Barbara O. Rothbaum has been working with people who have post-traumatic stress disorder, or PTSD, since 1986, not long after the condition became an official diagnosis back in 1980. She has seen it all – the jumpy, sweaty, can’t-breathe panic and near fainting that happen when the surf washes over someone’s waist and they’re sure they’ll be sucked under; the horror of impending abuse or trauma that flashes up with the click of a key in the lock. It’s never pretty and often doesn’t end well.
“Weekly therapy is like ripping off a scab,” says Rothbaum. “In the week between sessions, the scab heals a little – but you know you have to go back and experience the pain of ripping it off again. Who wants to do that?” Nobody. It’s why most PTSD treatment programs have a high dropout rate. Hell, it’s why a lot of those suffering from any kind of anxiety – whether it’s a serious fear of flying or an obsessive compulsive disorder (OCD) that keeps you from using public toilets – don’t go to therapy at all.
“Many people with anxiety avoid therapy because avoidance is part of the problem,” Rothbaum says. It’s also why she and a handful of other practitioners are getting radical, shortening the course of therapy for conditions like PTSD, OCD, panic attacks and certain phobias – sometimes to three weeks, other times three hours. They’re practising a new, more intense version of exposure therapy. Rather than scheduling weekly hour-long sessions to work on this, a therapist might spend three hours every day for three weeks incrementally increasing a patient’s exposure to their worst fear. A guy with a debilitating aversion to germs might eat from a shared tub of popcorn with no hand sanitiser in sight. Later that week, he might be asked to put his hands on the floor of a public bathroom without washing them afterwards. This approach is short. It’s intense. Adopters say it’s like HIIT for your emotions, and science is finding that it gets the job done.
INSIDE ANXIETY BOOT CAMP
It may be news to many therapists and anxious people, but condensed courses of treatment for anxiety have been around since the ’70s, the brainchild of Swedish researcher Lars-Göran Öst. As a young psychologist, he noticed that his phobic patients didn’t need the 10-12 sessions that were typical at the time; he was eliminating their phobias in just four or five. It wasn’t a superpower that he alone had; other therapists could get these results if they were willing to revise their treatment.
“Most patients come in for 50 minutes and make some progress, but when they come back the following week, they don’t start their second session where they ended the first – their anxiety has ratcheted back up,” says Öst, now a professor emeritus at Stockholm University. By using intense exposure therapy – coaching a patient with a fear of elevators into an elevator, for example, or letting a spider crawl all over someone with arachnophobia – he was able to disprove his patients’ beliefs about what catastrophic thing would happen if they came in direct contact with whatever it was they feared, usually in two to three hours, but often in as little as an hour.
To prove its effectiveness, Öst conducted a randomised controlled trial comparing his method to standard cognitive behavioural therapy (CBT) and found that not only did his approach work as well, but 90 per cent of his patients who were undergoing intense exposure therapy were either much improved or completely recovered after just one session. That’s the kind of time frame even the most overcommitted people can work with. Practitioners seeking a better way to help their patients have launched programs based on this research. For instance, Rothbaum’s therapy for veterans with PTSD requires only two weeks of intense work. The short time commitment has helped lower the dropout rate to about 10 per cent from its usual 25-50, she says. Thomas H. Ollendick, a specialist in child psychology, successfully treats kids with OCD in four days and those with specific phobias (like a fear of dogs or heights) in a single three hour session.
NOBODY CALLS HIIT EASY
In theory, any practitioner trained in CBT should be able to work intensively with people who have anxiety disorders. In reality, inertia and scheduling get in the way. “Despite no evidence that one 50-minute therapy session each week is the best way to do psychotherapy, it’s the standard,” says Ollendick. “We are unsure how this standard evolved.” Scheduling two or three hours at a time over the course of a few weeks is tough for most practitioners, although doctors say patients overwhelmingly prefer it.
And the work itself is hard. The majority of therapists don’t practise exposure therapy because it’s difficult logistically (how can you treat a fear of elevators if you’re in a building without an elevator?), because it makes them feel uncomfortable (exposure therapy is challenging, for both the patient and the doc, says Ollendick), or simply because they’re used to the standard approach.
“A lot of therapists will talk to you about things unrelated to your anxiety, and while that may feel good, it’s probably not helping the symptoms you’re dealing with,” says Rothbaum. Then there’s the money thing. Many private health insurance companies don’t cover these intensive outpatient treatments, which can cost upwards of thousands of dollars a week, even if it would mean fewer hours of therapy than the traditional model.
Still, there’s hope. At the forefront of intense exposure therapy are professors and researchers, teaching its methods to their students and publishing studies about the efficacy of this HIIT-style approach – two important steps necessary for it to really spread. All the quick results experts say, however, that CBT delivered in the traditional weekly format can still be very helpful for anxiety. “In the end, we know that learning to feel less anxious about your anxiety is key,” says clinical psychologist Jonathan Abramowitz, no matter how you get there. “But it’s important to note that it doesn’t have to take a lifetime on a therapist’s couch to get that lesson.”