As we approached a bridge, my client Amy started walking slower and breathing faster. “I’m nauseated and a bit dizzy,” she muttered. I encouraged her to carry on and assured her that the actual experience wouldn’t be as bad as she feared. About a hundred feet above the river, I stopped and modeled leaning on the railing to look down as the rowers slid by below. After a pause, she joined me, closing her eyes. More of my prompting led her to open them for a second before she jolted back and threw up all over herself—and me.
Stunned and feeling hot vomit seep through my blouse, I sat down with my back to the railing. I hadn’t realized how tense and anxious I’d been feeling for the past 30 minutes as I’d been doing this in-vivo exposure exercise with Amy—and now it had all come crashing down. Amy apologized profusely through tears and eventually heeded my nonverbal invitation to just sit beside me.
“I’m not going to pretend to have the answers, Amy,” I said. “Anything can happen, and that can suck and be scary. But the fact that anything can happen means that everything is possible, right? And that’s the most wondrous thing in the world!”
The two of us sat there, covered in vomit and baking in the sun. Suddenly, I started laughing at the absurdity of the situation and my assumption that I’d been in complete control of this exercise. Amy looked puzzled—and then joined me in uncontrollable laughter.
That day in the middle of Key Bridge, facing the limitations of traditional exposure therapy, I stumbled upon a way to reimagine it. I realized that I’d been holding my breath, physically and metaphorically, mirroring the mounting panic that Amy felt. As we sank to the ground, the relief of not knowing, together, was palpable.
It was hard to recognize that I’d been hiding behind psychoeducation, meticulous planning, expertise, and belief in techniques that are proven to work and have worked with many of my clients. I felt deeply exposed, as this clearly hadn’t worked. But, slowly, it allowed my heart to open to new possibilities.
When we approach each therapeutic encounter as a chance to explore universal struggles of existence, we can help clients develop confidence that they can deal with whatever life brings. Instead of guiding them with certainty through strategies designed to reduce anxiety, therapists and clients can confront together, with openness and wonder, the naturally unsettling and anxiety-provoking existential givens of mortality, uncertainty, and groundlessness, as well as all the discomfort they cause.
Clinical experience shows us that humans have to learn to face these existential givens head-on in order to live full, meaningful lives. In therapy, we can learn to do what matters even when we’re afraid.
The Problem with Exposure Therapy
Bridges had been a source of panic for Amy for years. Having watched many videos of bridge crossings and even driving over a few as part of our therapy, Amy had finally been willing to try the real thing—in-vivo exposure therapy, the most straightforward traditional behavior therapy approach that helps clients face their fears.
Though exposure therapy is a staple of our work in this field, I find many people aren’t familiar with its history. The first application of it dates to 1913, when Mary Cover Jones, one of the earliest American psychologists, cured a three-year-old boy’s rabbit phobia by gradually bringing a rabbit closer and closer to the boy while giving the boy his favorite food. This was theorized to produce a pleasure response that was incompatible with fear. The technique became known as systematic desensitization.
For much of the 20th century, relaxation techniques were used to help clients approach feared objects or situations. For instance, a germophobic client might learn to use slow, deep breathing as she touched progressively dirtier surfaces. But over the past few decades, this approach has mostly been replaced by exposure unaided by relaxation, because research suggests it works faster and better and leads to fewer relapses.
When in-vivo exposure is impossible or impractical, clients might be guided through an imaginal exposure—a combination of visualizing, narrating, recording, listening, or writing about anxiety-inducing situations or memories. An agoraphobic client might repeatedly imagine being on a crowded subway, or a traumatized client might recount in detail his encounter with a burglar. Virtual reality is increasingly being used to expose clients to wartime scenes, airplane turbulence, and other situations that can’t otherwise be readily accessed.
Finally, to combat clients’ fear of fear, so-called interoceptive exposure is recommended, which includes inducing physical sensations of anxiety in the therapy room by hyperventilating, spinning, breathing through a narrow straw, and facing a heater, among other things.
Why would anyone subject themselves to something so unpleasant?
Research shows exposure therapy to be remarkably effective. Some studies find it to be the most impactful CBT technique, yet it’s one of the most rarely used approaches, even among self-identified CBT practitioners.
When Augsburg University professor Stacy Freiheit and her colleagues asked psychologists—71 percent of whom identified as CBT therapists—which intervention they use for treating OCD, panic disorder, and social anxiety disorder, only about one-third said exposure therapy.
