Do you feel like anxiety and avoidance rule your life? Maybe you have obsessive-compulsive disorder and are constantly consumed by distressing obsessions. Perhaps you have post-traumatic stress disorder, and your trauma causes you to live in fear and avoid certain situations. Or, you might have anxiety or a phobia that keeps you from living your life to the fullest.
If any of this sounds like you, exposure therapy may provide a glimmer of hope. Exposure therapy is a popular evidence-based treatment option that can help people experience relief from various mental health conditions. Whether you’re personally seeking help or simply curious to learn more about this treatment modality, we’ll delve into what exposure therapy is all about and who it can benefit.
What Is Exposure Therapy?
Broadly speaking, exposure therapy involves exposing yourself to your fears or triggers with the goal of decreasing the fear and overall anxiety in time, alongside the help of a therapist, says Mindy Hall Czech, a licensed professional counselor with Grow Therapy.
Furthermore, exposure therapy helps people eliminate avoidance behaviors. Avoidance feeds fear, Czech says. When you continuously avoid something, you reinforce the fear in your brain, resulting in a vicious cycle. Exposure therapy allows you to break this cycle to regain control of your life, build confidence, and feel comfortable facing triggers.
Different types of exposure therapy may be used in the context of multiple mental health conditions, including:
- Post-traumatic stress disorder (PTSD)
- Obsessive-compulsive disorder (OCD)
- Specific phobias
- Anxiety disorders
Exposure therapy is a form of cognitive-behavioral therapy (CBT). CBT techniques and interventions will often be used alongside exposure itself for a well-rounded approach to psychotherapy and treatment.
What Are the Different Methods of Exposure Therapy?
Depending on your unique situation, different types of exposure may be used. Your therapist may use a combination of the following:
- Imaginal exposure: This exposure happens in a session with a therapist. “In an imaginary session, the client, guided by the therapist, recounts their traumatic experience or specific situations related to fears or phobias,” says Chance Reynolds, a licensed clinical social worker with Grow Therapy.
- In vivo exposure: Reynolds says this is the “in real life” part of exposure therapy. You will conduct exposures outside of therapy, facing fears head-on. You and your therapist will devise the best plan for approaching this.
- Virtual reality (VR) exposure: In cases where in vivo exposure isn’t practical, or when working up to in vivo exposure, a therapist may use VR as a tool. Virtual reality exposure therapy can create realistic simulations of triggering situations or environments.
- Interoceptive exposure: This technique helps people confront and overcome anxiety related to bodily sensations. You’ll deliberately induce similar sensations to those experienced during heightened anxiety or panic in a controlled manner, with the goal of improving tolerance and understanding of bodily sensations.
What Are the Four Principles of Exposure Therapy?
There are four main ways that exposure therapy delivers such valuable results. Reynolds says these include:
- Habituation: Fear and distress related to the feared stimuli decrease over time with gradual exposures.
- Extinction: Behaviors or other associations of adverse outcomes linked to the phobia diminish as exposures are conducted.
- Emotional processing: When first starting exposure therapy, a client is typically highly emotional when thinking about the fear, but over time with exposure, the individual views it in a different light and becomes less fearful and more comfortable.
- Self-efficacy: An individual gains confidence and learns that they are self-efficient and have the power to overcome their fear.
What Is a Fear Hierarchy?
Before diving into exposure therapy for different mental health concerns, it’s important to understand the fear hierarchy, sometimes called an exposure hierarchy, and how it plays a role in this type of therapy.
Often the key to successful exposure treatment is working slowly and gradually to not overwhelm someone and to help them build confidence as they go. Reynolds says one way to do this is by using a fear hierarchy created collaboratively by the therapist and client.
You will make a list or hierarchy of triggers or fears to work on. “If we are working up, we come up with smaller stressful tasks that the client feels confident in achieving. Gradually, they become harder, until we are facing the ultimate fear, or ‘fear boss,’ that must be overcome,” says Reynolds. This process is known as graded exposure.
Beginning exposure therapy can certainly be stress-inducing, but using a hierarchy and starting small can help the process feel less daunting. Less commonly, a technique called “flooding” is used, where you start with the most anxiety-inducing items on a hierarchy.
What Can Exposure Therapy Treat?
Exposure Therapy for Post-Traumatic Stress Disorder (PTSD)
A type of exposure therapy known as prolonged exposure (PE) is an effective treatment that can be very helpful for people who’ve developed avoidance behaviors due to trauma. People may try to avoid any reminders of their trauma to prevent distressing emotions, physical sensations, or flashbacks. Reminders could be certain people, places, situations, or even certain memories. If you’re a trauma survivor, you may think avoiding these reminders keeps you safe. However, continuous avoidance can reinforce your fear and maintain the cycle of PTSD symptoms, preventing you from progressing in your recovery.
PE challenges you to counter this avoidance by repeatedly gradually exposing yourself to the feared situation, memory, or other trauma reminders. This will help you learn that you can tolerate and manage uncomfortable feelings associated with your trauma, ultimately reducing the impact of avoidance on your day-to-day life and improving PTSD symptoms. Typically, PE involves a combination of in vivo, imaginal, and interoceptive exposure, Czech says. The process is slow and gradual to help you feel safe as you revisit traumatic memories. You may start with imaginal exposure, talking in vivid detail about the traumatic event that caused your PTSD. This can be very triggering, but your therapist will be there to provide comfort and reassurance in a safe, controlled space.
