Living With Chronic Pain

How Graded Exposure Therapy Works

Last week I explained how I used graded exposure therapy to start an exercise program that’s been a part of my life for decades, even though I didn’t know what the process was labeled. For me, it was just a slow, methodical and persistent process that moved me forward, away from the fears and habits that kept me stagnant. 

Graded exposure therapy is just that, a way to move forward.

There are many types. Each with their own inherent strengths and weaknesses.

Imagery. This allows you to deal with your fears through imagined settings that get purposefully harder and harder while in a safe environment. Especially helpful with settings that can’t be easily reproduced such as fear of flying or snakes.

Virtual. In this day and age virtual reality can be amazingly real to the senses. Making the sensation of being on that plane, or actually touching that snake more of a reality.

*  Interoceptive. Reproducing the physical manifestations that go along with the fears in order to calm and manage them. In this setting, running in place to escalate heart rate, induce shortness of breath…. Then learning ways to counteract the responses.

* In Vivo. Dealing with your fears in real life. As I did with getting more active. Here we actually learn skills to overcome the limitations we’ve created that keep us shackled to the fear of pain. This is the one I’ll discuss in more depth today.

We naturally limit our activities when they hurt. It makes sense. Why encourage pain? But over time more and more hurts so we do less and less, until we do nothing at all. Fearing anything that might worsen our pain we avoid everything. Initially it may seem productive, giving us a false sense of empowerment, but this viscous cycle of avoidance just leads to a life filled with fears, anxiety, worsening immobility and ultimately isolation. Eventually, the very act of avoidance compounds our fears, making the brain react as if even the thought of a particular action should cause pain. It’s a self-fulfilling prophecy. The muscles weaken from disuse and the action becomes harder to perform reinforcing why it should be avoided.

With graded exposure therapy we face our fears head on and prove those activities can be experienced, even if pain occurs, without causing damage or harm. Studies have shown when added to manual therapies e.g. physical therapy, it produces significantly higher rates of improvement than manual alone. 

It starts by learning what causes pain and why avoiding certain behaviors is maladaptive, not beneficial. Understanding :

  • Pain doesn’t always mean danger or imminent damage
  • Pain is always a result of brain signals. It’s how the body experiences pain, regardless of the inciting cause
  • Pain is influenced by everything we feel and do. By not only actions but stressors, how we sleep, relationships in our lives, work, settings
  • Acute pain protects us
  • Chronic pain is no longer responding to an actual danger but a hypersensitivity of the nervous system. Realizing this distinction is how treatments help to improve the quality of our lives.

Then learning how to slowly exposure yourself to those situations that illicit fear and avoidance until they no longer create issues that limit our activities.

Identify what situations elicit fear by completing and in depth list. Think about when and what activities spark concern. Or which have been eliminated all together as a defense against even the possibility it would cause pain.

Define which produce the most or least fears. Graded exposure therapy begins with the least fearful and works it’s way up. This way we teach our brains to stop reflexively reacting with fear and shut down the resultant pain signals those feelings generate. Each success builds confidence and acts to stop the cycle. 

Plan simple exposures. Is the idea of walking any distance too much to contemplate? Plan a few steps in the house, first. For added support ask a friend or loved one to participate in the beginning then slowly increase the length and time you’re walking alone.

*  Prepare responses. The minute fear and pain are felt remind yourself the simple act of walking is not the issue. Talk through it, reassuring yourself neither will cause harm or damage. Understanding the more you stretch, mobilize and surge, much needed nutrients to the areas, feeling pain the stronger they’ll become. Take frequent breaks and build up slowly. We aren’t running a marathon.

* Breathe. Don’t forget to breathe

It’s scary to face fears and push ourselves into the very activities we’re sure will hurt. But the more we do, the more we’ll realize those actions need not be feared. Confidence will grow and the shackles slowly removed.

In mild cases, trying this on your own may be an option. Incorporating aspects of this into daily life to gently push your boundaries and overcome fears is a reasonable option. But for most, finding a therapist trained in this type of cognitive behavioral therapy is best. Studies found therapist directed graded exposure was more effective than self-directed treatments.

Successful outcomes are defined by four different measurements:

Habituation. By performing a specific action repeatedly the anticipated fear it evokes is reduced over time.

Extinction. In time the brain learns a particular activity is no longer something to fear.

Self- efficacy. Confidence grows, reinforcing how capable we are at overcoming and controlling our pain. 

Emotional processing. Healthier emotions are attached to our pain and fears, changing how we see it and our lives 

Graded exposure therapy can be an effective treatment to help most past fears and become more active and engaged. Studies show up to 90% felt it significantly relieved their original symptoms after completing a course of treatment. 

It’s a great technique to have in our arsenal of responses when fear and pain threaten to shut us down.







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