Exposure Therapy Ineffective For Complex Situations And Very Old Fears?

[freakofnurture]

Are you sick of me harping on this subject yet? -.- Well, I've found a new angle to look at it. Rejoice.

It's common knowledge that, to reduce fears, you have to face that which you fear and endure the situation so you can make the experience that nothing happens to you. It just makes sense that you can un-learn a fear.

I have been on a mission to get over my fear of people and groups for years now. I have exposed myself to groups for several hours a day, five days a week, for a collective period of roughly six months now, all under therapeutic supervision.

The expectation would be that my fear was going to be strong in the beginning but would go down eventually when my brain realised that it had spent whole days in a group already without anything bad happening.

What really happened was that (after I did a month of hefty and very successful DBT for anxiety control) everything went great for one or two weeks; no fear, I didn't even tap my foot during group sessions. Everything went in an encouraging way, making me optimistic that I would be able to just feel normal. But from the middle of week two on things began to go downwards increasingly fast, the fear came back stronger each day and stopped to respond to the skills that had been super efficient only days ago, I started to dissociate during group sessions until finally, groups scared me so much that I had to hide under a blanket, unable to flee the situation because I was petrified with fear.

The fear didn't stay gone, it came back during exposure therapy, although nothing bad happened; I even felt not threatened in the last group I was exposed to! I knew the people were harmless, I didn't have any conflicts with them, there was no reason at all for my fear to flare up like this again.

Now, there has to be a logical reason for this and I want to find it. Not because I want to get back on my mission, no thanks, but because I want to understand what's going on in my psyche.

I have two hypotheses that I want to put forward for your amusement and/or evaluation:

1. My fear of groups is not a simple 'I'm going to be attacked'; I'm scared of complex mechanisms of personal antipathy and/or group cohesion being activated and used against me. It's something subtle, something that needs context and time in order to be identified. My scared little brain isn't put into a clear black-and-white situation where 'threat' and 'no threat' are easily distinguishable entities. It's put somewhere where 'threat' could be brewing invisibly at all times, so it can never know if it's actually safe to let its guard down. When nothing happens it keeps expecting for something to happen, and the longer it's been waiting, the more likely it believes it to be that something will happen soon - so it ramps up the anxiety in order to get me out of there before the shit hits the fan.
2. My fear of people is as old as I am. It has been written deeper and longer into my brain than anything else I have ever learned. 'People can't be trusted' - it's as true and absolute to my brain as gravity is. And my/the human brain's plasticity just can't reach this level of depth; it's like trying to teach your hippocampus how to understand the written word, or like trying to use your amygdala to knit a shawl. Some structures are sealed in their function and cannot be altered in any extensive way - at least not by exposure therapy.

I briefly thought about a third possibility along the lines of: Treatment made me feel so vulnerable that I couldn't keep the fear down any more. But for that to be likely the phenomenon would need to be absent in all non-therapeutical settings. It isn't, which falsifies this hypothesis.

What do you think?

And is there anybody else on this forum for whom exposure therapy didn't do the trick although they tried and tried and tried?

 

[Red Feather]

Hi freakofnurture. I never did exposure therapy. But I think because I am an artist, and also have a lot of experience performing, I have "exposed" myself a whole lot. I am diagnosed with PTSD but I also think I have Complex-PTSD or DESNOS. And I think that complex trauma is such a complicated and confusing layering of connections, that what you write makes a lot of sense.

For example, I once had an experience in which I felt I had made progress concerning my boundaries to my ex-husband. I was preparing for my diploma-presentation at the time and immediately knew that I should write down the experience. So I did and made a film about it. It kind of explained a real personal dissociative state I was in. It was exposure to say the least. I showed at my diploma exams. This was okay for me, because there were only 5-6 professors in the room and they were there for me and for no other reason. But when I showed the film to the public, it triggered me really badly. I felt like I was in constant anxiety everytime somebody watched it and I had nightmares.

In a way, it was almost like the progress I had made with that experience was just nullified or reversed through my blatant exposure in a public setting. I am not sure if this is making sense. I don't know why that happened. But that is my sense also. I have talked a lot about some of the traumatic episodes in my life and their effect on me didn't get reduced either. I think because mostly I had dissociated most of the experience and was really numb to it.

I think numbness is a big factor. Because you can make yourself numb, because you know this is therapy and not the real thing. And then later the other part rebels. Again, I don't know if this makes any sense. Just sharing some of my thoughts.

 

[Queen Boudica]

Yes I get where you are coming from. Can relate to both of those hypothesis.

