Let me ask you a question.
Imagine you have a daughter (or if you have a daughter, imagine her). She’s about 5, and one day she’s bitten by a dog.
Now she’s terrified of all dogs, and you notice her starting to avoid places she might run into dogs, like the park or the neighbor’s house. What would you do to help her?
(I’ll get back to the answer in a minute)
The secret to overcoming fear is facing it
As a psychiatry resident, over the last year I’ve treated many young veterans who have come back from Iraq and Afghanistan with Post-Traumatic Stress Disorder (PTSD). In our first session, as I seek to engage them in therapy and convince them why they’re about to start the difficult process of getting better, I ask this same question.
If you’re anything like my patients, you might have answered something like, “I’d get her a puppy” or “I’d take her to the pound and show her the cute dogs.”
Intuitively, we understand that the way to overcome a fear is to face it. In psychiatry or psychology, this is called exposure therapy.
What is the science of fear?
Before I explain why exposure therapy works, let me tell you a little bit about the biology of fear.
Let’s say you’re walking through the woods and all of the sudden you come across a giant grizzly bear. What happens? Your body will flood with stress hormones like adrenaline and noradrenaline (also known as epinephrine and norepinephrine), activating the “fight or flight” response.
Your heart will start to race, you’ll breath more heavily, your pupils will dilate, your hands will shake as your skeletal muscles tighten, and you might feel nauseated as blood flow gets diverted away from your gut and to more essential organs like the brain, heart and lungs. All of these sensations are mediated by the binding of stress hormones to receptors in your organs.
Now, fear can be a normal, adaptive response. When you come across a bear in the woods, you want to be prepared to fight, or most likely, run.
Fear becomes a problem, however, when you start to feel afraid in situations that aren’t truly dangerous.
How does fear hold you back?
For my patients with PTSD, fear held them back in sad, but predictable ways.
These young men had spent months, or even years, in combat zones, where their lives were in constant danger. Every sound or movement could indicate the threat of an enemy combatant or Improvised Explosive Device. Many had friends violently killed in front of them, or were themselves seriously injured. Even though they came back alive, they had spent many sleepless nights assuming they would not.
One of my patients, Aaron, found himself unable to adjust to life back in the States. He was terrified to be around people. Even though he wanted to go back to school, fear of setting foot on a crowded college campus kept him from pursuing his dream. Whenever he was outside of his house he would whip his head around every few seconds to see if anyone was behind him or following him.
He rarely left his apartment, and when he had to go to the grocery store for food, would choose 24-hour stores and go in the middle of the night, when almost no one else was there.
What stories does fear tell you?
You many not have experienced such an extreme version of fear, but chances are fear has held you back in small, but significant ways.
Maybe you’re so afraid of making a mistake that you don’t try new things?
Maybe you’re so afraid of saying the wrong thing and looking foolish that you don’t say anything at all?
Maybe you’re afraid that what you want to create (art, writing, a business) won’t be good enough, so you procrastinate and procrastinate?
Where our fears start
Ever heard of Pavlov’s dogs? Ivan Pavlov was a physiologist who set out to study the salivary glands of dogs, but inadvertently discovered that pairing a neutral stimulus (a bell) with an unconditioned stimulus (food) could lead the dogs to start salivating when you rang the bell, even in the absence of food.
If there is something you’re afraid of, chances are there was a point in your life when you learned to be afraid. Maybe you had a specific scary experience, or maybe it was many experiences over time, or maybe you just heard enough stories from influential people in your life (your parents, teachers, society, etc…).
Like Pavlov’s dogs, you may have learned to associate something that is not dangerous (making a mistake, speaking in public) with the emotion of fear. You’re just trying to ask a girl out on a date, but your body is acting like you’ve come across a bear in the woods.
But there’s good news! Fear is often learned, and what is learned can be unlearned. The process of facing your fears is an opportunity to learn a new story, and therefore, a new way of interacting with the world.
The science of exposure therapy
Exposure therapy teaches you a new story. As you face your fears, you start to realize, “Oh, this isn’t going to kill me!” Your body stops releasing stress hormones and starts reabsorbing the stress hormones that have already been released.
In psychological terms, you “activate the fear structure” (put yourself in a situation that makes you afraid), confronting incorrect cognitions you may have (“If I get rejected it will be horrible” or “If I get a panic attack I’ll die”), therefore allowing the fear structure to be modified.
You learn a new story.
With systematic practice, situations that used to evoke fear and anxiety will no longer do so. I promise. It’s science!
How to successfully face your fears
Don’t go for broke on the first try. When I helped Aaron come up with his homework assignments, I didn’t send him to a crowded movie theater to see a violent war movie on day one. This would have been too overwhelming and would have most likely led him to feel discouraged and to quit therapy. It’s much more important that you face smaller fears, but face them everyday.
Aaron and I created a “fear hierarchy” – a list of situations he was afraid of ranked from 1 to 10 (a “1” is when you feel bored, a “10” is when you feel you’re imminently going to die). The sweet spot it to choose activities that rank around a 6 to 7 out of 10 on your fear scale. For Aaron, this meant going to the grocery store at 6pm rush hour, or sitting in restaurants with his back to the door.
Prolonged and repeated. Repeated and prolonged. One of my supervisors told me that there are four secrets to doing exposure therapy right – “Prolonged and repeated. Repeated and prolonged.” (Get it? There are only two secrets!).
Whatever fear you are facing, you face it every day. You face it over and over for as long as you can possibly tolerate. If it’s not working, it’s because you’re not doing it enough. At minimum, do the exercise for twenty minutes every day. More is better.
Use narratives. If it’s not practical (or safe) to face your fear in real life, write it down. Write out a story of your worst fear coming true – the more detailed and gory, the better (first my business fails, then my wife leaves me, then everyone tells me I’m a loser…). Do it again and again. Voilá, you’ve just created your own “in vitro” (in the lab) exposure exercise!
After about six months of work together, Aaron was a changed man. He enrolled in classes at the local college, was dating, and had started going to parties and social events again. He wasn’t fear-free, but he no longer felt held back from living his life.
What about you? What’s a big fear you have? What exercises could you do to start to face your fear? Let me know in the comments!