In-vivo exposure

Summary

Exposure in-vivo is the primary and most broadly used form of exposure. The main principle in all exposure is to help the patient to come into contact with what he or she fears sufficiently long enough, so she can come to experience something new (other than fear). Through gradual and repeated exposure, the patient learns to overcome her fear and to do things in life she previously couldn’t do because of her anxiety (like going to a crowded store, use public transport or engage with people she doesn’t know so well). “In-vivo” means “in real life”; which means that what is sought out for the patient in exposure in-vivo is to come in (physical) contact with what elicits his or her fear.

Principles and practice

Exposure in-vivo is the primary form of exposure, in all senses of the term. Historically, it was developed first and has therefore the longest empirical support. It is also the primary form of exposure in clinical practice, in the sense that it is the type of exposure that primarily should be used. Other forms of exposure (imaginal and interoceptive exposure) are mainly used when exposure in-vivo isn’t feasible.

One common mistake in exposure therapy, especially by less experienced therapists, is to use imaginal exposure instead of exposure in-vivo, as a “first step”. An example of this is for instance the therapist that asks his or her OCD patient to imagine being in an anxiety provoking, “contaminated” environment (such as imagining using a public toilet). This is an example of an inaccurate use of exposure. It is always better, and more effective, to start in a real-world context, for instance the public bathroom in the clinic of the therapist. Imaginal exposure (see separate article) is only used when exposure in-vivo isn’t practically possible. If the therapist needs to find something “less difficult” for the patient, he or she should use the exposure hierarchy (see separate article), not change the mode of exposure (from in-vivo to imaginal).

Before engaging in exposure, the cognitive behavioral therapist has done an assessment phase with the patient, which includes a CBT case conceptualisation and a functional analysis (see separate article). This analysis assesses and details in what areas the patient’s anxiety is evoked, what safety behaviours and what avoidance that is present in the patient’s repertoire (see article on Exposure).

The five principles of exposure

All exposure as a specific therapeutic intervention follows 5 principles.

For it to be effective, exposure should be:

• planned and structured (by the therapist, in collaboration with the patient)

• gradual (by way of a exposure hierarchy, introduced by the therapist, in collaboration with the patient)

• prolonged (that is, be sufficiently long as to enable new non-fearful experiences)

• repeated (that is, be done a sufficient number of times, which also enables experiencing something new over time)

• without safety behaviours (that is, without the patient trying to distract him or herself or seeking other forms of temporary safety or temporary relief during exposure) (see separate article).

The three phases of exposure therapy

Every exposure therapy has three main phases:

1. Initial assessment and preparatory phase.

This initial phase also includes psychoeducation (see separate article) on the nature of anxiety and how it works in the body, as well as a therapy rationale (see separate article) and goal formulation (see separate article). The end of this initial phase should be that the patient chooses to engage in a therapy that he or she has a clear image of and that she perceives can help her in life with what she needs and with full consent.

In this phase an exposure hierarchy is also done with the patient (see separate article)

2. Exposure phase

When it comes to where to start with exposure, the rule of thumb is that to start with an exposure exercise that is located somewhere in the middle of the exposure hierarchy (that is not too difficult, but not too easy).

The ideal (especially with more severe problems of anxiety) is therapist-guided exposure, when the therapist guides the patients through the exposure exercise. In all exposure therapies, the goal should be that at-least the first exposure is therapist-guided; this is because it is usually very difficult for the patient to initiate exposure him- or herself and because the therapist can, during exposure, both help the patient observe and refrain from subtle safety behaviors/avoidance (see below, “During exposure”) and give support.

Every session in the exposure phase of therapy has three parts that mirrors the phases of therapy as a whole:

1. It starts with the therapist reviewing the homework with the patient (how the exposure has gone during the week) and with preparing the exposure to be done during the current session.

2. It continues with the exposure part of the session, when the therapist does a therapist-guided exposure. The limits of what exposure the therapist can do together with the patient is mostly limited by practical issues: It is often not practically possible (due to time constraints) for the therapist to take the bus with an agoraphobic patient or to go to the patient’s house for exposing the OCD patient for themes of contamination/cleanliness. But the therapist can ask the patient to bring things to the therapy session (from the home or elsewhere) that can serve in-vivo exposure, or one can use the context of the therapist’s clinic (for example its public bathroom for the OCD contamination patient, or a closed room or elevator for the agoraphobic or claustrophobic patient).

During exposure, the therapist will ask questions like “What goes through your mind right now” (to help identifying safety behaviors our subtle avoidance). The therapist will also guide the patient by asking him or her to focus on the anxiety provoking stimulus (“Try go look directly at it and describe it to me” or “Try to touch it with your hand and don’t let go until I say so”). The therapist also wants to continually assess the patient’s level of anxiety (“What is your level of anxiety at this moment?”) and provide support (“I can see how difficult this is for you, you are so brave!”).

3. Each exposure session should end with an evaluation: The therapists ask the patient what he or she has learned from the exposure, and is asked to define a homework to do for the next session that ideally is construed as a repetition of the actual exposure done with the therapist during the session. That is, after the therapist-guided exposure, the ideal is that the patient does the same exposure exercise that she did with the therapist, but this time by herself, as a homework exercise until the next session (see separate article on Homework).

3. Evaluation and relapse-prevention phase

At the end of exposure therapy, the therapist guides the patient in defining, and ideally writing down what he or she has learnt from therapy. The therapist also helps the patient to set up relapse prevention plan (see separate article).