The reason for this discrepancy is simple: therapists and clients, understandably, dislike engaging in things that make them uncomfortable.
Many therapists are concerned that exposure can be unsafe, intolerable, or even unethical—antithetical to our oath to do no harm. When they do engage in exposure therapy, they sometimes become uncomfortable or anxious themselves, as I had while walking with Amy over Key Bridge. This explains why exposures are often done cautiously and tentatively, resulting in ineffective or curtailed treatment. I’ve also found that many therapists dislike the roles they sometimes inhabit during exposure therapy—that of a coach, cheerleader, or salesperson.
What’s more, any therapist who’s tried to sell exposure therapy to their clients has sometimes, if not often, encountered obstinate reluctance. Even more frequent is noncompliance with exposure homework between sessions. For some clients, having a therapist they perceive as an authoritative guide is enough to convince them to try an exercise. But for many, a treatment that invites them to confront what they’ve long feared is just too much to bear.
Lauren Slater, a psychotherapist and writer who has chronicled her own mental health struggles, wrote a widely read New York Times article titled “The Cruelest Cure.” She describes exposure therapy as practiced by David Barlow, one of the best-known clinical researchers in the field, and warns that it can feel like “torture” and be “terrifying” and “grueling.”
Proponents of exposure therapy would see this as an example of its PR problem, given that the sense from the clinical trenches is that the treatment works amazingly well for people willing to go through (sometimes lots of) pain for long-term gain. These individuals are likely the same ones who self-select for exposure therapy randomized control trials. That, unfortunately, still leaves many—maybe the majority—of anxious people suffering.
The Fear of Mortality
In my own practice, I’ve found that exposure is often initially rejected by clients, who don’t understand that it’s a common CBT approach to anxiety disorders. Even my clients who ask for exposure-based treatment because they’ve read about it or were told by other healthcare professionals that it’s what they need frequently find it hard to follow through.
My 62-year-old client Sara came seeking Exposure and Response Prevention therapy (ERP) for OCD, which involves exposure while abstaining from rituals or compulsions. Her germaphobia was triggered when her home was infested by bedbugs. Even after having a professional treat the infestation, she obsessively continued laundering, cleaning, and scrubbing everything in the house. As she developed more and more involved rituals for cleaning, her relationship with her partner and her quality of life started to decline. Although she’d suffered with anxiety and obsessive tendencies off and on for most of her life, by the time she’d come to see me, she’d developed debilitating OCD.
Sara had researched OCD treatments methodically and said she’d chosen me because I provided ERP. “I’m ready to do whatever it takes to get better,” she’d remarked initially. Once we embarked on exposures, though, she hesitated. “I know I’ll get there, but I just can’t do this today,” she’d say when I modeled touching the floor, bathroom fixtures, or elevator buttons. After three months of treatment, we’d made some progress in the office, but Sara rarely practiced in between sessions.
No amount of discussion of the scientific support behind ERP or troubleshooting what was preventing her from completing the homework moved us closer to her therapeutic goals. “I just can’t go there. I can’t do it,” she moaned. “There’s too much pain there.”
“What are you afraid might happen if you go into that pain?”
“Darkness would swallow me,” Sara blurted out, instinctively covering her mouth with her hand and jolting back in her seat.
I knew then that we needed to shift gears and go deeper. We had to find a way to her ultimate fears and concerns, to confront them head on.
Much of anxiety boils down to an ultimate fear of death and nothingness, what Rollo May called “existential anxiety.” He contended that the unwillingness to face existential anxiety leads to feeling neurotically anxious and avoiding significant parts of life—what we today call having anxiety disorders. He believed that anxiety about nothingness ends up attaching to something specific.
Indeed, many anxiety-related disorders can be boiled down to the fear of harm and, ultimately, death—real or symbolic. My client with a fear of flying had intrusive images of plane crashes. Many people struggle with panic attacks because they feel like they’re having a heart attack or a stroke. Socially anxious individuals are mortified by the possibility of social ostracism, and perfectionistic worriers often catastrophize imagining work embarrassment or annihilation.
Research shows that death anxiety is related to the severity of psychological problems and that reminders of death increase anxious and avoidant behaviors, as well as OCD compulsions. The more we try to cheat death, the more it comes to poison our lives. As Leo Tolstoy once said, “When you shield yourself from death, you shield yourself from life.”
