Exposure therapy: Type of psychotherapy

Exposure therapy is a psychological treatment that was developed as a means of confronting fears. Most people avoid objects, activities, or situations they are afraid of when they are fearful. It is possible to reduce feelings of fear in the short term by avoiding the source, however, in the long run, it can make the fears worse. To break the pattern of avoidance and fear, a psychologist might recommend exposure therapy. During this type of psychotherapy, psychologists create a safe environment in which individuals can ‘expose’ themselves to the things they fear and avoid. A safe environment helps reduce fear and reduce avoidance when feared objects, activities, or situations are exposed. Several scientific studies demonstrate that exposure therapy can be beneficial for a range of problems, including:  

  • Phobias
  • Panic Disorder
  • Social Anxiety Disorder
  • Obsessive-Compulsive Disorder
  • Posttraumatic Stress Disorder
  • Generalized Anxiety Disorder

A collaborative approach is employed in treatment, with patient and therapist working together to decide how and when exposures will occur. A person’s exposure duration depends on a number of factors, including the type of stimuli they are afraid of and the severity of their fear.  Exposure sessions usually last between 20 and 90 minutes, and they are repeated until there is no fear left.  The sessions are either facilitated by the therapist or completed by the patient as homework.  

History of Exposure Therapy:

  • The concept of exposure therapy was developed by behaviorists like Ivan Pavlov and John Watson in the early 1900s. It derives from Pavlov’s classical conditioning principles. Classical conditioning is best known for Pavlov’s experiment with a dog in which he methodically trained it to salivate when it heard a bell.
  • In 1924, behaviorist Mary Cover Jones led the way with her work on counter-conditioning: a means of changing an unwanted, learned response to a more desirable one. Jones gradually eliminated the fear of rabbits using comfort food and pleasurable experiences.  
  • A few years later, in 1958, behaviorist Joseph Wolpe formulated systematic desensitization, involving relaxation training, anxiety hierarchy (filing anxiety-producing triggers from most severe to least severe), and exposure to allow one to reduce sensitivity to situations one fears.
  • In the 1970s, Stanley Rachman developed exposure and response prevention while treating people suffering from obsessions and compulsions. As part of this technique, individuals were encouraged to conjure up obsessive thoughts and refrain from committing to anxiety-reducing behaviors.  
  • The exposure therapy field has grown considerably over the past 30 years, and exposure and response prevention (ERP) and systematic desensitization continue to be used today.  

Ways in which it can be conducted:

The person may be exposed to real stimuli or may simply imagine the stimuli. Exposure may be too intensely fear-evoking stimuli or may be gradual, working up a hierarchy of feared stimuli.

  • In vivo exposure: Directly facing a feared object, situation or activity in real life. For example, someone with a fear of snakes might be instructed to handle a snake, or someone with social anxiety might be instructed to give a speech in front of an audience. In vivo exposure involves client exposure to the actual anxiety-evoking events rather than simply imagining these situations. Live exposure has been a cornerstone of behavior therapy for decades.
  • Imaginal exposure: In situations where in vivo exposure is impossible and virtual reality exposure is not available, imaginal exposure is useful. Imaginal exposure employs the client’s imagination to trigger the anxious response. The therapist will assist by giving the client prompts and cues to deepen their imagination and incorporate all their senses. The client will be encouraged to remain in the memory or fear until exposure is completed. For example, someone with Posttraumatic Stress Disorder might be asked to recall and describe his or her traumatic experience in order to reduce feelings of fear. Imaginal exposure, or exposure to one’s own thoughts and mental images, is an important element of CBT for health anxiety because many of the things most feared by the patient are typically hypothetical scenarios that are unlikely to ever materialize. Common examples include vivid mental images of a tumor growing inside one’s head, being told that one has a brain tumor, having to go through chemotherapy, and dying without the opportunity to see one’s own children grow up.
  • Virtual reality exposure: In some cases, virtual reality technology can be used when in vivo exposure is not practical. For example, someone with a fear of flying might take a virtual flight in the psychologist’s office, using equipment that provides the sights, sounds and smells of an airplane. Virtual reality therapy, also called virtual reality exposure therapy, allows you to enter a virtual world that is carefully constructed to increase your exposure to negative stimuli, so you can build resilience and emotional strength. Becoming engrossed in a virtual world can also help you shift your attention away from pain. This type of exposure therapy uses a computer program to stimulate the phobic situation (i.e. being on a plane, leaning over a large balcony ledge, seeing a spider, etc.) and integrates body tracking devices that allow you to interact with the virtual environment. 
  • Interoceptive exposure: Rather than exposing the person to thoughts or behaviors connected to their feared scenarios, interoceptive exposure works to bring about certain bodily sensations. For example, someone with Panic Disorder might be instructed to run in place in order to make his or her heart speed up, and therefore learn that this sensation is not dangerous. The aim of interoceptive exposure is to replicate actual symptoms experienced during an anxiety or panic attack and in the process desensitize ones conditioned response that the physical sensations will cause an attack to occur. The end result is that uncomfortable physical symptoms are seen as just that, uncomfortable, rather than a sign of impending doom or disaster. The good news interoceptive exposure is part of an arsenal of effective techniques for reducing and, eventually, gaining mastery over anxiety and panic.

