All about exposure therapy

Wondering about exposure therapy? Maybe a client or a colleague has asked you “What is exposure therapy?” and you’d like to be certain you understand the pros and cons before providing an answer. Or maybe you’re curious yourself.

Exposure therapy is one of the most effective therapeutic approaches for anxiety, providing clients with long-lasting relief from debilitating symptoms and a new sense of freedom

That said, exposure therapy is often misunderstood and therefore underutilized.

In this article, we’ll answer the most pressing questions you may have about exposure therapy, including What is exposure therapy?, Does exposure therapy work, and if so, how? 

This article also discusses who can benefit from exposure therapy and how to effectively administer it to your clients.

First, what is exposure therapy? At its core, exposure therapy is about empowering our clients to face their fears in service of living more rich and fulfilling lives, unencumbered by anxiety.

Effective exposure therapy is strategic and gentle, allowing clients to build confidence as they face increasingly uncomfortable situations.

Exposure therapy entails helping clients identify and let go of avoidant behaviors, confront their fears, and manage their trigger responses—giving clients the tools to alleviate their anxiety on their own.

It’s important to note that exposure therapy is always embedded in a broader, evidence-based modality such as cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), prolonged exposure therapy (PE), or narrative exposure therapy.

As clients begin the journey of facing their fears, it’s helpful for them to learn additional anxiety management skills, such as detaching from intrusive thoughts, emotional regulation, psychoeducation about their struggles, and ways to connect with their core values.

These skills will help enable clients to engage in exposure challenges, and exposure challenges will give clients valuable practice in applying these skills.

Who and what is exposure therapy effective for?

There is robust psychological literature showing that exposure therapy can be effective in helping children, teens, and adults.

Exposure therapy can alleviate or lessen symptoms for any of the following conditions:

• Panic disorder
• Specific phobias
• Social anxiety
• Generalized anxiety
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)

Answering the question Who and what is exposure therapy for? is essential to figuring out if it can be a helpful intervention for your clients.

Equipped with this knowledge, you can provide psychoeducation on exposure therapy to clients you’re considering for the treatment.

How does exposure therapy work?

After answering the question What is exposure therapy?, it’s essential to understand how fear is conditioned.

When someone has anxiety or OCD, their amygdala (the brain’s survival center) sends out “danger” signals even if no actual danger exists.

It’s as if their brain is an overprotective guard dog that barks to “alert” its owner whenever  triggered. Better safe than sorry, right?

When clients become anxious, their amygdala sends a cascade of adrenaline and noradrenaline through their body, which creates psychophysiological changes, altering their thinking patterns and creating intense discomfort.

A person’s instinctual response is to get away from the perceived danger by engaging in safety behaviors to avoid their uncomfortable feelings.

Alas, avoidance serves to reinforce the anxious cycle, leading to more anxiety in the long term and greater restrictions on the person’s ability to live a meaningful life.

So, what is exposure therapy’s role in mitigating these responses?

Exposure therapy helps clients break these cycles in two primary ways: 

Awareness

First, it helps our clients bring awareness to their safety behaviors and develop a game plan to reduce their reliance on avoidance (often called “response prevention,” as it prevents the feared response to false alarms).

Confidence 

Secondly, we want to develop a list of various activities or situations that trigger a client’s anxiety.

We rate these triggers on a scale of 0 to 10 and help the client start facing their fears without engaging in avoidance. It’s helpful to start with situations that cause low to moderate anxiety (e.g., situations rated a 4 or 5 out of 10).

That way, clients can build their confidence as they face increasingly difficult situations. As clients work through the exposure list, they commonly gain momentum as they discover that their anxiety is all bark and no bite.

Throughout their exposure therapy journey, the client should also be learning valuable lessons about the nature of their fears.

These include understanding that:

• Worries and intrusive thoughts are irrelevant and don’t need to be taken literally
• Clients can tolerate much more discomfort than their anxiety lets on
• Discomfort is temporary and will be alleviated without them having to do anything about it
• The values our clients hold are more important than avoiding the possibility of scary things happening

Types of exposure therapy

Not all forms of exposure therapy are universally applicable to clients who may be good candidates for exposure therapy.

Here are the various forms and how you can determine which one(s) to use:

Exposure in-vivo therapy

In-vivo exposure involves facing fears out in the world, such as in the office or surrounding community (e.g., having a client with contamination OCD touch a doorknob and then immediately eat a snack).

Imaginal exposure therapy

This form of exposure entails having clients develop vivid stories pertaining to their anxiety’s worst-case scenario and listening to or saying it repeatedly.

Imaginal exposures can be particularly useful for fears that cannot be tapped into with in-vivo exposures (e.g., fear of going to hell).

Interoceptive exposure therapy 

Interoceptive exposure is the act of exposing individuals to feared sensations in their bodies.

This form of exposure is usually a core element of panic disorder treatment, but can be used as exposure therapy for anxiety, of all kinds.

