Exposure therapy is a form of psychotherapy treatment for specific phobias. It involves exposing an individual directly with what they fear. The aim is for the individual to become accustomed to being around their fear and realize it's irrational and there is no reason to be afraid. People all over the world suffer from their fears, whether that may be a fear of heights or confined spaces. Phobia induced anxiety is more common than you might think, with 9% of Americans suffering from their fears.
The inhibiting factor of fear - Developing a solution
How and why do people develop fears? Some situations are understandable and definable. For example, a traumatic incident of a child trapped in an elevator may result in that child suffering from claustrophobia well into adulthood. Or a fear of flying, which is also objectively understandable as to what and how the fear manifests itself. However other fears like a fear of germs or blood may be harder to pinpoint the cause or explanation for the fear. People develop phobias for all sorts of things from spiders to flying to needles. Some phobias are less common than others though and levels of severity vary from individual to individual. Fears can become an extremely inhibiting factor in one's daily life. Imagine you suffer from claustrophobia, but to get to work you must ride an elevator or a train or enter a tunnel, each trip to work could be agonizing, anxious and frightening. Or say you suffer from a fear of needles, each trip to the doctor will be scary for you, or you may even avoid the doctor altogether, which can have dangerous consequences. This is why individuals seek out treatment for their irrational fears.
Psychological treatment for phobias may include medication, however this just slows the issue and a more direct approach may be needed. This is where exposure therapy comes in.
How exposure therapy works
Exposure therapy simply put, is as it sounds, exposure to that which you fear. Individuals confront their fears (through different methods as well soon see) head on. By literally forcing themselves to embrace seemingly frightening situations they hope to overcome the urge to flee, panic or pass out.
The traditional way of understanding what was happening during exposure therapy was grounded in the idea of habituation. Habituation means that over time the patient “gets used to” the fear. Most people are familiar with everyday examples of habituation such as being aware of the sound of a fan when it is turned on and then automatically ‘tuning out’ the noise so that you are not aware of it a few minutes later. The traditional goal of exposure therapy was fear habituation – exposure trials were continued for as long as was necessary for a patient to report a significant reduction in fear. Obviously the exposure is gradual, as to not immediately terrify the individual (however some forms of therapy reverse the process and have the individual head right to the deep end!).
However a more modern understanding of the effectiveness of exposure therapy is grounded in learning theory, specifically models of inhibitory learning. According to learning theory the extinction of fear is a form of associative learning. During exposure therapy, when a patient repeatedly confronts their fear without something bad happening, their expectations are shifted so that they no longer expect the bad to follow the exposure. Therefore their behavior is altered so that they approach the situation rather than avoid it. They are not actually erasing their fear by the new learning. Instead they learn that the outcome does not result in something terrible happening as they originally feared.
Different exposures. Same results.
Exposure therapy consists of a few methods,
- In-vivo exposure: In-vivo exposure describes exposure to a feared object or situation in real life. Examples of in-vivo exposure might include inviting a person with a phobia of spiders to look at pictures of a spider. Once you're able to do that, the therapist may encourage you to imagine more intense scenes with spiders while providing support and coping skills. Once you feel more comfortable, the therapist may progress to real-life exposure where they place a real spider in the room with you and eventually place it in your hand. The treatment can last a few hours or across multiple hour-long sessions. Other examples of in-vivo exposure include site visits by people with post-traumatic stress disorder (PTSD) where they revisit the scene of a trauma.
- Imaginal exposure: Sometimes it is impossible or impractical to conduct exposure in-vivo for example it would be both difficult and hazardous for someone with combat-related PTSD to experience the sights, sounds, and smells of combat in real life. Imaginal exposure consists of inviting a patient to hold the feared object or situation in their imagination. They might be asked to describe the stimuli or scenario in considerable detail. Imaginal exposure is a technique used in the treatment of PTSD – often called ‘reliving’ or ‘revisiting’ the patient is asked to give a detailed verbal account of their traumatic event from beginning to end in the first person present tense. Imaginal exposure is also used in the treatment of worry and OCD – patients are asked to describe and write details of a feared scenario in detail, and then to read the scenario or listen to an audio recording of it.
