Exposure therapy

exposure therapy, prolonged exposure therapy, what is exposure therapy, virtual reality exposure therapy

Exposure therapy’s beginnings can be traced back to Ivan Pavlov’s classical conditioning experiments with dogs in the 1920s. After pairing an unconditioned stimulus (food) with a conditioned stimulus (a bell sound) to cause salivation, he sought to decrease the salivation response by unpairing the bell sound’s association with food.

This process was termed “extinction” and formed the basis for exposure therapy. Exposure therapy is one of the central behavioral interventions under the umbrella of cognitive-behavioral therapy (CBT). It is the predominant treatment when addressing posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and multiple anxiety disorders.

How does exposure therapy work?

Exposure therapy is all about learning to reduce fear. When someone has fear and anxiety regarding a particular object or situation, they tend to want to avoid it. While avoidance may help to reduce anxiety in the short term, it makes it much worse over time. Exposure forces the individual to confront their fears and shows them that they are largely unfounded. When successful, this process reduces anxiety to manageable levels or makes it disappear entirely.

Types of exposure therapy
  • In vivo: In vivo exposure occurs when the client is exposed to a feared stimulus in reality. For example, someone with a fear of snakes will be exposed to a real snake. This is thought to be the most effective form of exposure in that it is the most realistic and mirrors what the person will encounter in their environment. Virtual reality is a variation of in vivo exposure. It allows the client to feel like they are confronting a stimulus in real life without actually having to do it. This is very helpful for stimuli that may be hard to experience in the client’s present environment. For instance, it is pretty much impossible for a person who has PTSD related to wartime atrocities to go back into a war zone just to expose themselves for the sake of treatment. While virtual reality may not be able to replicate the same total sensory experience, it is as effective as in vivo exposure in some cases.

  • Interoceptive: Interoceptive exposure intentionally creates physical symptoms that mimic signs of anxiety attacks. This is especially effective for people who suffer from panic disorder and believe they are having a heart attack. For example, a client may be asked to jump rope to raise their heart rate. The resulting heart palpitations will be similar to those felt during a heart attack and trigger a fear response. However, instead of calling 911 and going to the hospital, the client will be asked to endure their fears and do nothing. The heart palpitations will eventually subside and the client will learn that their symptoms are due to anxiety and they will survive unscathed.

  • Imaginal: Imaginal exposure is when the client is asked to imagine whatever it is that causes them anxiety. Although this might seem to be the least realistic type of exposure, it is the easiest way to simulate the anxiety-provoking situation. This is especially helpful for situations that might be difficult or harmful to recreate. For example, say someone has a fear of blood and needles. It may not be recommended (or even ethical) to inject someone and/or cause them to bleed. But, it is perfectly safe for someone to imagine the situation and confront fears in their mind.

Three exposure therapy techniques
Clinicians implement exposure therapy using the following techniques:
  • Graded exposure: Although exposure can be very anxiety-provoking, graded exposure uses a gradual approach to allay fears. The therapist first helps the client establish a fear hierarchy of a certain situation or object. Then, they expose the client over time to the feared stimuli from least to most anxiety-provoking. This gives people the opportunity to cope with less fearful events before they have to tackle situations that elicit high levels of anxiety.

As an example, let’s look at Joe, who suffers from ophidiophobia, or a fear of snakes. Joe starts to get scared when snakes are even mentioned but that is at the low end of his hierarchy. In the middle of his hierarchy is when he sees a movie or photos with snakes in them. At the top of his hierarchy is being left alone with a live snake. As such, the therapist would begin the treatment by simply talking to Joe about snakes. After he has gotten used to that, they would move up the hierarchy and maybe watch a video with snakes in them. Eventually, the hope would be that Joe could be left alone with a snake and endure it without crippling anxiety.

