Exposure Therapy: How Confronting Fears Can Help Clients Heal

what is exposure therapyYou have an important meeting with your boss today to discuss your job performance.

You tend to get good ratings, but meetings with the boss make you nervous.

As the meeting approaches, you decide to take several deep breaths before going in. This helps relieve your anxiety.

Once the meeting starts, you feel even better, as you find yourself handling the discussion well.

Whether consciously or not, you just had an informal experience with elements of exposure therapy, in facing an anxiety-provoking situation. It seems to have worked. You felt less anxious by deep breathing beforehand.

Once in the situation, it dawned on you that you have the resources to cope with fearful situations. The job performance review thereby became less threatening, even pleasant. And it ended with you feeling better about yourself.

If you’d like to know more about the theory behind how exposure therapy works; the types of fear or anxiety that exposure therapy is designed to relieve; the various methods exposure therapy has developed to counter anxiety; and helpful worksheets, read on as we share it all here.

What is Exposure Therapy?

Exposure therapy is a set of behavioral approaches designed to reduce anxiety in the face of situations (or objects or actions) that one finds anxiety-provoking.

 

How Does it Work? The Theory Behind Exposure Therapy

habituation exposure therapyThere are four interlocking ideas behind exposure therapy.

The first involves approach versus avoidance. Many of us avoid things, people, or situations we are anxious about (avoidance coping). However, avoidance coping does not ultimately make us less anxious about the thing in question.

There is significant research showing that avoiding the source of one’s anxiety tends to maintain that anxiety (Rudaz, Ledermann, Margraf, Becker, & Craske, 2017). If I am afraid of crossing bridges and always avoid them, I will never get over (no pun intended) my underlying fear of bridges. To get over that fear, I need to find some way to approach bridges, rather than avoid them. Exposure therapy is one such approach.

The second key idea is that of habituation. This idea holds that in approaching an object, I will become more used to it, and thus less reactive to it. This is a natural process that each of us can experience in our own lives.

As we become more habituated to things, we react less strongly to them, either positively or negatively. In the context of fear or anxiety, habituation means I have become less afraid, after repeated or prolonged exposure to a given object.

The third crucial idea behind exposure therapy is reciprocal inhibition (Wolpe, 1958). This idea holds that to reduce anxiety, we must create a state incompatible with anxiety, that neutralizes it. For Wolpe and others, this often meant using relaxation techniques, such as deep breathing mention before, to counter anxiety at each step of the way, as one progressively approaches a feared object.

Eventually, one would feel relaxed and unafraid, even at maximum exposure to a feared object (e.g., crossing the Golden Gate Bridge). In such a scenario, a relaxed state would enhance the underlying habituation process, that is already occurring through exposure alone.

The fourth idea behind exposure therapy is that of self-efficacy. In the course of facing our fears, we learn something crucial about ourselves: that we can cope with certain feared things, activities, or situations; and also more precisely, how to deal with them.

If I am anxious about bridges, it is only through approaching them that I can be assured of my ability to do so. This builds self-confidence. It is also the way I learn how to best make it across the bridge – for example, by breathing deeply as I cross, keeping my eyes on the far side, or feeling the stability of the road underneath – whatever works for me. This practical mastery also builds self-confidence and a sense of self-efficacy.

Exposure therapy can also be explained in neurobiological terms. In a review of the literature on the neurobiology of PTSD, evidence was found for disrupted connections between frontal lobe areas crucial for self-control (including emotional self-control), and other areas known to process strong emotions (amygdala) and form memories (hippocampus).

A form of exposure therapy called prolonged exposure (involving extensive processing of traumatic material, through the memory of traumatic events, and a safe approach to situations that evoke such memories) reportedly increases the neural connections between the brain areas cited above, allowing for “more effective downregulation of emotional processes in stressful situations” (Stojek, McSweeney, & Rauch, 2018) – in other words, better emotional control, and ability to cope with stress/anxiety.

 

Types of Exposure Therapy

using VR for exposure therapyThere are various forms of exposure therapy. Some are differentiated by the approach they take to the feared “object.”

