You’ve heard about exposure therapy. Maybe you’ve been interested in trying it out with patients, but you don’t know enough about the procedure, or you’re worried it could do more harm than good. This guide will give you an overview of why exposure therapy can be beneficial to your patients, how to get started, and where to learn more.
What is Exposure Therapy?
Abramowitz and colleagues define exposure therapy as “the process of helping a patient engage in repeated and prolonged contact with a feared stimulus,” meaning exposing the patient to something they are afraid of.  Essentially, it involves helping your patient approach the object of their anxiety and train their brain to recognize that the object does not have to be associated with danger signals.
The Society of Clinical Psychology identifies exposure therapy as having “strong” research support for specific phobias and obsessive-compulsive disorder.  This means that the treatment has proven to be efficacious in randomized controlled trials (RCTs), the gold standard in research. Studies show that exposure substantially enhances the outcome of therapy for anxiety disorders. 
Why Does Exposure Therapy Work?
The principle of inhibitory learning serves as a basis for optimizing the effectiveness of exposure therapy. Essentially, it means that, while the brain will never forget the original fear belief (e.g., snakes are scary), repeated exposure to the feared object will result in easier retrieval of a more neutral memory of the object (e.g., “That one snake wasn’t too scary…”). This should lead to a lowered physiological reaction and greater motivation to approach the once-feared object or situation.
For Whom is Exposure Therapy Potentially Beneficial?
Exposure therapy is typically used with patients with anxiety-spectrum disorders, which include generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, phobias, panic disorder, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).
Setting up Exposure Therapy
First, you and your patient will collaboratively create a hierarchy of the patient’s feared objects or situations, which will vary based on their anxiety diagnosis (see below for examples). The hierarchy will typically range from 1 to 10, with 10 being the most distressing stimulus. As the therapist, you will use your knowledge of exposure theory and clinical judgment to help the patient fill their hierarchy.
For example, a patient with a dog phobia might identify interacting with a pitbull as a 10 out of 10 (10/10) anxiety-provoking situation. You can help them fill in the gaps with appropriate, lower-level exposures, such as viewing a picture of a pitbull (2/10), standing outside the fence at a dog park (6/10), and petting a poodle (7/10).
Make Sure Your Patient is on Board
Some of the factors that make therapists hesitant to utilize exposure are the inherent legal and ethical risks. No one wants to move too quickly and push their patient into an uncomfortable situation or risk a lawsuit.
Exposures should always be a collaborative process. Take the time to explain to your patient the rationale behind exposure therapy and ask them to explain to you how it could be beneficial to them. This might sound like, “We’ve talked a lot about how nervous you feel in social situations like parties and family events. Exposure therapy would involve gradually going out into social situations where you experience anxiety so that you learn that you can handle the situations. How do you think this could help you?”
Use informed consent and be honest about the level of risk involved. Take cultural variables into account: children and patients with limited therapy backgrounds may need more psychoeducation to gain buy-in for exposure therapy.
Research to Guide Your Treatment
These strategies from Craske and colleagues  can help you maximize your exposure sessions.
- Exposure activities should violate the patient’s expectation of the feared outcome as much as possible. To do this, you will first need to draw out the patient’s predictions. For example, someone with social anxiety might imagine that they will excessively blush while giving a class presentation. Thus, the goal of this exposure could be to learn that they can survive the act of giving a presentation while blushing, or that no one in the audience noticed them blushing.
- The old rule of thumb was that patients had to engage in exposure until their Subjective Units of Distress (SUDs) rating (a numerical indicator of their current anxiety, typically ranging from 1 to 10, with 10 being the highest) dropped by 50%. Now we know that a patient’s SUDs do not have to lower at all for them to experience a successful exposure session. The most important thing is that the patient learns that they can experience high distress and still engage in a feared situation. Talk about gaining self-efficacy!
- You don’t necessarily have to follow the hierarchy in numerical order, and it can be best to skip items rated a 1 or 2. The best place to start is wherever the patient feels comfortable, and as high as they are willing to go. A patient’s first exposure session may involve a 3 out of 10 (3/10) anxiety-provoking situation, then a 6/10, followed by a 4/10. If the patient’s motivation or buy-in is dropping, then starting at a level 3 or 4 and working up may be best.
