Exposure Therapy 1

My name is James Weston. I have been feeling so much better after spending the past eight months working to improve my mental health. I can't say that the process was always easy though. I can recall one specific session, at the midway point of treatment, that really helped move me forward.

I sat in the waiting room at the university counseling center; it was an archetype of what one might expect for a college clinic. There was beige wallpaper, a few pictures of trees and rivers on the walls, lifestyle magazines splayed across a battered table, and a water cooler in the corner. I was sitting on the couch thumbing through a copy of Time magazine from two years ago.

"James, you can head back now," said the friendly receptionist.

I navigated through the hallway to the last office. The plastic name placard to the right of the door read: "Alex Nilsson, MS." The door was ajar with the light on. I pushed it open and proceeded to enter.

The office was on the smaller side, with a large, boxy, gray chair facing the door. There was a simple circular table next the chair; it had a clipboard, pen, and water bottle resting on top of it.

I settled into the black pleather loveseat with my back to the door. On the table to my left was a box of tissues, a small clock, and a Rubik's cube. I picked up the toy and stared to play with it. I don't remember why; I had never completed one of them in my life.

I felt a hand press on my shoulder as the door creaked behind me.

"It's good to see you, James," Alex said. "Sorry you had to let yourself in. I had to take a call between sessions."

His hand left my shoulder, and I was sad to feel it go. He walked across the small office and took his seat on the gray chair.

Alex was the kind of guy to whom I had always been attracted. At 6'3," he was much taller than me. He had a muscular frame; you could see his defined biceps through his clothing. Today, he was wearing a fitted periwinkle dress shirt, charcoal-colored dress pants, and a black leather belt with matching dress shoes.

I was not certain of his age, but I had ascertained through various comments that he was in his late twenties. I knew that he had completed his master's degree and was getting close to finishing his doctorate in psychology.

Alex had tussled, sandy-blond hair that he wore in a side part. His green eyes reminded me of a lush forest. He had a broad, well-defined jaw. His skin was fair; he had one slight line that would become increasingly defined on his forehead when his face expressed concern. He had a large, dazzling smile that revealed two small dimples when it reached full wattage.

"No worries," I said, pointedly returning the Rubik's cube to the table. "I always find a way to keep myself occupied."

At 19 years old, I was just starting the spring semester of my sophomore year. I had struggled with anxiety since high school but had never sought treatment. A few months prior, I'd had a small anxiety attack. My best friend had recommended I go to the university counseling center, since undergraduates had access to free sessions with a therapist-in-training.

I had initially been nervous about the prospect of having a guy for a therapist. I had always felt more understood by the women in my life; my dad and brothers were not the type to discuss their emotions. I think I'd been even more nervous because I had been shunned by my closest male friend after I'd come out as gay during my junior year of high school.

Upon first meeting Alex, I could definitely tell that he was a "guy's guy." He had asked me what sports I played when inquiring about my hobbies, and he'd talked about how he, too, had worked on cars with his father when he was a teenager. He'd also mentioned that he was going to be marrying his girlfriend in about six months.

I remember being worried at first that he would not be able to relate to any of my experiences, or that he might reject me, but he'd quickly won me over. He would tell me that it was normal to be sad and afraid, and even to cry. He even talked about how he'd struggled to accept that it was okay to do the latter for many years because of how he'd been raised.

I'd continued to keep myself guarded, though. Then, one day, Alex had asked if I had a boyfriend. We had never talked explicitly about my sexuality up to that point. He had previously asked if I "had a girlfriend," during the first session, and I'd vaguely replied that I was single. Alex had disclosed that he had been reflecting on our sessions and realized he had made an assumption, so he wanted to ask again in a less "heteronormative" way. I assumed that he must have a queer mentor to be tossing out a term like that.

I'd told Alex about my experiences with coming out and being rejected. He'd been empathetic, and had provided validation of what I had gone through. We'd talked about how my anxiety had really started to increase around the time I'd come out as gay. I had become so worried about others seeing me as defective that I'd started to be fearful of taking up space in certain contexts, especially in situations where I worried that I would be judged for my sexuality. That first month had really allowed us to build the foundation needed for our later work.

