Exposure Therapy
Introduction
Exposure therapy is a psychological treatment that was developed to help people confront
their fears. When people are fearful of something, they tend to avoid the feared objects,
activities or situations. Although this avoidance might help reduce feelings of fear in the short
term, over the long term it can make the fear become even worse. In such situations, a
psychologist might recommend a program of exposure therapy in order to help break the
pattern of avoidance and fear. In this form of therapy, psychologists create a safe
environment in which to “expose” individuals to the things they fear and avoid. The exposure
to the feared objects, activities or situations in a safe environment helps reduce fear and
decrease avoidance.
Exposure therapy is a specific type of cognitive-behavioral psychotherapy technique that is
often used in the treatment of post-traumatic stress disorder (PTSD) and phobias. Exposure
therapy is a safe and proven technique when used by an experienced, licensed therapist who
specializes in these kinds of conditions and treatments. When used properly, scientific
research has shown that it can be a powerful method to help a person overcome
the anxiety and fear associated with PTSD or phobias.
Exposure therapy is a type of behavioral therapy that helps people overcome their fears,
phobias, and anxieties. Exposure therapy teaches a person to develop a new reaction to a
given stimulus. For example, if someone feels a great sense of fear every time they hear a car
horn, exposure therapy will work to change that fear into a more neutral response to hearing
the noise
Types of Exposure therapy
In Vivo Exposure
In vivo exposure refers to the direct confrontation of feared objects, activities or situations by
a person under the guidance of a therapist. For example, a woman with PTSD who fears the
location where she was assaulted may be assisted by her therapist in going to that location
and directly confronting those fears (as long as it is safe to do so).
Likewise, a person with social anxiety disorder who fears public speaking may be instructed
to directly confront those fears by giving a speech.
Imaginal Exposure
In imaginal exposure, a client is asked to imagine feared images or situations. Imaginal
exposure can help a person directly confront feared thoughts and memories.
Imaginal exposure also may be used when it is not possible or safe for a person to directly
confront a feared situation.
For example, it would not be safe to have a combat veteran with PTSD to directly confront a
combat situation again. Therefore, he may be asked to imagine a feared combat situation that
he experienced.
Virtual reality exposure: In some cases, virtual reality technology can be used when in vivo
exposure is not practical. For example, someone with a fear of flying might take a virtual
flight in the psychologist's office, using equipment that provides the sights, sounds and smells
of an airplane.
Virtual reality exposure therapy exposes clients to anxiety-producing stimuli through
computer-generated virtual reality technology. It is a promising new method of treatment for
a variety of anxiety disorders, including phobias and posttraumatic stress disorder.
Interoceptive Exposure
Interoceptive exposure was originally designed to treat panic disorder. However, there is
evidence that it may be successful in the treatment of PTSD as well. It is designed to help
people directly confront feared bodily symptoms often associated with anxiety, such as an
increased heart rate and shortness of breath. The therapist may assist this by having a person
(in a controlled and safe manner) hyperventilate for a brief period of time, exercise, breath
through a straw or hold his breath.
Prolonged Exposure
Prolonged exposure therapy is a combination of the above three methods. It has been found to
be very effective for PTSD sufferers and involves an average of 8 to 15 sessions for about 90
minutes per session.
Prolonged exposure therapy consists of education about trauma and what you will be doing,
learning how to control your breathing (interoceptive exposure), practicing in the real world
(in vivo exposure), and talking about your trauma (imaginal exposure).
VARIATIONS OF EXPOSURE THERAPY
When ordering in some restaurants, you start with a basic dish. Then, you customize it by
specifying how you want it cooked (for example, grilled) and for how long (for instance,
medium-rare) and by picking and choosing toppings and sides. Even the basic dish may be a
variation involving “holding” an ingredient (such as no cheese on your cheeseburger) or
changing a main component (such as substituting turkey for corned beef in a Reuben
sandwich). As you are about to see, exposure therapy involves an analogous process.
1. Paradigm of exposure. There are two basic paradigms of exposure therapy.
Brief/graduated exposure therapy exposes the client to threatening events (a) for a
short period (ranging from a few seconds to a few minutes) and (b) incrementally,
beginning with aspects of the events that produce minimal anxiety and progressing to
more anxiety-evoking aspects. Graduated exposure is a prime example of the stepwise
progression that characterizes many behavior therapy procedures. In contrast,
prolonged/intense exposure therapy exposes the client to threatening events (a) for a
lengthy period (usually 10 to 15 minutes at a minimum and sometimes more than an
hour) and (b) at a high intensity from the outset.
