What is Exposure Therapy?
Exposure therapy — when done correctly — has helped millions of people overcome fear and anxiety. It is used by some therapists and behavioral health professionals to treat post-traumatic stress disorder (PTSD) and phobias.
What is exposure therapy, and how can clinicians learn whether this type of treatment is appropriate for their clients?
What Is Exposure Therapy?
Clinicians use exposure therapy to help people overcome their fears and anxieties by safely exposing them to a stimulus that causes fear. In the process, people learn to stop avoiding situations, objects, or activities that cause them to feel anxious or upset. As a result, people learn new ways of coping with anxieties.
The American Psychological Association (APA) reports that exposure therapy is a proven treatment for the following problems:
- Panic disorder
- Social Anxiety Disorder
- Obsessive-Compulsive Disorder (OCD)
- Generalized Anxiety Disorder
The Connecticut Women’s Consortium training, “Face Your Fears: Conducting Good Exposure Therapy Across Diagnoses” is an on-demand course that explores the psychological mechanisms of exposure therapy. It’s taught by David Tolin, PhD, ABPP, Director of the Anxiety Disorders Center at the Institute of Living/Hartford Hospital. Tolin demonstrates several types of exposure therapy and addresses several myths that lead to the underutilization of this effective treatment.
What Do We Fear?
Fears can generally be divided into two broad categories: things that are external to the person and things that are internal to the individual.
External fears include:
- Specific situations or activities, such as flying, heights, animals, receiving an injection, seeing blood, storms, contamination/germs, or imperfection
- Fears of social scrutiny, including being judged or evaluated, doing or saying something stupid or embarrassing, or fear that someone will see how nervous they are
- Fear of risk can include fears about harm coming to themself or others, causing harm, or fears of danger (a recurrence of a traumatic event)
Internal fears can include:
- Thoughts of harming themself or others, morally or sexually unacceptable thoughts, or fears that thoughts can cause harm
- Fears of intrusive memories or the belief that someone cannot tolerate remembering traumatic events
- Physiological sensations like a racing heart, dizziness, lightheadedness, or shortness of breath; worry about serious physical illness; worry that sensations will lead to an embarrassing outcome
The Connection Between Avoidance and Fear
It’s common for people to avoid the external and internal stimuli that cause fear. They stay away from activities, places, and people that evoke those sensations. People also try to avoid thinking about or remembering emotions, thoughts, or sensations connected with traumatic experiences.
Some of these avoidance behaviors are obvious. Someone with agoraphobia might avoid crowds or driving. A person with OCD might avoid environments they perceive to be dirty or germy. A client with PTSD might go to great lengths to avoid memories of traumatic events.
Other avoidance behaviors are less obvious. A person with social anxiety disorder will go to parties but only interact after having a few drinks, or a driver with PTSD from an accident will drive slowly, and only at certain times.
The problem with avoidance is that someone cannot avoid and overcome fear at the same time.
Have you ever tried not thinking about something, and found you thought about it even more?
The key to exposure therapy is helping people face or confront distressing stimuli rather than avoiding them.
Variations of Exposure
There are several main variations of exposure.
1. In vivo exposure. This is when clients undertake real-life activities that put them into contact with the objects or situations they fear.
- A client who fears snakes holds one.
- A person who is afraid of flying gets on a plane.
- Someone with social phobia gives a public presentation.
- A client with OCD touches objects that seem dirty.
2. Imaginal exposure. When it’s not possible to have in vivo experiences, this type of exposure is when a therapist helps a person think through bad scenarios.
- Someone with OCD imagines dying of a terrible disease because they didn’t wash their hands.
- A person with fear of flying imagines a horribly turbulent flight.
- A person with PTSD recalls a traumatic memory in detail.
3. Virtual reality exposure. VR technology such as flight simulators, can be used to help people experience the cause of their fear.
4. Exposure to thoughts. This is when someone confronts the thoughts that they are afraid of thinking.
5. Interoceptive exposure. This is when a clinical helps someone confront the physiological sensations they fear: getting dizzy, nauseous, or having trouble breathing.
Even though exposure therapy has proven to be effective in treating OCD and panic disorder, this type of therapy is underutilized in clinical settings.
There are several reasons for this; one of them is fear on the part of clinicians.
Exposophobia: Clinicians’ Irrational Fear of Conducting Exposure
Many clinicians are wary of conducting exposure therapy. Tolin calls this “exposophobia.”
What is the root of this fear? Some behavioral health professionals experience discomfort with their patients’ distress, or with the source material.
Tolin believes that it is important to dispel a number of myths surrounding exposure therapy so that more clinicians feel comfortable doing it. The following are some of the myths he has encountered in his experience:
- Exposure will make the problem worse
- Exposure will worsen a client’s substance use, psychosis, or other comorbid condition
- A client will hate it and/or drop out of treatment
- Clinicians can only do exposure after extensive coping skill training
- Clinicians should never do exposure therapy with children
- Clinicians should never do exposure with complex PTSD
- Exposure therapy will harm the therapeutic alliance
When clinicians believe these myths, they underutilize this promising tool, limit who they administer exposure to, or water down the therapy to the point where it weakens outcomes.
The reality is that exposure therapy can cause a temporary increase in anxiety. This anxiety decreases with time, and research shows that exposure makes the problem better in a majority of cases.
Fear is never erased, but it can be extinguished. That’s because our brains are resilient and can learn new things.
For example, exposure therapy has helped people with panic disorder learn that they can have an elevated heart rate without having a heart attack. People with OCD learn that touching “dirty” things doesn’t make them sick. People with social anxiety discover that minor blunders do not always lead to ridicule. And, perhaps most important, clients with PTSD are capable of remembering traumatic experiences without falling apart.
Does Exposure Therapy Work?
When it comes to treating phobias, anxiety disorders, OCD, PTSD, and panic attacks, a number of studies have shown that therapist-guided exposure therapy is effective.
The American Psychological Association website has listings for professionals that can be searched by region and specialty.’
As Franklin D. Roosevelt put it during his first Inaugural speech: “The only thing we have to fear is fear itself.”
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