Alex picked up the clipboard and placed it on his lap.

"How are you doing today?" he asked.

"I'm fine. I slept in a little this morning. I have been working on a paper for my econ class, so I stayed up too late last night. I had to have some coffee this morning."

Alex tilted his head and gave a little nod.

"I know, I know, we talked about how caffeine impacts my anxiety. I promise it won't start to become a regular thing again."

"I appreciate the insight," Alex replied with a slight smile. "Let's jump right into setting our agenda. I'm not going to let us get off track this time."

I knew what he was going to ask, and I felt my heart beating a little more quickly in my chest. I looked away, shifting my focus to the clock on the table next to me.

"So, did you do the homework?" he inquired. "You know, exposure can only lead to change if we are willing to push through the initial resistance and face what we fear head on."

"I did the assignment that I had been working on before," I replied. "The one where I use the swimming pool at the athletic center."

"Okay, so tell me about that."

I could see that he was taking a few notes in his pad. He seemed less interested in what I was saying than he had been in the past. I wondered if he was disappointed in me.

"Well, I went to the gym two times last week. I still felt some anxiety when the time to go there approached. About an hour before, I started to think of reasons I should just not do it, like having to work on projects and telling myself that not going is not that big of a deal."

"Where do you think that attempt to reason with yourself came from?"

"I know we've talked about avoidance. I'm sure my anxiety was making it so I was looking for reasons to avoid what is making me afraid."

Alex rubbed his hand against his defined jaw as he nodded in agreement with my self-assessment. I hoped that meant he thought I was making progress.

"When I was walking to the athletic center," I continued, "I kept thinking about how everybody would be staring at me and judging me. I still pushed myself to go, though. I had the hardest time when I was changing in the locker room. I kept worrying that the towel would fall from my waist as I changed into my swim trunks underneath it."

"What would have happened if the towel had fallen down, James?" Alex asked in a gentle tone.

"Everyone would have stared at me, and then I would have started to have a panic attack. I even imagined myself passing out naked in front of all those people."

I felt a shiver go through my body as I once again pictured myself in that scenario. I had imagined myself laying on the floor, unconscious, with my body exposed. The other men in the locker room were looking at my unimpressive body, wondering what to do. I played out how some of them would rush over, getting an even better view of my shortcomings.

I tried to redirect my attention back to Alex by focusing on his soft, pillowy lips as he spoke.

"James, we've talked about this before. Those people aren't watching you while you change. That's the 'spotlight effect,' remember? We tend to overestimate how much other people are paying attention to us."

I nodded. I knew he was right; everything he said made sense in these sessions, but I felt like it slipped away when I was out in the real world.

Alex uncrossed his legs and spread them far apart. I looked at his inner thighs; the fabric of his pants pulled tightly against them. They looked dense. I saw the outline of a small band pressing against that same fabric a few inches from his inseam. I wondered if it was the hem of his underwear.

"The more we engage with the exposure activities and move up the hierarchy, the more we can push back against the underlying cognitive distortions," he reiterated.

Alex placed his clipboard on the table and leaned forward towards me. The top two buttons of his shirt were undone; I could see a bit of his sparse, sandy-blond chest hair.

"We both know you have social anxiety, James. Part of it stems from your maladaptive core beliefs about your body. We have discussed how your body is normal, and it's something about which you should have pride."

"I don't think all of it is normal," I replied in a defeated tone "I think that is just something we say to comfort ourselves."

"How tall are you?" he asked.

"Five-eleven," I responded.

"Weight?"

"A hundred and eighty pounds."

"Do you have any physical limitations or congenital deformities?"

"No," I said, knowing what he was trying to accomplish.

"So, what is it that makes you so abnormal?"

I felt my heart begin to race. I'd never actually said the words, even though I suspected he knew the source of my insecurity. That was worse, somehow. It was like he knew the thing itself, and that I was right to be insecure, because I was abnormal.

