Exposure

Exposure is a psychological intervention with its roots in behavior therapy (Marks, 1978). It is considered to be the most effective psychological technique for the treatment of fear and anxiety. Exposure therapy embodies the ‘face your fears’ maxim and involves encouraging clients to repeatedly face an object or situation which causes them anxiety. Exposure therapy is an essential component of evidence-based cognitive-behavioral therapy (CBT) treatments for phobia, panic disorder, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD) and social anxiety disorder.

The traditional way of understanding what was happening during exposure therapy was grounded in the idea of habituation. Habituation means that the “original reaction towards the stimulus diminishes in intensity or even disappears” (Eelen & Vervliet, 2006). 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. Therapists would typically aim to wait prolong exposure until a 50% reduction in subjectively reported fear (Kendall et al, 2005). Read more

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57 of 57 resources

Embracing Uncertainty

Intolerance of uncertainty (IU) was first described in individuals suffering from Generalized Anxiety Disorder (GAD). Many behaviors associated with G ... https://www.psychologytools.com/resource/embracing-uncertainty/

Values

Meaningful activity is value-driven. This ACT-informed worksheet explores the key domains of values and encourages clients to reflect upon what is imp ... https://www.psychologytools.com/resource/values/

Intolerance Of Uncertainty

Uncertainty is a normal part of life – we can never be 100% sure about what will happen next. Many people feel good about uncertainty and live lives ... https://www.psychologytools.com/resource/intolerance-of-uncertainty/

Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Therapist Guide

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition) comes in two volumes. This page is for the Therapist Guide. ... https://www.psychologytools.com/resource/unified-protocol-for-transdiagnostic-treatment-of-emotional-disorders-second-edition-therapist-guide/

Behavioral Experiment (Portrait Format)

Behavioral experiments allow individuals to test the validity of their beliefs and assumptions. They are a core experiential technique for therapeutic ... https://www.psychologytools.com/resource/behavioral-experiment-portrait-format/

Behavioral Experiment

Behavioral experiments are planned experiential activities to test the validity of a belief. They are one of the most powerful techniques available to ... https://www.psychologytools.com/resource/behavioral-experiment/

Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Client Workbook

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition) comes in two volumes. This page is for the Client Workbook. ... https://www.psychologytools.com/resource/unified-protocol-for-transdiagnostic-treatment-of-emotional-disorders-second-edition-client-workbook/

Fear Ladder

The Fear Ladder is a tool for exploring and ranking the contexts or situations in which a client experiences fear. It is designed to help the client a ... https://www.psychologytools.com/resource/fear-ladder/

Habituation

The Habituation information sheets are designed to help clinicians to explain the concept of habituation and its role in exposure therapy. The handout ... https://www.psychologytools.com/resource/habituation/

Exposure And Response Prevention

Exposure And Response Prevention (ERP, EX/RP) is an effective treatment for obsessive compulsive disorder (OCD). This CBT worksheet guides therapists ... https://www.psychologytools.com/resource/exposure-and-response-prevention/

Treating Your OCD With Exposure And Response (Ritual) Prevention (Second Edition): Workbook

Exposure and Response (Ritual) Prevention for Obessssive-Compulsive Disorder comes in two volumes. This page is for the Client Workbook. Click on the ... https://www.psychologytools.com/resource/treating-your-ocd-with-exposure-and-response-ritual-prevention-workbook/

Managing Social Anxiety (Third Edition): Workbook

Managing Social Anxiety – A Cognitive-Behavioral Therapy Approach comes in two volumes. This page is for the Workbook. Click on the following link t ... https://www.psychologytools.com/resource/managing-social-anxiety-workbook/

Reclaiming Your Life From A Traumatic Experience (Second Edition): Workbook

Prolonged Exposure Therapy For PTSD comes in two volumes. This page is for the Client Workbook. Click on the following link to access the accompanying ... https://www.psychologytools.com/resource/reclaiming-your-life-from-a-traumatic-experience-workbook/

Exposure Session Record

The Exposure Session Record is a tool for recording clients’ use of exposure. The worksheet guides clients to identify a specific fear they are will ... https://www.psychologytools.com/resource/exposure-session-record/

OCD Hierarchy

Part of traditional CBT treatment for OCD is exposure to situations which trigger obsessions (classically accompanied by the prevention of the associa ... https://www.psychologytools.com/resource/ocd-hierarchy/

Nightmare Exposure And Rescripting

Imagery rescripting is an effective treatment for intrusive and unwanted memories. Nightmare Exposure And Rescripting employs similar techniques and c ... https://www.psychologytools.com/resource/nightmare-exposure-and-rescripting/

