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Exposure therapy is a technique used in the treatment of anxiety disorders like phobias or posttraumatic stress disorder (PTSD). Its goal is to help individuals overcome specific fears or sources of anxiety. It works by exposing them to anxiety-provoking situations or stimuli in a gradual, controlled way to reduce fear. For example, someone afraid of spiders would be systematically exposed to spiders under a therapist’s guidance.
The idea is that avoidance maintains anxiety, so controlled exposures teach the person to manage fear and decrease avoidance.
By creating a safe environment, the person learns the triggers are not dangerous, so anxiety is decreased through new learning.
Types of exposure can include real-life interactions, imagination, virtual reality simulated exposures, or intentionally bringing on bodily sensations like dizziness. It is often used within cognitive behavioral therapy (CBT) as well.
What Conditions Can Exposure Therapy Help With?
Exposure therapy is typically used in the treatment of anxiety disorders, as these are conditions where there is a lot of fear to overcome. Some of these anxiety disorders include the following:
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Posttraumatic stress disorder (PTSD)
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Phobias – such as specific phobias and agoraphobia
The Vicious Cycle Of Avoidance
When feeling anxious or fearful, it makes sense that people try to do what they can to reduce these feelings, such as avoiding what makes them anxious.
This avoidance will usually instantly decrease the anxiety as the person has not put themselves in a distressing situation. However, while avoidance can provide short-term relief from anxiety, it can worsen the anxiety in the long term.
An example of this can be someone avoiding leaving the house because outside the house is where they feel fear. In the short term, avoiding leaving the house can avoid any distress the person may feel.
But in the long term, they can become more fearful about leaving the house and become even more unwilling to confront their anxiety. If this person doesn’t try to break this cycle of avoidance, they will never know whether they can cope in these situations.
In situations like these, it may be recommended to undertake a program of exposure therapy to break this pattern of avoidance.
Types of Exposure Therapy
According to the American Psychological Association, some of the potential variations of exposure therapies include the following:
In vivo exposure
In vivo exposure involves directly facing a feared object, situation, or activity in real life. Some examples of how this can be put into practice include:
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Going to the supermarket if someone has a fear of supermarkets.
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Seeing and going into a car for someone fearful of cars.
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Attending a party for someone who gets anxious at parties.
This type of exposure is likely to be used if the fear that someone has is something that can be directly experienced at any time, so there is more opportunity to practice.
In many cases, in vivo exposure is not possible. For instance, for someone with PTSD, when exposed to the sights and sounds of combat, it is not possible or ethical to use in vivo exposure. In such cases, other types of exposure would be used.
Imaginal exposure
In imaginal exposure, the individual is asked to imagine and describe the feared stimulus vividly, usually using present-tense language and including details about external (sights, sounds, and tastes) and internal (thoughts and emotions) cues.
This can work best for someone with PTSD. Through this, they can re-imagine the sights, sounds, and emotions of being in a traumatic situation such as combat.
Imaginal exposure is useful for those who cannot expose themselves to the feared situation directly. It can also be useful as a stepping stone toward in vivo exposure. For instance, someone with a fear of spiders could vividly imagine a spider until they feel comfortable seeing a spider in person.
Virtual reality exposure
In recent years, technology means that the use of virtual reality devices can aid in exposure therapy. This can be especially useful in situations when it is difficult to experience the cause of the fear in reality.
For example, someone with a fear of flying could use a flight simulator to help expose them to flying, where it may be impractical to go onto a flight in person.
Interoceptive exposure
Interoceptive exposure involves deliberately triggering a physical sensation to show that it is harmless, although feared. This type of exposure is most useful for people who fear internal physical sensations.
For instance, someone who is afraid of feeling light-headed because they think it means they’re having a stroke may be instructed to stand up quickly to trigger this sensation to show it is harmless.
Likewise, someone with panic disorder may fear an increased heart rate as they think it may result in a panic attack, so they may be structured to run in place to purposely increase their heart rate to show that this sensation will not always result in a panic attack.
Techniques
Exposure therapy techniques depend on the condition or symptoms being targeted. Some techniques may be extremely useful for some conditions but not for others.