My face began to flush, and I crossed my arms in front of my chest.

"You are going to think I am crazy," I said. I took a long pause." I don't think I can do this."

"I promise you that I won't think you're crazy," he said gently. "It can be frightening to share things about ourselves, especially when they make us feel so much shame."

"I think I have a small penis," I blurted out in a whisper.

Alex nodded his head and furrowed his brow. I could see the small crease deepen on his forehead.

"You aren't alone," he replied. His tone was serious and professional. "I talk to guys about their insecurities every day. A lot of them worry about how they measure up. I think porn has given us unrealistic expectations of what is normal when it comes to penis size."

"Maybe," I said, averting my eyes.

"How many inches long is it?" he asked.

I couldn't believe what he was asking; had I misheard him? A wave of nausea overtook me. My breathing became a little shallow. I wasn't sure if I could reply.

Alex leaned forward a little more; he placed his hand on my left knee. I felt a shockwave shoot from the nerve endings in my knee to the ones in my groin. My scrotum pulled tighter against my body. Alex had only ever shaken my hand or patted me on the shoulder.

"It's okay," he said, looking directly into my eyes. "Just breathe."

I inhaled deeply while counting to five in my head, then exhaled.

"About five inches," I said. I realized I needed to offer some clarification. "...when it's hard. Three inches when it's soft."

"That's not abnormal," he said. "You have nothing to be ashamed of. Recent studies have found that the average length of an erect penis is somewhere between five and six inches."

I could feel myself blushing. I was struggle to accept that he was talking about this topic; it felt so taboo. I had never brought it up for the very reason that I didn't think I could handle having this discussion. Alex lifted his hand from my knee and slid back into his previous position on his chair. I wondered if had sensed my growing discomfort, causing him to pull away.

"So even if your towel were to fall down, nobody is going to mock you," he said. "Hearing this, I'm assuming you didn't move up the hierarchy to your next goal?"

I shook my head from side to side, indicating that he was correct.

"James, you have been stuck on this next exposure activity for three weeks. I'm so proud of you for confronting a trigger head on by going to the pool, but you're getting stuck. Tell me what your next task was again?"

"I was supposed to take a five-minute shower, at least once, after working out at the gym."

"And you know why this is important, right?" Alex asked. "Each time you back away from this next activity, the anxiety gains ground. And it reinforces this maladaptive belief that there is something wrong with your body."

I nodded, making an effort to meet his gaze. There was a kind, gentle expression on his face. I felt like he genuinely cared about me.

Alex unbuttoned the sleeves of his dress shirt. He carefully rolled the fabric up, leaving his forearms exposed. They were covered in the same soft, sandy-blond hair as his chest; they were vascular, with a few prominent blue lines bulging on each arm.

"What was our rule about homework? We talked about it when we first started treatment."

"I don't remember," I said, which was only partly true.

"We agreed that, if you avoided a specific homework activity for more than three sessions, we would use our time together to tackle it as a team. It is crucial that we don't enable avoidance in our work."

I was confused. I was not certain what he was talking about, or what he wanted from me. I could understand him forcing me to fill out a record of my cognitive distortions in session if I hadn't completed it, but what could be done about me failing at something like this?

"Do you have your student ID on you?" he asked.

"Yes," I replied, wondering why that was important.

"Let's go do your homework then," he said, standing from the chair.

I followed him, still perplexed about what was happening. I trailed him by a few feet until we made it out of the building. Once we stepped outside, he turned around, closed the distance, placed his hand on my shoulder, and looked me in the eyes.

"The athletic center is right over there," he said. "It's only a two-minute walk. We have more than enough time to go there and have you do your homework before the hour is up."

My eyes widened. I started to inhale frantically. I felt like someone just dropped a ton of bricks on my chest. I didn't think he could be serious, but was nevertheless afraid he was.

I imagined myself in the shower, struggling to breathe and feeling dizzy. I could see everyone nearby watching, wondering if I was crazy. I envisioned myself falling to the floor and hearing someone call for help. I pictured Alex running into the showers, still fully dressed in his professional attire.

