Exposure
Summary
Exposure is arguably the most well-known therapeutic intervention in CBT, used in some shape or form since the 1950s. It is probably the psychological treatment intervention overall that has the most robust empirical support for its effectiveness, when it comes to helping people with anxiety disorders. Exposure can be used as a part of a broader CBT or constitute a whole psychotherapy in its own right (“exposure therapy”).
This essential CBT intervention has three different main forms: exposure in-vivo (see separate article), imaginal exposure (see separate article) and interoceptive exposure (see separate article). The common main principle rests the same: 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).
Background
Exposure has its roots in behavioral basic research on classical and operant conditioning; that is, the experimental science on how fear is learned (Pavlov’s classical conditioning) and maintained (Skinner’s operant conditioning). In the 1950s and 1960s Joseph Wolpe developed what he called “Psychotherapy by reciprocal inhibition” which can be said to be the first structured form of what we today would call exposure therapy. In the 1960s Victor Meyer developed exposure and response prevention – which still today, with some modifications – is the primary evidence-based psychological treatment for obsessive-compulsive disorder. The main principle of this therapy – to expose oneself to what one fears repeatedly as to gradually become less afraid – was already described by the Muslim scientist Abu Zayd al-Balkhi in the 9th Century CE, who also gave an early conceptualisation of obsessive-compulsive disorder (see separate article on OCD).
Core principles
Similarly to Behavioral Activation, exposure is based on behavioral principles and thus on a functional analysis (see separate article) of how a problem with anxiety develops and is maintained. The basic way that anxiety and fear is acquired is through classical conditioning (Ivan Pavlov). One finds the clearest examples of this kind of fear acquisition in the specific phobias: for instance, the child that suddenly experiences the neighbour’s dog running against him while barking. The child experiences fear, and then through generalisation may develop fear of many different kind of dogs. The child may then deal with this generalised fear of dogs by an increasing avoidance behavior, which can be explained by so called negative reinforcement (operant conditioning, BF Skinner). The avoidance behavior hinders the person from having new, non-fear related experiences with dogs. Thus, the avoidance behavior maintains the fear.
As one can see, this functional analysis of how phobic fear is acquired and maintained also stipulates how the phobia can be overcome: If avoidance of what is feared constitutes the problem, exposure to the same constitutes the solution.
Many, if not all, patients come to therapy saying they “have already done exposure”, and that “it doesn’t work”. It’s easy to understand what they mean, from their point of view: They have often been in contact with what they fear, maybe hundreds or even thousands of times over the years, but they are still just as afraid. Here it is important to help the patient understand that exposure as a specific therapeutic intervention in several crucial ways distinguishes itself from what the patient usually has experienced by trying to face his or her fears on her own.
That is, 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)
- 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).
Here is an example that represents the importance of these core exposure principles:
A patient with agoraphobia, who usually avoids public transport, sometimes is obliged to take the bus to work because her husband needs the family car. The day she takes the bus, it’s unusually full of people, she gets off two stops before her work because she “can’t stand it any longer” and during the ride she distracts herself through listening to music in her headphones and breathing in a certain way (that a nurse once taught her). This patient may from her point of view understandably say that she has “exposed herself” to riding the bus, but this experience will be not be helpful for her agoraphobic fear, because it is not in line with any of the principles of exposure as a therapeutic intervention:
- it was not planned or structured as an exposure exercise (it’s just one day, the husband says that he needs the car
- it was not gradual (the bus turns out to be quite full; a gradual exposure would start with a less full buss)
- it was not prolonged (the patient gets off the bus when her anxiety is at its peak – that is she doesn’t stay long enough to experience something new)
- it was not repeated (ideally the same exposure exercise should be repeated several times)
- she used safety behaviours (distracting herself with music and seeking safety by breathing in a certain way in trying to “stop the anxiety from becoming worse”).
In therapy, after having the therapist has done a case formulation (see separate article) and functional analysis (see separate article) of the patients problems, and after having given the patient psychoeducation (see separate article) about what anxiety is, how it works in the body, and after haven given the patient a treatment rationale (see separate article) for how exposure therapy works, and gotten the patients consent and expressed with that she wishes to start such a therapy, then the therapy can start: Planned, gradual, prolonged, repeated and by helping the patient confront her fear without safety behaviours.
The example above is an example of exposure in-vivo. This is the primary form of exposure, that is preferred over imaginal exposure (which is mainly performed when in-vivo exposure is not practically or ethically possible (see separate article on imaginal exposure).
Apart from exposure in-vivo, imaginal exposure and interoceptive exposure, other modes of exposure (less used clinically) are through virtual reality and augmented reality.