Exposure Therapy

Intro to Exposure Therapy

You may be familiar with the term 'exposure therapy,' or may be able to surmise what this treatment entails. Exposure by definition involves coming in contact with something and/or being affected by it. Exposure therapy is an important component of CBT and behavioral therapies.

When describing exposure therapy, a helpful first step is to start by discussing the concept of avoidance. We tend to avoid things we dislike or fear. By avoiding, we are usually able to escape the discomfort that comes with approaching said situation. However, the problem with avoidance is it reinforces the idea that the situation was unsafe and worthy of fear, and/or that we would not have been able to handle the outcome of the situation nor our difficult emotions.

By avoiding, we do not give ourselves the opportunity to see that if we encountered the situation, either:

a) our feared outcome may not unfold, or

b) we can likely handle the situation or difficult emotions better than   we may expect.

Example: Fear of Heights

Let's take for example a fear of heights. For someone who is afraid of heights, when they think about going on a hike up the side of a tall mountain, they will likely feel intense anxiety. If they decide to instead skip the hike, they will feel better; anxiety will likely go away. However, the problem with avoidance is that the next time they think about going on a hike, anxiety may increase. As their avoidance led to relief,  they may now believe that heights are in fact dangerous. They were only safe because they avoided.

Exposure on the other hand, is difficult and takes time. Let me explain this through another example. What if instead this person decides to go on the hike? They will likely feel more anxious- because they are doing the very thing they fear! However there is a common misconception that fear will go up indefinitely or will not be tolerable. Sure, anxiety can reach a 10/10, but it will eventually reach its peak. People find that when they are in a feared situation long enough, their fear may even start to lessen or plateau.

In therapy, individuals are often encouraged to create what we call a fear hierarchy- a list of feared situations, ranking their predicted level of distress from 0-100. This is a way to work our way up from smaller to bigger fears.  For a fear of heights, this may involve starting by looking at pictures or watching videos of heights. Then, going to a third story apartment building, or on smaller hike, eventually with the goal of a rooftop or a larger hike. Building our way up a hierarchy increases confidence, and by the time we reach the top, usually our biggest fear is no longer as scary as it was initially. This is because we have worked on similar lower-level fears and the learning generalizes. 

Exposure Rationale

So, if anxiety is higher during exposure, why would we do this? The point is that the learning happens through repetition. While the first time someone exposes themselves to a situation they typically avoid is very difficult, the next time their anxiety may peak a little lower, plateau a little sooner, and go down a little more. 

Exposure will not happen instantaneously; however, through continuing to confront feared situations, we learn that if we stay in these situations long enough, our distress will go down and/or we can handle the distress better than we thought. We did not need to avoid for our distress to go down. Exposure also allows us to live life in line in line with our values. If you are afraid of flying, but you value spending time with family (who are a flight away), then through exposure you can ultimately get to a place where you are living life more in line with your values.

What are some fears of yours that you can start approaching, rather than avoiding?