Additionally, learning tools to calm down when feeling triggered, such as breathing techniques, is an important part of PE, Czech says. Not only will this help you calm down during a session, you can also use these skills during your in vivo exposure work.
For in vivo exposure, you’ll identify triggers, such as places or situations, that you typically avoid since they remind you of the trauma. You may use a fear hierarchy as a starting point.
Exposure Therapy for Obsessive-Compulsive Disorder (OCD)
A specific type of exposure therapy known as exposure and response prevention (ERP) is considered a first-line treatment of obsessive-compulsive disorder. On top of exposing you to triggers (exposure), it also helps you learn to stop engaging in compulsions (response prevention).
“It is gradual exposure in a safe environment designed to provoke a client’s obsessions. Once the client is exposed to the trigger, the goal is to refrain from the rituals and experience the awareness of the distress,” Czech says. “Once this is consistently successful, distress and anxiety decrease.”
The goal of ERP is to help you confront your obsession triggers and fears directly and gradually without engaging in the compulsive behaviors that you usually use to experience temporary relief, which fuels the OCD cycle.
Eventually, with practice, you will learn that your fears and obsessions are wrongfully sounding an alarm in your brain and that you can manage your anxiety and discomfort without relying on your compulsions.
After ERP, Czech says the obsessions that used to be present will no longer have the power that they once did, diminishing their intrusiveness, repetitiveness, and need for compulsions.
Exposure Therapy for Phobias
A phobia is an irrational and extremely intense fear of a specific object, situation, or activity. Being exposed to the cause of the phobia can trigger severe anxiety, distress, or panic attacks. Some common phobias include fear of flying, heights, or public speaking. Exposure therapy is frequently considered the most effective treatment for phobias, with some research estimating an 80% to 90% success rate.
Exposure therapy can help you confront specific phobias head-on to overcome your intense fear and anxiety. The aim is to desensitize you to the trigger. Over time, this gradual exposure aims to weaken the association between the phobia and your intense panic or fear response.
Fear hierarchies are commonly used for phobias. Czech says you may start by just talking about your feared object or stimuli, looking at pictures or videos, and then taking baby steps to face your fear outside of sessions. When you approach exposure in this manner, you’ll build confidence along the way as you realize you can confront your feared stimuli and still be okay.
Your therapist will encourage you to face the phobia in vivo without fleeing the situation, seeking reassurance from other people, or engaging in any rituals. When you do this, you’ll learn that your anxiety naturally diminishes over time and that you can tolerate the discomfort associated with your phobia – realizing your fear isn’t so bad, after all.
Exposure Therapy for Anxiety
Anxiety disorders like panic disorder and social anxiety disorder (formerly known as social phobia) can also benefit from exposure therapy. CBT is a first-line treatment for anxiety, and within CBT, exposure can be beneficial depending on an individual’s specific case.
For example, many people with panic disorder fear that their physical symptoms, such as shortness of breath or fast heart rate, could mean they’re in severe danger or even dying. This is a great opportunity for interoceptive exposure, purposefully bringing on these physical sensations. An exposure therapist may help you bring on these feelings by running in place or hyperventilating intentionally. By deliberately exposing yourself to these physical sensations and triggers associated with panic attacks, you will gradually become desensitized, learning that these sensations are not life-threatening.
In the case of social anxiety disorder, an exposure therapist may use a fear hierarchy to help you face social situations you typically avoid – whether that’s initiating conversations with a stranger or attending a big party – in order to become more comfortable and confident in these situations. As you face your social fears and experience successful outcomes, your social anxiety will start to lessen, allowing you to have a more fulfilling social life.
While exposure can help anxiety disorders, it’s important to also engage in talk therapy as well to address negative thought patterns and unhealthy behaviors, learn relaxation techniques, and more.
What Are the Dangers of Exposure Therapy?
For most people, exposure therapy is safe, although it can be uncomfortable at times. However, exposure therapy isn’t the right fit for everyone. For example, if someone does not have strong emotional regulation skills before starting exposure therapy, the process can be very triggering. Not to mention, if exposure is conducted improperly, it can cause retraumatization in those with PTSD.
If someone doesn’t have strong emotional regulation skills, they may not be able to manage difficult emotions that pop up with exposures, and their symptoms may end up worse than they were to begin with. This is especially a concern with virtual sessions since the individual can just disconnect from the session and be triggered all alone without a safety net. An additional danger of exposure therapy is if someone is experiencing suicidal ideation or desire to self-harm. If they’re triggered and unable to emotionally regulate, this could increase their risk of harming themselves. In these cases, the individual should learn coping skills and get to a more healthy mental place before they’re ready to safely engage in exposure therapy.
Can Exposure Therapy Be Done Online?
Yes. Many people today opt for teletherapy or online therapy for mental health – and you can certainly do exposure therapy online, too. “I have done both and seen similar results. It comes down to client readiness, rapport building, and clinicians’ willingness to use the platform that they have,” Reynolds says.
Regardless of whether you prefer in-person or online therapy, you will need to do exposure homework outside of sessions.
Takeaways
To sum it all up, exposure therapy is a promising intervention for people with fear, anxiety, or avoidance-based symptoms.
Embarking on the journey of exposure therapy isn’t always easy, and it can feel very challenging, especially at first. However, remember that you possess the strength and power to overcome your triggers – and a trained therapist will be there to support you along the way.
So embrace discomfort and trust the process. With patience, dedication, and repeated exposure, you may just experience life-changing benefits.
