Introduction to Exposure Therapy

Author: Katie Leoni, Psy.D.

Exposure therapy is an evidence-based treatment used by the clinicians at SF Bay CBT to help our clients struggling with anxiety. Avoidance is a strong component of anxiety and it is common for people to avoid something that makes them anxious or fearful. In exposure therapy, clients are asked to directly confront the anxiety and avoidance. The idea is that the more you expose yourself to whatever it is that is making you anxious (i.e., social situations, taking BART, public speaking) the more opportunities you have to modify your automatic thoughts and beliefs and create a more balanced and rational mindset. If this sounds nerve-wrecking to you, you’re not alone! It is natural to feel nervous and worried about confronting your anxiety triggers. A saying often used in exposure therapy is “short term pain for long term gain” which acknowledges the willingness to tolerate discomfort in the moment in order to overcome and effectively manage your anxiety in the long term.
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Rationale for Exposure Therapy
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Physiological changes happen in the body in response to danger. The fight or flight response is our body’s way of reacting to life-threatening situations and taking immediate action to keep us safe. Your amygdala is activated and you either stay and fight the threat or flee. This response sends signals to our bodies in order to help shut down unuseful systems and activate survival systems. However, our brain doesn’t always do the best job of distinguishing between actual and perceived danger. Because of this, fear (actual danger) and anxiety (perceived danger) produce extremely similar responses in the body.

For example, if a tiger were to come into the room that you were in (actual danger), your fight or flight response would be activated. You’d notice an increase in your heart-rate, your blood pressure would go up, your mind would go blank, and you’d become hyper-alert. This would be an adaptive response because you have to act quickly to the life-threatening danger in the room. The signals that your body is giving you physically would cue you to move out of the way, or avoid, in order to keep yourself safe. It’s based on survival. Now, imagine you are extremely anxious about public speaking. Public speaking is uncomfortable for many but is not a life-threatening situation. However, people’s bodies can react in ways that make it seem this way and thus, become anxiety provoking for that person. When you stand up in front of a room full of people, your body will react as if a tiger just came into the room and in order to prevent this response from happening, you do everything in your power to avoid public speaking. When you avoid or escape the trigger, the physical symptoms decrease, and you feel relieved. But you also teach your mind and body that those physical symptoms really were a sign of danger, and you strengthen the association between public speaking and that uncomfortable physical response. Avoiding only reinforces the idea that public speaking is dangerous and your ability to cope with it is low.

In exposure therapy, we work on educating clients about this response and help to retrain the mind and body when faced with perceived dangerous situations. Chances are you’ve been anxious about this thing/situation for some time and thus, it takes time to retrain your brain and central nervous system to differentiate between fear and anxiety and to respond accordingly to the threat that is present. In order to do this, a person must activate the fight or flight response, which is done by exposing oneself to the perceived danger/anxiety provoking situation.

​What Does Exposure Therapy Look Like?

There are several different types of exposures that exist and ways in which they can be practiced in therapy. Usually it is a gradual build-up (called a hierarchy) to the situation that makes you anxious. For instance, if you have a phobia of spiders, being asked to hold a spider would not be the first step. To start, you may be asked to think of spiders or look at pictures of spiders. This still activates the fight or flight response but in a way that allows learning to take place so that you are prepared to work through your hierarchy. The key in exposure therapy is to confront the avoidance and test out beliefs about perceived dangerous situations that may be distorted.
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Types of exposures often used:

• Imaginal exposure: This is when a person is asked to imagine the feared situation in great detail. If you have a fear of flying, you might be asked to imagine being at the airport, getting onto a plane, buckling your seatbelt etc.
• In-vivo exposure: This is when a person is asked to confront the feared situation in real life. If you have a fear of flying, you might walk around the airport, sit and watch the planes take off etc.

You might have to do things in session or exposures outside of sessions on your own. It depends on what your specific anxieties are. You and your therapist will collaboratively identify useful exposures for you based on your needs. Another important component of exposure therapy is learning relaxation techniques and other coping skills to help you before, during, and after exposures. Again, your therapist will work with you to teach you these helpful tools. If you’d like to learn more about exposure therapy and how it can help you, please contact us for a free phone consultation.

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