Sometimes I think it is like an addiction to fear. Like alcoholism. You can think you are fine and you can keep saying no to the alcohol and the longer you go the better it gets. Then one day something happens and that desire for alcohol becomes all consuming and you drink and then you can't stop drinking again. Your brain chemistry is wired for alcohol.

So you have exposed yourself to your fears, you do Ok for a while, then it all starts to get a bit overwhelming, something tiny happens and it starts to get the anxiety and doubts and whatever goes on in your head, starts to churn over again and you are so used to that feeling, that is what is normal, that you can't stop it again, your fears are back again and you are back to stage 1.

Not sure if that makes any sense.

 

[Queen Boudica]

Sometimes I think it is worse than drug or alcohol addiction because it is your own brain that is coming up with the fear that you are addicted to. :confused:

 

[freakofnurture]

I think numbness is a big factor.

That could be true.

When I am really depressed my fear of people vanishes completely because I don't care about self-preservation anymore.

At the same time the reasons for my DBT skills no longer working is that I get too scared to allow myself to stay relaxed or to even try and relax in the first place; because if I'm relaxed I'm not as quick to respond and that's dangerous. So using skills feels like it's numbing down my alarm system, and that feels dangerous.

Sometimes I think it is worse than drug or alcohol addiction because it is your own brain that is coming up with the fear that you are addicted to.

Oh dear, I feel very sheltered now because the word 'addiction' to me is connotated mostly positively -.-

But I get what you want to say, Lizio. I don't know if it feels like this to me, though, since the fear returning doesn't feel like it's triggered back into full blown activity by some singular instance, it's more of a continuous process, like creeping back in through a crack in the door or something.

Oh shit, now I've scared myself with that metaphor -.- I've been so afraid of the dark again for the last few days... there goes this night's sleep *face palm*

 

[timetorecover]

Its like you are re living the trauma. IMO expose slowly, like gently opening a bottle of Cola.

Be kind to yourself xx

 

[ericaboo]

I'm scared of complex mechanisms of personal antipathy and/or group cohesion being activated and used against me.

This sounds so much like me. In order to work on that kind of issue, what I have been doing is trying to identify the negative thoughts that are making me believe that people or groups of people would gang up against me. Then check those thoughts against reality and work through a process with that.

No amount of exposure to random people, would change my fear of people in work or family situations, where I feel there are politics and motives involved until my self esteem can heal to a level where I stop thinking people see me as bad/wrong/incompetent.

Not to say that I don't believe in exposure therapy, but it's just one tool - with a complex situation, I'm guessing we're going to need every tool in the box, and probably a few more they haven't even invented yet. It's going to be a lifetime process...

Hang in there :)

 

[Queen Boudica]

No amount of exposure to random people, would change my fear of people in work or family situations, where I feel there are politics and motives involved until my self esteem can heal to a level where I stop thinking people see me as bad/wrong/incompetent.

Yep definitely agree with that one. :(

 

[maddog]

I have long wondered as to the existence or otherwise of hypothesis 2 as well. I often feel as though this is my reality, particularly in relation to a lot of my held core beliefs and also in regard to my pattern and approach to interpersonal relationships and their associated issues.

Currently, I think my belief is that this hypothesis is partly true. I don't believe it's possible to delete or to completely unlearn things that have, as you say, been wired into your brain almost from birth and have become core components of your psychological, cognitive and emotional systems of functioning.

I do believe that it's possible to learn new neural pathways and structures that run in conflict with those we have previously learned, and this, obviously, is the goal of therapy.

Quite simply, I believe that the best outcome is in making the new pathways stronger than the old ones, and working to hopefully, over time, create a situation in which they are activated first and in place of the old ones. Using crude and simplistic language to describe this process of course, which in no way means I'm intending to simplify it or lessen the magnitude of this process, but in short, I think there is always the potential for the old hard-wired pathways to be activated, particularly in times of great stress or when developed coping systems are overwhelmed, and that is, in part, why I suppose they say that PTSD is never actually "cured", but is instead "managed".

I think that the extent to which new pathways can be created and set to default is very different for every person, every type of pathway being recreated, and to some extent, every context in which the individual finds themself.

I guess I don't feel qualified to speak to your own circumstance any more specifically, as I'm not sure what your group exposure therapy sessions entailed or what type and intensity of therapy(ies) were being provided in tandem with this. Those factors would have a significant bearing on the likely success of the strategy of frequent lengthy exposure to the feared situation.

Definitely a complex and challenging issue, and I really empathise with your frustration and inability to make sense of this, right when it seemed as though there was finally a way forward.

I am struggling badly with groups and social situations right now too, so this really resonates with me.