Exposure And Response (Ritual) Prevention For Obsessive Compulsive Disorder (Second Edition): Therapist Guide

Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder comes in two volumes. This page is for the Therapist Guide. Click on the f ... https://www.psychologytools.com/resource/exposure-and-response-ritual-prevention-for-obsessive-compulsive-disorder-therapist-guide/

Overcoming Your Eating Disorder: Workbook

Overcoming Eating Disorders comes in two volumes. This page is for the Client Workbook. Click on the following link to access the accompanying Therapi ... https://www.psychologytools.com/resource/overcoming-your-eating-disorder-workbook/

Exposures For Fear Of Uncertainty

Fear of uncertainty is commonly associated with many psychological difficulties, including generalized anxiety disorder (GAD), obsessive compulsive di ... https://www.psychologytools.com/resource/exposures-for-fear-of-uncertainty/

Exposure Practice Form

Exposure is an effective treatment for many forms of anxiety. The Exposure Practice Form is a CBT worksheet which guides therapists and clients throug ... https://www.psychologytools.com/resource/exposure-practice-form/

What Is EMDR? (Eye Movement Desensitization and Reprocessing)

Eye movement desensitization and reprocessing (EMDR) is an evidence-based treatment for trauma. Its theoretical basis is described by the adaptive inf ... https://www.psychologytools.com/resource/what-is-emdr/

Stimulus Discrimination

Stimulus discrimination is a component of cognitive behavioral treatment for post-traumatic stress disorder (PTSD). Clients are guided to deliberately ... https://www.psychologytools.com/resource/stimulus-discrimination/

Overcoming Eating Disorders (Second Edition): Therapist Guide

Overcoming Eating Disorders comes in two volumes. This page is for the Therapist Guide. Click on the following link to access the Client Workbook.&nbs ... https://www.psychologytools.com/resource/overcoming-eating-disorders-therapist-guide/

Safety Behaviors

Safety behaviors are actions carried out with the intention of preventing a feared catastrophe. In the short-term they often give a sense of relief, b ... https://www.psychologytools.com/resource/safety-behaviors/

Mastery Of Your Anxiety And Panic (Fifth Edition): Therapist Guide

Mastery Of Your Anxiety And Panic comes in two volumes. This page is for the Therapist Guide. Click on the following link to access the accompanying C ... https://www.psychologytools.com/resource/mastery-of-your-anxiety-and-panic-therapist-guide/

Interoceptive Exposure

Misappraisals of body sensations trigger emotional and physiological reactions of fear and heightened arousal. These feelings motivate behavioral resp ... https://www.psychologytools.com/resource/interoceptive-exposure/

Mastery Of Your Anxiety And Panic (Fifth Edition): Workbook

Mastery Of Your Anxiety And Panic comes in two volumes. This page is for the Workbook. Click on the following link to access the accompanying Therapis ... https://www.psychologytools.com/resource/mastery-of-your-anxiety-and-panic-workbook/

Prolonged Exposure Therapy For PTSD (Second Edition): Therapist Guide

Prolonged Exposure Therapy For PTSD comes in two volumes. This page is for the Therapist Guide. Click on the following link to access the accompanying ... https://www.psychologytools.com/resource/prolonged-exposure-therapy-for-ptsd-therapist-guide/

Uncertainty Beliefs – Experiment Record

Situations which are uncertain, novel, or ambiguous trigger a state of uncertainty. Evidence indicates that individuals who are dispositionally high i ... https://www.psychologytools.com/resource/uncertainty-beliefs-experiment-record/

Your Stone Age Brain

Your Stone Age Brain is an information handout which describes the freeze-flight-fight response: a set of evolutionary adaptations that increase the c ... https://www.psychologytools.com/resource/your-stone-age-brain/

Cognitive Behavioral Treatment of Childhood OCD: It's Only a False Alarm: Workbook

Cognitive Behavioral Treatment Of Childhood OCD: It’s Only A False Alarm comes in two volumes. This page is for the Workbook. Click on the following ... https://www.psychologytools.com/resource/cognitive-behavioral-treatment-of-childhood-ocd-its-only-a-false-alarm-workbook/

Managing Social Anxiety (Third Edition): Therapist Guide

Managing Social Anxiety – A Cognitive-Behavioral Therapy Approach comes in two volumes. This page is for the Therapist Guide. Click on the following ... https://www.psychologytools.com/resource/managing-social-anxiety-therapist-guide/

What Is Exposure Therapy?