In in vivo exposure, the client is brought into proximity with the actual object (e.g., a live spider placed on a table in front of them).

In imaginal exposure, the client is asked to imagine the object (e.g., imagine a spider coming into the room with them).

In virtual reality exposure, the client is exposed to a digitized form of the feared situation or object (e.g., spider graphic on a standard computer screen or virtual reality headset).

In interoceptive exposure, the client is asked to pay attention to their physical sensations or processes, including those they might find anxiety-provoking (e.g., rapid heart rate, shallow breathing, constriction in the throat, all when faced with a spider).

In narrative exposure, the client is helped to build a chronological narrative about their feared object (e.g., how one came to fear spiders, early to later experience of spiders).

In exposure therapy with response prevention, the client is exposed to their obsessive thinking through a recording they’ve made, a narrative, etc. They are then asked to inhibit a typical compulsive response to it (e.g., not allowing themselves to pray compulsively, or count, or wash their hands).

The response prevention component is meant to decouple one’s obsessions from their accompanying compulsions, thus weakening the obsession-to-compulsion link in OCD.

Other types of exposure therapy are differentiated by the intensity of the approach to the feared object.

In systematic desensitization, the subject and clinician develop a “fear hierarchy”, going from least distressing exposure to the thing feared (e.g., thinking about flying in a plane), to the most distressing exposure (e.g., actually flying in a plane).

The subject is put in a relaxed state, then exposed to a lower level of the feared “object.” Once they have gotten comfortable with that level of exposure, they are presented with an incrementally higher level of exposure. The goal is for them to eventually feel relaxed or comfortable at the highest level of exposure (e.g., actually flying in a plane).

In flooding, one jumps immediately to a high or highest level of exposure in one’s fear hierarchy. Flooding can be done in vivo, or by imaginal exposure. It is typically paired with a relaxation technique. Subjects can find this level of exposure difficult, but it can also quickly reduce deep anxiety and is often effective (Davis, Ollendick & Öst, 2012).

 

With What Conditions Can Exposure Therapy Help?

Common targets of exposure therapy include specific phobias, like fear of spiders (arachnophobia); fear of needles (trypanophobia); or fear of flying (aerophobia). Exposure therapy has been found quite adequate for such phobias.

For example, Lars Öst has used single-session flooding exposure for fear of flying. In one representative study, his single-session exposure therapy produced an average of 90% reduction in flight phobia, with treatment gains maintained at 4-year follow-up (Öst, 2012).

Exposure therapy has also been used to relieve more general forms of anxiety, such as

  • social anxiety,
  • chronic worry as occurs in Generalized Anxiety Disorder, or
  • hypervigilance to threats in the environment, and
  • traumatic memories or dreams as can occur in Post-Traumatic Stress Disorder (PTSD).

A form of prolonged exposure therapy – wherein individuals learn to approach their traumatic memories, feelings, and triggering situations gradually – has been found effective for PTSD, including that suffered by victims of sexual assault (Rothbaum, Foa, & Hembree, 2007).

In a study of 1,931 veterans referred for PTSD, prolonged exposure therapy was also found to reduce those meeting clinical thresholds for PTSD, from 87% to 46% (Eftekhari et al., 2013). Prolonged exposure is currently considered the gold standard treatment for PTSD.

Exposure has also been found useful for treating components of Generalized Anxiety Disorder (whose core feature is chronic worry), especially as concerns in vivo exposure – for example, inducing an actual worried state about a given topic, followed by induction of a relaxed state to neutralize the worry (Borkovec & Costello, 1993).

 

Real-Life Examples

getting into a lift after exposure therapyJacki Lee Somers, who blogs about OCD and creativity, relates her struggle with OCD growing up.

She describes two decades of suffering from OCD, in a rare form called “scrupulosity”.

Symptoms primarily involve religiously-oriented obsessions and compulsions, e.g., obsession with having blasphemed, and thus doomed to hell, requiring some kind of compulsive ritual such as excessive prayer to avoid hell.