- Patients should engage in exposures in a variety of situations. For example, a patient with social phobia might need to go on several different dates or ask a range of people out on dates before feeling more confident in romantic situations.
- Another great thing about the mechanism behind exposure therapy is that not every approach toward the feared object needs to go well or result in reduced anxiety. As clinicians, we cannot keep our patients’ feared outcomes from occurring.
For example, our patient with social phobia may ask someone out on a date and be rejected. That’s all right! The important thing is to continue asking others on dates so the brain learns that, although asking someone out can be scary, it can go well or poorly, just like any other situation.
Types of exposures
The type of exposure you use will depend on your patient’s diagnosis and feared object. Depending on the patient, only one of the following types of exposure may be applicable, or a combination of two or more could be part of the treatment plan.
Imaginal exposure involves talking about and picturing the feared situation in vivid detail. This type of exposure is used for intrusive thoughts, and when the feared situation cannot be enacted in real life. For example, if a patient with OCD experiences intrusive thoughts of hitting someone with their car, exposure may involve imagining what the patient’s car, the victim, and the scene would look like if their feared situation occurred .
In-vivo exposure means that the patient approaches their feared situation in real life. This form of exposure can be used across most disorders. It can range from a perfectionistic patient breaking apart a newly-created wooden model to a patient with a snake phobia touching a boa constrictor.
Interoceptive exposure is most often used for panic disorder and anxiety related to bodily or health concerns . It involves creating an unpleasant physical sensation, such as dizziness or a rapid heartbeat. Exposures might involve doing jumping jacks or breathing through a straw . These experiences help the patient learn that they can feel out of control and still manage their anxiety. Note: As a clinician, you should consult with your patient’s primary care physician to ensure that interoceptive exposure will not exacerbate any physical health concerns.
Exposure and Response Prevention (ERP)
Response prevention reduces reliance on behaviors patients might use to reduce anxiety artificially. In addition to engaging in exposure, the patient must resist the urge to engage in ritualistic or safety behaviors. This procedure is generally used for OCD. For example, a patient with OCD related to contamination might engage in exposure by touching a public toilet and then not washing their hands for 10 minutes.
Exposures Based on a Specific Fear
Designing a successful exposure involves creativity and trial-and-error on the part of the clinician. Therapists may find themselves employing new technology (e.g., virtual reality) and venturing outside the office to enhance the real-life feel of the activity.
Patients can always surprise even the most experienced of clinicians, but some common themes emerge in the world of exposure therapy. Listed below are a few examples of exposures for specific fears:
The clinician creates a fake “vomit” that the patient smells and touches.
The patient engages in a virtual-reality experience of flight.
Intrusive Thoughts About Being in an Accident
The patient accounts all details of the imagined scene of the accident.
The patient returns to the scene of the traumatic event (if clinically indicated).
OCD with Religious Themes
The patient conjures a sacrilegious thought and prevents themselves from praying (compulsive behavior) to relieve anxiety.
The child attends a sleepover at a friend’s house.
To Learn More
Video: Mattu, A. [The Psych Show]. (2019, February 12). How to start overcoming anxiety with exposure: 7 step guide [Video File]. Retrieved from https://www.youtube.com/watch?v=D0pxEmdHlqs
Book: Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety. New York, NY: The Guilford Press.
Article: Peterman, J. S., Read, K. L., Wei, C., & Kendall, P. C. (2015). The art of exposure: Putting science into practice. Cognitive and Behavioral Practice, 22(3), 379-392. http://dx.doi.org/10.1016/j.cbpra.2014.02.003.
 Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety. New York, NY: The Guilford Press.
 Division 12 of the American Psychological Association. (n.d.) Diagnosis: Obsessive-compulsive disorder. Retrieved from https://www.div12.org/treatment/exposure-and-response-prevention-for-obsessive-compulsive-disorder/
 Parker, Z. Waller, G., Gonzalez Salas Duhne, P., & Dawson, J. (2018). The role of exposure in treatment of anxiety disorders: A meta-analysis. International Journal of Psychology and Psychological Therapy, 18(1), 111-141.
 Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23. doi:10.1016/j.brat.2014.04.006.
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