Exposure Therapy Techniques

Exposure therapy is a psychological treatment that helps people approach what they fear rather than avoid it. Avoidance often brings relief in the short term, while the fear itself tends to persist. Exposure therapy uses planned, graded contact with the feared object or situation, so that the fear and the distress attached to it can lessen over time.

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Understanding Exposure Therapy

Exposure therapy is built on approaching what is feared rather than avoiding it. It uses a systematic approach that gradually brings you into contact with the object or situation you fear, in a safe and planned setting, so that the distress attached to it can decrease over time.

Historical Context

Exposure therapy grew out of systematic desensitisation and has since been adapted for a wide range of psychological difficulties.

Core Techniques of Exposure Therapy

• In vivo exposure. You approach the feared object or situation in real life rather than imagining it. This is the usual approach for specific phobias, such as fear of flying or fear of spiders.
• Imaginal exposure. Used where real-life contact is not possible or not appropriate, such as traumatic memories or feared events that cannot be recreated.
• Interoceptive exposure. Used with people who have panic disorder, where the fear attaches to bodily sensations resembling the start of a panic attack, such as a raised heart rate or difficulty breathing.

Which one is used, and in what order, depends on the nature of the fear and is worked out with your therapist.

With younger clients, exposure may be combined with play therapy tools, so that the work sits closer to how a child already communicates. A child who is afraid of the dark might use dolls or figures to play through a scenario involving darkness. This lets the child approach the fear in a way that suits their stage of development.

Advanced Concepts and Innovations in Exposure Therapy

Variable Practice

This involves varying the conditions under which exposure is practised: different settings, different times of day, different versions of the feared situation, and sometimes tasks taken out of hierarchy order. The reason this matters is that a proportion of people who improve during exposure find the fear returning once treatment ends, and one reason for that is context. What is learned in one setting does not automatically travel to another. Varying the conditions is an attempt to make the new learning easier to retrieve outside the consulting room, and so to reduce that return of fear (Craske and colleagues, 2014). The evidence is encouraging rather than settled: some trials of varied timing and varied stimuli found better follow-up outcomes, while others showed only trends in that direction.

Inhibitory Learning

More recent work focuses on inhibitory learning, where the aim is to build new, non-fearful associations with the feared situation alongside the old fearful ones, rather than relying on habituation alone.

Combination with Cognitive Enhancers

Some specialist research has tested whether a medication can make each exposure session teach more. The most studied is D-cycloserine, a partial agonist at the NMDA receptor, which is thought to help consolidate the new learning that an exposure trial produces (Bürkner and colleagues, 2017). Results are mixed. A meta-analysis pooling individual data from 1,047 patients across anxiety, obsessive-compulsive and post-traumatic stress disorders found a small advantage over placebo at the end of treatment, which weakened at follow-up (Mataix-Cols and colleagues, 2017). A separate meta-analysis published the same year found an overall effect close to zero, and noted that the better-designed and more recent studies reported the smaller benefits (Bürkner and colleagues, 2017). This is adjunctive, specialist practice under medical supervision, not part of routine exposure therapy, and it is not something to seek out on your own.

These are refinements to how exposure is planned and delivered. They are not separate treatments.

Ethical and Practical Considerations

Two things matter whenever exposure therapy is used.

Ethical Considerations

Confronting fears can be emotionally demanding. Therapists are required to make sure you are fully informed about what the therapy involves before it starts, and that the work is conducted in a safe and supportive setting.

Practical Application

Exposure therapy has to be planned and personalised. Therapists tailor the exposure tasks to your specific fears, so that the tasks are demanding without being overwhelming. If you are considering this work, find a qualified psychologist to plan it with you.

Personalising Your Exposure Therapy

Exposure therapy is adapted to the person doing it.

Working Collaboratively

You and your therapist identify the triggers together and set out a hierarchy of exposure tasks that increase in difficulty step by step.

Supportive Therapeutic Relationship

A trusting relationship with your therapist matters, because that support is what makes the harder parts of exposure manageable. Regular discussion allows the plan to be adjusted in response to your feedback and progress.

If exposure therapy does not seem right for you, look at the different therapy techniques and tools available and consider which approach suits you better.

Key Takeaways

• Approaching rather than avoiding. Exposure therapy works through planned contact with what is feared, in place of the avoidance that keeps the fear in place.
• Tailored to individual needs. The therapy is customised to your specific fears, so that exposure tasks are both manageable and demanding enough to be useful.
• A range of methods. Exposure may be in vivo, imaginal or interoceptive, and current practice draws on variable practice and inhibitory learning.
• Ethically grounded. Informed consent and a safe, supportive setting are conditions of the work, not extras.
• Discomfort is part of it. Anxiety often rises during an exposure task before it settles, and the pace is something to agree with your therapist rather than endure alone.

FAQ

What should I do if I feel overwhelmed during exposure therapy?

Tell your therapist straight away. The pace can be slowed or the approach modified, so that the work continues at a rate you can manage.

How can I tell if exposure therapy is working for me?

Progress usually shows as less fear and less anxiety in relation to the specific fear being worked on. You might notice less distress in situations that previously provoked a great deal, or that you approach those situations more often and with less difficulty.

Are there any risks associated with exposure therapy?

Confronting fears can temporarily increase anxiety or emotional discomfort. Working within a structured plan, with a trained professional, is what keeps that within manageable limits.

How long does it typically take to see results from exposure therapy?

This varies with the person and the complexity of the fear being addressed. Some people notice change within a few sessions, others need considerably longer. Keeping to the agreed plan between sessions is part of the work.

Can exposure therapy be used for children?

Yes. Exposure therapy is adapted for children and is used for anxiety difficulties such as phobias and separation anxiety. Child-focused approaches often involve play and parental involvement.

How do I prepare for my first exposure therapy session?

Preparation usually involves understanding the basic principles of exposure therapy and starting to think about your fear hierarchy: which situations are mildly anxiety-provoking, and which are the most distressing. Being open with your therapist about that ordering is what the plan is built from.

What happens if I cannot handle the exposure?

If an exposure task feels too overwhelming, your therapist will adjust the intensity or break it into smaller steps. The plan is flexible by design, and tasks are set to stay within what you can manage.

Further Reading

• American Psychological Association, information on exposure therapy for patients and families, apa.org.
• Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., and Vervliet, B. (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.
• Mataix-Cols, D., Fernández de la Cruz, L., Monzani, B., and colleagues (2017). D-cycloserine augmentation of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders: a systematic review and meta-analysis of individual participant data. JAMA Psychiatry, 74(5), 501-510.
• Bürkner, P.-C., Bittner, N., Holling, H., and Buhlmann, U. (2017). D-cycloserine augmentation of behavior therapy for anxiety and obsessive-compulsive disorders: a meta-analysis. PLoS ONE, 12(3), e0173660.