What is exposure therapy?
Exposure therapy is a behavior therapy used in cognitive behavioral therapy (CBT) that involves exposing yourself to something that causes you anxiety, distress, or another negative response. For instance, if you are afraid of heights, exposure therapy could involve you putting yourself in safe, controlled situations that involve being off the ground—such as taking an elevator to a rooftop. Although doing so may initially spike your anxiety or stress, the idea is that you eventually get comfortable with the discomfort and free yourself of the fear.
Fear is often maintained by avoidance behaviors. If you’re afraid of social situations, you may avoid being in public. If you fear dogs, you may avoid going places where a dog may be present. While this avoidance means you never have to confront the source of fears and experience the resulting anxiety, it can also have a negative effect on your well-being. Your fear can prevent you from enjoying social events, making the most of career opportunities, or living your life to the fullest.
Exposure therapy aims to overcome avoidance behavior by exposing you to your fears, usually one step at a time, and encouraging you to sit with the discomfort until it becomes manageable. Over time, you can learn that the thing you fear isn’t actually harmful, and create more realistic expectations and associations. For example, you may discover that being high off the ground doesn’t always result in injury, social situations don’t always end in rejection, and dogs don’t always bite.
How the exposure therapy process works
Exposure therapy is considered a form of cognitive behavioral therapy and is often used to treat anxiety disorders and obsessive-compulsive disorder (OCD). It works by changing your perception of the feared object or situation and building your self-confidence. Here are some of the ways in which the treatment may help:
- Repeated exposure gradually reduces the intensity of your reactions. The more you engage with the source of fear, the less it seems like a threat.
- It can reduce strongly held associations that you’ve developed from past experiences. For example, you might stop associating dogs with the thought of being bitten.
- It increases your confidence in your own ability to face your fears and manage your emotions. You might note that after an exposure session you didn’t faint or have a heart attack, and realize you’re able to tolerate the discomfort.
- You form new realistic beliefs around the source of fear. You might realize that dogs that are well-trained don’t bite, or that other people in social situations are less judgmental than you previously believed.
Benefits of exposure therapy
Some people, even some clinicians, see exposure therapy as an undesirable treatment option, because it requires you to experience distress. It’s true that the process can be uncomfortable. However, if you’re willing to embrace that discomfort, you may experience numerous benefits, including:
Improved quality of life. You may free yourself of time-consuming OCD rituals, lower your overall general anxiety levels, or let go of avoidance behaviors that have held you back.
Overcoming phobias. A 2020 review of studies found that in vivo exposure therapy was helpful in more than 80 percent of phobia cases.
Long-term improvement in symptoms. The effects of exposure therapy could potentially last for years. One follow-up study found that more than 80 percent of patients who received exposure therapy for PTSD as part of their treatment continued to benefit from it six years later.
Complementing other treatment approaches. You don’t have to rely exclusively on exposure therapy for results. It can be combined with other approaches, such as eye movement desensitization and reprocessing (EMDR) for PTSD or trauma symptoms.
Exposure therapy can also be combined with relaxation techniques, including diaphragmatic breathing and mindfulness. These coping strategies can be used during exposures to help you ease stress, manage difficult emotions, and increase your confidence.
Conditions treated with exposure therapy
Exposure therapy is a popular treatment for many anxiety-related issues, including phobias, social anxiety disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).
Specific phobias. A phobia is an irrational yet intense fear of something that is typically harmless. Some examples include a fear of clowns, spiders, or water. You can address many phobias through gradual exposure to whatever the source of fear is.
Obsessive-compulsive disorder. OCD involves uncontrollable, anxious thoughts that compel you to perform repetitive behaviors, such as excessive handwashing to counter germs. Research points to exposure therapy as a go-to treatment for OCD.
Post-traumatic stress disorder. PTSD is a mental condition that results from experiencing a terrifying event, such as abuse, war, or natural disaster. Exposure therapy—prolonged exposure in particular—is often recommended as part of PTSD treatment.
Social anxiety disorder. More than just shyness, social anxiety involves an intense fear of social situations. Exposure therapy allows you to manage social anxiety by confronting underlying fears and becoming more comfortable in your interactions.
Panic disorder and agoraphobia. Panic disorder and agoraphobia are two commonly co-occurring disorders. Both involve a fear of experiencing anxiety and panic, and both may be managed with exposure therapy.
Eating disorders. Exposure therapy could potentially help with eating disorders, as it can be used to gradually expose you to foods you have anxiety about eating.
