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If you've ever struggled with intense fears, or know someone who has, you might have heard of exposure therapy. In the business world, we often encounter a version practiced outside the realm of clinical psychology — training and coaching designed to overcome the fear of public speaking or presenting in front of a large group.
Few fears beyond fear of public speaking or fear of flying are considered fair game at work so exposure therapy isn't likely a lunchtime conversation topic. The reality is, even outside of work, we often don't know if someone suffers from anxiety or if they're seeking treatment — whether behavior therapy, psychotherapy, or medication — for it.
One silver lining of the pandemic is that mental health concerns are being brought into the open. While less stigma is good, there are still a lot of gaps in people's knowledge and inaccurate information.
In this article, I'll provide an overview of exposure therapy. I'll explain how exposure therapy works, its different types and techniques, what mental issues and specific phobias exposure therapy is an effective treatment for, and the effectiveness of prolonged exposure therapy.
What is exposure therapy?
Have you ever heard something along the lines of “you have to face your fears to get over them"?
Well, exposure treatment is similar to that. The basic idea of this type of therapy is that by controlled, safe exposure to a feared object, guided by a clinician, a person can achieve cognitive restructuring -- essentially, the pattern of stimulus and automatic response is interrupted. A new pathway and connection that is more adaptive are created.
Exposure therapy is a treatment option recognized by the American Psychological Association and other professional bodies around the world. It is a type of behavior therapy, sometimes lumped into a larger category of cognitive-behavioral therapy (CBT), which makes use of evidence-based techniques in order to expose a person to the stimulus that causes them anxious feelings or fear.
It is worth understanding that behavior therapy is one form of psychotherapy. It focuses on mapping stimuli and maladaptive responses and changing those responses. Behavior therapy is a fast therapy. It can bring significant benefits in the short term by focusing on the "what" without trying to understand the "why" or root of the stimulus-response patterns.
The final goal is to improve the client's ability to function by reducing their level of anxiety so that when faced with this stimulus again, it does not affect them the way it used to.
Four types of exposure
There are several different ways to approach exposure to feared stimuli. The best types of exposure for a given condition depend on several factors, as assessed by a trained clinician. Obviously, there are some limitations depending on the feared situation and the circumstances surrounding a specific phobia. In addition, the type and magnitude of response associated with the stimulus should be considered.
Placing someone back in a traumatic event or experience should not be approached lightly, say by a well-meaning family member trying to help.
- In vivo exposure. This kind of exposure implies that the person is faced with the feared stimulus that causes them anxiety, in real life. For example, if a person is afraid of dogs, a dog will be brought into the in vivo exposure, in real life. As long as the response isn't too traumatic or create a dangerous experience, this type of exposure can be practical for short-term, repeated habituation, such as to address social phobia.
- Imaginal exposure. This is the kind of exposure that is generally used when the stimulus isn’t easy to access and bring to a therapy session, therefore the therapist uses imagination techniques to work with the sensations that the stimulus brings, without having it physically there.
An example of this is a person who has a fear of flying. As it would be quite impossible to bring this to a session, the person has to imagine being in a plane.
- Virtual reality exposure therapy. This is used in the same cases that imaginal exposure is used, however, it does not require an imagination technique from scratch. Virtual reality helps to create the stimulus and the response to it, by observing and living within a different reality, as opposed to the current room and context the person would be in at that moment (i.e. the therapy room).
- Interoceptive exposure. This kind of exposure is used to expose the person to the physical sensations that they do not like, such as anxious feelings, in order for them to realize these sensations are not as threatening or dangerous as they thought.
For example, we could have a person do cardio exercises to activate and speed up their heart rate, which is one of the symptoms that they fear. The goal of the exercise is to realize that this physical feeling is not a threat and it is a bodily human response.
Exposure therapy techniques
- Graded exposure. The therapist helps the client define a list of situations that would cause their unpleasant response, and rank each one of them from 1 to 10 depending on how unpleasant each situation is. Once this is done, with each of these situations, they construct a list that goes from 1 to 10, 1 being the least worse situation, and 10 being the absolute worst.
The graded exposure consists of exposing the person to these situations, starting from the bottom and ending with the worst one.
For example, if the fear is “spiders”, the graded exposure would start off with having the person look at a picture of a spider, and it would end with the person being near a real-life spider.
- Flooding. Using the same fear hierarchy used in graded exposure, flooding consists of exposing the person to the worst situation on the list. Unlike graded exposure, which is gradual, flooding is like diving in the deep end.
For instance, using the same example as before, the person would be exposed to a real-life spider immediately.
- Systematic desensitization. This is a kind of exposure technique that is combined with relaxation techniques. The goal is to train the person so that they can associate the unpleasant stimulus with relaxing feelings and to use these relaxation techniques, if needed, during the time they are exposed to these situations outside of therapy.
For example, if a person is exposed to a spider, they will practice their relaxation techniques in the presence of this stimulus, to combat the anxious feelings that it may cause.
- Prolonged exposure. The person is exposed to the situation that causes them unpleasant feelings, during an extended period of time. This will cause their bodily responses to reach a peak and gradually decrease naturally.
An example of this would be exposing a person to a dog (presuming that they wanted to work on their fear of dogs), and having them experience all their usual anxious symptoms, and then waiting with them, without taking away this dog, until their body and mind naturally calm down.
- Exposure and response prevention. This kind of exposure is used especially with OCD. During the session, the person is exposed to the situation that sets off their obsessive thoughts. In their usual day-to-day, this would result in them engaging in an action cataloged as “compulsion.” But during this exposure technique, the person is trained not to engage in this action, preventing their usual compulsive response to the obsessive thought.
