Enhancing Exposure Therapy, Part I – It’s all Fun and Games

Exposure therapy is a treatment in which someone faces a situation that makes him or her anxious. We know that exposure therapy is the frontline treatment for anxiety disorders. It seems to be the active ingredient in cognitive behavioral therapy (CBT). For both children and adults there is excellent research supporting that this treatment works for OCD, PTSD, panic disorder, separation anxiety, social phobia, and specific phobias. Most people don’t even need medications to get this benefit! How awesome that we have such a great treatment.

However, exposure therapy is not done nearly enough in the community, to the point that if you go and see a provider for anxiety treatment you will likely not receive exposure therapy, and possibly won’t even receive any form of CBT. Even those who provide CBT focus very heavily on other techniques such as relaxation and cognitive therapy.

There are many reasons why providers don’t engage in exposure therapy. One of the major roadblocks is the belief that it is an unpleasant experience. I aim to show that it’s not. It really doesn’t have to be!

The purpose of this series is to show how exposure can be enhanced in various ways, the first of which is by using games or enjoyable activities. Believe it or not, exposure can actually be a fun and bonding process. By the end of treatment, patients often say that exposure is the reason they got better. Even in PTSD treatment, the literature shows that patients and families identify the exposure process (the narrative – talking about the trauma many times) as key. If exposure is going to be fun and bonding, it takes some skill, nuance, and creativity.

As we go through these ideas, I want you to remember one central tenet – you should always target the fear, and these strategies should supplement and not distract from that purpose.


It’s All Fun and Games

If you make exposures into games and fun activities, the outcomes will improve. Motivation and engagement in the process will increase for everyone involved. To know this works, look no further than in education; Look at the amount of apps that make learning into games so that kids enjoy it more. Or think about how many programs exist to make kids exercise more. It’s really hard! But then along came Pokemon Go and everyone was walking miles and miles a day. Games improve motivation, and they are crucial to successful treatment.

If you make exposures into games it turns what could be a dry and anxiety-provoking experience into a fun and anxiety-provoking experience. I am also of the belief that someone is far more receptive to new ideas when having fun. In addition, think about basic psychology for a second and you’ll realize that playing games while doing exposure is also pairing an anxiety-provoking stimulus with a pleasant one, which should create positive associations. Finally, I believe that playing games allows someone to look at a problem from a new angle, which should facilitate learning.

Below, are some of my favorite examples for different anxiety disorders:

Social Anxiety:

One of my favorite activities is playing the lost at sea or survival on the moon team activities for an individual suffering from social anxiety. These games are such novel tasks, and I love how everyone has fun messing up and playing with different ideas to come up with a solution. Depending on the fear, I purposeful ask my clients to say something that sounds really dumb during this activity.

How about walking outside with clothes on backward seeing who can get the highest number of strange looks from passers by?

Or going on a treasure hunt around town having to ask people for directions or information in order to get to the end.

Obsessive-Compulsive Disorder:

For OCD related to contamination, see if you can one-up each other in a grossness contest. You will need some sort of trophy!

For OCD related to scrupulosity, try to break the most rules in 5 minutes. Keep a “world record” tab of the most rules broken.

You can create a bowl of different exposure ideas, perhaps 20, and throw in a couple of reward ideas too. Each day pick a new exposure from the bowl that you have to do. Sometimes you’ll get lucky and just win a prize 🙂

Many people also do a bingo activity where the bingo board is different exposures, and you earn prizes for completing certain patterns on the board.

Generalized Anxiety Disorder:

Similar to OCD, I really like creating a bowl of exposure ideas to add some uncertainty and randomness to the exposures. It just depends on the fears.

Play any game about perfectionism! The game “Perfection” is a good start. Play Operation. Have a speed typing contest.

Imagine the bad outcome, and then try to make it end in a funny way. If you yell “ridikkulus”, you win!

Panic Disorder:

Once you have created the physical sensations (e.g. by spinning, hyperventilating), play a board game or throw a ball back and forth while the symptoms are going on.

Try and spin around in a chair the most times with only 1 push allowed.

Climb the stairs of the tallest building you see – You’ll feel so proud :)!

Recreate a movie scene that the person enjoys that involves lots of triggering physical sensations. You could try to recreate one of the scenes while the person breathes only through a straw while running.

Separation Anxiety:

While you are doing a separation with a child, write a story together about what could happen to their parents if the world was a fantasy world (e.g. a dragon appears and takes them on a journey). Read the stories together and compile a collection.

Map out a journey for the kid to take with you, leaving their parents. Make it interesting to them. For example, make it into a voyage with side quests, such as collecting different items around town.

Do something new that seems adventurous while on a separation. For example, take a boat ride!


Turning Common Games into Exposures

Another thing you can do is take a common game, and think about how to make it into an exposure. Here are a few ideas:

Hide and Seek: Increase the length of time before start looking (separation anxiety)

20 Questions: In front of people (social anxiety); play 20 questions (GAD (perfectionism))

Board Games: Play with strangers (social anxiety); Make mistakes on purpose (GAD (perfectionism))

Tag: Have to breathe through straw or spin every 20 seconds while playing tag (panic); While playing, other people have contaminated clothes (OCD)

Simon Says: Follow only instructions that begin with “Simon says” GAD (perfectionism)

Catch: Throw a ball or kick a soccer ball back and forth in public (social anxiety); Spin around in circles and then try to catch a ball (Panic)

Card Games: Have cards touch many people’s hands (OCD)

Jigsaws: Perform with others or alone (social phoba, GAD (perfectionism))


Well I hope this article helps with 2 things. Giving a license to have fun, and giving some ideas on how to do it. Look out for part II, which will talk about turning common daily activities into exposure targets.

Leave any ideas or comments below. Thanks!

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