Compared to our agrarian past, and to many non-Western cultures, we’ve almost completely banished death from everyday life. Dying often happens in institutions, and the dead are handled by an army of professionals, rather than by families. Intentionally meditating on death as part of rituals or even celebrations—common from ancient Greece to Buddhism to Mexico’s Day of the Dead—often seem incomprehensible to the contemporary Western mind. The unintended consequence of these societal changes is heightened discomfort with anything related to mortality, and an increase in death anxiety.
My treatment with Sara had stalled. But even after talking about how “the darkness would swallow” her if she did exposure work, she quickly regained her composure, sitting upright and retrieving a handkerchief from her purse to tidy up her barely smudged lipstick with the well-practiced movements of someone who spends lots of time on their appearance. Indeed, Sara was well-put-together every time I saw her. She was a beautiful woman, whose age had barely started to show on her impeccably made-up face. She seemed to have had some cosmetic work done, and her hair and clothes suggested she’d devoted great care to them.
I was curious to explore underneath this beautiful façade that Sara had worked so hard to maintain. When she’d first told me about herself and her reasons for seeking help, she’d notably glossed over any grief at having lost her husband three years earlier to a heart attack. I had a hunch that this could be a productive line of inquiry because she seemed uncomfortable even mentioning his death.
“I’m wondering if we could stay a little longer with the darkness,” I asked Sara.
She looked at me like a deer in headlights and said nothing.
“When we first met, you told me about your husband’s death. How long had you been together?”
“Almost 30 years.”
“That must have been so hard.”
“It was a shock, but you have to go on.”
“Can you tell me a bit more about the shock?”
“It was an adjustment. But I have my two wonderful sons, who are launched and doing so well. And I met Steve!”
“How often do you go to visit your late husband’s grave?” I asked. There was a long pause. “I see different emotions flickering on your face, Sara. What are they saying?”
Sara’s eyes watered for the first time in our work together, but she quickly dabbed them with the handkerchief. “I don’t know. And I don’t know why I haven’t gone to the cemetery in such a long time. I’m ashamed of it.”
We weren’t getting anywhere with words, so I decided to focus on the body, where emotions are felt. “Staying with not knowing, what’s showing up in your body right now? Is there something inside the shame?” I asked.
“I feel uncomfortable, my stomach is vibrating with this hollow sense of dread.”
“Go on. Let’s be curious about the dread. Such a familiar human emotion, isn’t it?”
As if startled, Sara started shaking and crying. But this time, she let her tears flow. “I’m mortally afraid of dying,” she confessed. “And of getting old. Steve asked me a few months ago if I wanted to move in with him and all I could think was: This will be my last move, my last big decision, the last hurrah. He’s 70 and he’ll die, or I’ll die first. And this was about the same time I got invaded by the bedbugs. It’s all too much. I can’t handle it.”
“But you’re handling it already,” I responded. “You’re naming your biggest fear here, with me. You’re being vulnerable and brave.”
Our work shifted after this session. Acknowledging existential concerns, as we’d done, made ERP possible. Confronting mortality allowed Sara to drop the shield that had provided false security and prevented her from emotionally connecting with grief, Steve, and herself. She was able to examine her life realistically and focus on what mattered the most in the time she has on Earth.
This allowed her to face her fears head-on and engage in our exposure treatment, which broadened from germs to include dancing with Steve, visiting her late husband’s grave, and going to a grocery store without makeup—all of which were previously inconceivable to her because they brought her in contact with life’s finitude.
The Fear of Uncertainty and Groundlessness
In addition to distancing us from the reality of mortality, our society has become good at trying to prevent or eliminate uncertainty and discomfort around it. Mary, another of my clients and a successful executive, planned her activities months in advance. Before buying or committing to anything, she’d painstakingly research and review all options. She always ate the same food from the same stores and restaurants. These behaviors felt good in the moment, but over time her regimented existence led to less tolerance of uncertainty and to more anxiety.
Intolerance of uncertainty has emerged as one of the most consistent factors predicting anxiety and related disorders. According to a 2019 study by Nicholas Carleton at the University of Regina, Americans have become increasingly intolerant of uncertainty during the past two decades, in step with growing cellphone and internet usage. In his conclusions, Carleton suggested that smartphones have allowed us to avoid sitting with uncertainty.