She tried extensive talk therapy, various medications, and psychiatric consults, with no improvement. She was finally referred to an OCD specialist who recommended prolonged exposure therapy with response prevention (ERP). This form of exposure therapy pairs extensive exposure to obsessive material, in this case, the client’s own tape-recorded descriptions of blaspheming, and “Hell”.

At the same time, preventing her from engaging in compulsive praying. This technique is meant to decouple one’s compulsions from their obsessive behavioral response.

In Ms. Somers’ case, the treatment was a taste of “hell” itself, quite long and very difficult – but to her great relief, it worked. She could now write: “It rescued me, and that period of ERP [exposure therapy with response prevention] is a defining period of my life” (Sommers, 2013).

Dr. Brenda Wiederhold treats anxiety disorders at virtual reality centers in San Diego and Brussels. She treated an 83-year-old woman with claustrophobia (fear of tight or enclosed spaces) whose physician had ordered an MRI without sedation.

This woman had completely avoided elevators for 40 years. She was too anxious to either ride the elevator up to the MRI clinic or be briefly enclosed in the MRI machine. Her exposure therapy included six virtual reality exposure sessions, which focused on virtually riding an elevator.

She was then able to take the actual elevator ride without distress and also proved able to undergo the (closed) MRI without difficulty. Dr. Wiederhold described this as “really a life-changing event” for her client. The client herself said, “I can’t believe I waited until 83 to do this” (Miller, 2016).

 

Guidelines, Worksheets, Workbooks

Guidelines

APA Division 12  of the Society of Clinical Psychology has described basic guidelines for what is typically called exposure therapy, the types of exposure therapy, and how to go about selecting the best approach for a given client along with a guideline sheet for exposure therapy for PTSD, in particular.

 

Worksheets

Anchor Breathing is a deep breathing exercise worksheet – which can be used to induce relaxation, to be paired with exposure to a feared object or situation.

This Progressive Muscle Relaxation (PMR) worksheet – can also be used to induce relaxation, to be paired with exposure to a feared object or situation.

This Graded Exposure Worksheet helps identify a client’s worst fears, and then guide them through gradual exposure from the least feared element to the worst.

 

Workbooks

Mastering Your Fears and Phobias (2006), by Martin M. Antony, Michelle G. Craske, and David H. Barlow is a workbook that contains step-by-step exposure strategies and user-friendly anxiety monitoring forms, to assist in self-guided work, as well as professional treatments. (Amazon)

 

Books

Exposure Therapy for Anxiety, Principles and Practice, Second Edition (2019), by Jonathan S. Abramowitz, Brett J. Deacon, and Stephen P.H. Whiteside, has been described as “the definitive book on exposure therapy for anxiety-related problems” (Mark M. Anthony, Ph.D., ABPP). (Amazon)

 

Exposure Therapy versus EMDR

Eye Movement Desensitization and Reprocessing (EMDR) is a complex treatment for PTSD, whose core feature involves the recall of traumatic memories. At the same time, the client is also engaged in some form of extraneous eye movement, such as tracking the therapist’s finger, until distress is reduced.

While it contains elements of exposure therapy with the exposure to traumatic memories by a deliberate recall, its focus on extraneous eye movements has led to its being considered a distinct treatment.

Several studies have compared EMDR with prolonged exposure therapy (PET) in the treatment of PTSD. One representative study found both EMDR and PET effective in reducing PTSD symptoms, though with greater efficacy for PET as concerns speed of reduction in avoidant symptoms; reduction in both avoidance and re-experiencing (of trauma) symptoms; and fewer clients in the PET group meeting criteria for PTSD following treatment (Taylor et al., 2003).

Still, EMDR has proven effective for relieving trauma symptoms. Clients should explore the range of exposure therapy options, as well as alternative validated treatments, such as EMDR, and choose the therapeutic option most suited to their needs.

 

Exposure Therapy Apps

Face Your Fears

Exposure- Face Your Fears AppExposure – Face Your Fears is an app available for Android phones.