- Interoceptive exposure: Fear and avoidance of particular body sensations is a core component of panic disorder, amongst other conditions. Interoceptive exposure describes the practice of deliberately inducing particular body sensations with the aim of fear extinction. Examples of interoceptive exposure exercises include deliberate hyperventilation to bring on respiratory alkalosis, or staring at oneself in a mirror for a prolonged period to induce feelings of unreality.
- Graded exposure: Graded exposure describes the process of developing a fear hierarchy, from least-feared to most-feared, and introducing patients to exposure trials of increasing difficulty. Graded exposure is less important than previously thought – developments in inhibitory learning theory indicate that factors such as variability of exposure and the creation of expectancy violation effects are more helpful therapist targets.
- Flooding: (which we mentioned earlier) Flooding describes a prolonged and intense version of exposure in which a client is exposed directly to the object or situation which they find most frightening until the fear habituates. Though today this practice you might say is “out of style ”
- Exposure with response prevention: Exposure and response prevention (ERP) is a treatment for obsessive compulsive disorder (OCD) in which a patient is exposed to their feared situation and encouraged not to engage in their typical neutralizing response. For example, a patient with a fear of contamination might be encouraged to touch a door handle, or the inside of a wastepaper basket, and encouraged not to wash their hands.
- Applied muscle tension. This treatment is similar to in vivo exposure but incorporates muscle tension exercises. During the treatment, you tense your body's muscles thus increasing your blood pressure, which makes it less likely that you'll faint. This can be especially helpful for people with a fear of things like blood or needles.
- Systematic desensitization. When you engage in this type of therapy, you are exposed to fear-evoking images and encouraged to imagine the things you are afraid of while pairing the exposure with relaxation to help manage the fear response. This treatment takes longer than other methods like in vivo exposure but tends to be more effective at reducing anxiety and avoidance tendencies.
But, does it work?
Nice, so exposure therapy has a lot of different methods and approaches but does it work?
Yes, exposure therapy can be a practical and cost-effective option for addressing irrational fears, phobias, anxieties, and more. The benefits of exposure therapy have been documented in many studies that are effective for several different mental health conditions:
- The Journal of Rehabilitation Research and Development showed that prolonged exposure therapy was the gold standard for posttraumatic stress, especially for trauma related to combat and military-related trauma.
- The International OCD Foundation found that 7 out of 10 people with obsessive-compulsive challenges experience a 60-80% decrease in symptoms when participating in a combination of exposure therapy and cognitive restructuring.
- According to an article published in the Psychiatric Times, participants who engaged in exposure therapy studies reported a 90% reduction in their anxiety symptoms and a 65% decrease in their phobia.
Exposure Therapy and VR - The next step in the evolution of therapy
Another more modern approach to exposure therapy is VR. VR which stands for virtual reality, usually comes in the form of a headset and until recently was more gameplay focused. However companies like BraVeR have taken VR to the next level. VR allows for a hyper realistic immersion into austere environments with almost zero risk and affordable prices. Its realism is what makes it a valuable tool in exposure therapy. Using a VR headset, individuals can immerse themselves into environments that they deem fearful, with the ability to exit at any moment. Here they can climb to high heights or face a massive spider, with each test they break the psychological barrier that tells them to run. The hyperrealism is enough to induce fear but the environment is completely in their control. This allows for growth in overcoming their fears. VR can also be a helpful approach when exposure to the real object or situation is impractical, and may prove to be a form of treatment which is more effective in terms of therapist resources.
Exposure therapy has limitations
Although research shows that exposure therapy can be effective for many, there are some notable limitations of the treatment. Despite the success rate, many professional counselors and therapists don't implement it. Some professionals believe that exposure therapy may make symptoms worse, especially when dealing with PTSD.
Additionally, exposure therapy is difficult work that causes people to feel and confront things that they have worked hard to avoid. Because of this, if the therapy is not implemented correctly, the positive effects of exposure therapy may wane over time. That's why patients must participate in the treatment to the fullest extent and follow a well-trained therapist's directions.
While exposure therapy is arguably a step in the right direction, there are offshoots that can also aid an individual. These include things like CBT where an individual is talked through their fear and they overcome it through exposure as well as logical thinking and reasoning as well as brain cognition. Another direction is through self help and meditation. Through introspection and meditation individuals can, on their own, work through their fears and overcome them.
So while exposure therapy may have its limitations, for many people, it has proven to be effective in delivering long-term results. The research continues to support its effectiveness for treating anxiety, phobias, and other mental health conditions.