Chronic pain. Exposure therapy might be useful in certain cases of chronic pain. If you avoid certain activities or movements because you expect pain, even in situations that won’t trigger discomfort, gradual exposure to those situations could help rebuild your sense of confidence.
Types of exposure therapy
Exposure therapy can come in many forms, but all of them require you to confront your fears, either in-person or in simulated circumstances. Although you can try many of these approaches on your own, exposure therapy is likely to be more effective when performed under the guidance of a therapist.
In vivo exposure. This involves direct exposure with your source of fear. If you have a fear of flying, you might get on a plane. If you have a fear of heights, you might take an elevator to the top floor of a building.
Imaginal exposure. As the name implies, this approach involves using your imagination to simulate or recall a frightening experience. An approach known as written exposure therapy takes this a step further. You repeatedly imagine a distressing situation, such as past trauma, and write it down.
Virtual reality exposure. This approach requires the use of VR technology but allows you to safely confront your fears. This might be used when in vivo exposure isn’t an option. For example, you might want to expose yourself to the experience of a plane flight without actually buying a ticket.
Interoceptive exposure. Interoceptive exposure requires you to induce physical sensations that you’re afraid of. This can be useful for panic disorder, in which bodily sensations, like increased heart rate, trigger panic.
Prolonged exposure therapy. This approach combines imaginal and in vivo exposure therapy and might be used to treat PTSD. You repeatedly recall the traumatic events to a therapist while using your imagination to visualize what happened. The aim is to process the event and reassess your perception, moving from negative to neutral or positive.
Exposure and response prevention (ERP). OCD can be treated with a type of exposure therapy called exposure and response prevention (ERP). If you have OCD, you may use ritualized behavior to manage anxious thoughts, such as repeatedly washing your hands to manage your anxiety of germs. However, in ERP, you practice tolerating the discomfort of anxiety without using your rituals.
Not all types of exposure are equally effective for every condition. Some research shows that in vivo exposure, for instance, may have longer-lasting benefits on social anxiety than virtual reality exposure.
Pacing of exposure
The speed at which you decide to confront your fears can make a difference. A gradual approach is most likely preferable for many people, although some may prefer to simply tackle the most anxiety-inducing circumstances first. This can be the difference between slowly dipping yourself into cold water versus jumping in all at once. The first approach, known as graded exposure, is more common and less distressing.
Graded exposure allows you to work your way up a hierarchy of fears or a «fear ladder.» You start with a mildly distressing exposure and then advance to more frightening situations. If you have a fear of snakes, you might look at a picture of a snake. Next, you progress to being in the room with a real but contained snake. Then, when you’re ready, you challenge yourself to stay in the room when the snake is released from its enclosure. Finally, you touch the snake or even hold it.
Flooding is the opposite of graded exposure. You jump to the most intense level of exposure first. If you have agoraphobia, you might travel alone to a foreign country. If you have arachnophobia, you might pick up a spider. Although this leads to a surge of adrenaline as your body’s panic response kicks in, eventually, your system may calm down and realize there’s no danger.
While it’s possible that flooding could lead to faster improvements than graded exposure, it definitely isn’t for everyone. In certain instances, flooding could trigger panic disorder symptoms or worsen depression or substance abuse. This is unlikely to be something you want to try without guidance from a mental health professional.
Systematic desensitization combines graded exposure therapy with relaxation techniques, like meditation. Whenever your anxiety rises, you incorporate a learned relaxation exercise to help you calm down.
Tips for success with exposure therapy
The first question to ask yourself is, “Should I try exposure therapy alone or seek out help from a professional?” You may be uncertain about which type of exposure is most effective for your situation or how to pace your sessions. Or the issue you’re trying to solve may feel too complex or overwhelming to tackle alone.
Finding a professional therapist can help you determine the most effective treatment and guide you through the process. Having a therapist can be especially useful if you want to try flooding, which can be intense enough to leave you feeling drained, or exacerbate any psychiatric issues.
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Whether you choose a self-directed approach or search for a professional therapist online or in-person, the following tips can help you find success with exposure therapy. You’ll want to start by pinpointing your fears and then structuring a fear ladder, the roadmap to confronting those fears.
Climbing a fear ladder will require patience as well as a willingness to continually challenge yourself. Self-reflection can help cement the lessons you’ve learned during your exposure sessions.
Tip 1: Organize a fear ladder
Think about the kinds of objects, situations, or events that you routinely avoid. You may avoid going to parties of a certain size, for example, traveling a certain distance from your home, or going into spaces where you could encounter a spider. This can help you create exposure ideas.
Thinking about your avoidant behavior can also be motivating, as you’ll start to take note of how your fears affect your life and limit you.
