What Is Exposure Therapy? How It Can Help Anxiety Disorders

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:

• Generalized anxiety disorder (GAD)

• Posttraumatic stress disorder (PTSD)

• Obsessive-compulsive disorder (OCD)

• Phobias – such as specific phobias and agoraphobia

• Panic disorder

• Social anxiety disorder

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:

• Going to the supermarket if someone has a fear of supermarkets.

• Seeing and going into a car for someone fearful of cars.

• 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

Trauma-focused treatments directly address the traumatic event(s) and related memories, thoughts, and emotions.

Examples include Prolonged Exposure (PE) therapy, Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR).

They involve exposure to the traumatic memory through techniques such as imaginal exposure (recounting the traumatic event) or in vivo exposure (confronting trauma-related situations or objects in real life).

The aim is to process and integrate traumatic memories, modify maladaptive beliefs related to the trauma, and reduce trauma-related symptoms.

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 (PE) therapy is a specific type of cognitive-behavioral therapy (CBT) that is commonly used to treat post-traumatic stress disorder (PTSD).

It is an evidence-based treatment that aims to help individuals process traumatic experiences and reduce trauma-related symptoms, such as avoidance, intrusive thoughts, and hyperarousal.

PE therapy typically consists of several key components:

1. Psychoeducation: The therapist provides information about PTSD, its symptoms, and the rationale behind PE therapy.
2. Breathing retraining: The individual learns relaxation techniques, such as diaphragmatic breathing, to help manage anxiety and stress.
3. In vivo exposure: The person gradually confronts trauma-related situations, objects, or activities that they have been avoiding due to fear or anxiety. This exposure occurs in real-life settings and is done in a hierarchical manner, starting with less challenging situations and progressing to more difficult ones.
4. Imaginal exposure: The individual revisits and recounts the traumatic memory in detail during therapy sessions. This is done repeatedly, with the goal of helping the person process the traumatic experience and reduce the emotional distress associated with the memory.
5. Processing: After each imaginal exposure, the therapist and the individual discuss the thoughts, feelings, and reactions that arose during the exposure. This processing helps the person gain new insights and perspectives on the traumatic experience.

PE therapy is typically conducted in 8-15 weekly or biweekly sessions, each lasting about 90 minutes. Between sessions, individuals practice confronting feared situations and listening to recordings of their imaginal exposure sessions as homework.

The goal of PE therapy is to help individuals process traumatic memories, reduce avoidance behaviors, and improve overall functioning. By confronting feared stimuli in a safe and controlled environment, individuals can learn that the memories and situations are not dangerous and that they can cope with the distress associated with them.

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.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR involves recalling traumatic memories while simultaneously focusing on an external stimulus, such as the therapist’s finger movements or tapping.

The goal is to help process the traumatic memory and reduce its emotional intensity.

Narrative Exposure Therapy (NET)

NET is an intervention that helps individuals create a coherent narrative of their life, including traumatic experiences.

The therapist guides the person through a chronological account of their life, focusing on both traumatic and positive events, to help contextualize and process the trauma.

How Exposure Therapy Works

It is believed that there are  six primary ways that exposure therapy may help people:

1. Extinction

Extinction involves the weakening of the conditioned fear response when the feared stimulus is repeatedly presented without the anticipated negative outcome.

Repeated exposure to a feared stimulus without the anticipated negative outcome can weaken the conditioned response (fear or anxiety).

Over time, this can result in gradually reducing or eliminating the fear response associated with the stimulus.

2. Habituation

Habituation refers to the gradual decrease in emotional and physiological reactivity to a feared stimulus over repeated exposures.

When an individual is repeatedly exposed to a feared stimulus, their emotional and physiological reactivity to that stimulus may decrease over time.

This process is known as habituation, and it allows the person to develop an increased tolerance for the anxiety or discomfort associated with the feared stimulus.

Therefore, repeated exposure to a feared stimulus should help decrease the reaction to it over time.

3. Self–efficacy

Exposure therapy provides individuals with opportunities to confront their fears and manage their anxiety in a controlled setting.

As they successfully navigate these experiences, they can develop a greater sense of self-efficacy, which refers to their belief in their own ability to cope with and overcome challenging situations.

4. Emotional processing

Exposure therapy allows individuals to confront their feared stimuli in a safe environment, which can lead to the development of new, more realistic beliefs about the perceived threat.

This process enables them to better understand and manage their emotional responses to the feared stimuli.

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.

5. Memory reconsolidation

Memory reconsolidation refers to the process by which a previously consolidated memory becomes labile and susceptible to modification upon retrieval.

During exposure therapy, when a person retrieves a fear memory in a safe environment, the memory becomes unstable and can be updated with new, non-threatening information.

This process allows for the modification of the original fear memory, reducing the associated emotional response.

Research studies have demonstrated that the timing of exposure sessions can significantly influence the effectiveness of the therapy.

Massed exposure sessions, which are closely spaced together, have been shown to lead to better outcomes compared to sessions that are spaced further apart (Craske et al., 2008; Wachen et al., 2019).

This finding aligns with the concept of memory reconsolidation, which suggests a specific time window after memory retrieval during which the memory is susceptible to modification (Nader et al., 2000; Schiller et al., 2010).

6. Integration

Integration involves incorporating the updated, less threatening memory into the person’s overall autobiographical memory and belief system.

This process helps individuals develop a more coherent and adaptive understanding of their experiences, reducing the impact of the fear memory on their daily life.

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:

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

Non-Trauma-Focused Treatments

It has also become clear that non-exposure-based treatments can be effective in treating PTSD.

Non-trauma-focused treatments do not directly focus on the traumatic event(s) or require the patient to revisit the trauma in detail.

Examples include Present-Centered Therapy (PCT), Interpersonal Psychotherapy (IPT), and Acceptance and Commitment Therapy (ACT).

Non-trauma treatments emphasize developing coping skills, improving interpersonal functioning, and managing current life stressors.

They aim to reduce PTSD symptoms by addressing factors that maintain them, such as avoidance, interpersonal difficulties, or maladaptive coping strategies.

Frequently Asked Questions

References

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