The spectrum of responses to anxiety you could display ranges from avoidance to exposure. The belief of a person who avoids is that he or she is in danger. In contrast, the belief of a person who exposes herself to the anxiety on purpose is that the anxiety is an opportunity to learn.

Exposure is the willing act of putting yourself in psychological and physical situations that induce fear and anxiety.

Willing exposure is challenging in the moment of anxiety, but in the long-term it decreases anxiety.

One theory of why exposure works is habituation. This theory understands the fear response to be similar to other senses. For instance, if you were to enter a room that smelled distinctly, if you stayed there, after a little while, your sense of smell would adapt to the smell in the room and stop notifying you of the smell. If, one the other hand, you left the room and reentered repeatedly, you’d notice the smell anew each time. In the first situation you are habituating. In the second situation you are not.

As it relates to anxiety, the theory is that patients expose themselves to the fearful stimuli until their anxiety decreases and overtime they become less and less anxious when presented with the trigger.

Another more recent theory suggests that habituation isn’t as important as willingness to have the sensations, thoughts, and behavioral urges that accompany anxiety. The willingness is important because of the cognitive component of anxiety. Unlike your sense of smell, which habituates regardless of what you think about the smell, anxiety increases and decreases based on how you interpret the situation. That is, if while your heart is beating quickly or you have unwanted intrusions or you cross over a bridge, you think to yourself, “This really is dangerous” or something equivalent, your brain will pump more of the fear response through your body and you will feel more afraid.

Again, this is unlike your sense of smell in that even if you thought, “this really smells bad” you would still eventually stop noticing the smell. The way in which cognitive interpretation influences the fear response is called anxiety sensitivity, or second fear. Anxiety sensitivity is responsible for anxiety disorders, not anxiety states themselves.

Thus, exposure in and of itself is not sufficient for overcoming anxiety disorders. Exposure must be done the right way. Exposure is done the right way when you understand the point of exposure and you willingly expose yourself to the possibility of anxiety with the belief that experiencing anxiety will actually help your body learn that you are not in danger, over time.

Frequently when you embody this attitude you will not feel anxiety. This attitude effectively conveys to the mind that it is not in danger! However, if then, you may start trying to trick your mind into wanting the anxiety, when you truly prefer not to have it. This is a common experience in the process of therapy: you start exposing yourself and get quick relief. Then, if you still fear anxiety, it is likely to come back or pop up at different times. You cannot trick your own mind. The attitude of acceptance towards the thoughts, sensations, and behavioral urges that occur when the fear response is triggered must be authentic for long-term relief.

Intentional practice is also known as exposure and response prevention, ERP. Anxiety is created, maintained, and intensified by experiential avoidance. We’re trying to do the opposite of experiential avoidance to recover from anxiety and OCD. We need the details of what you are triggered by, what you fear, and how you avoid to design effective ways for you to intentionally practice exposing yourself to anxiety and refraining from avoidance behaviors. Your past behavior helps us identify what will trigger your anxiety and in what way you will want to avoid.

As an example, if you have previously felt anxious and stopped driving when you had a thought about hitting someone with your car, the next time you drive, you will likely have that thought, feel anxiety, and have the urge to stop driving. You aren’t having that thought and feeling anxious because it is likely to happen. You are having that thought and feeling because you acted as though your thought was a threat in the past. For this example, exposure is driving and response prevention is not stopping. Easy, right? Just do the opposite of what your anxiety wants.

I hope this concept is actually easy for you to understand and I hope that you recognize how hard it is to practice.

Here are some reasons that ERP is hard:

1. Anxiety is everywhere. By the time you are seeking psychotherapy, you likely have had so much anxiety so often that it’s hard to tell what triggers it, what you are thinking and feeling, and what types of avoidances maintain it. That’s my job. It’s helpful if you self-monitor, but I have a responsibility to listen for and identify the patterns between your thoughts and your avoidances. It isn’t your fault if you can’t seem to figure out what you’re doing wrong and why you experience so much anxiety. Physicians listen to your lungs when you have a cold. Psychotherapists listen to thinking when you have anxiety to identify what maintains it. We don’t expect patients to identify bronchitis and the same goes for anxiety. It’s not your fault that it's happening and it is not your responsibility to identify what’s wrong on your own. It is your responsibility to take ownership over your recovery in the context of guidance and support.

2. Avoidance is experiential. Uncertainty responds to experience, not thinking. You have to teach your body that uncertainties that previously didn’t feel safe are safe enough to live within and that it isn’t helpful to brace against uncertainties with no answer. You can’t just tell yourself that driving is safe enough, flying is safe enough, you’ll be fine at that presentation, and no one will reject you at that social event. To overcome those fears and all others, you have to put your body in your feared situation, let yourself feel scared, stay in the experience, and refrain from anything afterwards that undermines your learning.