2. Mode of exposure. The mode of exposure in both paradigms can occur in four basic
ways that fall on a continuum. At one end is in vivo exposure—actually encountering the
event (such as taking a flight, in the case of fear of flying). At the other end is imaginal
exposure—vividly imagining the event, as one does in a daydream (for example,
visualizing taking a flight). Close to the in vivo end of the continuum, virtual reality
technology now allows clients to be exposed to anxiety-evoking events through
interactional computer simulations that appear almost real. Toward the imaginal end,
clients can listen to detailed verbal descriptions (read by the therapist or client) or view
visual (video) depictions of anxiety-evoking events.
3. Additional procedures. Exposure therapies may use one or more additional procedures,
with the three most common being:
● Competing response: During exposure, the client engages in a behavior that competes
with anxiety, such as relaxing muscles while visualizing an anxiety-evoking event.
● Response prevention: During treatment, the client is kept from engaging in the
maladaptive avoidance or escape behaviors he or she typically uses to reduce anxiety, such
as repeatedly washing one’s hands because of the possibility of having touched something
containing germs.
● Exaggerated scenes: To heighten the intensity or vividness of imaginal exposure, the
depiction of the event may be exaggerated. For example, a therapist might ask a client who is
afraid of snakes to imagine being in a pit with hundreds of snakes.
4. Administration of exposure. The exposure can be either therapist administered in therapy
sessions5 or self-managed by the client outside of the therapy sessions.6 Or, both
methods can be used, beginning with therapist administered exposure.
Exposure Therapy Paces
Exposure therapy can also be paced in different ways. These include:
Graded exposure: The psychologist helps the client construct an exposure fear
hierarchy, in which feared objects, activities or situations are ranked according to difficulty.
They begin with mildly or moderately difficult exposures, then progress to harder ones.
Flooding: Using the exposure fear hierarchy to begin exposure with the most difficult
tasks. The patient is directly exposed to the phobic stimulus, but escape is made
[Link] prolonged contact with the phobic stimulus, the therapist guidance and
encouragement and his modeling behavior reduce anxiety.
In a method called flooding, for example, clients who are crippled by fear of dirt or infection
might be asked to spend long periods of time touching and holding a variety of everyday
items that they are afraid might be “contaminated.” Exposure times must be long enough—
hours, if necessary—for anxiety to dissipate; exposure should not be terminated while the
client is still anxious because the resulting anxiety reduction would reinforce avoidance
behavior.
Indication: specific phobias
Systematic desensitization: In some cases, exposure can be combined with
relaxation exercises to make them feel more manageable and to associate the feared objects,
activities or situations with relaxation.
Rationale
The goal of exposure therapy is to help you become less fearfully aroused when you hear,
see, or otherwise sense stimuli that you associate with life-threatening situations. Exposure
therapy is considered the top treatment for a number of disorders, and it can change a
sufferer's life. Exposure therapy is designed to help people overcome mental health
conditions that arise from fear. The goal of exposure therapy is to create a safe environment
in which a person can reduce anxiety, decrease avoidance of dreaded situations, and improve
one's quality of life.
Procedure
The process of facing fears is called EXPOSURE. Exposure involves gradually and
repeatedly going into feared situations until you feel less anxious. Exposure is not dangerous
and will not make the fear worse. And after a while, your anxiety will naturally lessen.
Starting with situations that are less scary, you work your way up to facing things that cause
you a great deal of anxiety. Over time, you build up confidence in those situations and may
even come to enjoy them. This process often happens naturally. A person who is afraid of the
water takes swimming lessons every week and practises putting their feet and legs in the
water, then the whole body and, finally, diving underwater. People with a fear of water can
learn to love swimming. The same process occurs when people learn to ride a bike, skate, or
drive a car.
When people experience anxiety due to a fear, phobia, or traumatic memory, they often
avoid anything that reminds them of it. This avoidance provides temporary relief but
ultimately maintains the fear and pattern of avoidance. In some cases, the avoidance can
actually make things worse and give more power to the feared entity. Exposure therapy
is designed to reduce the irrational feelings a person has assigned to an object or
situation by safely exposing him or her to various aspects of that fear.
