Exposure Session Record

Exposure methods share the common feature of confrontation with frightening, yet realistically safe, stimuli.

(Rothbaum & Schwartz, 2002)

Exposure treatments are designed to reduce fear and anxiety by asking individuals to repeatedly face their fears, by either imagining or directly confronting them while remaining psychologically engaged (Magee, Erwin & Heimberg, 2009). Exposure aims to reduce the client’s fearful responses and reverse the patterns of avoidance that perpetuate the fear (Springer & Tolin, 2020). It is one the most effective interventions for overcoming fear (Kaczkurkin & Foa, 2022; Hofmann & Smits, 2008) and is the first-line treatment for some anxiety disorders (e.g., obsessive compulsive disorder: NICE, 2005). Exposure-based interventions have been incorporated into several therapies, most notably cognitive behavioral therapy (CBT), and can take several forms.

• In-vivo exposure: The client confronts their fear in real life. These fears may include objects, situations, bodily sensations (‘interoceptive exposure’), and thoughts.
• Imaginal exposure: The client confronts their fear using their imagination or a narrative form (e.g., re-reading a written description of their fear). Imaginal exposure is often used when exposure is impractical or impossible (e.g., the client’s fear relates to a traumatic event or potential disaster).
• Virtual reality exposure: This client faces their fear using virtual reality (e.g., giving a presentation to a computer-generated crowd of strangers). Like imaginal exposure, virtual reality is often useful when in-vivo exposure is difficult to facilitate.

Modern exposure-based treatments can be traced back to Joseph Wolpe’s (1958) use of ‘systematic desensitization’. Classically, this involved individuals imagining anxiety-provoking scenes (the conditioned stimulus) whilst using relaxation. Wolpe hypothesized that relaxation would reciprocally inhibit individuals’ anxiety responses, thereby replacing the association between the stimulus (i.e., the fearful scene) and old response (i.e., fear) with a new response (i.e., relaxation). Systematic desensitization largely disappeared by the mid-1970s, partly due to Marks’ (1975) review which concluded that the key ingredient in reducing fear was simply exposure to affective cues, rather than relaxation. 

Given the pragmatic focus of CBT, many therapists are primarily concerned with the effectiveness of exposure rather than why it is effective. Nevertheless, the change processes underlying exposure are understood in different ways (Craske, 2015; McNally, 2007; Tryon, 2005). Two of the currently most influential accounts are derived from emotional processing theory and inhibitory learning theory.

• Emotional processing theory (Foa & Kozak, 1986) proposes that fear is represented by associative networks that maintain information about the feared stimulus, behavioral fear responses, physiological fear responses, and the meaning of these stimuli and responses. When an individual encounters a stimulus that resembles the feared stimulus, the fear representation is activated. Kaczkirkin & Foa (2022) propose that a fear structure is pathological when “the relationship among stimuli, responses, and their meaning do not match reality, such as when it is activated for safe stimuli”, and that the fear structure is maintained by avoidance behaviors which prevent new learning from occurring. According to the emotional processing theory account, exposure modifies the pathological fear structure by first activating it, and then providing new information that disconfirms inaccurate or pathological associations in the fear structure. Emotional processing theory suggests that within-session habituation leads to between-session habituation, and subsequently longer-term change, although more recent research suggests that habituation is not a strong predictor of treatment effectiveness.
• Inhibitory learning theory (ILT: Craske et al, 2008; Tolin, 2019) proposes that the threat association learned during fear acquisition is not erased, replaced, or modified by new learning during exposure. Instead, the fear-inducing stimulus becomes ambiguous, with two meanings that both live in memory and compete for retrieval. Craske describes how a client might “enter therapy with a threat expectancy, such as ‘If I panic, I might die’ or ‘If I am socially rejected, it would be unbearable’. As a result of exposure therapy, a competing non-threat expectancy develops, such as ‘If I panic, I am unlikely to die’ or ‘If I am socially rejected, I will survive’. After completion of exposure therapy, the level of fear that is experienced when the stimulus is re-encountered depends upon which expectancy is activated. Activation of the original threat expectancy will enhance the expression of fear, whereas activation of the exposure-based non-threat expectancy will lessen fear expression.” Inhibitory learning theory helps to explain why fear can return easily, even in people who have successfully completed treatment, and why habituation does not seem to be important for exposure therapy to be effective.

Each explanatory model has important, and sometimes conflicting, implications for how exposure is best facilitated. Emotional processing theory emphasizes within-session habituation (e.g., fear reduction during exposure) as a necessary step towards between-session habituation and long-term fear reduction. Thus, reductions in fear during exposure are a critical sign of change. Inhibitory learning approaches recommend that exposure should incorporate strategies that maximize the development of new safety-based associations (such as varying the contexts in which exposure takes place), and which violate client expectancies (such as an experiment in which a client’s anxious prediction is not borne out by the evidence). Inhibitory learning also suggests that certain strategies can diminish the effects of exposure (e.g., working through exposure hierarchies in a linear fashion), while others are less important than initially thought (e.g., the need to achieve within-session habituation). Despite these variations, the stages of exposure remain relatively consistent: 

Stage 1: The client identifies a fear stimulus they are willing to confront. 

Stage 2: The client describes what they expect will happen when they face the stimulus. 

Stage 3: The client exposes themselves to the stimulus for a prolonged period, without distraction. 

Stage 4: Changes in the client’s fear levels are monitored. 

Stage 5: After exposure, the client and therapist reflect on what has been learned (e.g., whether the stimulus is as dangerous as initially thought). 

Stage 6: Exposure is repeated.

