CONTENTS
(1) An overview of exposure therapy
(2) The process of exposure therapy
(3) Getting started with exposure therapy
(4) For professionals
(1) An overview of exposure therapy
Exposure therapy is one of the primary methods in Cognitive Behavioral Therapy (CBT) for anxiety disorders, OCD, and PTSD. There is a considerable amount of scientific evidence that has established exposure therapy as a key component in the effective treatment of these disorders.
When people have problems with anxiety, they often cope by trying to avoid whatever it is that they fear. What they avoid can be external stimuli, such as situations, people, animals, or objects, or they can be internal stimuli, such as thoughts, images, physical sensations, and emotions. There are at least three problems with this coping strategy:
(1) These stimuli often can’t be entirely avoided.
(2) Avoiding often takes time and energy, and often causes people to restrict their life activities and sacrifice important goals.
(3) Avoiding prevents learning that these stimuli are not actually dangerous and that it is not necessary to avoid them.
In exposure therapy, people voluntarily agree to face the very stimuli that cause them to experience anxiety. This is done in a carefully planned, and systematic manner designed to help them successfully cope with the exposure. Typically, exposure starts with stimuli that cause mild to moderate amounts of anxiety, and as a person's confidence grows they agree to face stimuli that cause greater amounts of anxiety.
Successfully implemented exposure therapy promotes new learning, and often results in the person experiencing the following benefits:
(1) Increased confidence in coping with anxiety and previously feared stimuli.
(2) More objective and accurate beliefs about anxiety and feared stimuli (e.g., that the feared consequences do not occur and that anxiety is manageable).
(3) Habituation, which is a psychobiological process that occurs when repeated exposure to a stimulus decreases the strength of one's emotional and physical response.
There are two types of exposure exercises: imaginal and in vivo. Imaginal exposure involves repeatedly exposing oneself to feared stimuli via the imagination. In vivo exposure involves repeatedly exposing oneself to feared stimuli in real life. Some exposures can be done in the therapist's office, but many will have to be self-implemented outside of session. Exposure therapy typically takes several weeks and multiple exposure exercises. It also requires the willingness to repeatedly face what one fears and has been avoiding.
Throughout the process, the therapist and patient collaboratively design the exposure practice sessions. The aim is to plan an experience that is manageable and results in new and beneficial learning. The patient is never forced into an exposure.
(2) The process of exposure therapy
Step 1: Identifying the costs of anxiety and avoidance in terms of interfering with what the person wants to do in life, and the potential benefits of reducing anxiety and avoidance. This can help strengthen the motivation to do the hard work that exposure therapy requires.
Step 2: Developing a list of all of the stimuli that are feared and/or avoided. These could be external stimuli (e.g., situations) or they could be internal stimuli (e.g., physical sensations, mental images).
Step 3: Rating the amount of fear and avoidance each stimuli causes, ranking them, and arranging them in a list from most feared/avoided to the least. This is often referred to as the "Fear and Avoidance Hierarchy."
Step 4: Selecting stimuli from the Hierarchy for exposure practice. Often, stimuli that cause only mild or moderate levels of anxiety are selected for the initial exposures.
Step 5: Designing exposure practice exercises that are likely to be manageable and to result in the desired learning experience. The details of the exposure exercise are specified in advance (e.g., what to do, where to do it, how long to do it for). These practice exercises may be in vivo or imaginal.
Step 6: The patient implements the planned initial exposure and rates the level of anxiety they experienced on a form.
Step 7: Exposures need to be repeated multiple times to be effective, and not too much time should elapse between practice sessions.
Step 8: The patient continues to progress up the Hierarchy until they are willing to repeatedly face their most feared and/or avoided stimuli.
(3) Getting started with exposure therapy
I recommend doing steps 1 and 2 above in writing. First, list the costs of anxiety/avoidance in terms of how it interferes with your life. Then, develop a list of all of the stimuli that you avoid. Keep in mind that these can be either external stimuli (e.g., situations, people, animals, or objects), or they could be internal stimuli (e.g., thoughts, images, physical sensations, and emotions).
(4) For professionals
Abramowitz, J. S. (2013). The practice of exposure therapy: Relevance of cognitive-behavioral theory and extinction theory. Behavior Therapy, 44(4), 548–558. (PDF) (The most effective intervention for clinical anxiety is exposure therapy. This article explains how exposure is thought to work)