Below are some exposure therapy techniques:
Graded exposure
Graded exposure involves gradually exposing someone to their feared object, situation, or activity. This usually starts off with the therapist helping the client to construct an exposure fear hierarchy.
This is where the fears are given a score based on how fearful they are and ranked from lowest to highest.
The therapist and the client will then begin by tackling the mildly or moderately difficult exposures and then progress to the more challenging ones when the client is ready.
This technique can use variations of in vivo, imaginal, virtual reality, and interoceptive exposure, depending on the fear.
For instance, someone with a fear of crowded places may start by imagining they are in a crowded place, then see pictures or videos of crowds before progressing to being in an actual crowded place.
Flooding
In contrast to graded exposure, flooding uses the exposure fear hierarchy to begin exposure with the most difficult task.
The process usually involves first teaching the clients some self-relaxation techniques before exposing them abruptly and directly to the fear-evoking stimulus.
So, for the person who is anxious in crowded places, the therapist would expose them directly to a crowded place.
Classical conditioning has taught that people associate fear with the stimulus, but the same principles can be used to extinguish the fear via flooding.
Flooding is rapid exposure compared to other techniques and can yield quick results. However, it is an older type of technique, and most clients and therapists choose a graded approach because of their personal comfort level.
Systematic desensitization
With systematic desensitization, exposure can be combined with relaxation exercises to make them feel more manageable and to associate the feared objects, activities, or situations with relaxation.
This involves constructing a desensitization hierarchy with the therapist and working through these, visualizing each anxiety-provoking event while engaging in relaxation.
This differs from graded exposure as it happens at a slower pace, so it can be more time-consuming. Often the clients are taught deep muscle relaxation and breathing exercises to use when faced with each exposure.
They usually start with the least unpleasant stimuli and practice their relaxation techniques as they go. When the client feels comfortable enough, they move on to the next stage until they reach the most anxiety-provoking event.
This technique aims to remove the fear response associated with an event and substitute a relaxation response to the conditional stimulus, gradually using counter-conditioning.
Prolonged exposure
Prolonged exposure has proven effective with trauma-related issues. This exposure therapy technique is similar to flooding but also incorporates psychoeducation and cognitive processing. This technique uses imaginal and in vivo exposure.
During imaginal exposure, the client will discuss some of the events of the trauma. The therapist will guide the client through retelling and exploring thoughts and feelings, called processing.
This will help them to feel less distress when recalling the trauma. The in vivo exposure involves making a list of the things that have been avoided due to the trauma and encountering them during real-life interaction.
Exposure and response prevention
Exposure response prevention (ERP) therapy is an effective technique specifically for people who experience obsessions and compulsions, such as those with OCD.
This technique works to weaken the link between obsession and compulsions. The therapist intentionally provokes a person’s obsessions and then asks the person not to engage in their behavioral rituals or compulsions.
What Exposure Therapy Can Help With
It is believed that there are four primary ways that exposure therapy may help people:
Emotional processing
During exposure therapy, the person can be helped to create new and realistic beliefs about their feared stimulus. After learning these new beliefs, the idea is that they can become more comfortable with the experience of fear and manage their emotional response.
Extinction
Exposure therapy can help unlearn and weaken negative associations associated with a feared object or situation. Extinction refers to the gradual weakening of a conditioned response that results in the behavior decreasing or disappearing.
Habituation
This is known as a decrease in response to a stimulus after repeated presentations. Therefore, repeated exposure to a feared stimulus should help decrease the reaction to it over time.
Self–efficacy
Exposure therapy can help show the client that they can confront their fears and manage their feelings of anxiety.
How Effective Is Exposure Therapy?
A lot of research has supported the effectiveness of exposure therapy in the treatment of anxiety disorders.
Below are some of the key findings supporting the use of exposure therapy for anxiety disorders:
Posttraumatic stress disorder (PTSD)
A 2013 study found clinically significant reductions in PTSD symptoms among male and female veterans of all war eras and those with combat-related and non-combat-related PTSD.
The results also indicated that prolonged exposure effectively reduced depressive symptoms in these individuals (Eftekhari et al., 2013).
