Exposure Therapy for Anxiety-Related Disorders
Authors: Kirstyn L. Krause and Martin M. Antony Department of Psychology, Ryerson University
Exposure therapy is a behavioral treatment that involves gradually approaching a feared situation in a controlled and systematic manner. Exposure therapy is used to treat anxiety disorders, obsessive-compulsive and related-disorders, posttraumatic stress disorder, as well as other anxiety-related problems (Abramowitz, Deacon, & Whiteside, 2011; Nathan & Gorman, 2015).
Anxiety-related disorders are characterized by:
Excessive anxiety, fear, and distress that is out of proportion to the harm posed by the situation
Avoidance of feared situations
Inaccurate predictions about what might happen in a feared situation (e.g., predicting an inflated probability of harm, or an inability to cope with distress)
Exposure therapy provides an opportunity to experience something new in a feared situation that is incompatible with the usual excessive anxiety, avoidance behaviors, and inaccurate predictions that maintain anxiety-related problems (Craske et al., 2008; Foa et al., 2008). For example, exposure therapy may demonstrate that being in the feared situation is not as bad as expected, that anxiety comes down over time, or that the elevated distress is more manageable than expected.
Exposure therapy can take a number of forms:
In vivo exposure involves conducting exposures in real life (e.g., engaging in conversation with someone at a party to overcome a fear of interacting with others)
Virtual reality exposure involves exposure to virtual environments representing feared situations, especially ones that are difficult to recreate in real life (e.g., flying, thunderstorms)
Imaginal exposure involves exposure to feared mental experiences, such as thoughts, urges, and memories (e.g., bringing to mind the image of a past trauma)
Interoceptive exposure involves exposure to feared physical sensations (e.g., spinning to induce dizziness), and is often used to treat panic disorder
Many therapists have reservations about using exposure therapy due to concerns that the anxiety triggered by practices may cause unnecessary harm, exacerbate levels of distress, or lead clients to drop out of therapy (Deacon et al., 2013). However, widespread evidence demonstrates that exposure therapy is effective, and exposure is frequently recommended for treating anxiety-related problems (Katzman et al., 2014; Society of Clinical Psychology, 2016).
The following guidelines can help therapists conduct effective exposure therapy:
Exposures should be planned and predictable
It contrast to unintentional exposures that occur in the client’s everyday life, exposure therapy requires planning and structure. Before beginning exposure, allow clients to chose their exposure practices, identify what they are most afraid will happen, and decide how long the exposure will last. Exposure practices should last long enough for the client to learn something new about the feared situation (e.g., that the fear decreases; that the feared prediction doesn’t come true; Craske et al., 2014).
Exposures should evoke fear
It is important to select exposure practices that evoke fear, as this creates the opportunity to learn something new about the feared situation that is incompatible with the client’s usual pattern of avoidance. There is no need to suggest practices that are likely to be overwhelming. Pushing clients to take steps too quickly may lead to unnecessary distress or dropout from therapy. On the other hand, practicing more difficult exercises will likely lead to quicker improvements. The more anxiety-provoking the exposure exercise, the more opportunity the client has to learn that the feared consequences don’t occur (Craske et al., 2014). Creating an exposure hierarchy with exercises of varying intensities can be helpful for determining which exercise to choose first. Rather than starting at the bottom of the hierarchy, encourage clients to select the most difficult exposure exercise they are willing to attempt, and to try more difficult exercises as soon as they are ready.
Exposure should be practiced frequently. Clients should be encouraged to practice daily or almost daily. The more frequent the practices, the more likely they are to build on one another and lead to greater improvement.
Do not use subtle avoidance strategies during exposure practices. Encourage clients to eliminate subtle avoidance or safety behaviors (e.g., distraction, leaving early, alcohol use) during exposure practices. Clients may inaccurately attribute their ability to cope in the exposure to the use of these strategies, thereby preventing new learning.
Exposures can be combined or practiced in a variety of contexts
Once an individual becomes more comfortable practicing exposures, it can be beneficial to begin combining multiple anxiety-provoking elements from the exposure hierarchy into one exposure (e.g., a client with claustrophobia might wear a thick scarf while sitting in a small windowless room). It is also helpful for individuals to practice exposures in a variety of contexts to enhance generalization of learning (e.g., in the therapy session, at home, or in public).
Track progress and consolidate learning
Before, during, and after and exposure exercise, it can be helpful to track one’s experience. Ask clients to rate their subjective fear level and the extent to which they believe their prediction will come true, both on a scale from 0 to 100. Reflecting on these ratings and tracking change over time can provide an important learning opportunity. Rating one’s predicted fear of the items on the exposure hierarchy at each session can provide an additional measure of fear (Katerelos, Hawley, Antony, & McCabe, 2008).
Measure success by behavior, not emotion
The end of an exposure practice may or may not be accompanied by a reduction in fear level. New learning (i.e., recognizing that the feared outcome did not come true) can occur even if fear does not decrease (Craske et al., 2008).
Abramowitz, J.S., Deacon, B.J., & Whiteside, S.P.H. (2011). Exposure therapy for anxiety: Principles and practice. New York, NY: Guilford Press.
Antony, M.M., & Swinson, R.P. (2000). Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association.
Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5-27.
Craske, M.G., Treanor, M., Conway, C.C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.
Deacon, B.J., Farrell, N.R., Kemp, J.J., Dixon, L.J., Sy, J.T., Zhang, A.R., & McGrath, P.B. (2013). Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs About Exposure Scale. Journal of Anxiety Disorders, 27, 772-780.
Foa, E.B., Huppert, J.D., & Cahill, S.P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3-24). New York, NY: Guilford Press.
Katerelos, M., Hawley, L., Antony, M.M., & McCabe, R.E. (2008). The exposure hierarchy as a measure of progress and efficacy in the treatment of social anxiety disorder. Behavior Modification, 32, 504-518.
Katzman, M.A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., Van Ameringen, M., & the Canadian Anxiety Guidelines Initiative Group (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14 (Suppl 1), 1-83.
Nathan, P.E., & Gorman, J.M. (2015). A guide to treatments that work, 4th ed. New York, NY: Oxford University Press.
Society of Clinical Psychology (2016). Psychological treatments. Retrieved from http://www.div12.org/treatments/