Exposure is an effective evidence-based treatment for fear. This information handout describes the key principles of Exposure Therapy. Clients who are ... https://www.psychologytools.com/resource/what-is-exposure-therapy/

Maximizing The Effectiveness Of Exposure Therapy

Despite its position as the leading treatment technique for anxiety disorders, not all clients respond to exposure therapy and some individuals relaps ... https://www.psychologytools.com/resource/maximizing-the-effectiveness-of-exposure-therapy/

Exposures For Fear Of Vomiting

Fear of vomiting is a chronic and distressing difficulty that is associated with significant impairment. Exposure is an effective treatment for addres ... https://www.psychologytools.com/resource/exposures-for-fear-of-vomiting/

Exposures For Fear Of Body Sensations

Fearful responses to physical sensations are common in several disorders. Interoceptive exposure (or ‘symptom induction’) is an effective treatmen ... https://www.psychologytools.com/resource/exposures-for-fear-of-body-sensations/

What Is Imagery Rescripting?

Unwanted images are a feature common to a variety of problems including PTSD and depression. Imagery rescripting is an evidence-based treatment techni ... https://www.psychologytools.com/resource/what-is-imagery-rescripting/

Avoidance Hierarchy (Archived)

NOTE: An improved version of this resource is available here: Fear Ladder. Older versions of a resource may be archived in the event that they are ava ... https://www.psychologytools.com/resource/avoidance-hierarchy/

Facing Your Fears And Phobias

The Facing Your Fears And Phobias guide is written for clients who struggle with fears or phobias. It provides comprehensive information about what fe ... https://www.psychologytools.com/resource/facing-your-fears-and-phobias/

Cognitive Behavioral Treatment Of Childhood OCD: It's Only A False Alarm: Therapist Guide

Cognitive Behavioral Treatment Of Childhood OCD: It’s Only A False Alarm comes in two volumes. This page is for the Therapist Guide. Click on the fo ... https://www.psychologytools.com/resource/cognitive-behavioral-treatment-of-childhood-ocd-its-only-a-false-alarm-therapist-guide/

Exposures For Fear Of Death

Fear of death is common, and is associated with a variety of psychological disorders including generalized anxiety disorder, depression, panic disorde ... https://www.psychologytools.com/resource/exposures-for-fear-of-death/

Exposures For Fear Of Illness

Fear of illness is a common and persistent fear that can result in significant functional impairment. Exposure is an effective treatment for health-re ... https://www.psychologytools.com/resource/exposures-for-fear-of-illness/

What Are Safety Behaviors?

Safety-seeking behaviors (‘safety behaviors’) are actions that people take in response to a real – or perceived – threat. When a threat is rea ... https://www.psychologytools.com/resource/what-are-safety-behaviors/

Exposures For Fear Of Appearing Anxious

Concerns about appearing anxious in front of others plays a central role in social anxiety. Exposure is an effective treatment for tackling these fear ... https://www.psychologytools.com/resource/exposures-for-fear-of-appearing-anxious/

Facing Your Fears (CYP)

Graded or graduated exposure is a traditional way of overcoming fears and phobias. The therapist helps the client to draw up a list of feared situatio ... https://www.psychologytools.com/resource/facing-your-fears-cyp/

What Is TF-CBT?

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment for post-traumatic stress disorder (PTSD). This information handou ... https://www.psychologytools.com/resource/what-is-tf-cbt/

Understanding Fears And Phobias

Our ‘Understanding…’ series is a collection of psychoeducation guides for common mental health conditions. Friendly and explanatory, they are co ... https://www.psychologytools.com/resource/understanding-fears-and-phobias/

Exposures For Fear Of Losing Control Of Your Mind

Fearful responses to benign physical sensations are common in several disorders, and interoceptive exposure (or ‘symptom induction’) is an effecti ... https://www.psychologytools.com/resource/exposures-for-fear-of-losing-control-of-your-mind/

Nightmare Rescripting (Audio)

Nightmare rescripting is an evidence based treatment for nightmares, with medium to large effect sizes on nightmare frequency, distress, intensity, an ... https://www.psychologytools.com/resource/nightmare-rescripting-audio/

Exposures For Fear Of Flying

Fear of flying is a very common fear, affecting up to 18% of individuals, and is characterized by intense and persistent fear during, or in anticipati ... https://www.psychologytools.com/resource/exposures-for-fear-of-flying/

Self Practice Record

Out-of-session work (collaboratively generated and negotiated) is an essential component of effective CBT. This Self Practice Record helps clients to ... https://www.psychologytools.com/resource/self-practice-record/

