Monday, July 26, 2010

Social anxiety and the challenges of exposure therapy

It struck me as I jumped into the shower this morning, in the split second as I registered that the cold was not unbearable anymore, that the problem with winter is not winter but summer.

I wrote a piece about minor mishaps a while ago. One of my points was that if a crisis remains unresolved for a while it may cease to be a crisis as one adjusts to it. Winter is the same. As long as you have somewhere to live that offers reasonable levels of warmth in some rooms, eventually your body adjusts to the cold.

And just as you’ve become accustomed to it and have your bedtime routine worked out (in my case a hottie and four doonas, as well as copious layers of pyjamas), the Earth stretches as if from a long sleep and starts to exude warmth. The blossoms unfurl, the camellias drop liltingly to the ground in their prodigal abundance. Everything wakes up, and you have to adjust again.

This is not some idle complaint. It makes me think of exposure, now a central plank of short-term talking therapies for anxiety disorders and phobias. Exposure relies on the concept of increasingly difficult forays into feared experiences. These forays are graded so there is always a carefully calibrated level of discomfort, while the difficulty of the task increases. The theory is that the sufferer learns to tolerate an ever-greater degree of risk and is therefore able to deal with an increasing number of feared situations.

Exposure is an incredibly useful concept. I’ve never practised it in conjunction with a therapist, but I have a friend who is an exponent of it (he even wrote a book about it), and I practise it in very small ways.

But the challenging thing about exposure is that it is aligned to life yet also pitted against it. Creating a list of progressively more difficult tasks is a way of creating order, but the chaos of life is constantly intruding. And, depending on your disorder, it may not always be possible to retain control over the level of exposure.

Work is an area of life where I gain valuable exposure only to sometimes lose momentum. Because my work stops and starts, I don’t often get into a pattern of work. This is bad, because once the work starts again I not only have to adjust to the discipline but I also need to refamiliarise myself with processes and even skills.

As well, I have to ‘expose’ myself to a lower standard of self-care and housecleaning, which leads to an increase in anxiety levels.

I believe that I’d be able to gradually increase the level of work I was able to take on if I could control the flow of it – but that’s not the way the real world operates.

Social anxiety is another area where the exposure levels are difficult to control. According to psychologist Dr R. Reid Wilson, this is because the unpredictable nature of social life is such that it’s impossible to grade one’s exposures; and because their lifestyle may require the sufferer to carry out social tasks that go beyond their current level of comfort. 'When you have social anxiety, events that are high up on your list of threatening situations may take place before you have mastered your lower level tasks’, he says.

Dr Wilson’s excellent website is the first time I’ve come across a therapist who identified the unique difficulties of social anxiety in this way.

Another difficulty with conquering social anxiety he identifies is that the sufferer must focus on so many anxiety management skills at once, sometimes while performing a complex task like public speaking.

One way to get around the unpredictable nature of social exposure, according to Dr Wilson, is to simulate the scary situation using friends and family. For example, you could practise public speaking in front of a group of friends, conduct a role play on bumping unexpectedly into someone in the street, or ask someone to look over your shoulder while you practise writing.

Life, the universe and exposure

The chaos of life may pose a challenge to exposure therapy more generally. Unexpected stresses or adverse events in one area of life may temporarily lower our ability to challenge ourselves in the areas we need to work on. Sometimes I need to withdraw and regroup because of some unforeseen blow.

This is not to argue against exposure but to demonstrate how important it is for the individual to be in control of their therapy. This is the view of Bronwyn Fox, a recovered sufferer of panic disorder who has written books on the issue and now counsels sufferers.

The important thing is to get in touch with your gut feeling and obey it. I have learned this lesson painfully and slowly, sometimes suffering from too much exposure and sometimes not enough. In my experience both are harmful.

If I’d known about exposure earlier, there are definitely aspects of my social and working life I would have fought harder to retain, rather than simply letting them go because they were too hard. But not knowing about exposure also led me to throw myself into situations that were too difficult, which meant I got overexposed and therefore more phobic very quickly. In both cases I wasn’t managing my anxiety well because I didn’t have the knowledge or tools.

I’m not saying that everyone can expose themselves and eventually rid themselves of their anxiety. In my case I think there are some things that are just too hard and will be for a while, and perhaps forever. However, I do want to create some sort of graded exposure program.

Exposing myself

Recently I visited an arts event alone. I’ve done this heaps of times but it was in a venue that I was unfamiliar with. I’m an expert at subtle avoidance – I’ve been practising it my whole adult life – and I noted that two very effective avoidance strategies were in play: getting there late, and sitting in the back row.

The getting there late was partly my unconscious mind at work. I just missed the tram! How convenient!

Next time I will resolve to sit in a row that is somehow more ‘threatening’ (this could mean, for example, a row where the people look interesting, or towards the front, or both) and getting there before the event starts. I might have to tackle one of these tasks at a time. Even being in a room with others and experiencing my reactions can be difficult for me sometimes. The important thing for me is to stay with myself somehow, to practise mindfulness without buying into my fears.

And soon it will be time to get exposed to a completely separate dilemma – the extreme heat of a Melbourne summer.

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