Exposure Therapy Is Not a Treatment for Anxiety

Podcast 265: An Extreme Leech Phobia: Once Bitten, Twice Shy!

Today’s podcast features the treatment of an extreme leech phobia in real time, using live leeches. Dr. Danielle Kamis, a clinical psychiatrist practicing in Los Altos, California, is our courageous patient, and Dr. Matthew May, a frequent guest on the Feeling Good Podcast, conducts the treatment, while David and Rhonda observe and comment.

If you ever saw the famous Humphrey Bogart movie, “African Queen,” you know how terrifying leeches can be. But why in the world would anyone working in downtown Los Altos, California, need or want treatment for a leech phobia?

Danielle is an extremely brave and adventuresome young professional woman who loves traveling to remote places around the world (Danielle is an extremely brave and adventuresome young professional woman who loves traveling to remote places around the world.  She has had a keen interest in global health work and has spent a significant amount of time doing research with indigenous population in the pre-Andes mountains of Argentina. She has also spent time living with tribes deep in the Amazon forest as well as the jungles of Sumatra. These experiences have transported her back in time to better understand the core components of humans in our most natural state.

She described a terrifying experience while exploring in a jungle in Sumatra, where the leeches not only invade the water, but can also drop onto you from trees. After hiking through the beautiful, lush landscape for some time, Danielle began screaming and sobbing in terror when she noticed that her foot was bleeding because of a leech that had just detached itself. This was understandably embarrassing, and she realized that she needed to overcome this fear before going on another jungle adventure.

In today’s therapy session live leeches will be placed on Danielle’s skin, and she will be encouraged to surrender to the anxiety and make it as intense as possible, rather than running away or trying to control or avoid it. This is an extreme form of exposure called “flooding.” It  can be incredibly effective, and often works quickly, but requires great courage on the part of the patient and therapist, as well as a high degree of therapist skill.

To prepare for today’s exposure session, Danielle obtained four live leeches, which she kept at her apartment. She said that even looking at the leeches slithering around in the water and thinking about them biting her made her fear instantly jump to 9.5 on a scale from 0 (not at all) to 10 (the most intense anxiety).

She asked Matt if he’d be willing to do the leech exposure first. Matt agreed, since we never ask our patients to do anything that we wouldn’t do, ourselves. This modeling by a trusted friend or therapist can be a useful tool in the treatment of anxiety.

Danielle carefully removed one of the leeches with a spoon and placed it on Matt’s forearm. After crawling around for a minute or so, the leech attached itself and begin to engorge itself on Matt’s blood.

Danielle watched in fascination and fear, and then it was her turn. She bravely placed a second leech on her forearm. She was afraid it was going to be extremely painful, but was surprised when it was just a mild feeling of sandpaper on her skin. Over a period of about ten or fifteen minutes, with episodes of nausea and profuse sweating, Danielle’s anxiety gradually dropped from 9.5 at the start all the way to 1, and she felt triumphant.

You can see some photos and videos of the session here, including our lunch prior to the session at the Phoa Cabin in downtown Los Altos. It is a favorite local spot that features tremendously tasty Vietnamese food.  (LINK)

Teaching points in today's TEAM-CBT session include the following:

1. Avoidance is one of the major causes of all forms of anxiety. When you avoid or try to escape from your fears, they will always intensify.
2. Exposure is a powerful treatment tool for anxiety, but is not a treatment per se, and there are many additional tools with powerful anti-anxiety effects. I (David) use at least 40 tools in the treatment of anxiety, but exposure must always be included in the mix. It is probably impossible to cure any form of anxiety without exposure.
3. All patients and most therapists resist and fear exposure. Patients fear exposure because of the intense anxiety they must endure and their belief that something terrible will happen if they don’t avoid their fear, and most therapists are also afraid that the patient is too fragile, or the procedure is too extreme, and something terrible will happen. However, I (David) have never had a bad outcome when using exposure. I am convinced that poor therapy skills, and not exposure, cause negative outcomes in the treatment of anxiety.
4. Excellent empathy is extremely important in treatment of Anxiety. Danielle mentioned the importance of her trust in Matt, and in his modeling of the exposure in the treatment. I (David) strongly agree with this, as I have had to use exposure in the treatment of my own fears and phobias and have also benefitted from doing exposure with someone I trust and admire.
5. Once you’ve beaten a phobia, and no longer fear the thing that once caused terror, fears have a way of creeping back in, especially if you do not continue to face the thing our feared. To prevent this, ongoing exposure is needed. Although Dr. May treated Danielle for this problem successfully in the past, Danielle’s intense fear of leeches had returned during the COVID pandemic. While some form of relapse is almost always inevitable, the good news is that facing your fear frequently can massively reduce the frequency and intensity of relapses.

Danielle seemed pleased with her session and agreed to do ongoing exposure on her own every day with the leeches as homework. The next day, we received this email from Danielle.

Hello!

I had a fantastic time yesterday with you and I am so grateful for all of your support and guidance. Thank you so much for taking the time to help me overcome my fear and help others do the same!

It was so wonderful and special seeing you all again in person.

Here are some awesome photos from the session as well as our lunch at the Phoa Cabin, and this link contains two videos.

Rhonda, Danielle, Matt, and David