Acceptance or Willingness
After going through psychoeducation, values, and defusion, we circle back around to acceptance, also known as willingness. This was already touched on briefly when examining why exposure work happens, to increase Sarah’s willingness to engage in it.
Now Sarah has more tools in her kit, we can touch base and talk about transitioning into interoceptive exposure:
- What that looks like
- What to expect
- Helping her remember that she’s in control
- She controls the pace while moving through exposure work
- She can choose to stop at any time
- The therapist will be there creating a safe environment
Usually, at this point, clients are more willing to try it. However, if there is still hesitancy then frame it as an experiment: let’s just try it and see what happens.
“We know what happens if you stay on this path. Panic attacks have gotten worse. Your life has gotten smaller. So are you willing to potentially feel intense discomfort in exchange for a different outcome? Would you be willing to do that?”
A True Choice
Those may seem like rhetorical questions, but “no” is a perfectly acceptable answer. If a client is resistant, we want to honor that, talk through concerns, and repair misconceptions.
We then talk about values and committed action in a more unstructured way that doesn’t feel as scary as an exposure hierarchy. It’s best to start with the latter when possible, as there’s much evidence of its effectiveness. But if that feels too threatening, we do more defusion work. Committed action is basically exposure, we just don’t call it that. It’s a soft launch.
However, Sarah was game for interoceptive exposure. So for her, we specifically focused on feelings of shortness of breath, dizziness, disorientation, and increased heart rate.
Interoceptive Exposure and Symptoms
Increased Heart Rate
We want to start with the least frightening symptom then work our way up. Increased heart rate was the least distressing experience for Sarah, so she was asked to practice running by doing knee highs in place for a minute at first, then gradually up to two minutes.
You might want to practice exercises on your own so you can do them with clients in session. Some exposures such as those for hyperventilation might make both therapist and client flushed or dizzy. Trying them together helps to model for clients that it’s doable and not necessarily scary, just uncomfortable.
The goal is to create a safe space where the client knows she’s in control and can end exposure any time. Preface interoceptive exercises by saying that if the client is concerned about an immediate health crisis such as an imminent faint, stop. Safeguard their health.
However, if they just feel very uncomfortable, encourage them to try just 10 seconds longer, or 15, or 20, and see if they can do it even while feeling intense distress. It shows them that we’re not going to bail at the first sign of discomfort, and that you can do something distressing. Your mind says you can’t, but oh, look, you can do it anyway.
What your mind and body tell you don’t have to dictate your behavior. This is a very important lesson. You can feel uncomfortable and still live your values, your truth, and a meaningful life.
You might do knee highs two or three times, so the client gets familiar with it. Leave time at the end of session to debrief and help the client to calm down. Then work your way through other exercises. If you google interoceptive exposure there are many tips and worksheets.
Dizziness and Disorientation
For this set of symptoms, Sarah simply stood in place and turned in a circle for one minute with eyes open. Ensure chairs and other obstacles are cleared away, because people tend to sway somewhat. The idea is to create as tight a circle as possible while turning around.
Again, you can do this exercise together with the client. Then talk through the level of distress and what sensations she experienced, guiding her through using some of her skills to bring herself back down. You could then repeat that.
Shortness of Breath
For Sarah, the sensation of hyperventilation, feeling like she couldn’t get a full breath in, was very distressing. So you will induce hyperventilation for 30 seconds through fast and deep breathing, like panting but deeper. Again, you encourage her not to bail as long as she’s safe.
This helps her come into contact with those sensations and prove that she can feel them, yet not be thrust into a full-blown panic attack. The exercise is unlikely to result in a panic attack.
While it might take some skills application for someone to come down from feeling the intensity of those sensations, therapists should be aware of their own fears that they’re going to inflict a panic attack or cause other harm. Those are your own hooks.
From there, send the client home to practice on her own, recording her experiences. It is recommended that they practice three specific skills once daily. This could take up appreciable time every day, but it’s best to have as much committed repetition as possible.