When dealing with anxiety and trauma, people tend to avoid whatever it is that is causing them to feel pain or worry. For example, a soldier might avoid anything that reminds him of war. Someone with arachnophobia will avoid spiders. Although it is a natural response, it is that avoidance that causes symptoms to continue, and frequently, get worse. Exposure therapy is an effective treatment to help individuals confront their fears and alleviate maladaptive responses to certain triggers.
What is Exposure Therapy?
Exposure therapy is a behavioral-based treatment where a client is exposed to internal and external stimuli that cause feelings of anxiety and trauma. It can be used for a variety of anxiety disorders and post-traumatic stress disorder (PTSD.) It is theorized that exposure will make encountering the stimuli less aversive and help people cope more effectively with their distressing feelings.
What Are the Steps of Exposure Therapy?
In exposure therapy, clients will usually engage in a few stages to confront their fears. First, they will receive some education about the process, so they understand the theory and structure behind what they are about to undertake. Next, they will create an exposure hierarchy. This is a rating scale of all the stimuli that are causing discomfort. Individuals will rank the stimuli from least to most anxiety-provoking.
After a ranking is established, a therapist will help their client confront and work through the hierarchy, usually from least distressing to most. Care is taken to provide a safe environment and not push the client to the point that it would be counterproductive to the treatment goals.
An exception to this gradual confrontation is the use of flooding. In flooding, a person will start with more distressing stimuli first rather than work their way up to it. For example, throwing somebody with a fear of water into a pool would be considered flooding. Flooding is used to speed up the exposure process and overcome resistant behavior. As you might imagine, it is also controversial. It tends to backfire if the flooding event is perceived as traumatic in and of itself. As a result, it is rarely used.[1]
Types of Exposure Therapy
Therapists choose the type of exposure therapy treatment for each client based on their specific needs. They can include:
In Vivo Exposure
In vivo exposure is facing an anxiety-provoking stimulus in real life. For example, a person who has a fear of heights might climb to the top of a tall stairway or ride up many stories in a glass elevator. This is the most effective type of exposure because an individual must face the actual environment that is causing them distress. Of course, only certain types of situations can be confronted in vivo with a therapist. For example, someone with trauma from the Gulf War cannot be transported back in time to the Middle East to face his or her demons.
Imaginal Exposure
When in vivo exposure is not possible, imaginal exposure is often used. The limits of imaginal exposure are whatever you can think of in your own mind. A client, for instance, may recall their history of childhood abuse. Imaginal exposure is often used in cases of trauma because you want to remember the trauma without actually reliving it. Often, a therapist can help the client enhance the imagery if they know details of what occurred. Although imaginal exposure can be quite effective, a person may not want or be able to imagine the details that cause them anxiety.
Virtual Reality Exposure
The advent of virtual reality technology has made it possible to recreate certain events in a realistic environment. This is especially valuable for reliving situations that may be difficult to access in a therapist’s office. It also ensures a person cannot avoid situations, which can occur when using imaginal exposure.[2] For example, someone with a fear of human-like figures can use virtual reality to make it feel like they are walking among mannequins. Every aspect of this experience can be controlled and with the help of technology, gradually intensifying the exposure. In addition, virtual reality exposure has been successful in the treatment of PTSD due to war-related trauma.[3]
Interoceptive Exposure
Interoceptive exposure is used to bring about physical sensations that are associated with anxiety and distress. The most common example is when it is used in a panic disorder. Often, symptoms like a rapid heartbeat and sweating may trigger panic because they are associated with having a panic attack. Using interoceptive exposure, a therapist will recreate those triggers to help a client cope more effectively in preventing anxiety. For instance, a therapist may have someone do exercises (e.g., jumping jacks or running in place) to produce physical sensations that are associated with panic. The therapist can then help the client develop skills to deal with them without invoking an anxiety attack.
Systematic Desensitization
Systematic desensitization, also called graduated exposure, is a technique where gradual exposure is paired with a relaxation exercise in order to help the client cope with the distressing stimulus. It can be used with any of the above types of exposure. A therapist, for example, may have a client with a snake phobia engage in deep breathing when they encounter a picture of a snake. The pairing of relaxation with the stressor helps them cope with their phobia. They will then continue to use that technique as they incrementally increase their distress hierarchy.
