Graded Exposure Therapy...do you think it is too simplified...I do!

[star2sparkle]

I'm under the IAPT scheme (cynical viewpoint in that it is the Government's way of getting people off the sick in the most rapid way possible) and I have suffered from anxiety and panic disorder as well as emetophobia linked to a fear of loss of control for more than 30 years...also now partial/mild agoraphobia for more than 16 years. I can only receive 'primary' care because I present as positive (a coping/survival mechanism) with plenty of insight and because I haven't threatened to kill myself or anyone else which means I'm not entitled to secondary care. So no CPN for me, just a crap counsellor who has been on a training course for a year and thinks she knows more than me who I see once a fortnight and if she had her way it would be telephone contact only! They don't consider the fact that my life has been severely affected by these conditions and continues to be.
So my CBT therapist suggests graded exposure therapy and this is where it gets complicated and I can't help but think that so called therapists simplify complex conditions all too easily .
I can go to some places in my car on my own but I can't walk around a supermarket. I can't walk up my mile long drive but I can go to a pub (sometimes). I can go to the local shop alone but have problems picking up my daughter who lives 40 minutes away. It is very complicated. So to do a hierarchy is a mission in itself! And anyway, life gets in the way! Why can't therapists see this? They say you have to habituate yourself to each feared circumstance but what if a spanner gets thrown in the works and one minute you have just about got used to walking around the supermarket with a friend, only to end up in hospital with a broken ankle, propelling right to the top of your hierarchy!
I tried telling my therapist this today but she just talked over me. I said that I could go to a meeting tomorrow...which would make me very anxious as it is in a place I don't know, I'd have to go alone, etc, etc and she said to go for it. I am a very proactive person and will try absolutely anything but where the hell is this on the hierarchy?!
Does anyone else get this frustrated?
She said that she works with another person with emetophobia and that now this person has got to the stage of watching people on video puking. And I just think...whoopie doo...try ACTUALLY throwing up...totally different and could put her right back to the beginning of her hierarchy. I accept that she may have some better coping mechanisms and had habituated herself up to a point...but watching and doing are entirely different things. And after all, the only way we can really overcome our fears is to actually face them...head on.
I am not trying to be negative...I am a positive and cheerful person, which hasn't helped me to get the proper care but I get so, well, frustrated with it all.
What do you think?

[robinhall]

Hi Star2sparkle

Having suffered from Panic Disorder many years ago I appreciate your frustration - but also as a therapist I also know that it can be hard to pinpoint exactly what will work with a client sometimes for many sessions. I hope soon you will feel more of a connection with your therapist.

Can I suggest that you think about exposure in a slightly different way. It may seem like exposure is only to do with becoming less anxious about specific situations. With specific phobias (fear of heights or dogs and so on) that can be the case - but with panic disorder and agoraphobia the situations in themselves are not really the problem - the problem is that many situations either trigger a memory of a previous attack or else they just make us fear that we won't be able to 'escape' if we feel panic.

For instance I used to have panic attacks when playing snooker - clearly I didn't have a fear of snooker tables - the problem was that I had a big panic attack while playing snooker and AFTER that playing snooker would bring back the memory which would increase my anxiety to the point of panic.

And of course I had the usual feared situations, cafes, cinema, lifts, shops and so on - because they were places were I feared I might not be able to get away from quickly if I panicked - or I might totally embarrass myself.

So - as I was saying - I wasn't afraid of the situation itself - so when I practiced exposure in a shop it wasn't so that I would lose my fear of the specific shop - it was so that I could USE the feared situation to expose myself to a gradual level of anxiety in order to PRACTICE my coping skills and in order to gather evidence about what actually happens when I experienced panic - I was learning to challenge my mistaken beliefs that my life or sanity was in danger.

Like learning to swim, just knowledge about swimming wasn't enough - I had to get into the water and PROVE to myself that I wouldn't drown despite fearing that I would.

THIS is what exposure is for.

So - if you think about it in this way you can make many fear hierarchies and start to use them to practice your new CBT understanding and skills.