For example, if a client fears a racing heartbeat, a good interoceptive exposure might be for them to run in place for a minute and sit down to observe their heart rate.

Tips and tricks to using exposure methods

While helping clients to face their fears is a simple concept, exposure therapy in practice is more complex and nuanced than it may seem.

Below are some key elements that can help you practice exposure therapy:

Work collaboratively with clients to develop two lists

In one list, highlight all the various safety behaviors or avoidances.

In another list, organize the exposure challenges based on difficulty level (e.g., putting the most difficult exposure at the top and the least difficult at the bottom).

Have clients choose one or two safety behaviors to work on reducing over the next week and one or two exposure challenges to practice.

Do not skimp on psychoeducation 

Knowledge is power, and the more clients understand about how their anxiety is hijacking their nervous system, the better off they’ll be.

Before we start exposures, I always ensure my clients can confidently answer the question, What is exposure therapy, and why will it be helpful?. This will prevent many road bumps along the way.

Check in with clients throughout 

While clients are doing exposure exercises, check in with them about what they are telling themselves and what they are focusing their attention on.

We don’t want them compulsively reassuring themselves, engaging in distraction attempts, or trying to resist their feelings.

Instead, help clients practice mindfulness skills by observing their thoughts and feelings from a non-judgemental perspective and actively inviting any emotion or sensation that arises.

Select exposure activities with clients

Selecting exposure activities is quite simple. All you need to do is assess for things that trigger your client’s fears and the things they avoid.

This needs to be a collaborative and client-led discussion. Try to help them brainstorm up to 15 potential exposures with varying difficulties.

It’s good practice to do exposures with clients the first time, and make sure they practice in between sessions as well!

Connect exposure exercises to core values

Help clients connect their exposure exercises to their core values.

Have them reflect on the consequences of their anxious avoidance and how the hard work they are doing in therapy will ultimately lead to a more rich, fulfilling life.

Values work can act like a lighthouse, helping clients proceed through the storm of anxiety towards a beacon of hope.

Try different exercises and exposures The more variation you can include in exposure assignments, the more deeply clients will be able to unhook from anxiety.

Have clients use different forms of exposure (e.g., in-vivo and imaginal) and consider creative ways to vary relevant elements of the exposure exercises (e.g., time of day, location, type of exposure, people involved).

Build self-awareness 

Exposure therapy is about helping clients learn some important, underlying lessons of anxiety or OCD.

Ask them targeted questions before and after the exposures to help solidify their learning, such as:

• What do you think will happen when you face your fear?

• What about this exposure exercise surprised you? 

• What is exposure therapy’s outcome on you? Was the outcome different from what you predicted? If yes, how so? 

• What did you learn from it? 

• What might you change next time to create some variation here?

Common misconceptions about exposure therapy

Despite the overwhelming evidence of its effectiveness and relative simplicity in practice, many therapists still do not use exposure therapy, and in some cases, can’t answer the question What is exposure therapy?.

Here are some common misconceptions I’ve heard from colleagues and trainees:

Making clients anxious is unethical or causes harm 

It’s important to keep in mind that our clients are already experiencing anxiety.

Exposure therapy may cause a short-term increase in symptoms that are already present, but in the long term, it will likely provide them with a newfound sense of peace and agency.

Furthermore, while uncomfortable, anxiety itself is natural and harmless. There are no long-term negative effects of exposure therapy, but there certainly are negative effects of living a restricted life.

Clients won’t like exposures and will terminate treatment

Anxious clients want solutions.

The rationale behind exposure therapy is highly intuitive, and in my experience, when clients understand the treatment, they tend to be hopeful and motivated. This is why knowing the ins and outs of what is exposure therapy is crucial to client buy-in.

Many of my clients have tried years of failed talk therapy and are elated to hear that there is a more active way to evoke change.

Exposure therapy is a bandaid fix

Exposure therapy directly targets and addresses present-moment factors that are maintaining anxious distress.

It fundamentally changes individuals’ relationships with negative thoughts and uncomfortable feelings.

Sources

• Garner, L. E., Steinberg, E. J., & McKay, D. (2021). Exposure therapy. In A. Wenzel (Ed.), Handbook of cognitive behavioral therapy: Overview and approaches (pp. 275–312). American Psychological Association. https://doi.org/10.1037/0000218-010
• Langthorne, D., Beard, J., & Waller, G. (2023). Therapist factors associated with intent to use exposure therapy: a systematic review and meta-analysis. Cognitive Behaviour Therapy, 52(4), 347–379. https://doi.org/10.1080/16506073.2023.2191824
• Parker, Z. J., Waller, G., Duhne, P. G. S., & Dawson, J. (2018). The role of exposure in treatment of anxiety disorders: A meta-analysis. International Journal of Psychology & Psychological Therapy, 18(1), 111–141.

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