Exposure is putting your body in a feared situation, letting yourself feel scared, and staying in the experience while feeling scared. Response prevention is refraining from physical or mental compulsions, reassurance seeking, or avoidance of any form after the exposure.

3. Anxiety shifts. Anxiety and OCD are as smart as the person experiencing it. Sometimes avoidances and compulsions are very easy to identify but very hard to consistently challenge. Sometimes avoidances are primarily cognitive and emotional and they are hard to identify and trigger. Sometimes as soon as you go towards and surrender to one type of content, you have a new intrusion with the same pattern that seems unique and overwhelming.

4. Recovery requires an attitude shift. The concept of ERP can appear to give too much credit to content. If you identify what you fear and then make a hierarchy of steps to go towards it, this implies that the content of your fear is actually the issue, rather than the process by which you are responding to uncertainty.

ERP is a helpful technique, because it gives you a framework in which to practice your new attitude.

Rather than thinking, my ERP hierarchy is going to cure my anxiety forever!,

I want you to be thinking, I happen to currently fear this content. I am going to use exposure and response prevention with my current feared content so that I have the opportunity to practice approaching uncertainty with an open and willing attitude.

Good exposure and response prevention is like the fun and playful part of childhood. What comes to mind for you?

Young kids practice winning. Try playing cards with a four-year-old. They can’t wait to show you what they can do. First, they change the rules. Then, they change the game. It’s always fun because they always win.

As an adult in the external world, we all make mistakes and no one always wins. Pursuits we attempt may not work out. We can still win on the inside. You can change your game if you change your rules.

Here is the game I want to teach you: Internally, always ask for whatever is happening.

Here are the rules:

● Commit to the smallest next step towards what you value.

● If you want more, do more.

A major difference between intentional practice and incidental practice is creativity. Intentional practice is our creative attempt to trigger what you fear on purpose so that you have the exact opportunity you need to face your fear. We don’t have to be creative for incidental practice because life gives it to us.

As you use your creativity to create your intentional practice together, what’s the best way to trigger your anxiety in a way that is challenging, but manageable at the same time? Remember the strategy is: Practice winning. Make commitments small, frequent, and willing.

Small and frequent

Like any effective behavior change, you need to commit time to this. You’ll undermine the process if your commitment is too big, you try to commit in a perfect way, or you beat yourself up for any part of what happens when you try. You’ll dread your commitment and it will be another reason to be disappointed by yourself. You should commit to what is reasonable for you for who you are today. You must own that commitment until you’re ready for more. Small commitments will build over time. You will start to understand what’s happening and how to relate more effectively when you prepare for and own your small victories. Once you master the core skills needed to relate to anxiety well, you will naturally be able to take more anxiety-provoking challenges in your life.

Willing

It’s important that your attitude is I’m practicing to learn more about how my anxiety operates and to relate to it more flexibly rather than I must do these exposures perfectly to cure myself from anxiety. Sometimes when you do something anxiety-provoking with a willing attitude, it will be empowering and you will feel great. Other times you will get new thoughts and feelings and have the chance to observe and relate effectively to those. All of this is great. You get to learn from all of it.

When you are half a block away and people are getting on the bus you're about to miss, what do you do? Your answer helps us understand your experience during incidental exposure.

The short answer is run after the bus, sometimes. Flexibly. Humorously. Like your life depends on it.

You might feel empathic anxiety and embarrassment when you see someone running after a bus. You feel anxious and embarrassed on behalf of those that try. You would never do it yourself. You think, Look at how hard they are trying. They're going to fail. That's so embarrassing.

Or, you might think, Of course, I run after the bus. I would feel anxiety and shame if I didn't catch it. I'm mad at myself already for being in that hypothetical situation. I should have planned better. When I see someone missing the bus, I feel empathy for them because of the harsh internal self-criticism they must feel.

If you identify with the first answer, remember that content doesn't matter, and your process matters immensely. Your life depends on your process. You need to accept where you actually are. It's okay to be embarrassed. It's okay to feel shame or guilt. And, wherever you are is where you are and you need to start there. And, you need to try!

When your emotional disorder is triggered in everyday life, you have to try to relate effectively. You might feel embarrassment, guilt, shame, helplessness, hopelessness, and worthlessness about the fact that it happens. It's okay for those feelings to be there. Having a feeling doesn't make something true. What will it take to move past these interpretations? In any given moment, can you accept that you're having a thought, feeling, or sensation and choose to respond well to that experience, rather than trying to figure out why it's there or what it means about you?

