OVERCOMING PHOBIAS
WITH PROGRESSIVE EXPOSURE

Most people with panic disorder develop various phobias and limitations in their life. These phobias and limitations stem directly from their efforts to prevent panic attacks.

If you have a first panic attack in a grocery store you may begin avoiding that store, and maybe big grocery stores in general; if you fear an attack on a highway, you're likely to restrict your driving to local roads.

Unfortunately, these avoidances will, over time, make a person feel less secure, not more; and the phobias often tend to become more inclusive over time. For example, a person who avoids highways may begin to get uncomfortable at some busy local roads as well. Such a person may find that, over time, he also becomes uneasy about other situations from which escape may be difficult, like airplanes, crowded malls, or meetings.

In addition to the phobic avoidance, many people with panic attacks develop other rules in an effort to feel better, and again these rules tend to aggravate their condition over time. A person may feel that he/she can only travel to certain locations in the company of a support person; or with a water bottle; or with that same old bottle of xanax that expired six years ago.

While these rules are not terrible by themselves (although the first one can be wearing for all concerned), they have the unfortunate effect of leading you to think that you can't take any credit for your successes. Instead, you may come to believe that a success you had was due to the presence of your support person (or object).

For this reason, when I work with a client who has panic disorder, we use progessive exposure to enable them to return to their ordinary activities and situations without any special limitations or aids.

Progressive exposure is the process of practicing with the activities and situations that you fear, a little at a time, in order to become less afraid of them. It's called "progressive" because we approach it gradually, beginning with items that are only moderately anxiety provoking, and move up to the most difficult items over time, as you succeed with the lesser ones. It's called "exposure" because the point is to expose yourself to the situations and activies which lead you to panic, in order that you can practice with the panic feelings, and get better at managing and overcoming them.

It's important to see that we do exposure to the panic, not to the situations themselves. When I ask a client to drive on a highway, he's not exposing himself to the highway; rather, he's going on a highway because that is where he might experience panic, and he needs to experience panic, and work with it, in order to overcome the phobia.

So if he goes out on the highway and doesn't panic, that's okay, but it's not what he went out there for, and I'll probably ask him to try again. If we can arrange for this client to first practice with some panic symptoms in my office (and that's often possible), so much the better!

You might be wondering why anyone would do this.

My clients do this because they want to get better, and they've come to understand that avoiding the panic makes them worse. Only by experiencing the panic, accepting it, and letting it pass, will they become less afraid. It's a scary step for all of them, but one that leads to progress and recovery.

Think about what you would do if you wanted to learn self defense. Do you know how people learn self defense? They go to a coach, or a class, and learn a few techniques (blocking, punching, etc.) and then they practice them. How do they practice?

They ask somebody to take a swing at them.

That's right. They're learning self defense so that people won't hit them. Yet they need to have somebody hit them, so they can practice, and get better. If they avoid the classes, they won't learn self defense. If they go to all the classes, but won't practice with a sparring partner, they won't learn self defense either. They'll continue to be afraid, because they won't have any reason to be confident in their skills.

It's the same thing with panic attacks. If you don't learn a good set of coping techniques, you'll probably remain afraid of panic attacks. If you learn a good set of coping techniques but don't practice with actual panic situations, you'll probably still remain afraid of panic attacks. You only lose your fear of panic attacks by practicing with them, and developing confidence in your ability to cope. And the attacks only go away after you lose your fear of them.

Most people with panic disorder come to see me hoping that I will do something to take the panic away, so then they can resume driving, shopping in malls, or whatever they've been avoiding. And I tell them that I can help them get better, but the process will be the opposite of that. First they have to get back to driving and the malls, and then they can get rid of the panic.

Of course, I don't expect anyone to go out and experience a panic attack without first having a game plan, a way of responding to the panic attack. Before we do any exposure work, you first have to learn a variety of coping techniques. This is what distinguishes progressive exposure from a technique called "flooding" in which the client is asked to experience the panic and just wait it out, however long it takes.

If I were helping you to develop this game plan, we would likely go through the following steps.

• You would first learn an approach to managing a panic attack, represented by the acronym AWARE. This consists of an overall approach to panic, an attitude, and a variety of coping techniques, with which to respond to the panic.
  
  
• You would develop and use a hierarchical list of feared situations and activities, beginning with the easier ones and working up to the most difficult.
  
  
• You would make frequent, repeated ventures into the same and similar situations in order to build the confidence that will create a recovery. The principle here is "once is not enough".
  
  
• You would cultivate an attitude of acceptance toward the panic, and a willingness to experience panic, in order to have the necessary practice.
  
  
• When you did experience panic, you would focus on making the distinction between Danger and Discomfort. You would work with the discomfort, and recognize thoughts of danger as just another symptom of panic.
  
  
• You would let the panic peak and pass, in place. In other words, the best results come from your staying in the phobic situation, and following the AWARE steps, until the panic subsides. If you leave the situation before the panic subsides, you are unfortunately contributing to the strength of the phobia.
  
  
• During exposure practice, you would focus on behavior, not feelings. Do not expect to feel comfortable at first! During exposure you are supposed to get afraid. That's what we're doing it for, so you can practice. So you need to take it for granted that you will get afraid, and use the exposure time as a chance to practice different behaviors that will, over time, enable you to master the panic.
  
  
• And gradually, you would notice that it takes more and more effort to panic...that you have to travel further, go to scarier situations, to feel the fear. And you would become less and less afraid of panic. And as you lose your fear of panic, the panic attacks, which had been your constant companion, begin to feel more like a distant relative...and eventually fade away.

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This page was last modified on 6-10-2004.