How Exposure Makes You a Superhero
I found the shirt at the consignment store on the small main street in the downtown area of the North End of Tacoma. It was the skimpiest one in the store that actually fit me. It was covered in flowers and had a criss crossed pattern across the chest and a cropped area that left a small triangle of midriff exposed.
I could hear blood rushing in my ears as I walked, in this tiny (to me) shirt, along the waterfront path at 2pm on a sunday afternoon. I noticed and tried not to notice people looking at me, at my body, hiding my fear behind my sunglasses. I silently rated my anxiety and looked at my phone to type the number into the app. After 15 minutes of walking back and forth along the path I took off my sunglasses and did it again.
When I was on internship for my degree in clinical psychology at the VA American Lake in Tacoma, I began training in a technique called Prolonged Exposure. This is an evidence based treatment for PTSD where the client chooses one specific traumatic incident (usually the worst one they remember) and systematically reduces their avoidance of the memory and all associated people, places, and things. If this sounds rough to you then wait until you hear the process.
You start by identifying all the things you now avoid as a result of the incident. So if it were a car crash, maybe you avoid highways or the street that the accident occurred on, maybe you avoid driving at dusk or even watching shows that you think might have car accidents in them. So the first step is to make a list of things you avoid and rate how stressful doing them seems to you (from 1-10). Then you start with things at a 3-4 level and start doing them. One a day, every day.
At the same time, in your therapy sessions, you start telling the story of the memory. You do so including as much detail and sensory information as you can. Over and over again for the duration of the session. And you record it on your phone and then go home and listen to it every day, rating your distress from 1-10 each time you listen. If this sounds profoundly unappealing to you, you are not alone. Most people find this idea daunting if not outright terrifying. But for some, the symptoms of PTSD - the nightmares, hypervigilance, intrusive thoughts, flashbacks, and rumination, are worse.
The process of moving toward the things you fear (rather than avoiding them) is called exposure. Doing it in your outside life (walking the waterfront in a tight t-shirt) is called In Vivo (literally “in life”) exposure and doing it in your imagination or memory (recounting the trauma in a therapy room) is called imaginal exposure.
What our subjective ratings (and hundreds of randomized controlled trials) show is that our distress goes down over time. The more we face the thing we fear and discover that nothing bad happens, the less we fear that thing. This is a process called habituation. In the same way that when you live in a house near the airport, after a while you no longer hear the planes going overhead, when you are exposed to your memory and the things you fear and nothing bad happens, your fear response lessens.
You see, our brain registers and is bothered by loud noises like planes flying nearby because they are signals of possible danger. But if we hear the stimulus (loud noise) multiple times and nothing bad happens, our brain recategorizes that sound as “safe,” and focuses its anxieties on other potential threats. In the same way, my brain paired cute sexy clothing with danger. And I was walking the waterfront path to teach my brain that wearing a cute sexy top would not get me assaulted.
Often clients come to see me after trying to work with other therapists on their trauma. I always feel a tinge of grief and a lot of tenderness when this happens. So many therapists are still not trained in effective use of exposure, often because they are uncomfortable with the concept themselves. The urge to avoid what we fear is so powerful - it is endemic to our survival as organisms on this planet. And because we therapists care so much about our clients and their pain is painful to us, if we have not learned to face our own fear, we can collaborate with our clients in their avoidance.
But we do ourselves and them no favors. Instead, when we avoid, we make our (and our client’s) lives smaller and smaller, we never get to fully heal from our traumas and - worst of all in my opinion - we never become the superhero that we are meant to be!
Because here is the thing - I learned to walk that waterfront. I learned to walk it wearing whatever I wanted to, I learned to do it with my sunglasses off, I learned to do it making eye contact with the people I passed. I will admit, I got a little bit hooked - I wanted to find every damn thing I had ever been afraid of and do it just for the high it brought and to know that fear did not own me. And for those of us who have struggled with PTSD or any kind of intense fear reaction, we know that this is a tremendous liberation. Enough to make you feel like a superhero.
1 McLean, C. P., Levy, H. C., Miller, M. L., & Tolin, D. F. (2022). Exposure therapy for PTSD: A meta-analysis. Clinical psychology review, 91, 102115. https://doi.org/10.1016/j.cpr.2021.102115
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical psychology review, 30(6), 635–641. https://doi.org/10.1016/j.cpr.2010.04.007