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Exposure Therapy?

By Olivia Guy-Evans, published March 10, 2022

by Saul Mcleod, PhD


What is exposure therapy?

Exposure therapy is a treatment that helps people to overcome specific things, activities, or situations that cause fear or anxiety. The feared stimulus could be environmental such as an object, or situations such as social events or anything that can trigger feelings of trauma.

The fear can also be internal such as thoughts, mental images, and bodily sensations.

The purpose of exposure therapy is to either suddenly or gradually exposure someone to the feared stimulus, to bring down their fear reaction so that they can eventually be exposure to what they fear without feeling fearful or anxious.

This therapy helps people overcome fears and anxieties by breaking down the pattern of fear and avoidance. It is a common technique used within cognitive behavioural therapy (CBT), which is another type of therapy which aims at restructuring negative thoughts and behaviours.

People tend to avoid things and situations they are afraid of. The idea behind exposure therapy is to exposure people to their feared stimulus in a safe environment to help them overcome their fear and decrease avoidance. 

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:

The vicious cycle of avoidance

When feeling anxious or fearful, it makes sense that people will 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 make the anxiety worse 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 becoming 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 are able to cope in these situations.

In situations like these, it may be recommended to undertake a programme 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 anxiety 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 vividly imagine and describe the feared stimulus, usually using present-tense language and including details about external (sights, sounds, and taste) 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 where it is not possible to exposure themselves to the feared situation directly. It can also be useful as a stepping stone towards in vivo exposure. For instance, someone with a fear of spiders could vividly imagine a spider until they feel comfortable to see 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 exposure them to flying, where it may be impractical to go onto a flight in person. 

Interoceptive exposure

With interoceptive exposure, this 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

The techniques used in exposure therapy depend on the condition or symptoms being targeted. Some techniques may be extremely useful for some conditions but not for others.

Below are some of the techniques that can be used in exposure therapy:

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 harder 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 off 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 then 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 the fear with the stimulus, but via flooding, the same principles can be used to extinguish the fear.

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 the 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, visualising 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 then move on up 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 has proven effective with trauma-related issues. This technique is similar to flooding but also incorporates psychoeducation and cognitive processing. This technique uses imaginal and in vivo exposure. 

During imaginal exposure, the client will discuss some of the events of the trauma. The therapist will guide the client through the retelling, exploring thoughts and feelings, which is called processing.

This will help them to feel less distress when recalling the trauma. The in vivo exposure involves making a list of the things that have been avoided due to the trauma and encountering them during real-life interaction. 

Exposure and response prevention

This is an effective technique specifically for people who experience obsessions and compulsions, such as those in people 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 behavioural rituals or compulsions. 

What exposure therapy can help with

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

Emotional processing – 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 managing their emotional response. 

Extinction – exposure therapy can help with unlearning and weakening negative associations associated with a feared object or situation. Extinction refers to the gradual weakening of a conditioned response that results in the behaviour decreasing or disappearing.  

Habituation – this is known as a decrease in response to a stimulus after repeated presentations. Therefore, repeated exposure to a feared stimulus should help decrease the reaction to it over time.

Self-efficacy – exposure therapy can help show the client that they are capable of confronting their fears and that they can manage their feelings of anxiety.  

Effectiveness of exposure therapy

Research has consistently 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 on different anxiety disorders:

Posttraumatic stress disorder (PTSD)

A 2013 study found clinically significant reductions in PTSD symptoms were achieved 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 was effective in reducing 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 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 the treatment of 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, behavioural, and cognitive experiences of stuttering, but no change observed for stuttering frequency (Scheurich et al., 2019).

This suggests that even if some behaviours do not change, the anxiety associated with the behaviour can be minimised 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 randomised 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). 


How to get started

When you may need exposure therapy

If you feel that you experience a lot of fear or anxiety about many or specific things, beyond what you would consider a usual amount, you may benefit from exposure therapy.

If you find you have an extreme physical and/or emotional response to the feared stimuli and it is interfering with your life in a negative way, such as negatively affecting work, school, relationships, or other activities, this may be a sign that you need to seek help. 

How to seek exposure therapy

It can be useful to begin by speaking to your doctor if you think you may need help with your anxieties. They may recommend you take CBT sessions, which can incorporate a lot of exposure therapy. 

If you want to find a specialist in exposure therapy, you can search online, making sure to use reliable sources to find the right person.

Ensure you check the therapist’s credentials and ask whether they implement exposure therapy in their treatment.

You should ask what type of exposure therapy they use and the techniques they use.

It may also be useful to ask about their experience, what their area of expertise is, and what they would plan to do if exposure therapy does not work. 

Things to consider

Although there is a great deal of research to support the use of exposure therapy, many therapists do not implement it.

Some speculate that this is because the availability of specialised training is limited, while others may believe that exposure therapy may exacerbate symptoms in some conditions. 

It is important to note that exposure therapy can be extremely difficult for many people. As this involves often directly facing your fears, you can expect that you will feel the physical and emotional discomfort that comes with this.

You may find that there are times when you feel you cannot handle the exposure techniques. You should discuss with your therapist if something is not working for you or if you want to try a gentler approach.

However, to get the full benefits of the therapy, it is important to challenge yourself and expect to be pushed out of your comfort zone so you can eventually work through it to a place where you do not feel the anxiety so strongly. 

 

Do you need mental health help?

USA

Contact the National Suicide Prevention Lifeline for support and assistance from a trained counselor. If you or a loved one are in immediate danger: https://suicidepreventionlifeline.org/

1-800-273-8255

UK

Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email [email protected].

Availiale 24 hours day, 365 days a year (this number is FREE to call):

116-123

Rethink Mental Illness: rethink.org

0300 5000 927

Fact Checking
Simply Psychology content is rigorously reviewed by a team of qualified and experienced fact checkers. Fact checkers review articles for factual accuracy, relevance, and timeliness. We rely on the most current and reputable sources, which are cited in the text and listed at the bottom of each article. Content is fact checked after it has been edited and before publication.

About the Author

Olivia Guy-Evans obtained her undergraduate degree in Educational Psychology at Edge Hill University in 2015. She then received her master’s degree in Psychology of Education from the University of Bristol in 2019. Olivia has been working as a support worker for adults with learning disabilities in Bristol for the last four years.

How to reference this article:

Guy-Evans, O. (2022, March 10). What Is Exposure Therapy?. Simply Psychology. www.simplypsychology.org/exposure-therapy.html

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