Exposure Therapy

Exposure therapy is a form of cognitive-behavioral therapy that encourages the systematic confrontation of feared stimuli, which can be external (a spider-phobic patient handling a spider) or internal (a patient with panic disorder experiencing heart palpitations that elicit anxious reactions). The primary goal of exposure therapy is to reduce a person’s fear or anxious reactions to particular stimuli. This is done through gradually desensitizing the individual to the stimulus over time. Particularly useful in the treatment of anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, and phobias, exposure therapy has demonstrated efficacy as a safe and powerful method. Because exposing a client to their fears or prior trauma without first teaching them appropriate coping techniques can result in re-traumatization, exposure therapy is typically conducted within a psychotherapeutic relationship with a therapist who has been trained and is experienced with the technique.

There are several approaches a therapist may take when implementing exposure therapy as a treatment regimen. While most therapists and patients choose a graded approach to exposure therapy, which hierarchically targets mildly feared stimuli first, followed by more strongly feared stimuli, others opt for a flooding approach. Flooding entails exposing a patient to their most feared stimuli from the beginning of treatment.⁴ Further, in circumstances that in vivo exposure, or real-world confrontation of feared stimuli, is not feasible, imaginal exposure may be used. Imaginal exposure includes vivid imagination and description of the external and internal cues related to the feared stimulus.⁴

Substantial research indicates that exposure therapy is arguably the most effective treatment method for specific phobias and is associated with lifelong results.¹⁰ For example, one study found that single-session in vivo exposure for patients with specific phobias was associated a significant reduction in fear, avoidant tendencies, and overall level of impairment at follow-up, with many patients being completely recovered from their phobia.⁸ Some evidence further suggests that the efficacy of exposure is superior to that of certain medications used to treat phobias such as phenelzine.¹² Prolonged exposure, which is characterized by re-exposure to one’s phobic object without avoidance, is one strategy of exposure therapy that has been deemed efficacious, particularly when it is used with in-vivo exposure.¹³

In recent years, however, imaginal exposure for treating phobias has also been supported, with virtual reality exposure therapy used as an alternative means of this exposure.⁴ In virtual reality exposure therapy, patients are immersed in a virtual world that allows them to confront their fears. Data indicate that virtual reality may be an effective tool in exposure therapy, with the method associated with significant improvements in the treatment of arachnophobia (fear of spiders)⁵ along with acrophobia (fear of heights), aviophobia (fear of flying), claustrophobia (fear of confined places), and fear of driving, as demonstrated in one meta-analysis.³

Available evidence suggests that exposure-based therapy should be considered as a first-line treatment for a variety of anxiety disorders. It has been proposed that, in individuals with anxiety disorders, a fundamental aspect of anxiety-provoking situations is that individuals perceive these situations to be out of their control. One of the critical cognitive changes that occurs in exposure therapy is disconfirming this low sense of perceived control.⁶ For example, exposure therapy is as effective to cognitive therapy in the treatment of panic disorder and other anxiety-related disorders.⁹

Similarly, cognitive-behavioral therapy using exposure therapy has been shown to be more effective for maintaining treatment gains than imipramine and more effective than a combined-treatment of CBT and imipramine in patients with panic disorder.² Some studies may that cognitive therapy and exposure therapy alone, in combination, or combined with relaxation training, are efficacious across anxiety disorders, with superior outcomes for generalized anxiety disorder and posttraumatic stress disorder than for social anxiety disorder⁷, although one study did find that virtual reality exposure therapy or group exposure therapy was effective in treating social fears.¹ On a related note, similar to its efficacy in treating specific phobias, meta-analyses indicate that overall, virtual reality exposure therapy has shown to be as equally efficacious as in vivo exposure therapy in the treatment of anxiety disorders.¹¹

At this point in time, exposure therapy is often not considered for the treatment of various anxiety disorders, or is considered after other forms of psychotherapy and/or psychopharmacology. Considering the evidence, although exposure therapy is already a first-line treatment for specific phobias, the amount of evidence regarding exposure therapy as efficacious in the treatment of anxiety disorders suggests that it may be useful to expand its use further into this area.

1. Anderson, P., Price, M., Edwards, S., Obasaju, M., Schmertz, S., Zimand, E., . . . Nezu, Arthur M. (2013). Virtual Reality Exposure Therapy for Social Anxiety Disorder: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, 81(5), 751-760.

2. Barlow, D. H., Gorman, J. M., Shear, M. K., Woods, S. W. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA.

3. Côté, S. & Bouchard, S. (2008). Virtual reality exposure for phobias: A critical review. Journal of CyberTherapy & Rehabilitation, 1(1), 75-91.

4. Kaplan, J. S. & Tolin, D. F. (2011). Exposure Therapy for Anxiety Disorders. Psychiatric Times, 28(9).

5. Michalizsyn, D., Marchand, A., Bouchard, S., Martel, M. O., & Poirier-Bisson, J. (2010). A randomized controlled clinicaltrial of in virtuo and in vivo exposure for spider phobia. Cyberpsychology, Behavior, and Social Networking, 13(6), 689-695.

6. Mineka, S., & Thomas, C. (1999). Mechanisms of change in exposure therapy for anxiety disorders. In T. Dalgleish & M. J. Power (Eds.), Handbook of cognition and emotion (pp. 747-764). New York, NY, US: John Wiley & Sons Ltd.

7. Norton, P. J. & Price, E. C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. The Journal Of Nervous and Mental Disease, 195(6), 521-31.

8. Ost, L. G. (1989). One-session treatment for specific phobias. Behavioral research and therapy, 27(1), 1-7.

9. Ougrin, D. (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry, 11, 200.

10. Popescu, B. (2013). Exposure Therapy for Phobias. Europe’s Journal of Psychology, 9(2), 406-408.

11. Powers, M. B. & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: A meta-analysis. Journal of Anxiety Disorders. 22(3), 561-569.

12. Solyom, C., Solyom, L., LaPierre, Y., Pecknold, J., & Morton, L. (1981). Phenelzine and exposure in the treatment of phobias. Biological Psychiatry, 16(3), 239-247.

13. Watson, J. P., Mullett, G. E., & Pillay, H. (1973). The effects of prolonged exposure to phobic situations upon agoraphobic patients treated in groups. Behaviour Research and Therapy. 11(4), 531-545.

by Callie Patterson

Callie Patterson is a graduate student pursuing a degree in psychological sciences at Northern Arizona University.

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