Exposure Therapy 101
By: John D. Moore, PhD
Exposure therapy is a term you may have heard about in your quest to learn more about help with anxiety but what does it really mean? How does exposure therapy really work? Do people find any real benefits from this form of treatment?
This ultimate guide to exposure therapy examines how this form of psychotherapy can help you work through various forms of anxiety. The guide is being offered as a tool for education.
Three anxiety disorders are addressed: phobias, panic and PTSD respectively a gateway to greater understanding.
Let’s jump right in!
Exposure therapy, sometimes referred to exposure response therapy, is a form of anxiety treatment whereby a person is repeatedly exposed to various situations, objects or things that produce anxiety.
At its core, exposure therapy is based on Pavlovian respondent conditioning known as extinction.
How does Exposure Therapy Help?
When a person engages in exposure therapy, they are retraining their brain’s response to anxiety producing situations.
Bear in mind, this is not some form of hocus pocus that involves you acclimating to fear. Instead, it’s about changing the very way your brain perceives a situation with the ultimate goal of stopping the fear response.
The clinical research has been in for some time now and it is generally agreed upon that exposure therapy is considered one of the most effective ways to treat various anxiety disorders, including Post Traumatic Stress Disorder (PTSD), Panic Disorder and Specific Phobias (aka phobias).
While the body of evidence bodes well for exposure therapy as a form of treatment with anxiety disorders, there is some research to suggest it is underutilized by clinicians.
Fear and the Amygdala
It may be helpful to think of fear as your brain’s primal response to a perceived threat or situation. This is what evokes the classic “Flight or Fight” response that you may have learned about in school.
The previously mentioned “response” is primarily controlled by your brain’s right Amygdala. Comparatively, the left Amygdala is thought to heavily influence feelings of happiness and joy.
The Brain's Amygdala
How Does Exposure Therapy Work?
Exposure therapy works pretty much like the term itself sounds. The idea is to gradually exposure you to the anxiety/fear producing stimuli and create change around how your brain (specifically the Amygdala) responds.
Bear in mind exposure therapy is not the same as flooding, which isn’t gradual at all.
Exposure Therapy Example
Let’s pretend for a moment you have a terrifying phobia of pens. Anytime you see a pen, you become extremely anxious and find ways to avoid coming into contact with it.
Suppose for a moment that during your first visit to your counselor’s office, your therapist places you all alone in a room with a pen and locks the door. Your reaction would likely be extreme and you may even have a panic attack. After a period of time, your mind would adapt to the situation and you would eventually calm down.
In this scenario, the fear response, controlled primarily by the Amygdala, adjusts and adapts. As more time goes on, you would eventually not perceive any danger from the pen. You might even be able to pick it up and draw a picture or write out a paragraph.
You leave your therapists office and return for session #2 several days later. During this visit, your therapist places you in another room with 5 pens.
At first you start to panic but not nearly as much as you did during session #1. In a short period of time, you start to relax. The pens no longer are producing anxiety. You might even walk over to them and start to touch them or grab a pen and begin to draw shapes, like circles.
You see the human brain doesn’t want to be in a state of stress. The Amygdala begins to “chill out” once it adapts and stops sending signals to release anxiety producing hormones that get you all worked up.
So in a nutshell, that is how exposure therapy works. It operates on the previously mentioned construct of extinction, which is designed to gradually get your brain accustomed to the anxiety producing stimuli slowly over the course of time.
Anxiety Counseling with Exposure Therapy
Why Can’t Exposure Therapy Naturally?
You may be wondering why exposure therapy can’t work naturally? For example, couldn’t the irrational fear of pens be naturally “cured” by seeing pens around the office or at home?
The reason it doesn’t happen this way is because exposure therapy requires three things:
1. Gradual introduction to the anxiety producing stimuli
2. Time for the brain to adjust and adapt
3. New associations to be formed between the fear producing stimuli and the Amygdala.
It is under point number 2 where we see the issue. Most folks do not wait for the brain to adapt. Instead, they become terrified of the stimuli (like the pen) and run for the hills.
The effort being put into running away from the stimuli reinforces and even strengthens the fear response, which actually trains the brain to “freak out” so to speak whenever it comes into contact with the stimuli.
What is the ultimate goal of exposure therapy?
Generally speaking, the goal of exposure therapy is to significantly reduce the fear response of a given stimuli (thought, sensation, thing or object). An additional goal is to help the person eliminate avoidant behaviors.
What follows are three examples of how exposure therapy takes place using three of the six anxiety disorders: Specific Phobias, Panic Disorder and PTSD.
Exposure Therapy and Phobias
1. Phobias and Exposure Therapy
Exposure therapy essentially saw its beginnings in the treatment of phobias (see our phobias page). If you have a phobia, you have an irrational fear of an object, person or thing that causes intense feelings of anxiety. Here, we are talking about things like dogs, cats, clowns, snakes and so forth.
To help treat your phobia and reduce anxiety/fear, your therapist may engage in a related form of exposure therapy known as systematic desensitization.
Assume you have a fear of dogs. Your therapist may take the following steps to help you work through your phobia of dogs (Cynophobia).
1. You will be asked to close your eyes and think of a dog.
2. You will be asked to hold that thought, even though it makes you feel uncomfortable or anxious.
3. Sometime later, a small dog will be let into the therapy office that is in a cage.
4. During that same session or perhaps in a future session, the steps are repeated above but the dog is now out of the cage and on a leash.
5. At some point, the dog is let off the leash and comes over to sniff you. In return, you begin to pet it and he starts to show affection and even licks your hand.