“We’ve talked about how exposure can help people overcome their fears and what it involves. I’m glad you’re willing to try it for yourself. Remember that exposure works best when it is graded, prolonged, repeated, and without distraction. Have you ever seen a bodybuilder strengthen a muscle? When they do a session in the gym they will work out a particular muscle group with many repetitions (reps) of an exercise. They’ll stop when the muscle is tired. Exposure is like working out a muscle – instead of a session in the gym you’ll do a session of facing your feared situation, and within that session you’ll do multiple reps until you habituate and your fear has reduced. Before we start your exposure, I’d like to show you an Exposure Session Record. We can use this tool to develop exposure exercises that will help you face your fears and monitor what happens when you do them. It’s something we’ll go back to before, during, and after you do exposure. Can we look at it together?”

1. Help the client to choose a feared activity or situation which they are willing to expose themselves to. This may be an item from a fear ladder, or your clinical work together. One modern approach to exposure recommends optimizing for variability – choosing items from a fear ladder at random (Craske, 2015). Record what the exposure exercise will entail. Ideally, the stimulus will be moderately fear-inducing but not overwhelming. Ensure it is clearly specified. For instance, “I will hold a small spider I’ve found in the park in my hands” is easier to implement and less ambiguous than “I will touch a spider”.

• What situation on your fear ladder are you willing to expose yourself to today?
• For this exposure session, what situation are you going to choose?
• Let’s think about how you will do it: Have you got everything you need?
• Are there any safety behaviors that we need to be aware of and resist using?

2. Elicit the client’s prediction about what will happen when they face their fear. Eliciting predictions is important because research suggests that it is helpful to create expectancy violations – i.e. have the client create a prediction which is not borne out by the experiment. (Craske, 2015). Clarify what the client is most fearful of when they face the stimulus. Making these expectations as clear and specific as possible will aid their disconfirmation (e.g., “The spider will bite my hand several times – it will be extremely painful, and I will be poisoned”). These predictions should be revisited once the client has completed the exposure.

• What is the worst thing that you fear will happen?
• What do you predict will happen when you face your fear?
• What do you worry will happen when you carry out this exposure?

3. Start the first exposure. Help the client carry out the first exposure. Helpful points to remind clients of include:

• Exposure is effective when it is prolonged (traditional guidance is to remain in the presence of the feared stimulus until anxiety is reduced by half).
• Exposure is most effective when it is without distraction (so that safety behaviors can be anticipated and resisted).

Clients should rate their fear level at the start and end of exposure (some therapists prefer to collect subjective units of distress, or SUDs, ratings). Ask the client to rate their fear level throughout the exposure exercise (e.g., every five minutes or so). Their peak fear level should be recorded in the middle column. After exposure, some clients may need reminding that a limited change in their fear level does not mean the exercise has been ineffective (as described in inhibitory learning theory).

Exposure to the feared stimulus must be prolonged. However, the duration of exposure does not need to be uniform across exposure exercises. Traditional approaches to exposure recommend that exposure sessions should be continued until the client’s fear level has fallen by half or more. If fear does not fall by half, sessions can be terminated after an agreed period. Clients should be reminded that exposure is still effective even if habituation does not occur.

At the end of each exercise, ask the client to reflect on what transpired. This discussion can be brief and should not impinge on the time set aside to repeat the exposure exercise:

• What did you experience?
• You made a prediction before the exposure. Did your fear come true?
• What did you learn?
• What are you going to do in your next exposure session?

4. Subsequent exposures. In the time available, carry out multiple repetitions of the exposure. The form has space to record up to six exposure exercises within a single exposure session. This partly serves as a reminder that exposure must be repeated to be most effective.

5. Reflection. At the end of the exposure trials, explore what the client learnt in more depth. To consolidate their learning, focus the discussion on the expectations that were violated during exposure (e.g., the worst fears that did not come true) and how they knew this was the case.

• Did your worst fear come true? (If not, why not?)
• What happened? What did you learn?
• What do you need to do next to keep facing your fear?

• Craske, M. (2015). Optimizing exposure therapy for anxiety disorders: an inhibitory learning and inhibitory regulation approach. Verhaltenstherapie, 25, 134-143. DOI: 10.1159/000381574.
• Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621-632. DOI: 10.4088/JCP.v69n0415
• Marks, I. M. (1972). Perspective on flooding. Seminars in Psychiatry, 4, 129–138.
• Marks, I. M. (1975). Behavioral treatments of phobic and obsessive-compulsive disorders: A critical appraisal. Progress in Behavior Modification, 1, 65–158. DOI: 10.1016/B978-0-12-535601-5.50010-X.
• McNally, R. J. (2007). Mechanisms of exposure therapy: how neuroscience can improve psychological treatments for anxiety disorders. Clinical Psychology Review, 27, 750-759. DOI: 10.1016/j.cpr.2007.01.003.
• National Institute for Clinical Excellence (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment. Clinical Guideline [CG31].
• Rothbaum, B. O., & Schwartz, A. C. (2002). Exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy, 56, 59-75. DOI: 10.1176/appi.psychotherapy.2002.56.1.59
• Springer, K. S., & Tolin, D. F. (2020). The big book of exposures: Innovative, creative, and effective strategies for treating anxiety-related disorders. New Harbinger Publications.
• Tolin, D. F. (2012). Face your fears: A proven plan to beat anxiety, panic, phobias, and obsessions. John Wiley and Sons.
• Tryon, W. W. (2005). Possible mechanisms for why desensitization and exposure therapy work. Clinical Psychology Review, 25, 67-95. DOI: 10.1016/j.cpr.2004.08.005.
• Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press.