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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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Approach Instead Of Avoiding (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 avoi ... https://www.psychologytools.com/resource/approach-instead-of-avoiding-psychology-tools-for-overcoming-panic/

Chapter

Avoidance Hierarchy

Avoidance and safety-seeking behavior serves to maintain anxiety, and exposure to the fear stimuli/situation is an effective treatment for anxiety. Th ... https://www.psychologytools.com/resource/avoidance-hierarchy/

Exercise

Behavioral Experiment

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/

Worksheet

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/

Chapter

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/

Exercise

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/

Exercise

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/

Information Handout

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/

Exercise

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/

Information Handout

Narrative Exposure Therapy (NET)

Narrative Exposure Therapy (NET) is an empirically validated treatment for survivors of multiple traumatic events who are suffering from post-traumati ... https://www.psychologytools.com/resource/narrative-exposure-therapy-net/

Information Handout

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/

Exercise

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/

Audio

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/

Information Handout

Safety Behaviors Example

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-example/

Information Handout

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/

Exercise

Stimulus Discrimination (Audio)

Stimulus Discrimination is designed to help people with post-traumatic stress disorder (PTSD) to ‘retrain their brain’ in order to attend automat ... https://www.psychologytools.com/resource/stimulus-discrimination-audio/

Audio

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/

Chapter

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/

Information Handout

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/

Information Handout

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/

Information Handout

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/

Information Handout

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.