Compared to people in most societies, past and present, Americans enjoy unprecedented freedom—freedom to live where we want, marry whom we want, and earn money, raise children, vacation, and worship how we want. This array of choices is inherently anxiety provoking, as psychologist Barry Schwartz discussed in his book, The Paradox of Choice. Being left with the burden of creating our own destinies lays bare existential insecurity, the sense that we have nothing solid to hold onto. Striving for wealth, power, prestige, status, and fame can all be seen as attempts to overcome this groundlessness.
My client Amy, who had the fear of bridges, had started limiting her exposure to subways and buses too, after her fear had generalized to other situations where she felt she couldn’t easily escape. Through our work, it became clear that Amy intensely disliked work meetings in which she was expected to contribute. She said she often felt as if her heart was going to explode or she’d pass out, embarrassing herself in front of her colleagues. In therapy, she’d discovered it stemmed from a fear of losing control, the same fear that kept her from traveling around the city.
“That was quite an outing we had last week,” I said in the session after our Key Bridge episode. “I’d like to acknowledge it and see how you’re doing. Can you share how you’re feeling now?”
“It was as if my worst fear came true,” she replied. “It was awful. I couldn’t stop smelling the vomit.”
“I can see how much it affected you,” I replied. “That makes sense. And yet, there’s a calm in your body as you recall the experience, and your speech is a bit slower. This seems different.”
Amy paused. “Yes, it’s strange,” she said. “As bad as I felt on that bridge, my anxiety disappeared for a moment after we sat on the ground. Maybe because I’d hit rock bottom.”
“Tell me more about that.”
“Being slapped with the absurdity of it all. And you, visibly rattled, saying that you don’t always know what to do or how it’s going to work out!
“How did that help?”
“I felt like we were in the same boat, like you truly understood me. It felt like I wasn’t just crazy.”
Hearing Amy say this was humbling. I hadn’t realized how much I tended to rely on CBT techniques to protect myself from becoming vulnerable in sessions.
“It’s human to be uncomfortable with uncertainty,” I said. “But you confronted it and all the physical and mental anxiety that comes with it, and you’re here. I’m blown away by your courage, and I’m inspired by it to be more transparent about my own discomfort as we continue.”
After processing our bridge episode, my therapeutic relationship with Amy was greatly strengthened, and we were able to work on increasing her tolerance of uncertainty. Later, she reported that she’d been able to resist immediately messaging a friend who was running late and abstain from checking the weather and directions every time she went out. Her anxiety was still high going into work meetings and driving over bridges, but she was willing to show up and tolerate not knowing how things would go.
Helping Amy embrace uncertainty taught me that therapy is a way for clients and therapists to grapple with existential limitations together. I realized that in therapy, as in life, sometimes what seems like a big failure can become a transformative experience if we approach it with curiosity. That’s the best antidote for intolerance of uncertainty.
The Fear of Distress and Discomfort
Facing mortality, uncertainty, and groundlessness inevitably brings up uneasiness and distress—in clients and in therapists. Although negative feelings are a normal part of the rich tapestry of life, our contemporary culture emphasizes feeling comfortable and good above all else. We’ve mastered the ability to temporarily escape from anxious feelings and thoughts by habitually anesthetizing ourselves with screens, alcohol, food, drugs, and entertainment. We’ve become a nation of workaholics that limits our unstructured time so we can preempt what might come up if we slow down. I often hear statements from clients like, “I’m afraid I’ll have to face what’s inside if I stop moving.”
In the long run, avoiding undesirable sensations and emotions doesn’t work. Three decades of research on distress intolerance—our tendency to escape or minimize unwanted emotions—shows that it contributes to the development and persistence of most psychological disorders. The more we avoid painful feelings, the less distress it takes to bother us.
Carl Jung captured the idea in his maxim, “What you resist persists.” Deep down, we all know that negative emotions are an integral part of life. But cultural factors, combined with the medicalization of distress by Big Pharma and the ever-expanding DSM, have led to difficulty accepting this existential truth.
Although Amy became more willing to engage in activities that mattered to her, even when she couldn’t be sure how things would go or how she’d feel, she still reported a strong aversion to experiencing physical sensations of anxiety. She’d preemptively take antinausea medication or layer her clothes so she could take some off if she became flushed (these are called “safety behaviors” in CBT). Because of this, she was never able to discover that the physical distress that comes with anxiety is in fact safe and tolerable.
