Imagine you’re convinced that there’s a shark in a swimming pool. You may know logically that this is impossible. You may hear others assure you that the pool is safe, and even see them enjoying the water on a hot, summer day. You may even risk dipping your toes in when you’re feeling brave. But the second something reminds you of the threat of the shark – a splash, a sound, or even a memory – you can’t help but yank yourself from the water.
It’s not worth the risk, your brain and body might say.
This is what trauma does to us; painted by our past experiences, skewed beliefs and expectations about ourselves, our emotions, and the world lead us to interpret danger where there might be none. Driven by a biological need for safety, our instincts kick in to avoid this danger and keep us safe. But so long as we keep avoiding, we never have the chance to prove our fears wrong: There’s no shark in the swimming pool. It’s safe to swim here.
Avoidance maintains traumatic beliefs, and exposure can change them.
Exposure is a therapeutic technique that involves approaching safe but feared scenarios in order to lessen our emotional responses to them over time. By starting small and working our way up, we learn to no longer be afraid of the things we were avoiding. This can be applied to treat anxiety, phobias, OCD, and PTSD or complex trauma.
Let’s say someone was in a traumatic car accident. What might this make them avoid? Fear-wise, you’d expect that they would avoid cars. They’d avoid driving. They’d avoid the intersection where the accident took place. But it doesn’t stop there. Let’s say they have strong beliefs about this accident, like, it was my fault or I can’t be trusted. Due to intense guilt, shame, or self-disgust, they might also avoid things like applying for promotions, getting close with people, or practicing self-compassion. They’d avoid anything that would bring up the painful emotions associated with their traumatic beliefs. Unfortunately, this means they will never unlearn the idea that this avoidance is needed to keep them safe. I won’t get the promotion, but I won’t have to face rejection. I won’t get to swim, but I won’t be attacked by a shark.
Exposure for PTSD works by slowly approaching the things you’re avoiding in order to challenge your traumatic beliefs and increase your tolerance of the negative emotions that show up. Step one wouldn’t be to drive through that feared intersection, but it would be to sit in a car. It would be to apply for that promotion. It would be to talk through the incident, and unpack the emotions and beliefs it brings up. Over time, you’ll be driving again. You’ll trust yourself. You won’t be destroyed by memories. You’ll have your life back.
As Dr. Marsha Linehan, the creator of DBT said, “You can’t think your way into a new way of acting; you can only act your way into a new way of thinking.” Furthermore, you have to feel and experience your way into a new way of thinking via your actions. Both our brain and our bodyhave to unlearn our mistaken hypotheses. The best way to do this is through a surprise, or an expectancy violation.
Let’s take an imaginary client of mine, Sasha. Sasha’s traumatic experiences include growing up in a physically and emotionally abusive environment, as well as experiencing extensive bullying in middle and high school. All of this results in Sasha operating from the following assumptions: I have to be careful so others don’t reject me. If I don’t please people, they will hurt me. Being an inconvenience is unsafe. By operating from these assumptions, Sasha reinforces their traumatic beliefs: I am unloveable. I can’t stand people being mad at me. The world is a dangerous place. So long as they operate by avoiding inconveniencing others at all costs, these beliefs will persist.
The thing is, if I were to assign Sasha the task of asking a trusted friend for a small favor, this might make their beliefs budge a little, but not enough to really move the needle. I might start there, but to really shock Sasha’s belief system, I need them to do something that results in a surprise: I was sure x would happen, but instead, y happened. I thought I’d be hurt or rejected, but instead I was loved and embraced. I thought I’d be attacked by a shark, but instead I had fun in the pool. The more our expectations are violated, the more our beliefs will shift; the bigger the surprise, the bigger the change.
After getting through some of the easier tasks on Sasha’s fear hierarchy, I assign them one of the go-to exposures for fear of inconveniencing others. “Sasha,” I say, “I want you to go to an ice-cream shop and sample flavours. I want you to sample at least 3 flavours. Then, I want you to thank the ice-cream shop worker and walk out the door without buying any ice-cream. I want you to do this without apologizing or making an excuse.”
Sasha’s jaw drops. They are sure this will be intolerable; they will die of embarrassment. They are sure this is unsafe; what if the ice-cream shop worker gets upset, or gets violent? They are sure this will make them hate themselves more; how could they be such an inconvenience to an unsuspecting ice-cream shop worker just for the sake of their own trauma therapy?
I validate Sasha. It makes sense to be afraid! If they weren’t, it wouldn’t be a quality exposure in the first place. Sasha and I are able to determine that, logically, catastrophic consequences are unlikely to happen. This scenario is safe even though it is feared. Sasha agrees to do it. When they come in next session, they have some new information to share:
“I was terrified,” Sasha says, “Like, my heart was pounding in my chest. But then, nothing happened. The ice-cream guy said, ‘uh… okay.’ And then I left and couldn’t stop laughing.”
“Wait,” I say, “Are you telling me nothing bad happened? You didn’t die of embarrassment? The worker didn’t get upset or violent? You didn’t hate yourself more?”
Sasha rolls their eyes but smiles. “No, nothing bad happened,” they agree, “And actually, I’m glad I didn’t buy any ice-cream – it wasn’t that good anyway.”
Over time, by doing unorthodox tasks that violate the expectations of Sasha’s traumatic beliefs, Sasha will not only experience a shift in their beliefs, but also a sense of freedom. Sasha will no longer see their world as a caution-taped crime scene; Sasha will be able to live free from the traumatic beliefs that once dictated their every move. They will be able to say “no” to an unwanted request. They will be able to ask their friend for a favour without apologizing 10 times. They will be able to take up space.
What I’m describing here are in-vivo or “in life” exposures. These are used in many different therapy approaches and are one of the core methods in DBT-PE, the DBT Prolonged Exposure Protocol for PTSD. If you struggle with PTSD or traumatic beliefs, talking to a therapist is an important step to take on your healing journey.
Regardless of whether you’re in therapy, it may be helpful to ask yourself: what am I avoiding because of my past experiences? What beliefs are my avoidance maintaining? How can I challenge these beliefs through my actions? What will shock my belief system enough for it to change?
Now, until you swim to every corner of the swimming pool, touch the underwater surface, and cannon-ball into the deep end dressed as shark bait, part of you may still believe that there’s a shark in the water. But getting there takes time. For now, dip your toes in and breathe through the discomfort. Notice your emotions. Notice how you can tolerate them. Notice the difference between what you thought would happen, and what actually occurs. Tomorrow, maybe you can wade in the shallow end. And eventually, you just might be able to notice: I am capable. I can tolerate my emotions. The world is not as dangerous as I thought.
References:
Harned, M. S. (2022). Treating trauma in dialectical behavior therapy: The DBT prolonged exposure protocol (DBT PE). Guilford Press.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.