Exposure techniques are a powerful set of cognitive behavioral interventions that equip patients with tangible strategies for working through disabling fear. Rehab clinicians can implement them with patients who may experience anxiety blocks during acute rehabilitation or while re-establishing ADLs or functional tasks.

The basic concept involves getting the patient to engage with an anxiety-producing circumstance long enough to increase his or her tolerance of anxiety, thereby decreasing the intensity of the emotional reaction. By normalizing the anxiety, the patient will no longer fear the experience of fear.

When a patient can tolerate anxiety better, he or she will be less likely to fall into anxiety/avoidance patterns (see "Anxiety Management Training," May 26, 2008). Dr. Christine Zieglar, cognitive behavioral therapist and director of the Hudson Valley Cognitive Therapy Center, notes that in her experience using exposure interventions for anxiety, most patients "overestimate risk when anxious and underestimate their resources or ability to cope."

Preparing Patients for Exposure

Clinicians can implement exposure techniques following the steps of this basic model.

Step 1: Pinpoint the fear. Watch for signs of disabling fear to determine the need for exposure interventions. Some patients may be able to self-identify and ask for help with an anxiety block. However, most patients aren't aware of how their anxiety impedes them. Help the patient define the fear.

Fears can manifest as thoughts, feelings, physiological symptoms or behaviors. Examples include:

Behavioral: Has the patient stopped a behavior that is important to him? Are there any notable fear/avoidance patterns? How and what does the patient avoid, e.g., not going to a social outing for fear of using public transportation?

Cognitive: How does the patient express himself (cognitions, self-talk)? How does he perceive functional goals? The patient may engage in all-or-nothing thinking, such as "I can only go out when the weather is good."

A patient can have a variety of fears related to functional goals: walking with assistive devices, going to the grocery store, living independently, asserting needs, using public transportation, etc. Zieglar notes that fear becomes "ritualistic, and predictable: most patients have a formula for what helps them deal with anxiety; the problem is that short-term solutions turn into a long-term problem that inhibits a person's quality of life."

Engaging clients to talk about fear openly and without judgment is an important first step.

Step 2: Use psycho-education. Prepare the patient for exposure interventions. Provide educational handouts that the patient can review between sessions to help understand concepts such as:

• Anxiety is normal; we are wired to have the flight-or-fight response when we experience stress or danger.

• Exposure intervention is based on learning theory. With repeated exposure, we can normalize tolerating anxiety, problem-solve and assess risk more realistically. Zieglar teaches clients that by working to build tolerance for anxiety, with practice they can learn to cope with it creatively.

• Anxiety does not have to be a bad thing. Feeling uncomfortable can promote growth. It is not realistic to expect life to be anxiety free, but one can become skillful at anxiety management. Zieglar instructs patients to aim for a half-step above their current comfort level.

Step 3: Introduce a coping toolkit. Since exposure interventions are uncomfortable, it's important to equip patients with a coping toolkit. Techniques to manage the stress of an exposure intervention include guided imagery, breathing, thought stopping, positive thinking and self talk (see "Stress Management," April 28, 2008).

Fear-busting Interventions

Exposure interventions are used for a variety of anxiety disorders and phobias. If a patient presents with a more complex condition, such as PTSD or OCD, consult with a mental health provider and psycho-pharmacologist. For my own clinical work I prefer to use exposure techniques systematically, in the smallest doses possible, but there can be a wide variation in techniques, based on the clinical situation and the patient's ability.

Imaginal exposure engages the power of imagination. A patient imagines the feared situation and the clinician guides him to visualize working through his fears step by step. In this strategy, the patient can write scripts, use imagery or imagine himself in a movie until the fear image becomes boring or no longer evokes its original intensity.

It is helpful to elicit the patient's underlying beliefs about the feared subject and test out old fears with new data. The patient learns that beliefs can often be updated.

In vivo exposure is a real-time intervention considered to be the most effective exposure technique. The patient faces the feared situation in real time with the assistance of a therapist or caregiver. As the patient experiences anxiety, the therapist provides coaching to help the patient manage it. Pay attention to what the client is saying to himself (self-talk) and challenge those beliefs.

The goal of in vivo exposure, Zieglar notes, is to elevate one's anxiety level to its highest point and desensitize oneself to the fear. "I [use] the metaphor that fear is a monster that has teeth, and once you face the anxiety it is a monster that does not have teeth anymore."

Systematic desensitization is a variation of the exposure technique in which the patient moves toward the feared situation, starting with the least anxiety-provoking step. The patient establishes a hierarchy of steps and plans to take one at a time, starting with the easiest step on the list and moving progressively to more challenging ones.

For example, if a patient is afraid to fly, the first step could be to visit an airport and next watch a take-off and a landing. The therapist can help the patient break down feared situations into steps he can handle and then help him rate the level of anxiety/distress for each step. (An Exposure Intervention Worksheet is available at http://occupational-therapy.advanceweb.com/SharedResources/Downloads/2009/090709/OT_worksheet.pdf.)

Virtual reality exposure requires a referral to a cognitive-behavioral therapist with the necessary technology. The patient wears a head-mounted visual display and walks through a computer-generated fear scenario in real time. This technique is used in treating phobias such as fear of flying or driving, as well as PTSD. Research is currently being done on the advantages of virtual reality versus standard exposure techniques.

Progress, change or recovery can be fear-filled processes. Confronting disabling fear requires a mix of techniques, experimentation, and trial and error. When patients learn to master their fears, they can generalize those skills to their rehabilitation and life goals and move on to the next anxiety-producing situation with confidence.

Reji Mathew, PhD, is a psychotherapist/clinical instructor at the New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via e-mail at rqm3463@nyu.edu.

Resources

• Beck Institute for Cognitive Therapy and Research: http://beckinstitute.org

• National Association of Cognitive Behavioral Therapy Association: http://nacbt.org

• Cognitive Therapy: Basics and Beyond, by Judith Beck, PhD (The Guilford Press, 1995)

• Anxiety and Phobia Workbook, by Edmond J. Bourne (New Harbinger Publications, 2000)