In many industrialized countries, anxiety is now one of the most common mental health problems facing people of all ages. As it’s become more culturally accepted to discuss anxiety and to seek out treatment, various techniques aimed at reducing anxiety symptoms continue to evolve — one of which is called exposure therapy.
What kind of technique is exposure therapy (ET)? It’s a type of behavioral therapy that is intended to help people overcome fears, phobias and compulsions.
While ET may be a simple concept, it’s not so easy to actually carry out, since it involves exposing oneself to the very things that trigger worry or panic. Still, studies suggest that with some patience and commitment, ET can reduce symptoms tied to chronic stress, decrease avoidance of dreaded situations and improve one’s quality of life.
What Is Exposure Therapy?
As the name implies, exposure therapy is a behavioral technique that involves “facing your fears” and confronting situations or objects that cause you anxiety and distress.
The primary goal of exposure therapy is to reduce irrational feelings that someone associates with a stimulus (an object or situation). This can include both external stimuli (including feared objects, animals like snakes, activities like flying, etc.) or internal stimuli (such as feared thoughts and uncomfortable physical sensations).
Exposure is the opposite of avoidance, which is what people usually do when they fear certain things. As the American Psychological Association explains:
although avoidance might help reduce feelings of fear in the short term, over the long term it can make the fear become even worse…The exposure to the feared objects, activities or situations in a safe environment helps reduce fear and decrease avoidance.
In place of fear, new reactions to a fear-producing stimulus, such as calmness or neutrality, are learned through repeated exposure. This makes exposure therapy a form of desensitization, which refers to having diminished emotional responsiveness to something negative after being repeatedly exposed to it.
Types, Varieties and Techniques
Below are some of the most common variations of exposure therapy, as well as specific techniques used by psychologists in ET sessions:
- Prolonged exposure therapy (PET) — The type of ET most often used to help treat symptoms of PTSD (post-traumatic stress disorder), which is a condition characterized by unwanted thoughts, disturbing nightmares, feelings of hopelessness, depression and hypervigilance following trauma.
PET is based on the principle of associative learning theory, which states, according to Psychology Today, that:
when two things appear together the brain learns to connect or associate them. When a trauma occurs, there are many things in the environment — smells, sights, sounds — that the brain associates with the trauma. When we encounter those things outside of the trauma, the brain expects danger, causing fear and anxiety.
Something that makes PET different than other variations of exposure therapy is that it’s gradual and involves psychoeducation and cognitive processing/cognitive behavioral therapy. These techniques are used to reframe destructive thought patterns that contribute to ongoing fears.
- Graduated exposure therapy — This is when a patient is exposed to the least scary object/situation on that person’s hierarchical list of fears and then gradually exposed to scarier ones, usually with the help of a therapist.
- Flooding — This involves being exposed to the most feared object or situation abruptly, which can be anxiety-inducing but also effective within a short period of time. This is often used to treat specific phobias and is sometimes called “total immersion exposure.”
- Exposure and response prevention (ERP) — ERP is often used to treat obsessive compulsive disorder. This technique involves provoking the patient’s obsessions and then having them resist engaging in the normal ritual or compulsions.
- Self-exposure therapy — This is done without guidance from a therapist. It involves gradually or abruptly repeatedly going into feared situations until you feel less anxious. You may want to start by list your fears in order from least to most scary or by identifying a specific goal related to your fear and then listing the steps needed to achieve that goal.
Several techniques are commonly used during ET sessions, including processing, imaginal exposure, and in vivo or in vitro exposure.
- Processing refers to exploring thoughts and feelings.
- Imaginal exposure involves discussing traumatic events that happened in the past but not actually facing the situation/object in person.
- In vivo exposure involves facing a fear “in real life,” as opposed to only imaging it. On the other hand, in vitro exposure therapy (basically the same as imaginal exposure) involves imaging the unwanted outcome so it becomes more familiar and less intimidating.
- Virtual reality exposure therapy is sometimes used in place of in vivo exposure when exposure in real life on an ongoing basis is not practical. This technique is commonly used to treat phobias, such as fear of flying, snakes, etc.
- Systematic desensitization may also be combined with ET. This involves practicing relaxation exercises, such as deep breathing, in order to reduce physical sensations tied to anxiety, including a racing heart or tense muscles, while being exposed to the fear stimulus.
- Eye movement desensitization and reprocessing therapy (or EMDR therapy, also called “rapid eye movement therapy”) is another approach that can be helpful when used in combination with ET to decrease anxiety symptoms. During an EMDR session, the therapist’s fingers move side to side, while the patient follows the therapist’s finger (or an object) and tries to “let go” of controlling his or her thoughts. Thoughts are instead just “noticed,” much like during meditation, or they are replaced with more positive and realistic thoughts.
How Does It Work?
ET requires people to speak about or face in person their fearful thoughts, feelings and phobias. They may also need to relive trauma and encounter trauma-related situations.
For this reason, it can be a distressing technique, however sessions are usually only brief and often result in decreased anxiety within several treatments.
Here is what can be expected from an ET treatment session:
- A patient meets with a therapist for a one-on-one therapy session. Each session typically lasts 60 to 90 minutes and occurs about once a week.