Maddog

 

[Meadowsweet]

My fear of groups is not a simple 'I'm going to be attacked'; I'm scared of complex mechanisms of personal antipathy and/or group cohesion being activated and used against me. It's something subtle, something that needs context and time in order to be identified. My scared little brain isn't put into a clear black-and-white situation where 'threat' and 'no threat' are easily distinguishable entities. It's put somewhere where 'threat' could be brewing invisibly at all times, so it can never know if it's actually safe to let its guard down. When nothing happens it keeps expecting for something to happen, and the longer it's been waiting, the more likely it believes it to be that something will happen soon - so it ramps up the anxiety in order to get me out of there before the shit hits the fan.

This is something I can relate to, and I tend to find it difficult to explain. Perhaps because, if I say I have a fear of people, others have related it to the common fears of crowded places or to direct attack.

But perhaps its not really people I'm afraid of. Its a certain level of closeness or connection with people. Its opening up that little secret inside me that frightens me. Because that part can be hurt, manipulated,stolen and used to control me. But also I tend to feel that if people see that part of me, it actually encourages people to want to hurt, control etc. I hope that makes some sort of sense.

I've not tried exposure therapy. But my concern with therapy at the moment, is that I understand how traumatic incidents can be worked through. And that exposure to things that remind me of the specific incident can help re-train my mind etc.

But, the very personal connection or beginnings of closeness with people can't be constructed by any type of therapy. Its something that just sometimes happens. So I can't see how exposure therapy can reach that core of my fears.

I guess I live in hope that if I do everything else, I will have the tools to get myself through those subtle connections.

 

[freakofnurture]

what I have been doing is trying to identify the negative thoughts that are making me believe that people or groups of people would gang up against me. Then check those thoughts against reality and work through a process with that.

I have to think about if I have done that already.

I mean, I know exactly how my trauma gave rise to this fear, I can name situations in my later life that are prototypical of the situation I am scared of.

My problem - and maybe the point where I am boycotting myself? - is that what I'm scared of is statistically very likely to happen to me over and over again, especially if I act as if it were not and just behave like my 'natural', completely socially inept me. How could I ever get out of that, unless I avoid the situation as a whole?

I still have to try if people react differently to me if I prime them for greater acceptance by telling them that I have a brain injury which causes my social interactions to be wonky. But the lack of threatening behaviour from the group didn't do anything for me during my last in-patient stay, so I don't know if it will outside of a therapeutical setting.

where I feel there are politics and motives involved

Scary shit, that!

Hang in there

Thank you. I'm trying :)

I do believe that it's possible to learn new neural pathways and structures that run in conflict with those we have previously learned, and this, obviously, is the goal of therapy.

You know what? It actually feels like that sometimes. Like I am trying to build a bypass in my brain, but the old road and the bypass are very close to each other so that it's easy to fall off the bypass onto the old road.

I really empathise with your frustration and inability to make sense of this, right when it seemed as though there was finally a way forward.

It sucks so hard. It's like your brain is working against you, always pulling out new tricks. "Oh, so you want to use skills? Well, they are dangerous, too." "Oh, so you want to try to argue with your fear? Well, I'll make you extra paranoid so that you feel like arguing is dangerous, too." "See this cute widdle bunny rabbit? Well, now it's dangerous, too!!!" "Hey, look, a fluffy little cloud! Dangerous!!"

Scumbag brain.

But perhaps its not really people I'm afraid of. Its a certain level of closeness or connection with people.

Oh, that's most definitely true for me, too!

The thought of people directing any kind of emotion at me is scary as hell. And people thinking about me, having an opinion about me, however positive? It's mostly okay as long as it's possible for me to just run away and never see them again. But when I'm stuck? Feels life threatening.

Because that part can be hurt, manipulated,stolen and used to control me.

I think I get what you're trying to say, although for me it feels very different.

It's not about me being controlled, it's about me not having control over what others make of me in their heads and how they act out their image of me.

I guess I live in hope that if I do everything else, I will have the tools to get myself through those subtle connections.

I wish you the best of luck!

 

[Meadowsweet]

The thought of people directing any kind of emotion at me is scary as hell. And people thinking about me, having an opinion about me, however positive?

I understand that feeling and sometimes, for me, positive can feel like they want or will expect me to be a certain way.

I do sometimes want to control what people think about me. But it tends to be easier to control if you let people think the worst. Sadly, people are much more willing to hang onto negative opinions of others, that positive ones.

But at the moment I'm isolating instead.

It's mostly okay as long as it's possible for me to just run away and never see them again. But when I'm stuck? Feels life threatening.

This is why I'm thinking being in a group situation wouldn't feel like exposure for me, because I can be in a group situation and keep my inner self to myself. That way I feel safe.

So to be properly exposed, I'd have to be amongst the group for much longer, and start to form closer social relationships with people.