You are so right - something that might be a big problem for one person may be do-able to another and vice versa - but if you concentrate on USING exposure to LEARN then it doesn't matter too much what the exposure is.

Can I suggest that you simply write out as many fear hierarchies as you can and then start with the one you feel you can manage and that you can find the time to do each day

I would say that perhaps your therapist told you to go for the meeting because she was trying to support your willingness to go towards your anxiety. Sometimes it's a judgement call in the session.

Over the years I have learned that it is vital that clients know the EXACT reasons why exposure works - and once they have a deeper understanding they can then almost work out what needs to be done themselves rather than just following what the therapist suggests.

I think you maybe have CBT4PANIC from a while back - so why not read over it again and you may get a few more ideas from that.

The good thing is that you question what is happening in therapy - that is a good sign - it means you will eventually work it out :-)

[star2sparkle]

Hi Robin

Thank you so much for your reply. I do really agree with you yet I do think that anxiety, memories and cognitions are so much more complex than the therapists we are seeing at IAPT allow for.
I will certainly go for your suggestion for creating numerous hierarchies to tackle the fears but I do find it very confusing.
It has taken almost thirty years of thinking that I don't think will be undone very easily. I do appreciate your snooker real life example but I still think it is more complicated than that. Everyone is unique and to me, CBT and in relation to that exposure therapy is suggesting that one size fits all. I don't believe in that, I don't feel we can all be pushed into a stereotype of anxiety thinking; people experience things in their own way that may be similar yet different too. Some problems are very very deeply ingrained and this fast track CBT just isn't up to the job, not from my point of view.
I love your work and that it helps so many and I'm not saying that CBT and exposure therapy won't assist me to some degree, perhaps it will, but I have never been a great fan of CBT...perhaps I still have to be convinced! I have written an article for PsychTalk in the past for students about CBT, showing some of the pitfalls.
And as for the meeting today, I also think she was encouraging because of the way I am but sometimes, a situation like that that you enter into can create an almost negative experience because you haven't managed to habituate to something lower on your ladder yet...and that is what I meant about life interfering. Can you account for that? Being on the lower rung and then being pushed upwards because of life and consequently panicking and ending up lower on the rung? Plus, do you really believe it would work for an emetophobe like I was describing?
I really am uncertain about the meeting...life! It would take a lot of bravery to go. I just don't know.
Thank you so much for your thoughts Robin. It really does help.

---------- Post added at 07:39 ---------- Previous post was at 07:19 ----------

I hope it is okay to quickly add that I look after my husband who has clinical depression and his mother with alzheimers. Due to the agoraphobia and anxiety, I am very isolated. I don't have many friends and no family. To overcome my issues would help greatly as you can imagine and my life is very difficult. The course I am supposed to go on today is a 'Looking after me' course as a carer but I have just looked where it is, and for me, it is too far away...to travel alone as well. So I know it is (at this moment) beyond me. ..too far up the hierarchy to accomplish on my own. What do you do in a situation like that? It makes me feel depressed as this could be a way to meet people, yet I just can't do it at the moment.
I also had an email from Professor Isaac Marks, who is the leading expert in the field of exposure therapy and facing fear. He suggests his book and also fearfighter which as I'm sure you know is online. Would you recommend it? Many thanks!

[robinhall]

Hi

I know exactly what you are saying - that everyone experiences things in their own way

But I learned a long time ago that with panic attacks in particular, despite arriving at the point of the INITIAL panic attack in a multitude of ways (some may have had long term anxiety, another under a lot of stress, maybe even a chemical imbalance etc) AFTER the first panic we can all REACT in exactly the same way to the fight or flight and get caught in exactly the same cycle of fear. We ALL misinterpret and catastrophise the symptoms in exactly the same way. And the great news is we can all recover from this using exactly the same process.

I understand that daily worry, anxiety, stress can be different for each individual but honestly - ANYONE who repeatedly suffers from panic attacks is doing so because of very specific reactions to the fight or flight

I'm not even saying that recovery from panic attacks would mean the end of all your daily anxiety, worry or moods. But because panic is such an extreme overwhelming problem it is very very helpful to work on it first. Then when you are more able to cope with fight or flight you will have more reserves to deal with the other things in your life.