I floated the idea of doing interoceptive exposure to induce elevated heart rate, sweating, throat dryness, and nausea—her most commonly reported sensations. Even as we discussed it, I was conflicted. I find doing interoceptive exposures with clients very uncomfortable, given both the physical sensations they experience during them and that I have to watch them in anguish while we push though. Perhaps picking up on my ambivalence, Amy was reluctant.
“I dislike doing interoceptive exposure myself,” I said. “But I’ve found it extremely helpful for dealing with unwanted physical sensations. What’s coming up for you as we explore this possibility?”
“I’m getting sick just imagining it,” Amy replied. “I don’t think I could ever go there.”
I decided to switch gears. In previous sessions, Amy had softened when talking about her late Portuguese grandmother. I thought going deeper might be a productive way to access and make space for hard emotions, and facilitate exposure work.
“You’ve mentioned that, growing up, you were especially close with your grandma. Could you describe a fond memory from your school years? Maybe a scene with you and your grandma doing something together?”
Amy closed her eyes. “We’re in her kitchen. It’s warm and smells of garlic. I’m chopping vegetables to put in the stew. Granny is tending to three or four pots. Fado music is playing in the background, and granny is whistling along.” Amy’s voice trailed off as her Mona Lisa half-smile betrayed emotions bubbling up.
“What feelings are coming up for you?”
“Love. She had so much love for life. And for me. I’m so sad she’s gone.”
“What a beautiful memory,” I replied. “I’m sorry she’s not with us anymore. I’m noticing that you’re allowing more emotions into the room than before.”
Amy pulled back at my last comment, as if she wasn’t ready to go there.
“You mentioned fado: that’s such a soulful, wistful music!” I continued. “Did your granny talk to you about the songs?”
Amy’s smile widened. “Oh, yes! I knew enough Portuguese to figure out the songs were full of sadness, pain, and hardship, so I had a hard time understanding why she loved them so much. My granny grew up with fado and told me the songs reflected ‘our history and our reality.’ Portugal was often a tough place to live in. But then, she’d always add, ‘There’s catharsis in these songs. Sadness and joy are just two sides of the same coin. It’s about taking whatever life throws at you and really feeling the feelings.’”
“She sounds like a wise woman,” I replied, my eyes watering. “She reminds me of my own grandma.” I paused. “Could we honor your granny by opening up to all feelings, wanted and unwanted? Maybe listen to some fado now?”
“Oh, I don’t know,” she murmured. “It’ll make me cry!”
“What if we give ourselves permission to cry?”
Amy nodded. I pulled out my laptop and searched for “best fado music.” I had a hunch that making room for anything that showed up while we listened would help Amy start to allow negative emotions and physical sensations.
As the passionate, pained voice of Amália Rodrigues, “the Queen of Fado,” filled the office, Amy’s breathing quickened, and her face turned red. She closed her eyes as tears rolled down her cheeks. Minutes passed. Slightly shaking, Amy whispered, “I can’t fight this anymore. Every cell in my body is vibrating and I’m burning.” Then, as if surprised, she suddenly opened her eyes and added, “And I don’t want it stop!”
“How come?” I asked.
“Because I feel alive.”
Our therapy transformed after that session. Gradually, Amy came to tolerate an increasing amount of emotional discomfort and distress. We planned varied exposures: doing one thing each day that provoked some anxiety, foregoing safety behaviors when facing potently stressful situations, and noticing and naming bodily sensations whenever she felt powerful feelings arising, among others. Over time, she became willing to experience even the most difficult emotions, and fully embraced life.
My work with Amy, Sara, and many other clients who’ve benefitted from exposure therapy led me to confront existential fears myself. Facing my human limitations has helped me lean into exposure therapy, even as many clinicians avoid it.
We must be brave enough to stare into the abyss with our clients, be brutally honest about our own fears, and sit with not knowing. Our willingness to face shared existential struggles right alongside our clients can make exposure therapy not only tolerable, but transformative.
PHOTO © I STOCK/FERRANTRAITE
Jelena Kecmanovic, PhD, is a clinical psychologist, the founding director of the Arlington/DC Behavior Therapy Institute, and an adjunct professor at Georgetown University.