For example, while working with someone who has a fear of spiders—arachnophobia—
an exposure therapist might first ask the person to picture a spider in his or her mind.
This might lead to several sessions in which the therapist asks the person to imagine
more intense scenes with the spider, all while teaching coping skills and providing
support. Once the anxiety response is reduced, the therapist may progress to real life
exposure. In this type of exposure, the therapist might start by placing a contained spider
at the far end of the room and lead up to placing the spider in the person's hand.
Applications
Exposure treatments are especially effective in cases of obsessive-compulsive disorder (in
which clients experience obsessions—persistently intrusive and fearful thoughts—and
engage in compulsions, which are repeated behavioral rituals designed to reduce or prevent
anxiety stemming from their obsessions). In such cases, exposure is usually accompanied by
response prevention, meaning that clients are not allowed to perform the rituals they
normally used to reduce anxiety.
Exposure techniques are also used extensively with agoraphobia, a severe disorder involving
fear of being away from home or some other safe place, or of being in a public place—such
as a theater—from which escape might be difficult. Exposure treatments are also used for the
panic attacks that often precede the development of agoraphobia, for binge craving in
bulimia, and for other problems.
Exposure therapy is particularly useful for people whose fears and anxieties interfere with
them living their everyday lives. The following conditions are commonly treated with
exposure therapy techniques:
Panic Disorder: It is normal for all people to experience symptoms such as increased heart
rate or a stomach ache when confronted with something that causes them even mild fear or
anxiety. However, people with panic disorder grow to fear these symptoms, and thus they
become more intense. This leads people to panic disorder to avoid situations that may cause
these symptoms of fear. Exposure therapy helps people with panic disorder become more
comfortable with the physical sensations of fear. The goal is for the person to become
comfortable enough with these symptoms that they do not develop into a full panic attack so
that the person can stop avoiding so many situations or things out of fear.
Social Anxiety Disorder: People with social anxiety disorder tend to avoid certain, or all,
social situations out of a fear of being judged or rejected. This fear and avoidance can cause
major disruption to their lives. When someone has to participate in a social situation they
would have liked to avoid; it causes great distress.
Exposure therapy for social anxiety disorder will have the person face social situations that
they fear and ultimately remain in those situations until the fear subsides. In the long run, it
will show them that social situations are not to be feared.
Phobias: Exposure therapy for phobias is typically done by systematic desensitization so that
the person slowly becomes more comfortable with the thing that they fear to ultimately
overcome the fear and associate the feared object with relaxation. It should always be a
controlled exposure, in which the person is a comfortable, safe environment, and has the
support of the counselor with them.
Obsessive Compulsive Disorder (OCD): Often, the obsessions,and compulsions that
characterize OCD are based on irrational fears, like fear of germs. If someone with OCD
based on a fear of germs is forced to touch a doorknob, for example, they will become
overwhelmed with thoughts of the germs and proceed to wash their hands repetitively, in
whatever fashion is typical for their obsession. Exposure therapy for OCD is two-pronged. It
both exposes the person to a trigger for their obsessions and compulsions and also practices
response prevention. In the case of the example given above, the person would be exposed to
germs in a normal, daily situation (like touching a doorknob) and try not to have the
responsibility of washing their hands obsessively afterward.
Post-Traumatic Stress Disorder (PTSD): Everyone experiences fear when something scary
or shocking happens, but most people recover from the trauma relatively quickly. For people
who develop PTSD, the fear and trauma linger, and leads them to feel scared and stressed
even when they are not actually in danger. They may experience flashbacks to the traumatic
event or nightmares that trigger their symptoms or avoid certain places or situations that
remind them of the initial event. Both of these things cause significant stress and interfere
with one's daily life.
Exposure therapy for PTSD is conducted as prolonged exposure therapy. PET is based on the
associate learning theory and is conducted one-on-one between the patient and a therapist.
They work to dissociate certain triggers from the trauma that cause a negative response. For
example, if someone had a traumatic experience with a fire, the smell of smoke may cause
them severe anxiety now. During PET, the person will be exposed to the smell of smoke, and
dissociate the smell from their trauma so that the smell no longer causes them severe distress.
Ultimately, someone undergoing PET should be able to reduce their response to triggers of
their PTSD and greatly reduce their overall anxiety and distress.