I pictured him looking down at my pathetic body as he towered over me, the water from the shower falling on him, making his periwinkle shirt transparent. I could imagine the fabric clinging to his defined biceps and accentuating his small nipples as he stared at my crotch. I could hear him saying, "Wow, it really is small. I thought you were just being self-conscious, but guess I was wrong," as I started to pass out.

"Just breathe," the real Alex instructed. "Remember, inhale through the nose and exhale through the mouth."

Alex waited while I spent a minute regulating my breathing pattern. He modeled the correct pace so that I could focus on him, rather than trying to count in my head.

"I can't do this, Alex," I pleaded. "You saw it; I almost just had a panic attack. I'm going to freak out in the shower and not be able to breathe. I'm going to pass out in front of everybody."

I felt a single tear roll down my cheek. I didn't think I was going to be able to hold back the rest.

Alex lifted his hand from my shoulder; he used his soft thumb to wipe the tear from my face. He positioned his hand under my chin, using it to direct my gaze from the ground back into his forest-green eyes.

"Okay," he said simply. "We will do this together then. I'll come with you, so I'll be there to help you if you feel too overwhelmed. That way, you know that you aren't going to get to the place where your biggest fear becomes reality, since I am not going to let you pass out."

I didn't know what I felt hearing him say this. I knew I liked that he cared about me enough to reassure me, and I was also frightened. I believed he would do his best to support me but I questioned my ability to do the same for myself.

"You trust me, right?" he asked.

"Yes, I trust you," I responded, feeling a sudden sense of calm push back against the anxiety.

Alex moved to stand at my side. He wrapped his large arm across the back of my shoulders. I could feel his muscular bicep as it slid past the nape of my neck. We walked over to the athletic center together.

We were in the men's locker room within two minutes of arriving. The walk over from the counseling center was already a blur. I was following Alex to the lockers near the end of the room; they were positioned next to the entrance to the communal showers.

Alex opened one of the lockers. There were a few other people coming and going nearby, but I was trying not to focus on them. Luckily, it was a time of day when things were a little less busy, since most student were either in class or eating lunch.

"Okay," he said, "I am going to go grab a towel for you. I'll turn the other way while you undress. The showers are only ten feet away from here. If you take the one closest to the entrance, I can still speak with you from around the corner. I can check in to see how you are doing, and help you with your breathing, if you begin to struggle."

I stood there as Alex went to grab a towel. I knew I couldn't do this. Everyone in that shower was going to be staring at me. If my anxiety made me do anything odd, they were going to think I was some kind of gay pervert. My habit of engaging in predictive thinking reared its ugly head: what if I looked at one of them by accident and they thought I was checking them out? What if they freaked out? What if I freaked out?

Alex returned; he placed the towel inside the open locker. I could feel my anxiety growing as any former sense of calm slipped away.

Alex turned so that his back was facing me. I rapidly took off my shirt and stuck it in the locker. I was less ashamed of my torso. I tried to regularly lift weights and exercise. I had moderately sized biceps, although nothing massive. I had unblemished, pale skin with no hair on my chest. I had lightly defined ab muscles; below them, a small trail of dark hair led down from my belly button into my pants.

I fumbled to undo the button on my jeans; my hands were shaking. When the button came undone, I started to hyperventilate.

"I can't do this," I whimpered.

Alex turned around. He could see that I was taking shallow breaths and shaking. "Focus on your breath; in through the nose and out through the mouth."

I was trying, but it I felt like I couldn't slow my breathing down. I was having a hard time getting the air I needed.

"You're breathing into your chest," Alex said. "Pull the air down into your diaphragm." He placed one of his hands over my pecs and the other across my abs.

I flinched, since I had not been expecting the physical contact. His hands were soft and firm; they were warm against my skin. After my initial shock wore off, I found that I was able to use them as focus points. I worked to pull the air towards the hand on my abs, and I felt it rub me every time I inhaled. After a few minutes, I was able to breathe normally again.