What If Exposure Shouldn’t Make You Anxious?

The following is a thought piece.  In contrast to my other articles, it’s not meant to educate as much as to start a conversation. 

When I started on my journey away from the importance of desensitization, I initially just let go of the idea that feeling anxious during an exposure was an important mechanism in ERP.  Later on, I started seeing the goal of feeling anxious during an exposure as not only unhelpful, but actually a harmful distraction from the mechanisms that actually make ERP work.

At the same time, my understanding of the vast role of compulsive rumination in OCD was growing.  First I saw it in Pure O, then I began to think about its role in several other types of OCD, and finally I realized it was everywhere.  Rumination is the cornerstone of OCD.  It’s a radar system that is constantly monitoring for threat, and thus constantly making a person feel threatened.

These two lines of thinking slowly converged and led to the following unorthodox idea:

Not only is it unnecessary for a person to feel anxious during an exposure,

Feeling anxious often indicates that the person is ruminating.*

And since rumination is a compulsion, that would undermine the exposure.

So it might actually be the case that the less anxious a person feels, the better.

This does not mean that a therapist should tell a patient to stop feeling anxious during an exposure.  It means a therapist should see anxiety during an exposure not as an accomplishment, but as a potential indicator that the patient is ruminating.  The therapist can then ask the patient if the latter is ruminating, and address that issue.  In my experience, the less a person ruminates during an exposure, the less anxious they feel; this is part of what they learn from the exposure.

Now, an exposure might accomplish something even if the person was ruminating.  Specifically, it might teach the person that they have the ability to do an action they were previously avoiding, or to eliminate other compulsions they would usually do.   But it won’t solve the whole problem, because even though the person would learn that they can do whatever the action is, they would also learn that doing it makes them feel anxious.**

The idea that an exposure is supposed to make you anxious is ingrained in us as exposure therapists.  The idea that anxiety during an exposure is a bad thing is wildly countercultural.  But I’m pretty sure it’s the truth, and that it’s the conclusion we will eventually reach as a field.  I’m pretty sure we’ve had it backwards this whole time.

  

*I am referring to the broadest possible definition of rumination, by which I mean not only actively trying to solve a problem, but even monitoring or paying attention to the problem.  In other words, I’m using the word rumination to refer to any controllable thought process that is aimed at protecting the person from what they’re afraid of.  This would include, for example, paying attention to body sensations during a panic attack, as opposed to noticing them (which is uncontrollable) without engaging further mentally. 

**For example, if a person contaminates something as an exposure, and then thinks about what might happen as a result of that contamination, or mentally keeps track of what has been contaminated (two forms of rumination), they will continue to feel anxious about the exposure, and though they will learn that they have the ability to contaminate something, they will also learn that doing so makes them feel anxious.