- How long does exposure therapy take to work? Depending on the person, it may take anywhere from four to 15 sessions to experience significant improvements in symptoms.
- In addition to utilizing the techniques explained above, a patient’s therapist may encourage the patient to make a list of things he or she avoids due to anxiety or write down her or his fears, worries and experiences with past traumatic experience, then read them out loud. (This is also called narrative exposure therapy.)
- Fears might also be ranked in terms of least scary to most scary (put into an “exposure hierarchy”).
Who can benefit from exposure therapy? This technique seems to be most appropriate for anyone who experiences these conditions:
- Ongoing anxiety and stress, especially about specific objects or situations. Many experts feel that based on available research, exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders, including generalized anxiety disorder.
- Phobia disorders, defined as an unreasoning fear to a non-dangerous thing or situation.
- Post-traumatic stress disorder (or PTSD), which is anxiety and unwarranted fear due to traumatic events and/or witnessing something disturbing. ET is considered by many therapists to be the “gold standard” for PTSD related to combat and military-related trauma..
- Obsessive compulsive disorder (OCD).
- Panic disorders.
- Social anxiety disorder.
Here’s more about the specific ways that exposure therapy can benefit people with the above conditions:
1. Decreased Anxiety and Stress (Due to Habituation)
Surveys suggest that individuals with traumatic histories often express a preference for exposure therapy over other treatment methods, even though it can be a frightening technique to get started with.
The more that someone is exposed to a feared object without anything bad happening, the more comfortable that person will gradually become with facing the fear more often. This is known as habituation, in which responses to feared objects and situations decrease as they become more familiar.
Studies show that habituation seems to be especially helpful for people with PTSD. It’s been found that exposure-based therapy is associated with improved symptomatic and functional outcomes for patients with PTSD and that it can help those suffering to resume day to day activities.
It’s also been found to reduce symptoms, including anger, guilt, negative health perceptions and depression, among those with anxiety disorders.
2. Help Stopping Unwanted Habits and Thought Patterns (Extinction)
One of the main goals of ET is to break associations in the mind between feared situations and bad outcomes. For example, exposure therapy for OCD can be effective because it teaches the person that stopping unwanted rituals/behaviors (such as obsessive washing or checking) will not result in anything scary actually happening.
ET and ERP for OCD is most often done gradually, using a “fear ladder.” By reaching the end of the fear ladder the patient learns how to identify the things that are bothering her or him, recognize the desire to engage in a compulsion, and then handle anxiety in real time by using other coping mechanisms.
3. Improved Coping Skills and Confidence
When people commit to confronting their own fears, research suggests that they often gain confidence in their ability to handle intimidating or scary situations in the future. New coping skills become available, as avoidance and compulsions are no longer used to manage anxiety.
For instance, exposure therapy for social anxiety can be helpful because it teaches people to trust themselves around others, rather than avoid social situations due to fear of rejection or looking stupid or unintelligent. Avoidance is eventually replaced with self-confidence, good communication and trust in others.
Concerns and Limitations
What are some of the disadvantages of exposure therapy? One issue is that it can be difficult to find a therapist who is comfortable and familiar with this approach.
An article published in Psychiatric Times states that while “it is well established that exposure-based behavior therapies are effective treatments for anxiety disorders, unfortunately, only a small percentage of patients are actually treated with exposure therapy.”
ET may be most effective when combined with other therapeutic approaches, such as cognitive behavioral therapy (CBT), which focuses on identifying and changing destructive thoughts. CBT seems to be especially beneficial for emotional processing, or learning “how to attach new, more realistic beliefs about feared objects, activities or situations, in order to become more comfortable with the experience of fear.”
Some patients with phobias, PTSD, severe anxiety or other conditions may also need to combine medication with exposure therapy in order to experience benefits. Examples of psychotropic medications that therapists may recommend to patients undergoing ET treatment include antidepressants and benzodiazepines, which are used to manage biological symptoms of anxiety.
Certain therapists may also recommend patients try biofeedback therapy in addition to ET and/or medication. Biofeedback training is all about learning how to recognize and become aware of one’s response to anxiety, then using relaxation skills to reduce and control the stress response.
Overall, some ET techniques may be riskier than others. While self-exposure therapy is an option that some people may find attractive, it poses risks, such as potentially worsening anxiety.
The same can be said about flooding, which can provoke panic attacks in some cases.
Finding a Therapist
The most effective and safest way to benefit from ET is to work with a therapist or health care provider who has been trained and certified in exposure therapy techniques. Unfortunately, many health care professionals do not understand the principles of ET and worry that it may make patients’ symptoms worse, so it’s best to seek out someone who is familiar with this specific method.
To find a qualified therapist in your area, you can visit the American Psychological Association’s website here.
- What is exposure therapy? It’s a psychological treatment that was developed to help people confront their fears and phobias by exposing them to the very situations or objects that cause them anxiety.
- Some of the uses for exposure therapy include treating conditions like PTSD, OCD, phobias, panic attacks and symptoms of generalized anxiety.
- Research studies have found that ET benefits can include reducing chronic stress and anxiety, stopping unwanted compulsions and habits, improving coping skills and self-confidence, and improving relationships and communication with others.
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