If you identify with the second answer, remember that your content doesn't matter, and your process matters immensely. Your life depends on it. Your process is hijacked by perfectionism. We have to challenge your perfectionism so that you have the chance to change the way you relate to your content. You can let the bus go sometimes. You don't always have to try your very hardest. Your opportunity is to try less hard. Notice that opportunity to do an exposure and let it pass. Notice your fear, guilt, and shame and get distance from the narrative that feeds those feelings. Your hard work is to trigger the narrative that says that you must be perfect and try your best in every moment and do the opposite. Don't just do something, sit there. You got it. Stand there. Put your phone down and stand there with your feelings. They're just feelings! It's just a moment! Hey, look at you! Being alive! Standing there! Having all those feelings! Thinking all those stories! What a moment! The moment you see that for what it is is a really great moment. Let's try to get you that perspective more often.

Your incidental exposure is your real life. You're in your real life and you get triggered. What do you do? Run after the bus. That is, let yourself feel anxious and embarrassed and do what you value anyway. Do the thing that's hard even if your anxiety tells you not to do it. And, if the hard thing is to stop running, just stand there.

Having the opportunity to run after the bus means that you're heading somewhere and you care that you arrive. Do the work to figure out your plan for learning to relate effectively to your emotional disorder. Assess where you are and what you need to do next. Make a plan to try to get there. When the opportunity shows up to practice in real life, run towards it. Your life depends on it.

When the opportunity for practice relating more effectively to your emotions shows up in your everyday life, do you tend to run after it? Do you avoid it or force yourself into it? Reflect on your most common incidental exposures and whether you need to run towards them more often or be more gentle with yourself when they occur.

Acceptance and commitment theory teaches us that the trick is to strive for psychological flexibility. The three components of psychological flexibility are:

● Show up to the present moment.

● Let go of unhelpful thoughts and feelings.

● Do things that you value.

If we, regularly committing to things that we value, are able to do those things with present moment awareness, and allow any thoughts or feelings that are uncomfortable as we engage in our valued action, then we might not feel happy every moment, but we’ll have all kinds of different thoughts and feelings. Within our varied thoughts and feelings, there will be more likelihood of moments where we feel happy.

The paradox is if you strive to feel something all the time, it’s going to feel more and more elusive. But if you commit to things that you care about and live with the possibility that your thoughts and feelings change, then, over time, you’re likely to feel as though your life is rich, full, and meaningful.

As we’re striving to accept and embrace uncomfortable emotional experiences, we want to use metaphors to facilitate our personal internalization of relevant ideas, frameworks, and concepts. While the concept of going towards our internal experiences is theoretically simple, it isn’t easy to do and there are numerous nuances to it that can make it hard to remember.

Metaphors fall into two major categories: identifying symptoms through personification and metaphors to help you remember effective processes.

One category includes personifying the different internal experiences. Personification of our internal experiences helps us to notice the different voices, in real time, and decide how to respond to each particular personified voice.

Examples of personification of our different internal voices include Worried Voice, False Comfort, and Wise Mind. Once personified, we can notice the voices as they happen, label them, and respond to them more effectively. For instance, we know to challenge Worried Voice, particularly when it’s urgent and spiraling. We also want to intentionally access our Wise Mind to help us defuse from the back and forth between worried voice and false comfort. You could also have the voice of Depression, the voice of OCD, the voice of Mania and the Self-Critical voice. All these examples can help you personify your experience and help you remember that just because a certain thinking pattern arrives in your mind doesn’t mean you have to follow it.

The other category for metaphors includes processes. If certain processes get you stuck, you can use a metaphor to help you remember what to do differently.

For instance, inflated responsibility is a process that many people get stuck in. Inflated responsibility occurs when patients take as much responsibility for a thought as they would for an action (e.g., thinking about hurting someone is equally as terrible as actually hurting someone). The other form of inflated responsibility is taking responsibility for something that we don’t have control over, like how other people think or feel.

One example of a metaphor that could help you remember what inflated responsibility is:

“My OCD has a Rolodex of bad memories. Whenever I feel guilt, it starts thumbing through that Rolodex.”

You could use this as a reminder that having the feeling of guilt is making the thoughts seem true or seem like you’ve done something wrong. Rather than engaging it, you could think, “I’m going to throw away that Rolodex.”

The next metaphor is for intolerance of uncertainty. The metaphor is:

My OCD is like a congresswoman filibustering any decision I try to make.

When you notice the filibuster, you can think, Quit the filibuster, Mind. I should make a decision and live in it.

Here’s a third metaphor:

My worry is like a faucet. I’m trying to contain it before it spills over.

This metaphor could cue you to use scheduled worry time to contain your worrying.