What is Exposure Therapy?

By Milam Freitag, Ph.D., Clinical Psychologist in San Francisco, CA

Exposure therapy is a technique in behavior therapy that I commonly use to treat anxiety disorders. It involves the exposure of the client to the feared (but in and of itself non-dangerous) object, thought, or context, in order to help them overcome their anxiety.  A related treatment I also utilize is Exposure and Response Prevention, a method widely used for the treatment of Obsessive–Compulsive Disorder (OCD).  Numerous studies have demonstrated the effectiveness of exposure work in the treatment of anxiety disorders such as Post-Traumatic Stress Disorder (PTSD), OCD and specific phobias.

Some examples of anxiety-related and avoidance behaviors that I’ve successfully used exposure therapy to treat:

• Using public transportation including subways, planes and buses
• Crowded and public places like movie theaters and restaurants
• Public speaking and performance situations
• Obsessive fears of contamination (body fluids, germs/disease such as herpes or HIV)
• Obsessive fears of hurting or harming others or losing control
• Unwanted sexual thoughts or images and fears of acting on them

I do such exposure work with clients in my office when possible and/or will even venture out of my office with them to do the work when that is indicated (for instance, if a client has been avoiding using elevators or the underground train due to fear or past panic attacks and would like to reclaim using elevators or trains again, we will eventually ride them together).

I let my new clients know and have them keep in mind that exposure exercises are done in a gradual way, moving toward a goal slowly, with an attitude of support and understanding. We start with a situation or object or thought that causes only minimal distress and stay with that until the client has little or no reaction to it (a process called desensitization).

For instance, with someone who has developed a phobic reaction to riding elevators, the first exposure step might be simply imagining getting on an elevator. Only after the client has desensitized to that target do we take on another target (usually in a subsequent meeting) that’s only slightly more difficult than the first one and stick with it until the distress evaporates. Next targets of desensitization for the elevator phobia might include standing in front of an elevator without stepping on, until the client is no longer distressed by that, followed by stepping quickly on and off the elevator repeatedly, and finally riding the elevator for increasingly longer amounts of time.  We work through this hierarchy of fearful targets over the course of a few or several therapy sessions. This process of moving slowly toward a goal in small steps that only take the client into minimal or moderate emotional and/or physical distress (backing off if greater levels of distress occur) is an important part of the recovery process and helps the client develop the courage and motivation to do the work of desensitization through exposure.

Clients gain a sense of progress and mastery as we go, and they see for themselves the benefits of doing the exposure work.  Catastrophic thoughts and bodily reactions that the trigger once provoked fall away and a sense of increasing freedom and even vitality takes their place–not by avoiding or trying to control these reactions, but rather by gradually facing and accepting them and through desensitization.

Exposure therapy works by helping clients break through habitual behavioral patterns of Experiential Avoidance (EA),  which is broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences—even when doing so creates harm in the long-run. The process of EA is thought to be maintained through negative reinforcement—that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the behavior will persist.  It is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings (and the associated avoidance, inhibition and self-judgment of these experiences) is thought to be linked to a wide range of problems (for example, PTSD involves avoiding trauma reminders, Social Phobia involves avoiding social situations).

It’s quite understandable how someone can begin to avoid what makes them uncomfortable, unknowingly developing an anxiety disorder that can then limit their life. With the elevator phobia example, the client has usually had a challenging spike of anxiety or panic on an elevator and/or during other confined situations.  They often have subsequently avoided using elevators for some time or when using elevators have tried to control their reactions or not have them. Such avoidance is in effect what builds and strengthens the fear-avoidance cycle, usually without the client realizing what is occurring, (and not yet knowing that the fearful reactions can be dismantled little by little and with an attitude of acceptance and self-empowerment).

Experiential “Anti-Avoidance” techniques such as exposure therapy can lead to a freer life and are an integral part of Acceptance and Commitment Therapy (ACT), a cutting-edge “third wave” Cognitive-Behavioral Approach that I integrate into my work. ACT also employs the acquisition of techniques involving mindfulness, acceptance and self-compassion, skills that become immediately helpful for clients as they confront, rather than avoid, what scares them.  When doing an exposure session with a client, for example having them stepping on an elevator for the first time (in some time), I guide them to simply observe with awareness what thoughts, sensations and feelings are occurring, non-judgmentally, with acceptance and an attitude of self-compassion and self-acknowledgement of their courage.  Clients find that these skills and attitudes are a helpful and preferable replacement of the cycle of avoidance and feelings of frustration and often shame that they have endured.

National Public Radio (NPR) recently started an excellent series called Invisibilia.  Their first program called “Dark Thoughts” highlights such exposure-based treatment. The story involves a man with OCD with “harming” obsessions who gains freedom with a combination of exposure-based Cognitive Behavioral Therapy (the 2nd historical wave of Psychotherapy) and Mindfulness and Acceptance strategies (the latest 3rd wave of Psychotherapy). It’s a good demonstration of how I help clients with OCD and various kinds of obsessional thinking, ruminations and worry.  Click here to hear this worthy and helpful Podcast.

About this Contributor: Milam Freitag, Ph.D., is a doctoral-level psychologist trained in both empirical research methods and clinical practice.  He has a private psychotherapy practice in San Francisco, specializing in the treatment of Anxiety and Phobias.  He blends science and art when connecting with clients, using the empirically validated methods of Cognitive-Behavioral Therapy, Mindfulness-Based Therapy and EMDR.  He writes: “I teach clients in effect to become their own therapist, practicing the techniques they learn outside of sessions as well. Such work is usually structured; short-term and problem-solving oriented, making room as well for open-ended exploration and reflection and movement beyond cognitive insight.” For more information about Milam’s work, please visit his website: Milam-Freitag.com.