Another study examined the effectiveness of virtual reality exposure therapy for active-duty soldiers and found there was a significant reduction in self-reported PTSD symptoms (Reger et al., 2011).
Social anxiety disorder
Virtual reality exposure therapy has been shown to be effective for those with public speaking anxiety, decreasing catastrophic belief expectancy and distress and increasing perceived performance quality (Linder et al., 2021).
Another study found that exposure therapy was effective in treating social anxiety, with no significant difference in effect sizes between virtual reality, in vivo, or imaginal exposure (Chesham et al., 2018).
A 2019 exposure therapy intervention was tested on people with social anxiety who also stuttered.
There were shown to be substantial reductions in social anxiety and considerable improvements in affective, behavioral, and cognitive experiences of stuttering, but no change was observed in stuttering frequency (Scheurich et al., 2019).
This suggests that even if some behaviors do not change, the anxiety associated with the behavior can be minimized with exposure therapy.
Phobias
A review into phobias found that most phobias respond robustly to in vivo exposure therapy, with few studies obtaining a response rate of 80-90% (Choy et al., 2007).
Another review found evidence that virtual reality exposure therapy is an effective treatment for phobia, concluding this is also a useful tool to combat these fears (Botella et al., 2017).
Obsessive-compulsive disorder (OCD)
Exposure therapy has been supported for the treatment of OCD. Exposure and response prevention is seen as one of the first-line treatments for this condition (Law & Boisseau, 2019).
A study randomized patients with OCD to either receive in vivo exposure and response prevention, a type of antidepressant (clomipramine), or a combination of both.
For those who completed the study, 86% in the exposure group improved on measures examining the frequency and severity of obsessions and compulsions, compared with 48% in the antidepressant group and 79% in the combined treatment group (Foa et al., 2005).
Panic disorder
A 2018 study found that a three-session therapist-guided exposure treatment was effective at treating panic attacks in a group of eight participants.
Six of the participants saw a reduction in symptoms, and four showed remissions. Although this is a small sample size, it suggests that exposure therapy can be effective for those with panic disorder (Bergmark Hall & Lundh, 2019).
Limitations Of Exposure Therapy
While exposure therapy can be highly effective for many individuals, there are some downsides and situations where it may not produce the desired outcomes. Below are some potential limitations of exposure therapy:
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Emotional distress: Exposure therapy involves intentionally exposing individuals to their feared situations or stimuli, which can elicit intense emotional distress. This distress can be challenging to manage and may temporarily increase anxiety levels before reducing them.
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Initial worsening of symptoms: As individuals confront their fears through exposure therapy, it’s not uncommon for their symptoms to temporarily worsen before improving. This initial increase in anxiety can be discouraging and may require additional support and reassurance from the therapist.
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High dropout rates: Exposure therapy can be challenging, and some individuals may struggle to complete the treatment due to the discomfort and anxiety it evokes. High dropout rates can impact the overall effectiveness of the therapy and hinder progress.
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Trauma reactivation: For individuals with a history of trauma, exposure therapy has the potential to reactivate traumatic memories or emotions. Careful assessment and modifications to the treatment approach are necessary to ensure that the therapy does not cause retraumatization.
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Underlying issues: Anxiety disorders and phobias can sometimes be symptoms of underlying psychological or emotional issues. It’s important to consider whether additional therapeutic interventions or treatments are needed to address these underlying issues alongside exposure therapy.
Despite these considerations, exposure therapy remains a highly effective treatment for anxiety disorders and phobias.
It’s essential to work with a qualified mental health professional who can assess individual needs, provide appropriate guidance, and tailor the therapy to maximize its benefits while minimizing potential downsides.
Frequently Asked Questions
When should exposure therapy be considered?
If you feel that you experience a lot of fear or anxiety about many or specific things beyond what you would consider a usual amount, you may benefit from exposure therapy.
If you find you have an extreme physical and/or emotional response to the feared stimuli and it is interfering with your life in a negative way, such as negatively affecting work, school, relationships, or other activities, this may be a sign that you need to seek help.
How can I seek exposure therapy?