Exposure therapy can also be placed in different ways. These include:

  • Graded exposure: Graded exposure therapy helps you face your fears in a gradual way. It can be used for any sort of anxiety but is often used to break the pain cycle by tackling fear based avoidance which so often accompanies chronic pain. The psychologist helps the client construct an exposure fear hierarchy, in which feared objects, activities or situations are ranked according to difficulty. They begin with mildly or moderately difficult exposures, then progress to harder ones. By teaching your mind that the activities you have been avoiding do not need to cause fear, you can eliminate fear and in turn reduce pain and associated symptoms. Instead of avoiding situations, you can face them head on and with confidence. For example, if an individual is afraid of insects, the therapist may begin by asking the patient to look at images of “nice” insects such as ladybugs or dragonflies. Once the patient has become accustomed to these images and is able to control their emotional responses, the therapist may introduce them to a live bug inside a plastic box, allowing the patient to observe the insect in a safe and controlled way. As the patient moves into more advanced stages, the therapist may ask them to hold a live insect in their hands, for example.
  • Flooding: Using the exposure fear hierarchy to begin exposure with the most difficult tasks. Traditionally, flooding has been defined as a technique that involves prolonged exposure to feared stimuli or situations at full intensity, in an attempt to extinguish anxious responses. In other words, from the beginning of treatment, the client is exposed to stimuli that evoke maximal anxiety. The client is exposed to these stimuli for prolonged periods of time, until anxiety has begun to dissipate. Flooding typically is conducted in vivo, with live presentation of anxiety provoking stimuli. While this approach can be the quickest way to help the patient overcome their fear, the approach can also be incredibly stressful or traumatic to experience, especially if the patient is not ready for such a strong exposure. This method should only be used once the therapist considers that the patient has the appropriate foundation and that their anxiety has decreased to a manageable point through less severe methods.
  • Systematic desensitization: In some cases, exposure can be combined with relaxation exercises to make them feel more manageable and to associate the feared objects, activities or situations with relaxation. Systematic desensitization is a venerable behavior therapy technique developed by Joseph Wolpe for the treatment of fear- and anxiety-related disorders. It helped launch the behavior therapy movement and was the first psychological treatment that produced behavioral improvement reliably. It is a therapeutic procedure for overcoming fearful responses or anxiety in certain situations. It consists of graded exposure to fear-provoking stimuli under special conditions so that emotional reactions other than fear or anxiety predominate. This technique belongs to the family of techniques based on learning principles called behavior therapy.

Exposure therapy can help in:

  • Habituation: Habituation is defined as a decrement in response as a result of repeated stimulation not due to peripheral processes like receptor adaptation or muscular fatigue. It is a process occurring within the nervous system (in animals with nervous systems). Habituation is defined in more detail by a number of parametric properties, involving such factors as stimulus frequency and intensity, spontaneous recovery of the habituated response, etc. Over time, people find that their reactions to feared objects or situations decrease.
  • Extinction: As the exposure therapy continues, the therapist will seek to offer a safe environment for the patient to learn that the fear-inducing stimulus does not pose a serious threat to them. The process can weaken the association between the stimulus and the negative outcome the patient expects until eventually the patient can eliminate the overwhelming fear response and develop healthier mental models of the stimulus.
  • Self-efficacy: As the patient progresses with the exposure therapy, it becomes easier for them to feel confident in their ability to confront the fear-inducing stimulus and manage the anxiety it causes without the need for supervision.
  • Emotional processing: As the patient develops healthier reactions to the stimulus, they begin to be able to process and evaluate their emotional responses to the stimulus in a clearer way and explore the source of their fear. The therapist looks to help the patient replace unhealthy, instinctive responses to the feared stimulus with responses based on more realistic thoughts and beliefs, making it easier for the patient to overcome their fear and anxiety.

Expectations and Limitations:

Exposure therapy has been proven to be very effective by numerous research studies. In fact, it has been shown to be the most effective way to treat fear. However, exposure therapy does have its limitations. Here are a few of the drawbacks of this type of therapy:

  • In spite of the fact that exposure therapy is very effective, very few therapists used it in practice. This might be because of the fact that many therapists do not have formal training in exposure therapy.
  • Another limitation is that symptoms can come back, this is especially true if therapy is ended prematurely.
  • Exposure therapy isn’t always the best choice for everyone, especially if you feel like it might be too overwhelming in your current state. Sometimes this type of treatment can make people feel worse instead of better at first since they’re facing fears that scare them a lot or cause uncomfortable feelings to surface which is why it’s important not to rush into anything.
  • This therapy may also trigger panic attacks in people who are especially sensitive. If anyone is considering exposure therapy, they should talk to their doctor first.
  • This can also create more trauma or memories. These are more difficult to deal with in some cases.  Make sure you are ready for anything before trying exposure therapy on your own.

In spite of the limitations, exposure therapy is worth serious consideration when it comes to treating many forms of anxiety. Research continues to support the use of this treatment for overcoming fear and phobias.

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