For example, a person who suffers from OCD might have obsessive thoughts of feeling like they haven’t locked the door correctly after leaving the house. The usual compulsion that they follow is going back home and checking this after they have already left. So during this exposure technique, we would have this person leave the house, have this obsessive thought, but restrain themselves from going back and checking.
Of course, this isn’t a one-time technique. It has to be trained in order for it to have lasting and noticeable effects on their day-to-day OCD.
What mental issues can exposure therapy treat?
Obsessive-compulsive disorder (OCD):
People who suffer from OCD experience obsessive thoughts centered around a certain theme. They engage in compulsive behaviors to relieve the anxiety they feel due to these thoughts.
Obsessive thoughts can vary, however, some common themes are:
- Germs and cleanliness
- Illness and disease
- Controlling their environment
- Religious obsessions
- Unwanted sexual obsessions
The compulsions that people can experience due to these obsessive thoughts are also diverse. Common compulsive behaviors include excessive cleaning, disinfecting, checking, repeating, counting, evening out numbers, and even body movements such as exaggerated posture correction.
While OCD is sometimes portrayed as quirky in pop culture, obsessive thoughts can be very distressing. The compulsive behaviors can become so elaborate or constant — such as hand-washing to the point of bleeding or sequences that have to be restarted if they aren't executed perfectly — that they interfere with basic daily living and working.
Post-traumatic stress disorder (PTSD):
This is a disorder that may happen when a person has witnessed or experienced a traumatic event, such as sexual assault, a serious accident, a natural disaster, a terrorist attack, or violence.
People who suffer from PTSD may have disturbing thoughts and feelings related to the trauma they experienced, but that has already ended. These responses may come out of the blue, or they could be triggered by a stimulus that reminds them of the trauma. Moreover, these may include bodily responses (anxious symptoms, freezing up…), sadness, fear, flashbacks, nightmares, or night terrors.
For example, a person who has been sexually abused may experience flashbacks of the moment it happened and might have an unpleasant bodily response to physical touch.
Generalized anxiety disorder (GAD):
This disorder is characterized by constant worry about everyday life events and topics. Anxiety is a necessary response our body has as a survival mechanism, but it becomes a problem when this anxious response is not necessary because there is no danger or threat that needs a “fight or flight” response from us.
For instance, a person with GAD could experience anxious symptoms over a loved one not responding to their texts, or over fear of the future.
This includes any extreme and persistent fear of something or of a situation that causes the person to avoid it at all costs, sometimes resulting in issues in everyday life activities.
Some common phobias are agoraphobia (fear of open and public spaces), claustrophobia (fear of closed spaces), and phobia of specific things such as a certain animal or object.
Social anxiety disorder:
This disorder consists of an extreme fear of social situations that involve meeting people or engaging in interaction with others. It can include thoughts of being constantly watched and judged by others.
A person who suffers from social anxiety disorder might avoid social situations such as parties or work colleague gatherings in order not to feel this anxiety. They suffer additionally the loss of social connection.
This anxiety disorder is characterized by regular panic attacks that sometimes have no specific trigger. This can often interfere with everyday tasks and activities.
This can include a wide variety of trauma, which is a response our body and mind have to a stressful or distressing situation. Trauma can leave the person feeling helpless, wounded, and lacking the ability to cope with certain feelings and emotions.
Examples of trauma include having experienced sexual assault, a terrorist attack, a natural disaster, domestic violence, or an abusive upbringing.
What is prolonged exposure therapy?
Prolonged exposure consists of having a person face their fear for an amount of time that enables them to experience the peak of their unpleasant and anxious bodily responses, and then a decrease of this anxiety for the body to reach its neutral state.
With this kind of exposure, it is very important not to interrupt the exposure period before the person’s body has reached its neutral and relaxed state again, as doing so could result in the opposite effect that the therapist wants to achieve with this exercise (i.e. the person’s fear is even more instilled in them).
Is exposure therapy effective?
That is the key question, right? It is unlikely for us to make an effort to do something when the results are unclear. Of course, when we talk about techniques to improve our lives, to adapt our behavior, or to face and overcome irrational fears, the degree to which we succeed will depend on our particular case. Certain variables must be taken into account.
Before jumping into them, it is useful to consider some data. Exposure therapy is a scientifically proven type of therapy. Between 60% and 90% of people experience a significant improvement after receiving it.
It is a powerful and effective technique.
This might leave you wondering why it works for some people, what the variables are that predict success, and if you would be able to overcome your fears through this technique. Those are all relevant questions.
To answer them, two primary variables come into play:
- Type of exposure techniques. Depending on the person’s fear, they have a higher chance of succeeding depending on the technique that they engage in. For example, exposure and response prevention is especially effective on people who suffer from OCD.
- The patient’s engagement. As much as we wish we had a magic wand that we could swish and make the fear disappear, that is far from reality. It is necessary for the person to actually engage properly in the exercises, and trust their therapist and the process.
This is a two-way street where not only are the therapist’s efforts important, but also the patient’s. This is the recipe for a successful exposure technique.
As we have seen throughout this article, there are many ways a licensed therapist may apply exposure therapy. It isn't a pleasant process for the individual, but it tends to have rapid and significant benefits for their quality of life and well-being.
Think of it like going to the physical therapist: in the sessions, some massages on the affected muscle may hurt. After a few sessions, the pain starts to lessen, until you are finally feeling much better, able to move in ways you couldn’t before, and without having to experience muscle pain.
Exposure therapy is similar. The sessions are sometimes difficult to go through, but if you visualize your end goal and keep at it, it will gradually get easier. Soon you will be able to live and move about with greater ease, without this fear getting in the way of your day-to-day life.
BetterUp Care Coach