How Does Exposure Therapy Work?

Exposure therapy is a form of behavioral therapy designed to help people overcome their fears. If you're afraid of enclosed spaces, for instance, you may avoid taking the elevator, especially if it's crowded. But what if you work on the top floor of a tall building? Finding a way to overcome this fear can make it easier to get to and from your office.

If you're interested in exposure therapy or it has been recommended to you, it helps to know the types available, techniques used, and the conditions it can help treat. It's also beneficial to understand what research says about the effectiveness and limitations of exposure therapy so you can decide if it's the right approach for you.

How Exposure Therapy Works

When you’re scared of an object or activity, you may avoid it. While this may help you feel better in the short term, it can cause both fear and anxiety to worsen long term. Exposure therapy helps break the fear-avoidance cycle by exposing you to the source of your fear in a safe environment.

The goal of exposure therapy is to help you overcome your fear so the object, activity, or situation doesn’t cause anxiety, and you can engage with it meaningfully. “A motto of exposure therapy is ‘Let's get comfortable with being uncomfortable,’” says Courtney DeAngelis, PsyD, a licensed clinical psychologist at Columbia University Medical Center who specializes in this form of therapy.

Types of Exposure Therapy

Exposure therapy can help treat several conditions, including phobias, generalized anxiety disorder, and social anxiety disorder. There is also a specialized form of exposure therapy, known as exposure and response prevention therapy (ERP or Ex/RP), that can help treat obsessive-compulsive disorder (OCD).

According to DeAngelis, ERP helps individuals with OCD face uncomfortable situations and reduce compulsions they engage in to relieve anxiety. “By preventing the compulsion or ritual, you can build insight so that individuals learn that bad things do not happen, even when they do not follow the OCD ‘rule,’” says DeAngelis.

Studies indicate that ERP has great success in reducing the symptoms of OCD, a condition that was once considered untreatable. Research published in 2021 further suggests that when exposure occurs using virtual reality, it may help people engage more fully in this therapy type.

The Exposure Therapy Process

Exposure therapy can progress at different paces. Per DeAngelis, your therapist will guide you to face your fears according to a fear hierarchy or "ladder" that serves as a roadmap for treatment. This can help you cope with the trauma and anxiety that each step of the process involves.

The process can include:

• Graded exposure: This involves exposing you to the source of your fear gradually by going up the ladder one step at a time. For instance, if you are afraid of needles, the steps could include looking at a picture of a needle, having a covered needle near you, holding a needle, etc., until you’re able to do what you fear most, which is getting an injection.
• Systematic desensitization: Your therapist may employ systematic desensitization methods to help you relax and get comfortable with each step of this process. These methods can include relaxation exercises like meditation, deep breathing, guided imagery, and progressive muscle relaxation.
• Flooding: This method involves exposing you to the highest level of the ladder all at once. Therapists may use flooding if your fear interferes with your ability to go about your daily life. While this approach can help you overcome your fear faster, flooding can be traumatic to experience. A therapist may consider this method only after your anxiety has decreased significantly.

Exposure Therapy Techniques

Therapists who practice exposure therapy may draw upon a variety of techniques, which DeAngelis outlines as including: 

In Vivo Exposure 

In vivo exposure involves directly approaching a feared stimulus or situation in real time. For instance, if an adolescent is afraid to be away from their parents, this would mean practicing to gradually separate from the parents in various situations (with guidance from a clinician and consent from the parents).

Imaginal Exposure

Imaginal exposure involves imagining the feared situation coming true in great detail. For instance, if you have a phobia of vomiting, you probably would not be encouraged to eat something to intentionally vomit as an exposure. Instead, a therapist may ask you to describe in a written narrative what you imagine would happen if you did vomit, perhaps in public.

The therapist may ask you to reread or listen to this imagined script repeatedly. The general idea is to help bore you of these feared situations rather than bring about the same level of anxiety.

Interoceptive Exposure

Interoceptive exposure can help tackle a feared physical sensation; it is generally employed when treating panic attacks. For instance, your therapist may ask you to do jumping jacks for one minute to increase your heart rate. You will eventually learn that this is not dangerous nor a sign of a heart attack.

