All Therapy Is Exposure Therapy

One process may underlie many effective therapy approaches.

Posted Dec 18, 2020

Therapy works, but the debate persists about its active ingredients. Research has shown that “specific processes”—those attached to a certain theory or school (like dream interpretation in psychoanalysis) tend to matter less than “nonspecific processes” like therapist-client rapport and the client’s positive expectations.

Yet actual therapy time is mostly spent on specific processes—psychoanalysts interpret dreams, CBT practitioners examine distorted thought habits, Humanist therapists reflect, and behaviorists tweak reinforcement schedules—all of which appear to often work equally well, a phenomenon known as the Dodo bird verdict.

This raises the possibility that all of these different techniques are in fact doing the same thing. Perhaps nonspecific factors predict success mostly by facilitating, through myriad techniques, an underlying healing process. But what might this process be? A strong case can be made that the answer is exposure.

The exposure process is deployed most clearly in the course of exposure therapy. The origins of exposure therapy date back to Russian scientist Ivan Pavlov, who, in the early 1900s, mapped out the principles of classical conditioning—learning by association—by which, when paired repeatedly with an aversive stimulus, a neutral stimulus will elicit aversive reactions.

Pavlov’s work was popularized in the U.S. by John B. Watson, who in 1919 famously conditioned a 9-month-old baby (AKA Little Albert) to fear a white rat by pairing the rat’s approach with a noxious sound. In 1923, psychologist Mary Cover Jones treated Peter, a three-year-old boy terrified of a white rabbit, with “direct conditioning,” in which she paired a pleasant stimulus (food) with the rabbit, extinguishing the boy’s fear. Following in Cover Jones’s footsteps, South African Psychiatrist Joseph Wolpe developed systematic desensitization in the 1950s, an approach for treating phobias that involved pairing relaxation with anxiety-provoking stimuli, presented gradually.

In the mid-1960s, British psychologist Victor Meyer decided to apply to humans a "flooding" intervention he’d seen work with frightened animals: Exposed continuously to a fearful object while prevented from escaping, the animals exhibited reduced fear. He tried this approach with two hospitalized OCD patients, exposing them to objects that triggered their anxiety while preventing them from carrying out compulsive rituals. The treatment proved successful enough to spark interest. Before long, others like Canadian psychologist Stanley Ranchman and Israeli-born Edna Foa were treating OCD outpatients, along the way finding that exposure to the feared stimulus was the active ingredient in Wolpe’s system. By the 1980s, exposure therapy was being applied with success to a host of psychological disorders, including phobias, panic disorder, and PTSD. Today, it is considered the first-line treatment for anxiety disorders.

How does exposure work? Initial models of exposure therapy centered on the phenomenon of habituation, by which nervous system activation is reduced after prolonged exposure to a stimulus. In exposure therapy, habituation is evident when the client’s aversive response to a noxious stimulus diminishes following repeated presentations of the stimulus.

In the 1980s, as the limitations of applying a habituation model derived from animals to humans were becoming clearer, psychologists were moved to elaborate on this basic process. The pioneering Edna Foa advanced an emotional processing theory of exposure, arguing that the effects of exposure therapy “derive from activation of a ‘fear structure’ and integration of information that is incompatible with it, resulting in the development of a non-fear structure that replaces or competes with the original one.”

Once the fear structure is activated through exposure, corrective learning takes place as information that is incompatible with the structure is integrated. Foa argued that such incompatible information derives from two primary sources—within-session habituation, in which fear declines during an exposure session, and between-session habituation, in which the fear declines over repeated sessions.

Foa’s model has over time come under criticism, as her hypotheses about the process of change failed to receive consistent support. For example, research showed that habituation is neither necessary nor sufficient for long-term symptom reduction.

A more recent, alternative formulation, based in part on the work of University of Vermont professor Mark Bouton, UCLA's Michelle Craske, and others, has sidestepped habituation to argue for an Inhibitory Learning model, according to which exposure does not eliminate old fear learning but rather introduces a new, more powerful competitor to inhibit it. In this view, exposure therapy “leads to the learning of new non-threat (i.e., inhibitory) associations that compete with (rather than “break”) older threat associations.”

The new associations are learned through “expectancy violations,” by which clients experience a discrepancy between their fearful predictions and their actual experience. “When an individual expects a negative outcome in response to a fear trigger, and these expectancies are violated during exposure…a non-threat association is established.”

In addition, exposure may also exert its effects by allowing for the acquisition and application of coping skills. Most successful coping in life involves a measure of skilled performance; you cannot learn a skill by avoiding it. Exposure lets you enter and remain in a previously avoided territory long enough to learn how to handle it better and become familiar with it, and with yourself in it. Skill begets success.

Further, exposure, while involving short-term discomfort, may facilitate a sense of psychological empowerment and increased self-efficacy. While escape and avoidance of feared situations may reduce anxiety in the short term, they tend to beget a sense of defeat (“I couldn’t handle my anxiety and had to leave”) and a loss of self-confidence. Exposure produces experiences of competence and resilience (“I felt scared, but I persisted, and I’m ok"), which are empowering and motivating, and instill further confidence (“I can handle this”).

As the efficacy of the exposure process, delivered through exposure therapy, was becoming clear, psychologists began wondering whether other approaches in fact utilize the same process, albeit indirectly. For example, neuroses in the Freudian system constitute attempts to avoid disturbing experiences, which psychoanalysis is designed to bring to awareness (i.e., confront). As personality theorists Neal Dollard and John Miller noted, “The therapeutic situation which Freud hit arranged so that anxiety can be steadily weakened by extinction.” Processing emotions in the psychoanalytic tradition is to a large degree de facto exposure.

Gestalt theory holds that people often try to disown unacceptable thoughts and feelings, thereby disowning valuable parts of themselves. Gestalt therapists use "experiments" to bring the client into here-and-now contact with their experience so they may reintegrate these parts into the self and resolve unfinished businessPerls described psychotherapy as "a process of experimental life-situations that are venturesome as explorations of the dark and disconnected, yet are at the same time safe, so that the deliberate attitude may be relaxed.” Gestalt therapy is de facto exposure.

More contemporary therapy approaches follow the same tack. Mindfulness work, for example, involves nonjudgmental careful observing of difficult internal states, such as anxiety. Mindful meditation "resembles an exposure situation because [mindfulness] practitioners 'turn towards their emotional experience,' bring acceptance to bodily and affective responses, and refrain from engaging in internal reactivity towards it." Imaging studies of brain function have shown that the ventromedial prefrontal cortex hippocampus and the amygdala are involved in both mindfulness practice and exposure therapy.

Acceptance Commitment Therapy (ACT) is explicit in viewing experiential avoidance as the source of most psychopathology. ACT focuses on value-guided, committed action in the face of obstacles as it seeks to improve the client’s flexibility (adaptive coping) by letting them experience discomfort while taking meaningful action. In this way, ACT is de facto exposure.

Further support for the power of exposure comes from the literature on the benefits of confiding in others. As I described in a recent post, telling and writing out one’s secrets in a safe context are beneficial for mental health. A meta-analysis of this literature found that the positive effects of confiding are best explained by the exposure process. 

In sum, much psychopathology involves an attempt to avoid difficult thoughts and emotions. Therapy involves a guided attempt to overcome such experiential avoidance. The remedy for avoidance is exposure. It appears that most therapy conditions and therapy techniques that work do so in part by (unwittingly or indirectly) enacting the exposure process. To a non-trivial degree, all therapy is exposure therapy.