It would be extremely helpful for you to differentiate (for now) between daily stress, worry, moods and 'panic attacks'

A panic attack is not a 'weakness' nor is it to do with emotions or even life situations (other than they might trigger fight or flight)

A panic attack is ALWAYS the same 'process' in anyone who experiences one (with a variety of symptoms of course)

To put it very simply - for one reason or another one day we experience extreme physical sensations that we dont realise are to do with our fight or flight response being triggered and this can happen out of the blue.

Because we cant see any clear reason why these feelings should be there (like a lion running at us or some obvious danger) we think we must be seriously ill or going mad - we 'misinterpret and catastrophise' the sensations

This sends fear signals through the body and the body 'senses' we are in some kind of possibly mortal danger and tries to help again through the fight or flight response - ie. MORE extreme sensations. Because of this and the fact that we STILL can't connect the sensations to any outside cause we feel another increase in fear and so we get caught up in a cycle of fear even further

Can you see that this has very little to do with any particular life situation, money worries, relationship problems and so on (although negative life experiences aren't exactly helpful - but they aren't the actual cause of the process, the cycle, that keeps us 'stuck' in repeated attacks)

So what I am saying is that panic understanding and panic treatment CAN be a 'one size fits all' - IF you remember that you are treating this PRECISE cycle of fear and the PRECISE mistaken reactions - namely the misinterpretation and catastrophisation of the fight or flight symptoms - along with avoidance and safety seeking behaviours

But I absolutely agree that this won't necessarily deal with all your OTHER life situations. After I knew I had absolutely recovered from panic disorder (I honestly knew 100% that I simply couldn't have panic disorder again due to my understanding and the certainty I reached through practice and exposure) I still had many many other issues to deal with - relationships, moods, stress, uncertainty, insecurity, poor self esteem and so on - and I continued to learn new ways to tackle these issues - such as Mindfulness Meditation and of course CBT

It would be very helpful for you if you can see panic as a separate issue that CAN be dealt with using SPECIFIC techniques that will work for everyone (with some variations obviously but basically the same underlying techniques)

This might help you to stay focussed on the treatment rather than worry that it may not work for you because everyone is different. You will find it less effective if you attempt it with those reservations.

Give it a try - let go towards it (as you do with the fight or flight) and see what happens.

I agree with you also that it pays to try to move forward very gradually so that you don't get knocked back below where you were - so yes it is wise to stick to graduated hierarchies. But sometimes life does throw up something that feels out of your comfort zone and you have to decide yourself if you feel up to trying it. As long as you are still determined to move forward with planned exposure then of course it is NOT avoidance to decide not to do something that seems too much too soon - in fact that might be the sensible thing to do. Don't worry about explaining this to your therapist.

I haven't seen fearfighter but it's CBT so it can only add to your overall understanding.

Have you still got CBT4PANIC? Do you read over it?

[star2sparkle]

I have had anxiety for many many years now so I suppose, to be honest, I don't actually suffer that much from panic attacks anymore. They do come sometimes, but only when I consider there to be a threat.
If you put me in a busy street, I'd probably have one then!
I think this is one area that exposure therapy might help...that and supermarkets and a few other marked areas of fear but to overcome deep rooted specific fears, I don't believe in it. I think exposure therapy is ideal for those who suffer from panic attacks and some phobias but the example I gave of emetophobia...exposure therapy falls down. It can only disensitise a person to everything about vomiting but not the actual vomiting itself. People are saying they are cured because they can watch puking videos and even make their own vomit...yet they haven't been sick themselves. Now I think this, in some ways, is harmful. My counsellor believes she can cure her client with emetophobia using exposure therapy. She will get her client to be habituated to a high degree but she obviously has to face her fear repeatedly to overcome it. Hopeless optimism in my book that I feel can even be dangerous.
However, I will try with my own haphazard agoraphobia. I am very educated on all aspects of anxiety and panic but sadly when the learning took place many years ago and has become firmly entrenched, it can be very hard as I know you appreciate.
Sometimes I feel almost demeaned by my counsellor when she goes on about how successful she is in curing people...I haven't suffered this way for 30 years because I missed the signposts along the way that said stop catatrophising...you will be fine! I have tried very hard to overcome my problems and have done everything possible to make my life better. If my attempts had been a job, I would have been very well paid! Also when she talks of her other patient who is further along, I feel bad too. But alas, her supervisor is the same person that I had a problem with before as I felt let down by him. I think they see me as too much of a challenge and I won't just let them get away with their so called 70% success rate. I wonder what happened to the 30%?
I did have your book on my laptop but it seems to have vanished!
Thank you again Robin, for taking the time with me.