It allows you to select your personal fear(s), build a fear hierarchy around it, and complete exposure tasks while recording anxiety levels.

 

Breathe To Relax

Breathe2Relax AppBreathe2Relax is a free app available for iPhone, iPad, and Apple Watch, through the Apple App Store.

It guides users through breathing exercises, which can be used to induce relaxation and manage fear or stress. It is considered easy to use and is supported by research from the Anxiety and Depression Association of America (ADAA).

 

CPT Coach

CPT Coach AppCPT Coach is designed for clients in treatment for PTSD. It is available for Apple or Android platforms. The app was created by the Veterans’ Administration National Center for PTSD, in conjunction with the Department of Defense’s Health Division.

It offers psychoeducation about PTSD, step-by-step tools for creating a fear hierarchy, and other relevant exposure therapy tools. It is considered relatively easy to use and is supported by research (per the ADAA).

 

A Take-Home Message

Exposure therapy, in its various forms, has proven very effective in alleviating a wide range of anxiety disorders, including Specific Phobias, OCD, and PTSD.

Clients struggling with anxiety should consider which form of exposure therapy might work as the best anxiety therapy for them.

Further, exposure therapy is meant not only to help us lose anxiety or fear, but it can also help us gain a sense of self-efficacy and mastery in conquering our fears. It can open doors leading you to new experiences, even if it might be something as simple as an elevator door or a meeting room door.

Life is for living, don’t let fears, doors or spiders hold you back.

If you would like to learn more about leaving your fears behind and instead focus on self-efficacy and mastery of your strengths, consider our Maximizing Strengths Masterclass©. It is a complete, science-based training template for practitioners that contains all the materials you’ll need to help your clients identify their unique potential, feel more energized and authentic, and perform at an optimal level.

 

  • Antony, M., Craske, M., & Barlow, D. (2006-08). Mastering Your Fears and Phobias: Workbook. New York, NY: Oxford University Press.
  • Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of consulting and clinical psychology, 61(4), 611–619.
  • Davis, T. E. III, Ollendick, T. H., & Öst, L.-G. (Eds.). (2012). Autism and child psychopathology series. Intensive one-session treatment of specific phobias. Springer Science + Business Media.
  • Eftekhari A, Ruzek JI, Crowley JJ, Rosen CS, Greenbaum MA, Karlin BE. (2013) Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care. JAMA Psychiatry. 2013;70(9):949–955.
  • Miller, A.M. (May 12, 2016). How to Cope with Claustrophobia: Whether You’re Debilitated By MRIs Or Just Uncomfortable On Elevators, The Feeling Can Be Overcome. U.S. News and World Report, online.
  • Öst, L.-G. (2012). One-session treatment: Principles and procedures with adults. In T. E. Davis III, T. H. Ollendick, & L.-G. Öst (Eds.), Autism and child psychopathology series. Intensive one-session treatment of specific phobias (p. 59–95). Springer Science + Business Media.
  • Rothbaum, B. O., Foa, E. B., & Hembree, E. A. (2007). Treatments that work. Reclaiming your life from a traumatic experience: Workbook. Oxford University Press.
  • Rudaz, M., Ledermann, T., Margraf, J., Becker, E. S., & Craske, M. G. (2017). The moderating role of avoidance behavior on anxiety over time: Is there a difference between social anxiety disorder and specific phobia? PloS one, 12(7), e0180298.
  • Sommers, J.L. (2013, August 27). My Journey to Hell and Back: A Personal Experience with CBT and ERP. International OCD Foundation Blog. https://iocdf.org/blog/2013/08/27/my-journey-to-hell-and-back-a-personal-experience-with-cbt-and-erp/
  • Stojek, M. M., McSweeney, L. B., & Rauch, S. (2018). Neuroscience Informed Prolonged Exposure Practice: Increasing Efficiency and Efficacy Through Mechanisms. Frontiers in behavioral neuroscience, 12, 281.
  • Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K., & Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of consulting and clinical psychology, 71(2), 330–338.
  • Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford Univer. Press.

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