Virtual Reality Exposure

Virtual reality exposure is a more novel approach that allows you to confront your fears using virtual reality devices. If, for example, you have a fear of flying, you may benefit from videos that simulate flying before going on a vacation that involves air travel. 

Conditions Exposure Therapy Can Help Treat

According to DeAngelis, exposure therapy is particularly helpful when treating conditions that can cause anxiety. She explains that anxiety can prompt you to overestimate the threat of danger or discomfort, also causing you to underestimate your ability to cope with the danger or discomfort. 

“Exposure therapy works to address both of these challenges," says DeAngelis, "so that you can realize that your anxiety will naturally fade over time when facing an uncomfortable or scary situation and that you can handle that anxiety."

Specific conditions and anxiety disorders exposure therapy can help treat include:

• Phobias
• Panic disorder
• Generalized anxiety disorder (GAD)
• Social anxiety disorder
• Post-traumatic stress disorder (PTSD)
• OCD

Benefits of Exposure Therapy 

Exposure therapy offers many benefits, such as:

• Habituation: As you gradually and repeatedly expose yourself to the source of your fear, your reaction to it may decrease over time.
• Extinction: Exposure therapy can offer a safe environment for you to learn that the situation you fear does not pose a threat to you. It can help weaken your association between the situation and the negative outcome you expect.
• Emotional processing: This form of therapy can help you explore and understand the source of your fear. It can also help you replace your instinctive response with more realistic thoughts and beliefs about the feared situation and make you more comfortable with fear and anxiety.
• Self-efficacy: Over time, exposure therapy can help you realize that you can confront the situation you fear and manage the anxiety it causes. 

Exposure Therapy Effectiveness

“Exposure therapy is an evidence-based treatment, which quite simply means that the research has shown us that it works,” says DeAngelis. Empirical evidence has shown that exposure therapy can help treat anxiety disorders, including phobias, panic disorder, social anxiety disorder, GAD, PTSD, and OCD.

One study found that people who received exposure therapy to treat phobias had fewer symptoms not only immediately after treatment but eight years later as well. This suggests that exposure therapy has long-term benefits.

Limitations of Exposure Therapy

Facing your fears can be difficult. So, exposure therapy can be uncomfortable and challenging. When undertaking this therapy, DeAngelis says, “It's important to understand that the clinician's goal is not to torture you, and to feel willing to tolerate uncomfortable situations or stimuli that you have been avoiding.”

Exposure therapy can also have occasional drawbacks:

• Symptoms may return: Some patients may see their symptoms return over time. This is especially likely if the treatment ends prematurely.
• Simulated conditions don’t always reflect reality: The conditions in exposure therapy do not always reflect reality. Someone with PTSD, for instance, may be able to handle simulated conditions in a therapist’s office but not be able to cope with the situation if it presents itself in reality.

Despite these limitations, exposure therapy is worth considering as a treatment option as research supports its effectiveness. In fact, one of its limitations is that it is not utilized enough. Many therapists do not have formal training in exposure therapy and therefore cannot practice it to help people with anxiety disorders.

How to Get Started With Exposure Therapy

If you would like to seek exposure therapy, start by looking for a qualified therapist, psychologist, or psychiatrist trained in this form of therapy. You can ask your primary care physician for a recommendation or find one through local or state mental health associations.

Once you find a qualified professional, make an appointment with them and ensure they accept your insurance. Your first appointment will probably involve filling out the necessary paperwork, which can include details regarding your symptoms, medical history, and insurance plan.

Work with the mental healthcare provider on mapping out your goals for therapy and strive to build a strong, collaborative rapport with them. Therapeutic rapport is vital to exposure therapy because you need to feel safe and supported as you confront your fears.

Summary

If you have a fear that is getting in the way of you living your life, exposure therapy MAY help treat it. While the prospect of facing your fears can be daunting, A therapist can guide you through the process and equip you with tools to cope with the anxiety you experience. “There is great reward for those who are willing to ride the wave of anxiety and start to feel better again in their daily life,” says DeAngelis.