---------- Post added at 16:35 ---------- Previous post was at 15:48 ----------

Oooh, just discovered a pdf file on my laptop of your Rapid Recovery Skills...and that is definitely me on the front cover! All you needed was a mass of red hair sticking out of the helmet and that really would be me . I'm reading...

[robinhall]

Hi

It sounds like your main concern at the minute is the emetophobia - but I will send you the link to download CBT4PANIC again - it may be of help with the panic and agoraphobia

Possibly your therapist is talking about success rates with other clients to try to reassure you(or motivate you) that exposure can be very successful. Very often I find that people are quite desperate to know if the treatment is successful with others. But as you said everyone is different and I can see how this could also be counterproductive.

I'm thinking it may help to tell your therapist that apart from the treatment, you aren't feeling unhappy about how she is presenting the therapy. I know that can be difficult but it can also help to create a shift in the alliance in a positive way.
I would rather know if a client is unhappy about something I am doing or saying.

have you seen this site http://www.emetophobia.org

I see there are members there discussing their exposure hierarchies. It may be of some interest.

I will resend the link to CBT4PANIC via a PM

Robin

[star2sparkle]

Thank you Robin. Actually, no, I'm just going on about emetophobia to show exposure therapy doesn't work ultimately on some specific phobias! I know I have the fear but at the moment, working on the anxiety and agoraphobia is my aim. I suffer greatly from derealisation too.
I really don't have the urge (oops, excuse the pun) to make vomit out of flour and God knows what else right now
I have read the threads before but mostly I get a little concerned for people...I do think it is good for anyone with the fear to relax and habituate themselves to the word, and other people being ill, etc. But the practical side doesn't equate itself with exposure therapy.
I found a website where a woman also professed to help people and had the 'cure' but it turned out her life story was actually more to do with a fear of other people vomiting, not herself...and of course, this fear can indeed be gradually faced practically.
Thank you for your message, I will certainly log in.

[robinhall]

Check out the Mindfulness Workbook in CBT4PANIC - it can be very helpful with derealisation because it helps you to feel 'grounded' and more connected with your body and immediate environment. Let me know how you get on.

[star2sparkle]

But just to add, I think CBT could help someone with emetophobia...at least the fear won't be buried so deeply...Thank you again Robin

[Spoolie]

Hello
Sorry to hear of your frustrations. I also have emetophobia, however I feel it has improved with exposure to anxiety provoking situations. I have had emetophobia for 35 years and in the last few years I have worked in mental health hospitals and then a general hospital, during this time there were many situations such as stomach bugs going round, people vomiting in a&e and people vomiting following surgery. These situations caused me huge panic and anxiety but they were situations that I could not escape from, I had (and wanted) to learn to tolerate the anxiety. It got to the point that I managed to stay in the same room as someone vomiting which was unthinkable for most of my life. I am not completely over my phobia as I still avoid things at times and slip back into old habits but I feel a bit less afraid of it.
I know you mention that it is different to actually be sick and yes I agree and yes this is where therapy for emetophobia is so tricky. However I do think that learning through exposure that the anxiety is the worst thing about it has been helpful. I was last sick at age 11 and I remember even at that age thinking after a night of being sick that my fear was much much worse than the reality.
I truly believe that exposure can work even with emetophobia. I also totally understand the frustrations with this phobia! Good luck!