In episode 303, I received a question from a listener who has struggled following through and being consistent with the exposure work set by their therapist. In this post, I discuss these issues in more detail, looking at possible obstacles and highlighting actions you can take to start moving forward with your exposure work.
Hey Dr Duff,
I have had GAD, major depressive disorder, and agoraphobia with panic attacks for about 2 years, following an MS relapse. My question is… how do I get the motivation to do my exposures when I am comfortable always being at home? My therapist wants me to do exposures, and sometimes I lie and tell her I went for a walk, or rode in the car with my boyfriend, when I did not. I don’t know why I feel like I want her to be proud of me. But I can not get myself to do the exposures. Probably because my boyfriend enables me and I am terrified of panic attacks, as I have them often. Any advice?
Love you podcast
Thank you for writing in. This is a really good question. I’m glad that your therapist is doing exposure work with you – that is the more important thing you can do when it comes to treating anxiety. Exposure essentially helps you to prove your anxiety wrong. Your anxiety wants you to believe that a situation is potentially dangerous and it wants you to think that it is saving you from that danger. By engaging in exposure work, you are proving to your body that the fight or flight response that happens in a panic attack is not necessary. That there’s nothing to be saved from.
I’ve mentioned before, but a lot of people understand the broad concept of exposure, which is basically to avoid avoidance, but they don’t really know the ins and outs of how it works. Have you guys established an exposure hierarchy together yet? If not, this would be something really valuable for you to do. Essentially, what we are looking for is a systematic way to gradually desensitize yourself and gain a better tolerance for anxiety. There’s nothing inherently wrong or dangerous about being thrown off the deep end with exposure. Like you aren’t going to hurt yourself if you go out and do something so challenging that you are thrown into a massive panic attack. The only thing that will happen is that you will have panic, you will be very scared and uncomfortable, and then eventually it will fade. BUT – the gradual method is often much more attractive to people like you because, as we can see, sometimes the prospect of doing exposure work is too intimidating to actually get started.
If you have not already gotten it, I would HIGHLY suggest for you to go through my online course. The entire 4th module is dedicated to exposure work. I walk you through the process step by step. You see me physically write out a courage ladder in my notebook, explaining the process from start to finish.
Doing things right
A couple points to clarify about your situation. If you are finding the initial exposure activities too difficult to complete, you are starting in the wrong place. The first activity on your courage ladder should be something that provides you with a moderate amount of challenge, but not so much challenge that you are unable to complete it. The other thing is that exposure work is often done in a way that is too short and/or infrequent. This is a surprise to a lot of people, but exposure activities whenever possible should be at least 30 minutes long. So if you are going on a walk around the neighborhood, you aren’t just walking once around your block and then coming right back inside. That can actually reinforce your anxiety because you are essentially escaping and getting relief from the anxiety symptoms. Instead, you want the wave of your anxiety to rise and fall on its own.
It’s common for you to want to please your therapist – a lot of people do or at least have the urge to lie about their progress. It’s a normal urge, but if you want this to work for you, you’ve gotta stop lying to your therapist. They can’t effectively help you that way. Right now, they think that you are on the right track with exposure, when in reality, you are starting in the wrong place. What you have experienced is a totally understandable scenario and it points out how panic disorder and physical health issues can be tied together. Essentially, your body learned that it’s not safe to be out in public situations because of the MS relapses that you had in the past. SO you are always on edge waiting for the other shoe to drop. This has led to agoraphobia where you don’t want to leave the house for fear that you might be caught in a bad situation where you have a relapse in some place other than home. But that’s not the life that you want to live. Of course home is comfortable for you and it’s easier to avoid situations that would cause you panic and discomfort, but as we can see, this is limiting you. You don’t have the options and fulfillment out of life that you would otherwise have. It’s not your fault that this happened and it IS treatable. It’s just going to take an adjustment in the approach.
Be honest and build a support network
Be honest with your therapist about the situation. If you feel like your therapist just isn’t quite the right match for you in terms of their specialization, then you may want to switch. The order of operations should be to teach you coping skills like breathing exercises, get you working on interoceptive exposure through exercises at home, building a courage ladder, and starting at the bottom of it – consistently engaging in exposure exercises as often as possible and building mastery as you go. This will allow you to build scaffolding and help you feel more confident in approaching rather than avoiding. It would also be helpful to get your boyfriend on board with this as well. He doesn’t have to try to be your therapist here or nag you about things, but you could let him know what your goals are and he can try to facilitate you. Getting everyone on board makes a big difference. Simply having an extra ounce of accountability may give you the extra push that you need.
As someone with relapsing and remitting MS, the unfortunate reality is that you have to live with a degree of uncertainty. However, I do know that it’s beneficial in living with the disease to take good care of yourself mentally and physically. Even though it’s scary, this kind or work may be exactly the right approach for you. If you aren’t getting support from other people that understand what you are going through, it would also suggest for you to do that. There are support groups for both people with panic disorder and for people with MS. This is another part of having that full wrap-around support that makes such a difference.
So, consider this a little bit of a false start. You haven’t done anything wrong, you and your therapist just need to make a few tweaks to find a better start for you. You got this!
You can listen to this on Episode 303 of the podcast!
Thank you for the great question!
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