Exposure therapy

What is exposure therapy?

Exposure therapy is one of the most well-known and powerful approaches in cognitive behavior therapy. It was introduced in the 1950s, and since then many scientific studies shows that it is a very powerful treatment for anxiety and related disorders. The most common disorders it treats are obssessive-compulsive disorder, agoraphobia, social anxiety disorder, GAD and specific phobias. What all these disorders have in common is the presence of anxiety and fear related to certain situations or objects that trigger your anxiety. Exposure therapy helps you by gradually bringing you into contact with what you fear, allowing you to test and challenge those fears through direct experience, and eventually overcoming your fear.

Why am i afraid ?

If you’re anxious or afraid, it doesn’t just come out of nowhere (even if it may feel like that). Behavioral psychology has shown that fear and anxiety are often learned through experience. To help you visualize this, let’s take the example of a child and for the sake of the argument, let’s say it was you.

One day, you are out with your father and suddenly you see barking dogs coming toward you. You look at your father and notice that he looks very afraid. He grabs your hand and tells you to get in the car. As a child, you don’t fully understand what is happening. You just learn that the barking of a dog is linked to an alarming situation.

At that moment, you quickly form a link between dogs, their barking, and danger. But it doesn’t stop there. Weeks, months, or even years later, simply seeing or hearing a dog bark whether it is a Chihuahua or a bulldog can trigger fear, even if the dog is friendly and presents no real danger. Through this experience, the fear becomes a learned behavior. But, it doesn’t stop here, you may also start making associations with places. As a result, you may begin to avoid going to parks for a picnic with friends, or avoid any place where there might be a dog present.

Overview of how it will happen

First, your therapist will first give you psychoeducation about the nature of anxiety, going through what is physically really happening in your body. The therapist will also help you see how what you do and what you think are related to your anxiety; how avoidance behaviors may feel like they help in the short run but unfortunately makes the problem worse in the long run (read more about Psychoducation in this article). One early exercise is often self monitoring (by observing and writing down your own feelings, thoughts and behaviors). At the end of this initial assessment phase, your therapist will assist you to create a list of anxiety-provoking situations, from the least to the most scary.

Then your therapist will assist you in gradually exposing yourself to the different situations. The primary type of exposure is in vivo exposure (in real life): your therapist will accompany you during exposure, initially for example to videos of dogs and then gradually, after working through the hierarchy, doing an exposure to an actual dog, in the therapist’s office. The goal is then that you continue the exposure on our own, or with the help of someone close to you (as “homework”, see separate article). The logic behind this technique is for you to test out your anxiety and fears, in a new way, without safety behaviors, through direct experience. At first when you start the exposures you might think that it is counterintuitive: Why would I face the thing that scares me the most and that makes me feel high levels of anxiety? You may also think “I have already done that, it just makes it worse”. But the big difference with exposure as a part of therapy is that it is done gradually, and without the safety behaviors that actually maintains the problem. Safety behaviors are all those things that you do to feel better in the anxious situation (like breathing in a certain way or saying calming things to yourself, see separate article).

Even though it may feel like that helps, in the moment, it actually maintains the problem in the long run. The goal of exposure is to help you experience something new - that when you accept the anxiety in the moment and don’t try to escape it (or use safety behaviors) the fear actually will diminish by itself if you stay with it long enough. That is, after multiple exposures in this new therapeutic way, you will see that nothing bad happens, you will start adapting to the feared situation and experience something new. This will disconfirm your fears, and the levels of anxiety will drop. The continuous exposure process will break the cycle of the feared situation fueling your anxiety, and you’ll break free from the very thing limiting you in life.

Read about specific types of exposure

Interoceptive exposure (further reading)

Real life exposure (further reading)