Exposures For Fear Of Breathlessness

Fearful responses to benign physical sensations such as breathlessness are common in several disorders, most notably panic disorder (with and without ... https://www.psychologytools.com/resource/exposures-for-fear-of-breathlessness/

Coping With Body Sensations (Psychology Tools For Overcoming Panic)

Psychology Tools for Overcoming Panic takes a cognitive behavioral therapy (CBT) approach to this common anxiety problem. This chapter discusses inte ... https://www.psychologytools.com/resource/coping-with-body-sensations-psychology-tools-for-overcoming-panic/

Stimulus Discrimination (Audio)

The Stimulus Discrimination audio exercise is taken from the Psychology Tools For Overcoming PTSD Audio Collection. It is designed to help people with ... https://www.psychologytools.com/resource/stimulus-discrimination-audio/

Exposures For Fear Of Heights

Fear of heights is a very common fear, characterized by an avoidance of high places including staircases, tall buildings, and bridges. Exposure is an ... https://www.psychologytools.com/resource/exposures-for-fear-of-heights/

Approach Instead Of Avoiding (Psychology Tools For Overcoming Panic)

When we start to avoid things it can shrink the number of places that it feels ‘safe’ to go. It can cut us off from rewarding experiences, and avo ... https://www.psychologytools.com/resource/approach-instead-of-avoiding-psychology-tools-for-overcoming-panic/

Testing Anxious And Panicky Predictions (Psychology Tools For Overcoming Panic)

Psychology Tools for Overcoming Panic takes a cognitive behavioral therapy (CBT) approach to this common anxiety problem. This chapter introduces beh ... https://www.psychologytools.com/resource/testing-anxious-and-panicky-predictions-psychology-tools-for-overcoming-panic/

Links to external resources

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Exercises

Facing your fears: Exposure | Anxiety Canada
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Information (Professional)

Interoceptive Exposure Definition | White, Basden, Barlow
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Narrative Exposure Therapy (NET) | Shauer, Neuner, Elpert
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Prolonged Exposure (PE) | Edna Foa
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Presentations

Family affair: involving a partner or spouse in exposure and response prevention for OCD | Jonathan Abramowitz | 2018
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Interoceptive exposure: an underused weapon in the arsenal against obsessions and compulsions | Jonathan Abramowitz | 2018
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Using exposure to treat PTSD: why, when, and how? | Fyvie
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What Is Exposure?

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 a fear-inducing stimulus (conditioned stimulus: CS) without a terrible consequence happening (unconditioned stimulus: US) their expectancies are altered such that they no longer expect the US to follow the CS, and their behaviour is altered so that they approach rather than avoid. Inhibitory learning theory (Lang, Craske & Bjork, 1999) proposes that the original threat association learned during fear acquisition (CS predicts US) is not erased by the new learning. Instead, the CS becomes an ambiguous stimulus with two meanings that both live in memory and compete for retrieval (called the ‘retrieval competition’). ILT is powerful because it explains why fear can easily return even after successful completion of treatment, and because it has been used to develop ways of conducting exposure therapy which are even more effective (see Craske et al, 2008). For a comprehensive guide to conducting effective exposure therapy see our worksheet Maximizing The Effectiveness of Exposure Therapy or read our article Delivering more effective exposure therapy in CBT.

Types of exposure

Exposure therapy can be practiced in a variety of forms:

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, or to hold a small spider in their hand. 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. 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.
Virtual reality or computer-aided exposure: Exposure to feared situations in a realistic computer simulation is becoming increasingly prevalent alongside technological advances. This can 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 resource.
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: 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. In modern times flooding is not practised widely.
Exposure with response prevention: Exposure and response prevention (ERP) is a treatment for obsessive compulsive disorder (OCD) in 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.

References

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27.
Eelen, P., & Vervliet, B. (2006). Fear conditioning and clinical implications: What can we learn from the past? In M. G. Craske, D. Hermans, & D. Vansteenwegen (Eds.), Fear and learning: From basic processes to clinical implications. (pp. 17–35). Washington, DC US: American Psychological Association.
Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12(1), 136-148.
Lang, A. J., Craske, M. G., & Bjork, R. A. (1999). Implications of a new theory of disuse for the treatment of emotional disorders. Clinical Psychology: Science and Practice, 6(1), 80-94.
Marks, I. M. (1978). Exposure treatments: Clinical applications. In Behavior modification: Principles and clinical applications (pp. 204-242). Little, Brown Boston.

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