Exposure therapy is a type of behavioral therapy that is designed to help people manage problematic fears. Through the use of various systematic techniques, a person is gradually exposed to the situation that causes them distress. The goal of exposure therapy is to create a safe environment in which a person can reduce anxiety, decrease avoidance of dreaded situations, and improve one's quality of life.
When people experience anxiety due to a fear, phobia, or traumatic memory, they often avoid anything that reminds them of it. This avoidance provides temporary relief but ultimately maintains the fear and pattern of avoidance. In some cases, the avoidance can actually make things worse and give more power to the feared entity. Exposure therapy is designed to reduce the irrational feelings a person has assigned to an object or situation by safely exposing him or her to various aspects of that fear.
For example, while working with someone who has a fear of spiders—arachnophobia—an exposure therapist might first ask the person to picture a spider in his or her mind. This might lead to several sessions in which the therapist asks the person to imagine more intense scenes with the spider, all while teaching coping skills and providing support. Once the anxiety response is reduced, the therapist may progress to real life exposure. In this type of exposure, the therapist might start by placing a contained spider at the far end of the room and lead up to placing the spider in the person's hand.
Exposure therapy originated from the work of behaviorists like Ivan Pavlov and John Watson in the early 1900s. Its roots trace back to principles of Pavlov's classical conditioning. Probably the most famous example of classical conditioning is Pavlov's dog experiment in which he methodically trained a dog to salivate at the sound of a bell. In 1924, behaviorist Mary Cover Jones shifted the field closer to exposure therapy with her studies on counter-conditioning: the process of changing an unwanted, learned response to a more desirable learned response. Cover Jones used comfort food and pleasurable experiences to gradually “erase” a little boy's fear of rabbits.
Years later, in 1958, behaviorist Joseph Wolpe developed systematic desensitization, a technique in which relaxation training, anxiety hierarchy (listing anxiety-producing triggers from most to least), and exposure are used to reduce one's sensitivity to situations he or she dreads. Later in the 1970s, Stanley Rachman developed exposure and response prevention while working with people experiencing obsessions and compulsions. In this method, people were encouraged to conjure up obsessive thoughts and then refrain from performing anxiety-reducing compulsions or behaviors.
Over the last 30 years, exposure therapy has continued to expand and both exposure and response prevention (ERP) and systematic desensitization are still used today.
Exposure therapy employs several methods to support the reduction of troubling emotional responses. Exposure therapists will conduct assessments to determine what combination of techniques will prove most effective.
Types of Exposure:
- Imaginal Exposure: In this type of exposure, a person in therapy is asked to mentally confront the fear or situation by picturing it in one's mind. For example, a person with agoraphobia, a fear of crowded places, might imagine standing in a crowded mall.
- In Vivo Exposure: When using this type of exposure, a person is exposed to real-life objects and scenarios. For example, a person with a fear of flying might go to the airport and watch a plane take off.
- Virtual Reality Exposure: This type of exposure combines elements of both imaginal and in vivo exposure so that a person is placed in situations that appear real but are actually fabricated. For example, someone who has a fear of heights—acrophobia—might participate in a virtual simulation of climbing down a fire escape.
Specific Exposure Therapy Techniques:
- Systematic Desensitization: This technique incorporates relaxation training, the development of an anxiety hierarchy, and gradual exposure to the feared item or situation. The relaxation training might include progressive muscle relaxation, soothing sights and sounds, and/or guided imagery. The anxiety hierarchy might use something like Wolpe's Subjective Units of Discomfort Scale (SUDS) to create a list of anxiety-producing events on a scale from 0-100. Then, during the gradual exposure to the ranked items, the learned relaxation techniques are applied to offset stress and anxiety.
- Graded Exposure: This technique is similar to systematic desensitization, but does not integrate the use of relaxation techniques.
- Flooding: In this technique, exposure can be in vivo or imaginal. A person is intensely exposed to anxiety-evoking events for a prolonged period of time. Flooding is usually done until the anxiety is significantly diminished.
- Prolonged Exposure (PE): Proven effective with trauma-related issues, this technique is similar to flooding but also incorporates psychoeducation and cognitive processing.
- Exposure and Response Prevention (ERP): An effective technique for people experiencing obsessions and compulsions, ERP works to weaken the link between obsessions and compulsions. Therapists provoke a person's obsessions and then ask that person not to engage in their behavioral rituals or compulsions.
- Cognitive Restructuring: Many therapists supplement exposure therapy techniques with a cognitive component in order to reinforce further progress. Therapists help to reframe faulty thought patterns that keep a fear or phobia in place.
- Medication: Psychotropic medications like antidepressants and benzodiazepines have been shown to be effective in reducing the biological symptoms of anxiety. However, in most instances, a combination of pharmacotherapy and exposure therapy is encouraged.
A number of mental health issues can be treated with exposure therapy. Many people with anxiety and trauma-related issues have found exposure therapy to be helpful. Applicable mental health issues include but are not limited to:
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- Social anxiety
- General anxiety
- Posttraumatic stress (PTSD)
- Obsessive compulsive anxiety issues (OCD)
- Acute stress or other trauma-related issues
- Panic attacks
The benefits of exposure therapy have been well documented and many studies cite exposure therapy as a first-line treatment for several mental health concerns.
- A 2012 study published in the Journal of Rehabilitation Research and Development cited prolonged exposure (PE) therapy as the gold standard treatment for posttraumatic stress, especially for combat and military-related trauma.
- According to the International OCD Foundation, 7 out of 10 of people with obsessive-compulsive issues experience a 60–80% decrease in concerning symptoms when they participate in a combination of exposure and response prevention (ERP) and cognitive restructuring.
- According to a 2011 article published in the Psychiatric Times, a meta-analysis of those who participated in exposure therapy studies reported positive results at post-treatment follow-up, approximately four years after receiving treatment. Ninety percent of participants reported their anxiety at a reduced level and 65% of participants were no longer experiencing their specific phobia.
Although there is a great deal of research to support the efficacy of exposure therapy, there are some notable limitations of the treatment. Sources report that in spite of the well-documented success rate of exposure therapy, many professional counselors and therapists do not implement it. Some speculate that this is because the availability of specialized training is limited. Additionally, a survey of psychologists who treat PTSD revealed that many believe exposure therapy may exacerbate symptoms. Beliefs that exposure therapy might make things worse may prevent many professionals from using it.
According to Mark Pfeffer, director of the Panic and Anxiety Center in Chicago, IL, exposure therapy is difficult work that causes people to feel things they have worked hard to avoid. Because of this, if not implemented properly, exposure therapy's positive effects can wane. That is why, even if you start to feel better, it is important to participate in treatment to the fullest extent and follow the prescription of a well-trained therapist. For many people, the effects of exposure therapy are lasting, and research continues to support its efficacy for treating anxiety, phobias, and many other mental health issues.
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