If you have a serious dog phobia, the last step mentioned was probably terrifying to read. With the help of exposure therapy however, many people have learned to work through their fears so they can be in the presence of animals, such as dogs.
The steps outlined above might be one of several ways your therapist helps you with a dog phobia or any other type of phobia.
Exposure Therapy and Panic Disorder
2. Panic Disorders and Exposure Therapy
Exposure therapy has been used to effectively treat people who suffer from panic disorders. If you have a panic disorder, you experience a rush of anxiety, accompanied by strong feelings of fear and doom.
Your heart races and you may even become dizzy and feel like you will faint. Some people even feel like they are watching a slow motion movie when the attack “kicks in”, which is clinically referred to as depersonalization or derealization.
While it is true that panic attacks can strike us from seemingly out of the blue, they most often are triggered by some type of stimuli. Examples include intrusive thoughts, physical sensations, or even health fears. In many ways, panic attacks thrive off of a fear of fear.
Anxiety counselors may use exposure therapy to minimize the impact of these triggers. The ultimate goal is to train your brain to not experience panic when the trigger happens. In super successful cases, the trigger itself becomes neutralized.
Here are a few physical triggers that commonly set off panic attacks for some people:
- Rapid heartbeat
- Chest pains
- Difficulty breathing
- Light headedness/dizziness
- Hot flashes or chills
- Tingling sensations and numbness
There are a number of ways therapists that specialize in anxiety use exposure therapy as a form of treatment. Examples include visual imagery to recreate mental triggers, sounds and scents or an object. It just depends on the dynamics and what acts as a your “trigger” so to speak.
Exposure Therapy and PTSD
3. Prolonged Exposure Therapy and PTSD
Use of exposure therapy as a way of helping someone work through PTSD happens in much the same way it does for the other anxiety disorders mentioned previously. The general goal is to help a person decrease feelings of fear and distress gradually, over the course of time. This type of therapy is also known as prolonged exposure therapy.
There are four main parts to prolonged exposure therapy related to PTSD.
This therapy works by helping you approach trauma-related thoughts, feelings, and situations that you have been avoiding due to the distress they cause. Repeated exposure to these thoughts, feelings, and situations helps reduce the power they have to cause distress.
Prolonged exposure therapy helps you to approach thoughts, feelings, emotions and situations that you may be avoiding because they cause major discomfort and distress. This is a graduated process that is done slowly and gently.
Generally speaking, there are four main components to prolonged exposure therapy:
You learn about PTSD and gain greater insight into how PTSD can manifest in your life. An exploration of exposure therapy is part of the dynamic. Goals of counseling are discussed that include a realistic set of expectations. This step helps to provide a starting point for counseling.
2. Mindful Breathing Training
Your therapist will work with you to learn how to use Mindfulness Based Cognitive Behavioral Therapy (MBCT) to focus your attention on the here and now through breathing. This centering technique helps you to work through distress and minimize fear.
3. Real Life Practice
Slowly and gradually getting accustomed to stimuli you have been avoiding in a safe manner. This part of therapy is designed to ease you into exposure to that stress producing situation.
As the brain is “re-trained” on how it reacts to the stimuli (over the course of time), distress gradually subsides.
4. Imaginal Exposure through Talk-Therapy
As part of the counseling process, your therapist will encourage you to talk about the traumatic event over the course of time in sessions.
Fear is reduced by learning that memories, in and of themselves, cannot hurt you. Feelings of shock, sadness, anger and helplessness are processed as part of the experience. Components of Acceptance Commitment Therapy are infused, borrowing from the family of CBT therapies.
Prolonged Exposure Therapy Video
There is a great video put out by the United States Veterans Administration that walks you through the essential elements of prolonged exposure therapy.
Prolonged Explosure Video
PTSD and Military Families
If you are a family member of a service member who may have PTSD, it is encouraged that you think about receiving counseling. This is particularly true if your family member was involved (or is involved) in a long term deployment in a combat zone.
Because some people cope with PTSD using emotionally numbing substances to “check out”, substance abuse education may be part of the dynamic.
Below is a presentation on Long Term Deployments and Stress, PTSD and Families.
Key Point on Exposure Therapy Recap
The goal of exposure therapy is to create change around how a person experiences the stimuli, thereby reducing overall fear. Through a graduated process of exposure and talk therapy, perceptions are transformed.
Exposure therapy has practical uses for the other anxiety disorders, including Obsessive Compulsive Disorder (OCD) and PTSD. This is particularly true when combined with different forms of cognitive behavioral therapy [see our extensive CBT for anxiety page].
If you are considering receiving exposure therapy to help you work through your own anxieties, particularly for phobias, panic and PTSD, be sure to identify a therapist who is knowledgeable on this form of therapy.
- Association of Behavioral and Cognitive Therapies
- Anxiety and Depression Association of America
- Substance Abuse and Mental Health Services Administration
One of the best ways to push back against anxiety is to learn everything you can about a given disorder. A pathway to greater insight is to engage in “bibliotherapy”, which a 25-cent term for using a book or other is reading material for the purpose learning and healing.
One resource we would like to recommend is The Anxiety and Phobia Workbook by Dr. Edmund Borne. What we like about this book is how the author uses a holistic approach to educate readers about anxiety.
Practical, simple yet thought provoking exercises are provided to help gain new insight into anxiety with the goal of effecting positive change.
Disclaimer: The material presented in this guide is for educational purposes only and is not designed to act as a form of “home treatment” for anxiety disorders.
Copyright 2015. John D. Moore, PhD. 2nd Story Counseling. All Rights Reserved