Brainstorm possible exposure sessions. With your avoidant behavior in mind, establish ways that you can safely and gradually confront your fears. Consider a mix of imaginal and in-person tasks. If you’re afraid of dogs, you might imagine petting a dog, visiting a local animal shelter, or spending an afternoon with a friend’s pet.
Ensure the exposure steps and goals are specific and measurable. “Be more social” or “Go to a party” may be too vague. Instead try, “Make small talk with two strangers by noon” or “Spend 30 minutes at a party.”
Arrange the exposure activities in order from least to most distressing. This is how you create a fear ladder.
A fear ladder for a fear of spiders might look like this:
- Focus on a photo of a spider for 30 seconds.
- Spend 60 seconds imagining yourself handling a spider.
- Observe an actual spider in a plastic container for several minutes.
- Hold the plastic container with the spider inside for 30 seconds.
- Be in the room when the spider is released or handled by another person.
- Allow the spider to crawl on your arm for a minute.
Patience is key to the approach. You stick with the same rung until you feel ready to move to the next one. Starting with easier situations can help build your confidence.
Tip 2: Challenge yourself further
Making small tweaks to your exposure sessions can make the treatment more effective.
Mix it up. With social anxiety, you might practice interacting with people in various settings—at the grocery store, at parties, and in classes. If you’re afraid of dogs, you might practice interacting with different breeds. If your fear involves driving, practice driving on different types of roads at different times of day.
Practice letting go of safety behaviors. If you are able to endure anxiety-inducing social situations if your friend is nearby, for example, challenge yourself to go out in public alone, even if just briefly.
Stay immersed. During exposure, you might be tempted to distract yourself from the situation. This can be a form of avoidance. Instead, try being mindful and present despite the discomfort. If your exposure involves getting on public transportation, allow yourself to tune into the sounds and sights during the ride, rather than trying to block everything out with headphones. What sounds is the train making? What’s the view like from your bus seat?
Tip 3: Use soothing techniques to stay calm
While you want to let go of safety behaviors, you can instead rely on stress management practices to ease any distress or discomfort you feel during exposure sessions.
Ground yourself in the moment. One of the fastest ways to manage stress in the moment is to engage your senses—sight, sound, taste, smell, touch—or through movement. Try looking at a beloved photo, for example, smelling a favorite perfume, squeezing a stress ball, or chewing on gum. It can take some practice to find the technique that works bests for you, but read Quick Stress Relief for more tips.
Acknowledge anxiety and its limitations. When you start to feel anxious or distressed, you might tell yourself, «I’m experiencing anxiety. It’s not dangerous. And it will pass.» You might even take things a step further and «welcome» the anxiety. «I can take the anxiety. I want it to be here. It can’t stop me.» In doing so, you normalize anxiety as an emotion and reduce the need to protect yourself from it. Read: I Feel Anxious.
Learn to manage overwhelming emotions. By building emotion management skills you can learn to cope with unpleasant emotions that can arise during exposure sessions. Explore HelpGuide’s Emotional Intelligence Toolkit to help you learn to cope with waves of intense emotion.
Tip 4: Reflect on outcomes and progress
It may not be enough to simply expose yourself to your fears. To really change your perception of the feared situation, take a little time to reflect on how each session went.
Before each exposure, write down your expectations. What do you fear might happen if you go to a large party? Will you be humiliated or freeze up and have a panic attack? Will petting a dog result in a disfiguring attack? This can be an uncomfortable but enlightening exercise.
After each exposure, reflect on how the actual outcome differed from your expectations. What surprised you? Maybe you expected a cat to be aggressive toward you, but it was very affectionate. Perhaps you expected to experience social rejection at a party, but instead you had a pleasant conversation with a stranger.
Keep past successes in mind. When you’re feeling anxious or unconfident, think back to past exposures and how they turned out better than expected. Remember that you have faced your fears before and can do it again. This can be especially important during graded exposure, in which you’re building confidence based on earlier successes.
Be gentle with yourself when setbacks occur. You might notice that you’re making progress but later experience a resurgence in anxiety. Acknowledge the setback, but don’t allow it to discourage you from trying again. Deeply ingrained phobias and anxieties can take time to overcome.
The more you avoid sources of fear and anxiety, the more exaggerated they can become in your mind. Exposure therapy pushes you to face your fears head-on. The approach isn’t easy, and it requires both patience and resilience. However, it may be an effective way to free yourself of phobias, OCD tendencies, and other anxieties.
Última actualización o revisión el agosto 14, 2024