It can be useful to begin by speaking to your doctor if you think you may need help with your anxieties. They may recommend you take CBT sessions, which can incorporate a lot of exposure therapy.
If you want to find a specialist in exposure therapy, you can search online, making sure to use reliable sources to find the right person.
Ensure you check the therapist’s credentials and ask whether they implement exposure therapy in their treatment.
You should ask what type of exposure therapy they use and the techniques they use.
It may also be useful to ask about their experience, what their area of expertise is, and what they would plan to do if exposure therapy does not work.
What are some key considerations when thinking about having exposure therapy?
Although research strongly supports exposure therapy, its implementation is not widespread among therapists. Limited availability of specialized training and concerns about symptom exacerbation in certain conditions may contribute to this.
It’s crucial to acknowledge that exposure therapy can be highly challenging. Directly confronting fears entails experiencing physical and emotional discomfort.
There may be moments when you feel overwhelmed by the exposure techniques. In such cases, it’s important to communicate with your therapist about any concerns or the possibility of trying a less intense approach.
However, to fully benefit from the therapy, it’s necessary to push yourself beyond your comfort zone and anticipate a reduction in anxiety over time as you work through it.
References
Dissociative Disorders. (Jul 05, 2021). 2021 Traumadissociation.com. Retrieved Jul 5, from http://traumadissociation.com/dissociative.
Beaudoin, M. N., Moersch, M., & Evare, B. S. (2016). The effectiveness of narrative therapy with children’s social and emotional skill development: an empirical study of 813 problem-solving stories. Journal of Systemic Therapies, 35(3), 42-59.
Cashin, A., Browne, G., Bradbury, J., & Mulder, A. (2013). The effectiveness of narrative therapy with young people with autism. Journal of Child and Adolescent Psychiatric Nursing, 26(1), 32-41.
Ghavibazou, E., Hosseinian, S., & Abdollahi, A. (2020). Effectiveness of narrative therapy on communication patterns for women experiencing low marital satisfaction. Australian and New Zealand Journal of Family Therapy, 41(2), 195-207.
Botella, C., Fernández-Álvarez, J., Guillén, V., García-Palacios, A., & Baños, R. (2017). Recent progress in virtual reality exposure therapy for phobias: a systematic review. Current psychiatry reports, 19(7), 1-13.
Chesham, R. K., Malouff, J. M., & Schutte, N. S. (2018). Meta-analysis of the efficacy of virtual reality exposure therapy for social anxiety. Behaviour Change, 35(3), 152-166.
Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of specific phobia in adults. Clinical psychology review, 27(3), 266-286.
Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA psychiatry, 70(9), 949-955.
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., Huppert, J. D., Kjernisted, K., Rowan, V., Schmidt, A. B., Simpson, B. & Tu, X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of psychiatry, 162(1), 151-161.
Hall, C. B., & Lundh, L. G. (2019). Brief Therapist-Guided Exposure Treatment of Panic Attacks: A Pilot Study. Behavior Modification, 43(4), 564-586.
Law, C., & Boisseau, C. L. (2019). Exposure and response prevention in the treatment of obsessive-compulsive disorder: Current perspectives. Psychology research and behavior management.
Lindner, P., Dagöö, J., Hamilton, W., Miloff, A., Andersson, G., Schill, A., & Carlbring, P. (2021). Virtual Reality exposure therapy for public speaking anxiety in routine care: a single-subject effectiveness trial. Cognitive Behaviour Therapy, 50(1), 67-87.
McLeod, S. A. (2015). Systematic desensitization as a counter conditioning process. Simply Psychology. www.simplypsychology.org/Systematic-Desensitisation.html
Reger, G. M., Holloway, K. M., Candy, C., Rothbaum, B. O., Difede, J., Rizzo, A. A., & Gahm, G. A. (2011). Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic. Journal of traumatic stress, 24(1), 93-96.
Scheurich, J. A., Beidel, D. C., & Vanryckeghem, M. (2019). Exposure therapy for social anxiety disorder in people who stutter: An exploratory multiple baseline design. Journal of fluency disorders, 59, 21-32.
