Exposure treatment is a technique that is widely used in cognitive-behavioral therapy (CBT) to help patients systematically confront a feared stimulus in a live or virtual environment or in the imagination. Through repeated exposure to the stimulus, patients are helped to nullify fears and increase self-efficacy. Exposure treatment is also called exposure therapy.
Exposure treatment is used for a variety of anxiety disorders , and it has also recently been extended to the treatment of substance-related disorders. Generally speaking, exposure treatment involves presenting patients with anxiety-producing stimulus for a long enough time to decrease the intensity of their emotional reactions. As a result, the feared situation or object no longer makes the patients anxious. Exposure treatment can be carried out in real situations, which is called in vivo exposure, or it can be done through imagination, which is called imaginal exposure. More recently, exposure treatment has been extended to include the use of computer-based virtual environments.
The category of imaginal exposure includes systematic desensitization , in which patients imagine certain aspects of the feared object or situation combined with relaxation. Graded or graduated exposure refers to exposing the patients to the feared situation in a gradual manner. Flooding refers to exposing patients to the anxiety-provoking or feared situation all at once and keeping them in it until the anxiety and fear subside. There are several variations in the delivery of exposure treatment: patient-directed exposure instructions or self-exposure; therapist-assisted exposure; group exposure; and exposure with response prevention.
The basic purpose of exposure treatment is to decrease a person’s anxious and fearful reactions (emotions, thoughts, or physical sensations) through repeated exposures to anxiety-producing material. This reduction of the patient’s anxiety response is known as habituation. A related purpose of exposure treatment is to eliminate the anxious or fearful response altogether so that patients can face the feared situation repeatedly without experiencing anxiety or fear. This elimination of the anxiety response is known as extinction.
Exposure treatment is generally a safe treatment method; however, some patients may find that the level of anxiety that occurs during treatment sessions is higher than they can handle. Some studies of exposure treatment have reported a high dropout rate, perhaps because the method itself produces anxiety. In addition, exposure treatment is not effective for all patients; after treatment, some continue to experience anxiety symptoms.
Exposure treatment usually begins with making lists or hierarchies of situations that make the patients anxious or fearful. The situations are ranked on a scale of zero (representing the situation producing the least anxiety) to ten (representing the situation of highest anxiety). In addition, patients are usually asked to rate their level of anxiety in each situation on a scale from zero (no anxiety or discomfort) to 100 (extreme anxiety and discomfort). This scale is called the subjective units of distress scale (SUDS). Patients may be asked to provide SUDS ratings at regular intervals (for example every five minutes) during exposure treatment.
Methods of delivering exposure treatment
Patient-directed exposure is the simplest variation of exposure treatment. After patients make their hierarchy lists with their therapist, they are instructed to move through the situations on the hierarchy at their own rates. Patients start with the lowest anxiety situation on the list, and keep a journal of their experiences. They continue the patient-directed exposure on a daily basis until their fears and anxieties have decreased. For example, if patients are afraid of leaving the house, the first item on the hierarchy might be to stand outside the front door for a certain period of time. After they are able to perform this action without feeling anxious, they would move to the next item on the hierarchy, which might be walking to the end of the driveway. Treatment would proceed in this way until the patients have completed all the items on the hierarchy. During therapy sessions, the therapist reviews their journal, gives them positive feedback for any progress that they have made, and discusses any obstacles that they encountered during exposures to the feared situation.
In this form of exposure treatment, therapists go with patients to the feared location or situation and provides on-the-spot coaching to help them manage their anxieties. Therapists may challenge their patients to experience the maximum amount of anxiety. In prolonged in vivo exposure, therapists and patients stay in the situation as long as it takes for the anxiety to decrease. For example, they might remain in a crowded shopping mall for four or more hours. The therapists also explore the thoughts of patients during this exposure to confront any irrational ways of thinking.
In group exposure, self-exposure and practice are combined with group education and discussion of experiences during exposure to feared situations. These sessions may last as long as three hours and include 30 minutes of education, time for individual exposure practice, and 45 minutes of discussion. Group sessions may be scheduled on a daily basis for 10-14 days.
Exposure treatment for specific anxiety disorders
Many research studies have shown that graded exposure treatment is effective for agoraphobia. Long-term studies have shown that improvement can be maintained for as long as seven years. Exposure treatment for agoraphobia is best conducted in vivo, in the actual feared situation, such as entering a packed subway car. Exposure treatment for agoraphobia is likely to be more effective when the patient’s spouse or friend is involved, perhaps because of the support a companion can offer the patient during practice sessions.