Systematic desensitization, while beneficial for an individual learning to tolerate their discomfort, has been criticized by some because they see the relaxation component as another form of avoidance. The criticism is similar to what you would find in using anti-anxiety medication. If you are relaxing or taking medication, it is preventing you from fully confronting the provoking stimuli.
How Long Does the Treatment Take?
Exposure therapy is a brief treatment. Although it is usually not time-limited, you can likely expect to see results within a few months. For example, prolonged exposure therapy is a particular form of exposure that is described as having nine to 12 sessions, each 90 minutes in length.[4] The length of treatment will largely depend on how quickly one ascends their anxiety hierarchy. Someone who uses flooding, for instance, may see quicker results. If you are not seeing results within six months, exposure therapy is likely not working for you.
Why Exposure Therapy Works
Multiple theories form the basis for the success of exposure therapy:
Extinction
Extinction is a behavioral process where learned associations are eliminated. Exposure aids in the extinction process by showing the client that feared associations between specific objects or situations are not valid. For example, when a person with a blood phobia learns to tolerate the sight of blood without passing out, they are extinguishing the anxious association.
Habituation
The theory of habituation is at the heart of exposure therapy. It states that when a person repeatedly confronts a stimulus, their reactions to that stimulus are sure to decrease in intensity. For example, say a person has an anxious reaction to a certain smell because it reminds them of the cologne worn by their abusive father. After encountering that smell multiple times without aversive consequences, they are likely to have a less severe reaction to the cologne.
Self-Efficacy
Self-efficacy is the perceived ability to accomplish your goals. When an individual successfully confronts their fears, they begin to believe that they can banish their negative reactions to stimuli that invoke trauma and anxiety. Confidence in one’s ability is essential for a person to succeed in treatment. That is why a gradual exposure hierarchy is frequently used. It is critical to taste some success if you are going to be successful outside the therapy office.
Emotional Processing
Emotional processing recognizes that all human operations have a cognitive component. When you are exposed to fearful stimuli, without a harmful outcome, you begin to attach new meaning to those situations. Instead of thinking about those objects and activities as something to be feared, you think about them in more neutral terms. As a result, they are seen as less ominous and you become more comfortable with them.
Summary
Individuals who suffer from anxiety and trauma perpetuate their negative symptoms by avoiding triggers that cause them distress. Not only does avoidance lead to increased deterioration, but it is also highly disruptive. People may steer clear of important activities, such as work, social gatherings, and going to the grocery store. The effectiveness of exposure therapy is that it forces you to confront what you would otherwise avoid. In doing so, you learn to break maladaptive associations and give yourself a chance at a happier, more productive life. It is a courageous step to seek exposure therapy. Although it will take effort and determination, it will help you to face your problems and live your best life.
References
- Henry J. Kandel, Teodoro Ayllon, Michael S. Rosenbaum, Flooding or systematic exposure in the treatment of extreme social withdrawal in children, Journal of Behavior Therapy and Experimental Psychiatry, Volume 8, Issue 1, 1977, Pages 75-81, ISSN 0005-7916, https://doi.org/10.1016/0005-7916(77)90109-4.
- Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., & Nixon, R. D. (2003). Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder. Journal of consulting and clinical psychology, 71(4), 706–712. https://doi.org/10.1037/0022-006x.71.4.706
- Kothgassner, O. D., Goreis, A., Kafka, J. X., Van Eickels, R. L., Plener, P. L., & Felnhofer, A. (2019). Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): a meta-analysis. European journal of psychotraumatology, 10(1), 1654782. https://doi.org/10.1080/20008198.2019.1654782
- Perelman School of Medicine at the University of Pennsylvania. (n.d.). About Prolonged Exposure Therapy. Retrieved January 13, 2022, from https://www.med.upenn.edu/ctsa/workshops_pet.html
MS Broudy is a psychologist, writer, and consultant. He has a Ph.D. in Clinical Psychology and a master’s degree in Social Psychology. He has spent over 20 years providing therapy and assessment services for a diverse set of clients. MS specializes in writing about mental health, parenting, and wellness. He has his own blog, mentalspokes.com, where he writes about psychological issues.