Exposure treatment is a technique that is widely used in cognitive-behavioral therapy (CBT). 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 a patient with anxiety-producing material for a long enough time to decrease the intensity of their emotional reaction. As a result, the feared situation or thing no longer makes the patient 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. The category of imaginal exposure includes systematic desensitization , which asks the patient to imagine certain aspects of the feared object or situation combined with relaxation. Graded or graduated exposure refers to exposing the patient to the feared situation in a gradual manner. Flooding refers to exposing the patient to the anxiety-provoking or feared situation all at once and kept 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 the patient 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 a list or hierarchy of situations that make the patient 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, or SUDS. Patients may be asked to provide SUDS ratings at regular intervals during exposure treatment, for example every five minutes.
Methods of delivering exposure treatment
PATIENT-DIRECTED EXPOSURE. Patient-directed exposure is the simplest variation of exposure treatment. After the patient makes his or her hierarchy list with the therapist, he or she is instructed to move through the situations on the hierarchy at his or her own rate. The patient starts with the lowest anxiety situation on the list, and keeps a journal of his or her experiences. Patient-directed exposure is done on a daily basis until the patient's fears and anxiety have decreased. For example, if a patient is 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 the patient is able to perform this action without feeling anxious, he or she 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 patient has completed all the items on the hierarchy. During therapy sessions, the therapist reviews the patient's journal; gives the patient positive feedback for any progress that he or she has made; and discusses any obstacles that the patient encountered during exposures to the feared situation.
THERAPIST-ASSISTED EXPOSURE. In this form of exposure treatment, the therapist goes with the patient to the feared location or situation and provides on-the-spot coaching to help the patient manage his or her anxiety. The therapist may challenge the patient to experience the maximum amount of anxiety. In prolonged in vivo exposure, the therapist and patient 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 therapist also explores the patient's thoughts during this exposure so that any irrational ways of thinking can be confronted.
GROUP EXPOSURE. 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
AGORAPHOBIA. 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 done in vivo, in the actual feared situation, for example 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.
PANIC DISORDER. Exposure treatment is the central component of cognitive-behavioral treatment for panic disorder . Treatment for this disorder involves identifying specific fears within the patient's experience of panic, such as fears of being sick, fears of losing control, and fears of embarrassment. Once these fears are identified, the patient is instructed to expose himself or herself to situations in which the fearful thoughts arise (walking away from a safe person or place, for example). The rationale behind this instruction is that enduring the anxiety associated with the situation will accustom the patient to the situation itself, so that over time the anxiety will diminish or disappear. In this way, the patient discovers 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 a panic attack . This technique is called interoceptive exposure. The patient is asked to induce the feared sensations in a number of ways. For example, the patient may spin in a revolving chair to induce dizziness or run up the stairs to induce increased heart rate and shortness of breath. The patient is then instructed to notice what the symptoms feel like, and allow them to remain without doing anything to control them. With repeated exposure, the patient learns that the bodily sensations do not signal harm or danger, and therefore need not be feared. The patient is 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 the therapist's office. The patient may be instructed to practice at home and then practice in a less "safe" environment, such as the patient's 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. The patient would be instructed to go back into a situation that he or she has been avoiding, such as an elevator or busy railroad terminal. If the patient develops symptoms of anxiety, he or she is 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 phobia or simple phobia. In graded exposure, the patient approaches the feared object or situation by degrees. For example, someone afraid of swimming in the ocean might begin with looking at photographs of the ocean, then watch movies of people swimming, then go to the beach and walk along the water's edge, and then work 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 the 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 the patient has 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 the patient needs.
OBSESSIVE-COMPULSIVE DISORDER. The most common non-medication 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 OCD in children and adolescents.
Prolonged continuous exposure is better than short, interrupted periods of exposure in treating OCD. On average, exposure treatment of 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 suffering from 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 include in vivo exposure, such as fears of a loved one's death. Patients usually prefer gradual exposure to the most distressing situation 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. Such intrusive symptoms of PTSD as nightmares and flashbacks may be reduced by having the patient 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 persons who have undergone sexual assault or rape meet DSM-IV-TR criteria for PTSD. They may re-experience 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 patient's verbal description of the traumatic event, along with the expression of thoughts and feelings related to it, occur as early in the treatment process as possible. It is in the patient's "best long-term interest to experience more discomfort temporarily in order to suffer less in the long run."
Prolonged exposure is the most effective non-medical 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 behavior and decrease fears. Prolonged exposure may occur over nine to 12 ninety-minute sessions. During the imaginal exposure phase of treatment, the patient is asked to describe the details of the traumatic experience repeatedly, in the present tense. The patient uses the SUDS scale to monitor levels of fear and anxiety. The in vivo component occurs outside the therapist's office; it involves the client exposing himself or herself to cues in the environment that he or she has been avoiding— for example, the place where the motor vehicle accident or rape occurred. The patient is 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 patient experiences less anxiety.
Recent innovations in exposure treatment
VIRTUAL REALITY EXPOSURE TREATMENT. Virtual reality is a technique that allows a person to participate actively in a computer-generated (or virtual) scenario or environment. The participant has the 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 would protect patients from harm or social embarrassment during their practice sessions. Third, it could 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 recreate real-life situations in a safe therapeutic environment 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.
Persons diagnosed with alcohol dependence face a number of alcohol-related cues in their environment, 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 a person who practices coping skills in the presence of cues will find the coping skills strengthened, along with the conviction that he or she 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 a patient may learn to cope successfully with one cue (such as 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. The patient 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 the therapist's help.
More specifically, cue exposure focuses on the aspect of alcohol consumption that produces the strongest urge. The patient would report each change in their level of urgency, using a scale of zero to ten that resembles the SUDS scale. The urge to drink usually peaks after one to five minutes. When the desire for a drink arises, the patient is 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 patient expected. In later sessions, the patient is instructed when the urge peaks to imagine using the coping skills that he or she was recently taught. The patient 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 due to exposure from the benefits due to 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.
Progress in exposure therapy is often slow in the beginning, and occasional setbacks are to be expected. As the patient gains experience with various anxiety-producing situations, his or her rate 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 also Agoraphobia ; Alcohol and related disorders ; Anxiety and anxiety disorders ; ; Cognitive-behavioral therapy ; Obsessive-compulsive disorder ; Panic attack ; Panic disorder ; Systematic desensitization
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Joneis Thomas, Ph.D.