Exposure treatment is the central component of cognitive-behavioral treatment for panic disorder . Treatment for this disorder involves identifying patients’ specific fears within their experiences of panic, such as fears of being sick, of losing control, and of embarrassment. Once these fears are identified, patients are instructed to expose themselves to situations in which the fearful thoughts arise (such as walking away from a safe person or place). The rationale behind this instruction is that enduring the anxiety associated with the situation will accustom patients to the situation itself, so that over time the anxiety will diminish or disappear. In this way, patients discover that the feared consequences do not happen in real life.
In some patients, physical symptoms of panic lead to fears about the experience of panic itself. Fears related to the physical symptoms associated with panic can be targeted for treatment by inducing the bodily sensations that mimic those experienced during panic attacks. This technique is called interoceptive exposure. Patients are asked to induce the feared sensations in a number of ways. For example, patients may spin in a revolving chair to induce dizziness or run up the stairs to induce increased heart rate and shortness of breath. They are then instructed to notice what the symptoms feel like, and allow them to remain without doing anything to control them. With repeated exposure, patients learn that the bodily sensations do not signal harm or danger, and therefore need not be feared. Patients are taught such strategies as muscle relaxation and slow breathing to control anxiety before, during, and after the exposure.
Interoceptive exposure treatment for panic usually begins with practice sessions in a therapist’s office. Patients may be instructed to practice at home and then practice in a less “safe” environment, such as their work setting or a nearby park. The next step is the addition of the physical activities that naturally produce the feared symptoms. Situational or in vivo exposure would then be introduced for patients with agoraphobia combined with panic disorder. Patients would be instructed to go back into situations that they have been avoiding, such as elevators or busy railroad terminals. If patient develop symptoms of anxiety, they are instructed to use the techniques for controlling anxiety that were previously learned.
The effectiveness of exposure treatment for decreasing panic attacks and avoidance has been well demonstrated. In research studies, 50-90% of patients experience relief from symptoms.
SPECIFIC PHOBIA AND SOCIAL PHOBIA
Graded exposure is used most often to treat specific or simple phobias. In graded exposure, patients approach the feared object or situation by degrees. For example, those afraid of swimming in the ocean might begin by looking at photographs of the ocean, then watching movies of people swimming, then going to the beach and walking along the water’s edge, and then working up to a full swim in the ocean. Graded exposure can be done through patient-directed instruction or therapist-assisted exposure. Research studies indicate that most patients respond quickly to graded exposure treatment, and that the benefits of treatment are well maintained.
Treatment for social phobia usually combines exposure treatment with cognitive restructuring. This combination seems to help prevent a recurrence of symptoms. In general, studies of exposure treatment for social phobia have shown that it leads to a reduction of symptoms. Since cognitive restructuring is usually combined with exposure, it is unclear which component is responsible for patients’ improvement, but there is some indication that exposure alone may be sufficient.
Exposure treatment can be more difficult to arrange for treating social phobia, however, because patients have less control over social situations, which are unpredictable by their nature and can unexpectedly become more intense and anxiety-provoking. Furthermore, social exchanges usually last only a short time; therefore, they may not provide the length of exposure that patients need.
The most common nonmedication treatment for obsessive-compulsive disorder (OCD) is exposure to the feared or anxiety-producing situation plus response prevention (preventing the patient from performing a compulsive behavior, such as hand washing after exposure to something thought to be contaminated). This form of treatment also uses a hierarchy, and begins with the easiest situation and gradually moves to more difficult situations. Research has shown that exposure to contamination situations leads to a decrease in fears of contamination, but does not lead to changes in the compulsive behavior. In a similar fashion, the response prevention component leads to a decrease in compulsive behavior, but does not affect the patient’s fears of contamination. Since each form of treatment affects different OCD symptoms, a combination of exposure and response prevention is more effective than either modality by itself. Exposure combined with response prevention also appears to be effective for treating children and adolescents with OCD.
Prolonged continuous exposure is better than short, interrupted periods of exposure in treating people with OCD. On average, exposure treatment of people with OCD requires 90-minute sessions, although the frequency of sessions varies. Some studies have shown good results with 15 daily treatments spread over a period of three weeks. This intensive treatment format may be best suited for cases that are more severe and complex, as in patients with depression as well as OCD. Patients who are less severely affected and are highly motivated may benefit from sessions once or twice a week. Treatment may include both therapist-assisted exposure and self-exposure as homework between sessions. Imaginal exposure may be useful for addressing fears that are hard to incorporate into in vivo exposure, such as fears of a loved one’s death. Patients usually prefer gradual exposure to the most distressing situations in their hierarchy; however, gradual exposure does not appear to be more effective than flooding or immediate exposure to the situation.