  • Flooding: Flooding is when a person is introduced to an anxiety-provoking stimulus at the highest levels of their fear hierarchy. For example, this would involve leaving Joe in a room with a live snake at the beginning of treatment instead of waiting until he has coped with less fear-inducing stimuli. Flooding is a controversial technique. Although it can speed up the exposure process, it may also cause so much fear that the whole treatment is sabotaged. As a result, it is not often used compared with graded exposure.

  • Systematic desensitization: Systematic desensitization—pioneered by psychiatrist Joseph Wolpe - is the pairing of relaxation methods with exposure techniques, most commonly graded exposure. The underlying premise of the approach is that if you are relaxed you can’t also feel anxious. The therapist will first have the client undergo a relaxation exercise, such as deep breathing, imagery, or progressive muscle relaxation. Then they will introduce the anxiety-producing stimuli. It is hoped that in a relaxed state, the stimuli will not produce as much fear. Eventually, through classical conditioning, the client begins to associate the stimuli with relaxation rather than fear.

Does exposure therapy work?

There is abundant research in support of exposure therapy but that doesn’t mean it is for everyone. By its very design, it will make clients feel anxious and uncomfortable, which may act as a deterrent for certain people.

In any case, here are a few of the many studies supporting its efficacy:
  • Exposure therapy was found to help treat multiple anxiety disorders, including specific phobia, panic disorder, generalized anxiety disorder, and social anxiety disorder, along with OCD and PTSD.

Exposure therapy training resources:
  • The University of Pennsylvania Perelman School of Medicine is offering a two-day workshop using exposure therapy in the treatment of PTSD. For clinicians experienced in dealing with trauma only.

  • PESI offers a two-day comprehensive online seminar for incorporating prolonged exposure therapy into your clinical practice.

  • Here is a quick video explaining exposure therapy from the Anxiety and Depression Association of America.

Exposure Therapy is one of the principal behavioral treatments for PTSD, OCD, and anxiety. Although not for the faint of heart, its effectiveness speaks for itself.

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Chowdhury, N., & Khandoker, A. H. (2023). The gold-standard treatment for social anxiety disorder: A roadmap for the future. Frontiers in psychology, 13, 1070975. https://doi.org/10.3389/fpsyg.2022.1070975

Corliss, J. (2022, February 2). Six relaxation techniques to reduce stress. Harvard Medical School. https://www.health.harvard.edu/mind-and-mood/six-relaxation-techniques-to-reduce-stress

Eftekhari A, Ruzek JI, Crowley JJ, Rosen CS, Greenbaum MA, Karlin BE. (2013) Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care. JAMA Psychiatry, 70(9):949–955. http://doi.org/10.1001/jamapsychiatry.2013.36

Gupta, S. (2023, November 22). What Is Exposure Therapy? https://www.verywellmind.com/exposure-therapy-definition-techniques-and-efficacy-5190514

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience, 17(3), 337–346. https://doi.org/10.31887/DCNS.2015.17.3/akaczkurkin

Lange, I., Goossens, L., Leibold, N., Vervliet, B., Sunaert, S., Peeters, R., van Amelsvoort, T., & Schruers, K. (2016). Brain and Behavior Changes following Exposure Therapy Predict Outcome at 8-Year Follow-Up. Psychotherapy and psychosomatics, 85(4), 238–240. https://doi.org/10.1159/000442292

Marques, Luana (2023, June 16). Avoidance, not anxiety, may be sabotaging your life. The Washington Post. https://www.washingtonpost.com/wellness/2023/06/16/avoidance-not-anxiety-patterns-strategies

Polak, M., Tanzer, N., & Carlbring, P. (2022). PROTOCOL: Effects of virtual reality exposure therapy versus in vivo exposure in treating social anxiety disorder in adults: A systematic review and meta-analysis. Campbell systematic reviews, 18(3), e1259. https://doi.org/10.1002/cl2.1259

Rachman, S. (2000). Joseph Wolpe (1915–1997). American Psychologist, 55(4), 431–432. https://doi.org/10.1037/0003-066X.55.4.431

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