Exposure Therapy Basics: What It Is & Why It Works

Written by Lauren Helm, M.A.

 

“Face your fears.” The wisdom of this adage is built into exposure therapy, an intervention that has been extensively researched and shown to be very effective in treating various anxiety disorders. What is exposure therapy? We break it down here.

Anxiety disorders are usually characterized by excessive and debilitating fear or anxiety. The anxiety may become so powerful that it can feel as though it has taken on a life of its own, domineering a person’s relationships, work, and quality of life.  Though fear and anxiety are normal emotional responses to a threat (they motivate us to avoid potentially harmful situations), those with anxiety disorders often experience debilitating anxiety even when a truly dangerous threat is not present.  Despite the absence of something that may cause physical harm, the brain’s fear centers are fully activated, and for someone with anxiety, it strongly feels as though something bad will happen. It is proposed that anxiety disorders in part develop as a result of both classical and operant conditioning, two important psychological concepts that inform and guide exposure therapy.

Basically, fear and anxiety are actually reinforced and strengthened when we avoid whatever causes it (whether it be a person, place, thing, thought, memory, emotion, or physical sensation that acts as a trigger). When we avoid or escape something that makes us feel afraid, it’s like our brain sends us a message that says, “Thank goodness I got away from that scary thing! It must have been truly dangerous. I am safe now that I am not longer in contact with the threat. If I get close to it again, I better make sure to get far away again!” A cycle is created. The next time we encounter the feared stimulus (i.e. whatever it is that triggered our anxiety), the more likely we are to experience a heightened fearful or anxious response, and to have stronger urges to avoid or escape.

In exposure therapy, the therapist leads her client through a set of experiences intended to elicit the very fear that the person has been avoided. Though this may seem counter-intuitive, it is an extremely effective behavioral approach that helps the client free themselves from the cycle of anxiety and avoidance. Essentially, avoidance is “blocked;” the client begins learning how to face his or her fears, and in doing so, experiences habituation. Habituation is like desensitization. When someone is exposed to something repeatedly, it begins to lose potency. Anxiety and fear naturally drop off, and with repeated exposures, become less intense and long-lasting. Additionally, when avoidance is prevented, the fear/anxiety response is no longer reinforced and strengthened. This leads to an extinguishing of the fear response. In other words, a fearful or anxious response is “extinguished” and fades away over time.

Most people have trepidation about starting exposure therapy. It is admittedly uncomfortable, at least in the short-term. However, the long-term benefits far outweigh the discomfort that may occur along with exposure therapy. Usually, it turns out that we hold beliefs about emotions (especially fear and anxiety) that interfere with our willingness to effectively face our fears.

Common myths about emotion typically include beliefs that:

• Fear or anxiety will continue to escalate (without a ceiling effect or peaking) indefinitely until the person gets away from whatever is causing them anxiety
• Fear or anxiety will become so intense that it will cause physical harm or death
• Fear or anxiety will become so intense that it will cause psychological damage, insanity, a loss of control, etc.

These beliefs often reflect a fear of emotions stemming from a commonly-held belief that emotions are dangerous. In and of themselves, emotions are not dangerous – they are physiological sensations (along with thought & urges). The sensations are designed to motivate us to act. The feelings that come along with emotions may be experienced as overwhelming (especially when we don’t understand them or it feels as though they can do us harm), but they will not hurt you (and it is not physically possible for them to intensify beyond a certain point). Frequently, exposure therapy results in the added benefit of being able to tolerate intense emotions, and learn that it is safe to fully feel your emotions. It’s what you do with your emotions that count – how we ACT can have a beneficial or detrimental effect on our lives and well-being. Therapists help you to learn how to effectively respond to your emotions, so that they don’t restrict your way of life. Your CSAM therapist is well-trained in exposure therapy principles and will explain in more detail why it is not the case that intense, acute emotional experiences cause harm. In fact, one of the principles of exposure therapy is to ensure that individuals are absolutely not caused harm – otherwise that would defeat the point! Exposure therapy is all about learning that despite the anxiety, there is no danger, but rather, safety. Once this is sufficiently experientially learned and processed (not just known intellectually), dramatic change begins to occur.

Don’t worry – your therapist will collaborate with you to figure out the best pace of treatment. Depending on your needs, you may opt to participate in flooding (which essentially means that you face some of your most intense fears right away), or the more commonly used approach, gradual exposure (you work your way up an exposurehierarchy, starting with mild-moderate fears). Both approaches have been found to be equally effective, but differ in the length of time that they may take to complete, and in the likelihood of premature drop-out. Remember, exposure requires repeated practice facing your fears until a re-learning occurs. Sticking with exposure therapy until anxiety has naturally begun to dissipate (or tolerance of anxiety has increased) is essential for success.

Are you interested in using exposure therapy to tackle your fears? Our CSAM therapists are trained in exposure therapy and can help you effectively respond to anxiety using evidence-based methods. If you'd like to speak with a professional at the Center for Stress and Anxiety Management for help with anxiety, please click here.

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References

Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioral treatment of panic disorder. Behavior Therapy, 20(2), 261-282.