POST-TRAUMATIC STRESS DISORDER
Exposure treatment has been used successfully in the therapy of post-traumatic stress disorder (PTSD) resulting from such traumatic experiences as combat, sexual assault, and motor vehicle accidents. Research studies have reported encouraging results for exposure treatment in reducing PTSD or PTSD symptoms in children, adolescents, and adults. Intrusive symptoms of PTSD, such as nightmares and flashbacks, may be reduced by having patients relive the emotional aspects of the trauma in a safe, therapeutic environment. It may take 10-15 exposure sessions to decrease the negative physical sensations associated with PTSD. These sessions may range from one to two hours in length and may occur once or twice a week. Relaxation techniques are usually included before and after exposure. The exposure may be therapist-assisted or patient-directed.
A recent study showed that imaginal exposure and cognitive treatment are equally effective in reducing symptoms associated with chronic or severe PTSD, but that neither brought about complete improvement. In addition, more patients treated with exposure worsened over the course of treatment than patients treated with cognitive approaches. This finding may have been related to the fact that the patients receiving exposure treatment had less frequent sessions with long periods of time between sessions. Some patients diagnosed with PTSD, however, do not seem to benefit from exposure therapy. They may have difficulty tolerating exposure, or have difficulty imagining, visualizing, or describing their traumatic experiences. The use of cognitive therapy to help the patient focus on thoughts may be a useful adjunctive treatment, or serve as an alternative to exposure treatment.
Many people who have experienced sexual assault or rape meet the criteria for PTSD defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). They may reexperience the traumatic event, avoid items or places associated with the trauma, and have increased levels of physical arousal. Exposure treatment in these cases involves using either imaginal or in vivo exposure to reduce anxiety and any tendencies to avoid aspects of the situation that produce anxiety (also known as avoidance behavior). Verbal description of the event (imaginal exposure) is critical for recovery, although it usually feels painful and threatening to patients. It is important that the patients’ verbal descriptions of the traumatic events, along with their expressions of thoughts and feelings related to it, occur as early in the treatment process as possible, to minimize long-term suffering.
Prolonged exposure is the most effective nonmedical treatment for reducing traumatic memories related to PTSD. It combines flooding with systematic desensitization. The goal is to expose patients using both imaginal and in vivo exposure techniques in order to reduce avoidance behaviors and fears. Prolonged exposure may occur over nine to 12 90-minute sessions. During the imaginal exposure phase of treatment, patients are asked to describe the details of the traumatic experiences repeatedly, in the present tense. Patients use the SUDS scale to monitor levels of fear and anxiety. The in vivo component occurs outside a therapist’s office; this component involves having clients expose themselves to cues in the environment that they have been avoiding—for example, the place where the motor vehicle accident or rape occurred. Patients are instructed to stay in the fear-producing situation for at least 45 minutes, or until their anxiety levels have gone down significantly on the SUDS rating scale. Often patients will use a coach or someone who will stay with them at the beginning of in vivo practice. The coach’s role gradually decreases over time as the patients experience less anxiety.
Recent innovations in exposure treatment
VIRTUAL REALITY EXPOSURE TREATMENT
Virtual reality is a technique that allows people to participate actively in a computer-generated (or virtual) scenario or environment. The participants have a sense of being present in the virtual environment. Virtual reality uses a device mounted on the participant’s head that shows computer graphics and visual displays in real time, and tracks the person’s body movements. Some forms of virtual reality also allow participants to hold a second device in their hands that enables them to interact more fully with the virtual environment, such as opening a car door.
Virtual reality has been proposed as a new way of conducting exposure therapy because it can provide a sense of being present in a feared situation. Virtual reality exposure may be useful for treating such phobias as fear of heights, flying, or driving, as well as for treating PTSD. This method appears to have several advantages over standard exposure therapy. First, virtual reality may offer patients a greater sense of control because they can instantly turn the device on and off or change its level of intensity. Second, virtual reality protects patients from harm or social embarrassment during their practice sessions. Third, it can be implemented regardless of the patient’s ability to imagine or to remain with prolonged imaginal exposure. These proposed advantages of virtual reality over standard exposure therapy have yet to be tested, however.
Some studies have been conducted using virtual reality in the treatment of patients with fear of heights and fear of flying, and in a sample of Vietnam veterans diagnosed with PTSD. These studies of virtual reality exposure therapy have limitations in terms of study design and small sample size, but their positive results suggest that virtual reality exposure therapy deserves further investigation.
CUE EXPOSURE TREATMENT FOR ALCOHOL DEPENDENCE
Cue exposure is a relatively new approach to treating substance-related disorders. It is designed to re-create real-life situations in safe therapeutic environments that expose patients repeatedly to alcohol-related cues, such as the sight or smell of alcohol. It is thought that this repeated exposure to cues, plus prevention of the usual response (drinking alcohol) will reduce and possibly eliminate urges experienced in reaction to the cues.
