a sense of impending doom but that you know, or trusted others around you know, that you are safe. If you’re unsafe you need help with that first. If you’re suffering with anxiety having been through something traumatic, this all does still apply but might be too hard to do on your own. I’m sorry you’re suffering, please do get some help. 

Credit to Joseph Wolpe for his work on exposure and habituation, published in 1958, which totally changed the treatment of anxiety. Prior to this, extremely anxious people, disproportionately female, were institutionalised lightly. 

So what is it? Assuming this is an anxiety problem and not one of danger, through repeated exposure to the same scary thing, we find it less and less scary – we habituate. Can you think of things you habituated to? Got used to? 

Maybe a boss who intimidated at first? Speaking in meetings at work? Your mother in law? Only joking.

Increasingly in my work with patients we bring in the concept of exposure and habituation, not just to things that elicit anxiety, but also to practice tolerating all sorts of different emotions. We can improve our capacity to cope and our distress tolerance. We also do this when we meditate. Sitting with things as they are through meditation is a form of emotional exposure. 

Some examples of how we might use exposure and habituation in CBT. A man with a phobia of spiders causing panic attacks – with a goal to be able to go in the garden shed. I would start by exploring the causes of their phobia – any formative scary experiences or assumptions we need to explore, and then introduce the concept of exposure and habituation. I find that showing my all time favourite graph really helps give a rationale for why they need to face their fears. Avoidance or escape maintains anxiety over time. Exposure allows habituation to the threat, bringing down anxiety levels over time. 

We would devise and then work through what we call a hierarchy of feared situations; starting with whatever could just about be managed. Doing that repeatedly if the task allows – it can be hard to find spiders on demand I find – until the challenge is no longer anxiety inducing. You know you have habituated when you’re bored. Then up to the next challenge. If the first was to look at a photo of a spider, the next might be to watch them on TV. Then to find one in the garden, etc etc. 

If a patient had a fear of speaking to strangers and their goal to be able to be more outgoing and sociable at work I would at some point bring in my favourite graph and we would devise a hierarchy of feared situations to work through. We might start with asking someone the time, and a series of repeated small interactions with strangers. Building up to striking up a conversation in the laundrette. Possibly considering going for a ‘strike’ by doing a reading at church, knowing that pushing firmly outside the comfort zone will expand the comfort zone. 

An interesting discovery in the treatment of anxiety disorders was the understanding of ‘safety behaviours’ as a mechanism which keep anxiety going. There was always the big question – if nothing bad happens, why don’t we update our anxious predictions? Why such impending doom around a spider even though the worst arachnophobia scene has never actually played out for me? This is where safety behaviours come in. We do something to help us manage our anxiety – always with the goal of avoidance – often quite random and unrelated like listening to music on a tube, always drinking water, playing a game on my phone – fine, harmless who cares – EXCEPT we get this odd thing happening where we start to think we were only ok in our anxiety inducing situation, because we did something to keep ourselves safe. We just about got away with it. We didn’t reveal our REAL self, or sit in the feelings, or acknowledge our anxiety with kindness. All of which take bravery but would be helpful, by the way. 

To get the benefits of exposure therapy we need to lean in and be really brave, dropping our safety behaviours – those things we do to keep ourself feeling safe. We might find we are ok, just the way we are – just the ways things are. And if things don’t go that well – but we’re not in actual danger – it’s really good for our confidence to know that we can tolerate that. 

There’s a short story I tell my patients somethings that’s popular CBT folklore. It helps illustrates how safety behaviours can be maintained, become quite stressful crutches and prevent us from learning that we would have been ok anyway – which would be more conducive to reducing our anxiety over time.

There’s a man down the road at train station, every day he throws salt up and down the rail way tracks and then rushes off to work. One day I stop him. “Why do you do that?” I ask. “It’s to keep the crocodiles away” he replied.  “But we don’t have any crocodiles around here”, I protest. “Exactly! You’re welcome!” 

How do you think this man might feel about being persuaded to experiment with dropping this ‘safety behaviour’? It would take a LOT of persuading. If no crocodiles came on day one, he wouldn’t be fully assured. He’s need repeated exposure, without the use of safety behaviours (we don’t want him developing another crutch which stops him – over time – from relaxing. He’s safe anyway. 

So exposure and habituation only works if you’re not using safety behaviours. These vary as much as people do which I always find interesting. If you’re in a social situation, exposing yourself for social anxiety purposes, counting backwards from a hundred, rubbing a lucky stone, preparing excessively or worrying about how you’re coming across could count as safety behaviours. They might seem harmless – only distracting to various degrees – but actually they prevent you from getting lost in the moment with all your awareness. So you’re not open to positive feedback from the world, with which you might find you can update some of your anxious predictions.  But what’s needed really is just time for your adrenaline levels to drop back down, your nervous system to settle and for this to happen in the presence of the thing that you fear. You can form new associations. You’ll need to do this regularly and repeatedly or you’ll think it’s a fluke. 

I wonder if there’s anything you’re avoiding that you might want to consider facing? Could you bring in the principals of exposure and habituation if so, and do this in a graded way? Good luck! It’s empowering once you’ve started and I find my patients go from strength to strength, enjoying sudden gains and reclaimed freedoms.