Barlow, D. H., Rapee, R. M., & Brown, T. A. (1992). Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23(4), 551-570.

Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2004). Myths regarding exposure therapy for PTSD. Cognitive and Behavioral Practice, 10(1), 85-90.

Foa, E., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. Oxford University Press.

Hofmann, S. G. (2008). Cognitive processes during fear acquisition and extinction in animals and humans: Implications for exposure therapy of anxiety disorders. Clinical psychology review, 28(2), 199-210.

Phobias, Fear, & Exposure Therapy

by Lucas Myers

At the Center for Stress and Anxiety Management Halloween has got us thinking about fear. We deal with it all the time, but at CSAM we call fear by another name: Phobia. Classified as a form of anxiety disorder, a phobia is a persistent, irrational, and severe fear of a particular situation, object, or activity. A phobia is much more intense and persistent than ordinary fears. The desire to avoid the source of terror is very powerful. People might avoid certain situations, things, and conditions in an effort to circumvent their fears. Most of those suffering from a phobia recognize that the fear is excessive or unreasonable. More than 12 percent of individuals develop phobias at some point during their lives. In fact, these fears may change over time. For example, fears of crowds, separation, injury, illness, and death are more common among people over 60. Among 20 year olds, common fears included snakes, heights, storms, enclosures, and social situations. 

There may be as many as 700 different phobias. Many of them may only be uncomfortable or embarrassing, but the ones listed below can be so severe that they cause major changes in the way you live your life.

• One of the most well known phobias, arachnophobia is also believed to be one of the most common. If spiders make you feel overwhelmed by extreme anxiety and fear, you have arachnophobia. 

• According to a 1980 study by the Boeing Aircraft Corporation, 25 million Americans suffer from aerophobia. Celebrities Billy Bob Thornton and Cher are two household names that have reported suffering from this powerful aversion to flying in airplanes or hot air balloons.

• Halloween can be tough if you experience necrophobia. Caskets, dead bodies, funeral homes, and funerals or anything that invokes thoughts about death can cause extreme fright. This phobia may develop from attending a loved one's funeral when the painful memory sticks around and develops into a fear of anything related to death.

• You may have Social Phobia if the thought of being watched or scrutinized by other people causes overwhelming panic. Social and performance anxiety can be experienced by anyone but Social Phobia like other extreme fears, can cause nausea, sweating, and a racing heart. Those with Social Phobia may become very reclusive.

• Another common phobia is claustrophobia, an anxiety disorder that sometimes develops in response to an occasion, often in childhood, when a person was trapped in an enclosed space with no way to escape. Claustrophobic individuals may find themselves irrationally fearful of elevators, airplanes, trains, or subways.

• A bout of agoraphobia can really wreck your plans. It can include fear of wide, open spaces, tunnels, bridges, traffic, crowds, airplanes, and public transportation. In it’s most severe form, agorophobia can cause people to refuse to stray far from home. If you have agoraphobia you're in good company. According to many reports, Oscar winning actress Kim Basinger struggled with panic attacks and severe agoraphobia, publicly sharing how difficult it has been for her friends and family to understand.

• Those that suffer from acrophobia are likely to have a convenient excuse when it comes time to visit the Empire State Building with their family, or disappear to the bathroom when everyone gets in line for the Ferris Wheel. That's because acrophobia is the fear of heights. It isn't always seen as very serious, after all, how hard can it be to avoid ladders? For some people though, acrophobia can be a huge problem because it prevents them from crossing bridges. Imagine doubling the length of your commute just to avoid taking the bridge home.

• An irrational fear of germs can be referred to as germophobia, bacterophobia, or mysophobia. Some believe Michael Jackson may have suffered from mysophobia. This is because he was often photographed wearing a surgeon's mask out in public. Others with mysophobia may feel compelled to wash their hands all the time in an attempt to remove germs. Mysophobia is often a form of obsessive compulsive disorder.

If you are suffering from a phobia, there is hope! Specific Phobias can be treated using a powerful intervention called exposure therapy. Exposure therapy involves systematically and gradually exposing individuals to the objects or situations they dread. Exposure therapy works because once individuals have faced the source of their fear, they learn the object or situation is not as dangerous as they previously believed and they learn they can cope with the object, situation and their fear. Ample research has demonstrated the efficacy of Exposure Therapy for phobias and other anxiety disorders as well (e.g., obsessive compulsive disorder, panic disorder, post-traumatic stress disorder).. 

If you would like to talk to one of our expert therapists about a phobia, or any anxiety disorder, contact us at CSAMSanDiego@gmail.com or call us at 858-354-4077.

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 24 Octorber 2013]. dsm.psychiatryonline.org doi:10.1176/appi.books.9780890425596.744053

Comber, Ronald J. 2008. Fundamentals of Abnormal Psychology: Fifth edition. New York: Worth.

Smolowe, Jill. “Too Hot to Handle”. People Magazine, Vol. 55, 4. Retrieved on October 24th 2013 from: http://www.people.com/people/archive/article/0,,20133526,00.html

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