Exposure therapy

Michael Cruz, MHC-LP December 28, 2022

While avoidance may seem like a good idea at first, long-term it can make anxiety and phobias worse. Enter exposure therapy.

For a few minutes, I want you to clear your mind and imagine the following scenarios. Pay attention to your thoughts, your bodily sensations, your reactions. 

First, imagine that you are standing at the top of a New York City skyscraper on the very edge of the roof. You feel the bitter wind against your skin. You find yourself unable to move much because you have such limited room. You stare down the skyscraper and see that there is nothing beneath you but a 1,400 foot drop – and at the very end you see the cold concrete ground. 

Imagine another scenario where you are in an elevator and it gets stuck with no one to hear you. You look around this confined space and you start to feel as though the walls are moving in and the space is getting smaller. 

Imagine you find yourself in a room full of clowns, snakes or even spiders. 

Lastly, imagine yourself on the stage of a sold out concert at Madison Square Garden.

How did these scenarios make you feel? Did they give you goosebumps? A chill down your spine? Increased heart rate? Or did even imagining these situations make you want to run the other way and avoid thinking about them at all?

Why do we have phobias?

The scenarios we just walked through are all common phobias. Phobias occur when we associate a negative past emotional experience with a specific situation (also known as a stimulus). Phobias can be related to unpleasant past experiences; a near drowning incident could lead to an aversion to swimming or even the sight of water, for example. Or a child getting lost in the crowd may lead to fear of crowds or social anxiety. You may associate a specific stimulus with a negative experience and thus to protect yourself from experiencing negative emotions you find yourself avoiding this stimulus at all costs or reliving the negative experience (i.e. panic attack, hyperventilation, crying, etc.) if you come into contact with the stimulus.

Whether or not these scenarios are likely to occur or not isn’t as important as our reactions, emotions and behaviors. We may find ourselves wanting to avoid any mention of the aforementioned scenarios resulting in us altering our behavior to avoid dealing with these scenarios in the first place. This can look like: total avoidance, trying to think about something else or relying on social support. 

Even if we do not have a specific phobia, we might find ourselves with excessive worries. These worries can be wide ranging and can include having repeated negative predictions about our future or even overestimating the possibility of a dangerous situation happening to us or our loved ones. We may find ourselves feeling trapped in our minds by these worries and unable to think about anything else. This can lead us to exhibit many symptoms similar to those affected with phobias, such as the inability to think about anything but the situation/stimulus, anxiety, panic attacks, increased heart rate, hyperventilation, psychological distress.

So how do we change this?

That’s a great question and the answer is that there are many possible ways to change our thoughts, behaviors and emotions when it comes to phobias and anxieties. That said, contemporary research indicates that one of the most effective strategies for reducing these undesired emotions, thoughts and behaviors is through exposure therapy. (Barlow, 2004). 

What exactly is exposure therapy?

Exposure therapy is essentially what it sounds like: using exposure to stimuli and situations in the therapeutic setting in order to reduce our undesired automatic behaviors, thoughts and emotions pertaining to specific phobias and worries. 

So how does it work? 

The mechanism of change in exposure therapy has been debated and two schools of thought posit findings on how this form of therapy works. The most well-known and often discussed view of exposure therapy states that through repeated exposure to our undesired stimulus we can adjust to the stimulus, thus unlearning the connection we have between the stimulus and our maladaptive responses (crying, hyperventilating, panic, etc.). 

The other theory behind the mechanism of change in exposure therapy is a relatively new one, which states that exposure therapy works because of the process of inhibitory learning. This big fancy psychological term really just means that we overcome our phobias and worries through the process of new learning. In exposure therapy, we learn that prior to treating these phobias and worries, we often overestimated the risk of danger and threats due to the stimulus while at the same time underestimating how strong and resilient we are in coping through our phobias and worries. In essence, we implement the teaching of a brand-new lesson and correct our misconceptions about our previous views on the stimulus. The new lesson informs us that the situation is not as scary or life-threatening as we once thought and that we are in fact able to handle and cope with it. 

While the debate for the mechanism of change is still up to interpretation, the results of exposure therapy are very well documented and it has been proven that exposure therapy can lead to lifelong sustained changes in one’s behaviors, thoughts, and emotions about a phobia or worry. (Bourne, 2011). 

What does exposure therapy look like?

Exposure therapy, like many other forms of therapy, varies from person to person. We are all unique after all! The length of time depends on the person and situation as well. For some it may take a few weeks and for others it may take many months or even years. What is important to note is that exposure therapy can also look completely different by the presenting case and the individual. 

Types of exposure therapy include:

  1. In vivo - This is when people are exposed directly to the feared stimuli in real-time.  
  2. Imaginal exposure - A more indirect approach than in vivo, imaginal exposure is based purely on thoughts. Without having to come into contact with the stimulus, a person is asked to vividly imagine the feared situation.
  3. Virtual reality exposure - Another indirect approach, this time using technology to recreate the feared scenario.
  4. Interoceptive exposure -  Again, an indirect approach, we can elicit similar bodily sensations without needing to come in contact with the stimulus. This can look like shaking your head from side to side to experience dizziness or swallowing quickly to feel tightness in the throat. The idea is to break down the associations between those sensations and anxiety.

Sometimes one form of exposure therapy might be more favorable due to its practicality in therapy; it would be very hard for a therapist to bring a client to the top of a skyscraper thus virtual reality or imaginary exposure might be easier to use.

How long does exposure therapy take?

Just as there are different types of exposure therapy, the pace at which one undergoes therapy differs as well. Everyone has a different level of comfort in regard to exposure therapy. Some individuals prefer diving into the deep of a stimulus and coming face-to-face with their phobia or worry. Others might find that taking small gradual steps that lead up to their big stimulus or worry works better for them. Some might even find that they need additional support and may want help developing coping skills and relaxation techniques to get through their exposure. Regardless of the approach, it is crucial in exposure therapy to understand and process the emotions you experience, the behaviors you engage to feel better and the thoughts that run through your mind as you are exposed to the stimulus. With the help of a therapist, you will find yourself receiving the support and care you need to overcome these phobias and worries.

The timeline for treatment does vary person to person, but those who dive into direct exposure typically find themselves in treatment for a shorter amount of time as the process of change occurs much faster than a more gradual or indirect route. All of these approaches are valid and meet the individual wherever they are. 

Is exposure therapy right for me?

You can ask yourself the following questions to gauge where you are in the process and where your comfort level lies. 

Probing questions:

  • Do you find yourself excessively worrying about certain situations? Do you find yourself avoiding certain activities or stimuli because of adverse behaviors or feelings?
  • Are you prepared to take a chance and face distressing situations or stimuli?
  • Do you think you would be able to commit to repeated exposure? Are you willing to commit to homework and the duration of therapy?
  • What would be your reaction to coming into contact with said situation or stimulus? Do you think you would be able to tolerate doing so or would you find yourself struggling?
  • Is direct or indirect exposure more appealing to you? 
  • What would it mean for you to overcome worrying and/or phobias?

Remember there is no one size fits all model for exposure therapy and as is the case when trying to overcome anything, recovery rarely looks “perfect,” – and that’s OK. The process will be unique to you but through exposure therapy you will have the support of qualified therapists to ensure you do not feel alone in this process. Ultimately, through repeated exposure, you will harness your inner strength and be able to challenge your worries and phobias to overcome them. Lastly, our goal in therapy is to support you on your terms.  

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