If you’ve struggled with a crippling fear, you’ve probably been told you "need to face it.”

But it’s no easy thing to face what terrifies us. We might as well tell someone with insomnia that they should get more sleep. The goal might be reasonable, but how do we get there?

Exposure therapy, a type of cognitive behavioral therapy (CBT), offers a pathway. This research-tested approach has helped countless individuals conquer the fears that were holding them back from living fully and freely. 

I recently spoke with Dara Lovitz and Dr. David Yusko about exposure therapy on the Think Act Be podcast. Lovitz overcame an intense vomit phobia (emetophobia) that she’d suffered with for decades; Yusko was her CBT therapist. (They describe the story of Lovitz's emetophobia and treatment in their co-authored book, Gag Reflections.) These factors were key to her recovery.

1. Start when you’re ready.  

Most of us are willing to tolerate a certain amount of fear without seeking treatment for it. I’m not a huge fan of snakes, but I don’t live in daily fear or avoid any activities because of it (besides holding snakes).

We generally seek help, according to Yusko, when we “cross a threshold where things are no longer acceptable.”

Sometimes it’s a degree of suffering that’s intolerable; other times it’s interfering in our lives in ways that are unacceptable—especially when it intrudes on what we consider sacred space, like our relationships.

For Lovitz it was when her phobia was getting in the way of parenting her twin daughters. “When I couldn’t be a nurturing mother to my baby who needed me, I realized, This is unacceptable, and I need to work on it. It was unacceptable for me to not be there for my child. The thought of not being there for them was just intolerable.”

If you find that you’re fed up with feeling afraid, or that you won’t tolerate how fear is interfering with things you care about, it’s probably a good time to seek treatment. That intense desire to change can provide the motivation for the challenges of therapy.

2. Do it on purpose.

Most of us encounter things we’re afraid of regularly, but the fear remains. What makes exposure different? As Yusko points out, the framework matters.

He emphasises the importance of “bringing purpose and intentionality, and deciding to engage your fears,” as opposed to incidental contact with what we’re afraid of.

Waiting for frightening things to happen to us “is a pretty scary way to go about change,” he observed. “So the intentional practice gives a little bit more control and predictability, and therefore more effective in the learning process.”

It’s a powerful learning experience when we approach something frightening on purpose. Our brains are constantly making inferences based on our actions.

Lovitz found that avoidance “strengthened the lie that you’re telling yourself”—in her case, “that vomit was something to be scared of and something to avoid.” But when she saw herself facing her fears, it strengthened an opposing pathway in the brain—one that knew she needn’t be afraid.

3. Make it systematic.

Exposure therapy is based around an organized hierarchy of feared situations, which are ranked from easiest to hardest. Treatment involves practicing with the more approachable items first, and working up to the harder ones. Many people, including Lovitz, take heart in knowing that there’s a plan for working progressively through their fears.

Start with situations that are somewhat challenging but manageable. For someone with a vomit phobia, that might include reading articles that mention vomit. Over time the harder situations become more approachable, just like the upper rungs on a ladder are within reach as we ascend the lower ones. The goal is to be able to deal with any situation that might reasonably arise, without excessive distress and without running away.

4. Stay.

A crucial part of the learning process as we face our fears is seeing that what we’re afraid of (usually) doesn’t happen. We handle a snake and aren’t harmed. The dog we pet doesn’t bite us. The elevator we ride to the top floor doesn’t get stuck halfway up. And we find that over time, our anxiety diminishes, and we’re better able to tolerate the discomfort.

If we run away when our anxiety rises, we’ll never have a chance to learn what’s on the other side of it. So during exposure, we stay in the scary situation long enough to gain new information. Typically we aim to stay for a certain amount of time (e.g., 20 minutes). That way when we leave it’s because time is up, not because we had to escape from our anxiety.

5. Repeat.

A single exposure is an act of bravery, but it’s unlikely to conquer our anxiety. That’s why flying on a plane once a year for the holidays doesn’t make us less afraid of flying. The therapy is in the repetition. Plan to do your exposure exercises multiple times to wear down your fear.

6. Expect ups and downs.

Like many people I’ve treated in my clinical practice, Lovitz found that her response to phobic situations was not always the same. “In some ways I feel totally cured,” she said, noting, for example, that she has no problem watching people vomit in movies.

But she said that depending on what else she’s dealing with in her life, “maybe my reactions aren’t as great as I want them to be all the time.”

Sometimes she’ll find that her heart is racing or she’ll feel sweaty and uncomfortable, and disgusted, when confronted with vomit. “But I’m able to get through it,” she said.

We’re humans, not machines. Our reactions will depend on many variables and won’t always be the same.

Just because something didn’t upset us today doesn’t mean it won’t tomorrow.

So go easy on yourself as you experience these ups and downs. And keep practicing the principles of exposure.

“I think I’ll always be in recovery,” said Lovitz. She accepts that she’ll probably always have some degree of upsetting thoughts when it comes to vomit.

“I think I’m just wired this way,” she said. Thankfully her reaction to these thoughts is completely different now that she’s done the hard work of therapy. “It’s how I react to them—the stories I tell myself, and what I do once the thoughts occur—that makes me a recovering emetophobe and not a suffering emetophobe.”