People diagnosed with alcohol dependence face a number of alcohol-related cues in their environments, including moods associated with previous drinking patterns; people, places, times, and objects associated with the pleasurable effects of alcohol; and the sight or smell of alcoholic beverages. Exposure to these cues increases the patient’s risk of relapse , because the cues can interfere with a person’s use of coping skills to resist the urge to drink. The purpose of cue exposure is to teach patients coping skills for responding to these urges. It is thought that people who practice coping skills in the presence of cues will find the coping skills strengthened, along with the conviction that they can respond effectively when confronted by similar cues in real-life situations.
There are various approaches to cue exposure. The choice of cues is usually based on treatment philosophy and goals, which may require abstinence from alcohol or permit moderate drinking. In abstinence-only programs, patients may be exposed to actual alcohol cues and/or imagined high-risk situations. This imaginal exposure is useful for dealing with cues and circumstances that cannot be reproduced in treatment settings, such as fights. Patients learn and practice urge-specific coping skills. While patients may learn to cope successfully with one cue (e.g., the smell of alcohol), the urge to drink may reappear in response to another cue, such as seeing a friend with whom they used to go to bars. Patients would then learn how to manage this particular cue. This program may take six to eight individual or group sessions and may occur on an inpatient or outpatient basis. Often patients remain in the treatment setting for several hours after the exposure to ensure that any lasting urges are safely managed with a therapist’s help.
More specifically, cue exposure focuses on the aspect of alcohol consumption that produces the strongest urge. Patients would report each change in their level of urgency, using a scale of zero to 10 that resembles the SUDS scale. The urge to drink usually peaks after one to five minutes. When the desire for a drink arises, patients are instructed to focus on the cue to see what happens to their desire. In most cases the urge subsides within 15 minutes, which is often different from what the patients expected. In later sessions, the patients are instructed when the urge peaks to imagine using the coping skills that they recently learned. Patients may also be instructed to imagine being in high-risk situations and using the coping skills. Some examples of these coping skills include telling oneself that the urge will go away, picturing the negative consequences of drinking alcohol, and thinking of the positive consequences of staying sober.
Although there has been little research on cue exposure, available studies show positive outcomes in terms of decreasing the patients’ consumption of alcohol. There have been, however, few outcome studies comparing cue exposure treatment to other treatment approaches. It may be hard to separate the benefits of exposure from the benefits of coping skills training. In any event, cue exposure treatment is a promising approach that deserves further study to determine if either component alone is sufficient or if a combination of the two is more effective.
Cognitive restructuring —An approach to psychotherapy that focuses on helping patients examine distorted patterns of perceiving and thinking in order to change their emotional responses to people and situations.
Cue —Any behavior or event in a person’s environment that serves to stimulate a particular response. For example, the smell of liquor may be a cue for some people to pour themselves a drink.
Desensitization —The reduction or elimination of an overly intense reaction to a cue by controlled repeated exposures to the cue.
Extinction —The elimination or removal of a person’s reaction to a cue as a result of exposure treatment.
Flooding —A type of exposure treatment in which patients are exposed to anxiety-provoking or feared situations all at once and kept in it until the anxiety and fear subside.
Habituation —The reduction of a person’s emotional or behavioral reaction to a cue by repeated or prolonged exposure.
Hierarchy —In exposure therapy, a list of feared items or situations, ranked from least fearsome to most fearsome.
In vivo —A Latin phrase that means “in life.” In modeling and exposure therapies, it refers to practicing new behaviors in a real setting, as distinct from using imagery or imagined settings.
Interoceptive —Referring to stimuli or sensations that arise inside the body. In interoceptive exposure treatment, patients are asked to exercise or perform other actions that produce feared internal physical sensations.
Modality —The medical term for a method of treatment.
Subjective units of distress (SUDS) scale —A scale used by patients during exposure treatment to rate their levels of fear and anxiety with numbers from zero to 100.
Virtual reality —A realistic simulation of an environment, produced by a computer system using interactive hardware and software.
Progress in exposure therapy is often slow in the beginning, and occasional setbacks are to be expected. As patients gain experience with various anxiety-producing situations, their rates of progress may increase. While flooding can produce positive results more quickly than graded exposure, it is rarely used because of the high level of discomfort associated with it.
See alsoAgoraphobia; Alcohol and related disorders; Anxiety and anxiety disorders; Anxiety-reduction techniques; Cognitive-behavioral therapy; Obsessive-compulsive disorder; Panic disorder; Panic disorder with agoraphobia; Panic disorder without agoraphobia; Phobias; Systematic desensitization.
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Joneis Thomas, PhD
Ruth A. Wienclaw, PhD