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An Unusual Twist to Exposure Therapy

Milton Erickson’s strategy of prescribing the symptom.

This post is in response to
Facing Your Fears: Dispelling the Myths of Exposure Therapy

Exposure therapy is not only used by cognitive-behavioral therapists. As a strategic therapist, I have done exposure therapy for many years with individuals who suffer from fears and anxieties. In strategic therapy, we have another name for exposure therapy: We call it “prescribing the symptom.” We arrange for the patient to face his greatest fear, either inside or outside the therapist’s office. This strategy dates back to an early guru of strategic therapy, the great psychiatrist Milton Erickson.

Erickson not only did exposure therapy in his office; he sometimes arranged for a patient to face his greatest fear in the outside world where the fear occurred. One famous case is an older gentleman who feared riding in elevators. He had to ride an elevator every day to get to his office, as he was getting too old to climb the stairs to the top floor. So he came to Erickson for help in overcoming his fear.

Erickson knew that his patient was a proper prudish gentleman who was married to a prudish woman like himself. So Erickson made a private arrangement with the elevator operator in his patient’s building. The elevator operators in this building were pretty young women.

One day, Erickson escorted his patient to an elevator in his office building. He had his patient walk into and out of the elevator a few times. Then when the patient was comfortable, he told the operator to take the elevator up.

She did and stalled it between the first and second floors. Then she turned to the gentleman and said, “I must kiss you right now.” As she started to move toward him, the gentleman demanded, “Take this elevator up right now.” She did as he asked, but stalled the elevator again before reaching the top floor. Again she said she wanted to kiss him. The gentleman demanded that she start the elevator again and take him to the top floor.

When he exited on his floor, he realized that he had been so scared that the girl would kiss him that he had forgotten all about his fear of the elevator ride. After that, he never again feared taking elevators. Erickson had exposed his patient to an even more fearful situation to distract him from his fear of elevators.

One of the most typical fears I deal with is social anxiety. One young man was very successful in his career as a manager in a tech company. But he had a fear of going to happy hour on Fridays with his employees. He was terrified of making a mistake and being judged, so he always made excuses not to join the others to socialize after work.

In my office, I asked him to imagine going to happy hour. His anxiety level shot up to a 10 out of 10. I asked him what he was afraid of. He said, “I’ll make a mistake, and people will laugh at me. I’ll want to run out of there, and that will look bad.”

I told him the only way to overcome his fear was to go to a happy hour and deliberately make a mistake. He looked at me in surprise. “Will that really help?” he asked. I assured him that it would. He said he would try it.

We then spent a long time talking about the various kinds of mistakes he could make. He could order something he didn’t like. He could forget his wallet. We went through many mistakes that he feared he could make in the situation.

In the next session, I asked him if he had gone to the happy hour and deliberately made a mistake. He said jovially, “I got so drunk that I made a lot of mistakes!” After that, he went to happy hour every Friday.

One important caveat about prescribing the patient’s symptoms or doing exposure therapy is that the client should have a strong, trusting relationship with the therapist. It helps if the therapist has a track record of helping the client with other problems, so the client trusts her. Whether the therapist does cognitive-behavioral therapy, strategic therapy, or some other kind of therapy, the therapist-client relationship is a key component in helping a client overcome his fears by experiencing them.

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