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Therapy

3 Myths About Exposure Therapy

Myths about exposure therapy may be keeping people from a treatment that works.

Key points

  • Exposure therapy is a type of Cognitive Behavioral Therapy (CBT) and is the gold-standard behavioral treatment for anxiety disorders.
  • Exposure therapy generates anxiety in the short term but reduces suffering in the long run.
  • People with severe symptoms may actually benefit from more intensive exposure therapy, such as intensive residential treatment for OCD.

Sara Brown, BS, contributed to this post. Sara is a member of the Cognition and Affect Research and Education (CARE) Lab at McLean Hospital and is currently a Patient Experience Representative.

Exposure therapy is the gold-standard behavioral treatment for anxiety disorders. Exposure therapy is part of Cognitive Behavioral Therapy (CBT) and typically involves someone repeatedly facing their fears with the goal of (1) breaking the avoidance cycle that keeps them anxious and unable to live their life fully, (2) learning that their feared outcomes usually don’t happen and/or are not nearly as catastrophic as they believed, and (3) learning that they can cope with feeling anxious.

Achieving these goals allows people to take their lives back from the grips of anxiety. Exposure is among the tried-and-true psychological interventions, having been found effective in hundreds of randomized controlled trials (see Craske et al., 2014). Specifically, exposure therapy is effective in treating generalized anxiety disorder, panic disorder and agoraphobia, specific phobias, social anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, hypochondriasis, and body dysmorphic disorder (Olatunji et al., 2009).

There are many ways to deliver exposure therapy, and it can be done flexibly depending on the person’s needs and preferences. For example, you can approach feared situations gradually in a systematic manner over several months or you can jump in the deep end of the pool all at once and treat some fears over a weekend. People can approach their fears through their imagination, virtual reality, and in real life. Exposure therapists are very creative and can help people design exposures to anything—certain thoughts, physical sensations, memories, or actual situations.

As an exposure therapist myself, I have had the privilege of witnessing people bravely do things that they never thought they could do—whether it be driving over a bridge, giving a speech, or being in a crowd—there is nothing better than seeing someone liberate themselves from fear. I remember how wonderful it felt to help one of my clients use a public restroom for the first time in 25 years! And another client who drove from Rhode Island to Boston for the first time. Simply put, exposure therapy helps people regain control of their life and in some cases, save it.

Yet many people, including clinicians, are still hesitant to try exposure therapy. Negative attitudes toward exposure therapy have been found to inversely correlate with knowledge about the treatment (Becker et al., 2004). In other words, unfamiliarity and misinformation seem to explain some peoples’ hesitancy toward exposure, rather than the treatment itself. The good news is that the more information and training a therapist receives about exposure, the more comfortable they feel implementing it as a treatment for their clients (Harned et al., 2013).

Below, we address three myths about exposure therapy.

Myth #1: Exposure therapy is unethical and harmful.

  • When people seek treatment for anxiety, they are already feeling anxious despite all their efforts to avoid feeling anxious. Most people intuitively understand that the only way to get over a fear is to ultimately face it. In fact, helping someone face their fears is helpful and ethical.
  • Some people misunderstand exposure as unethical or punishing because of the incorrect idea that it forces people into distressing or dangerous situations (Farrell et al., 2013). In reality, a therapist would NEVER force someone to do something. Exposure is only helpful when the person chooses to do it. This choice can be really empowering. Moreover, I was taught that a therapist never asks someone to do something that they themselves would not do. Therapists typically do an exposure with a client together before the client practices on their own.
  • When it comes to PTSD, some people understandably believe that asking someone to relive their scariest and worst experience is cruel. But with a well-trained therapist and proper preparation, exposure for traumatic memories is effective, albeit very difficult. However, imaginal exposure to the trauma is not the only way to treat PTSD. Other types of CBT, such as Cognitive Processing Therapy (CPT) involve processing the trauma without repeatedly reliving it through imaginal exposure. Finally, exposure therapy can also be incredibly helpful to people who are avoiding all sorts of situations in their life because it reminds them of the trauma.

Myth #2: Exposure doesn’t work because it makes people more anxious.

  • In the short term, exposure therapy generates anxiety because people approach situations that make them anxious. But this willingness to experience short-term anxiety reduces suffering in the long run.
  • Studies have shown that when people experience anxiety in a controlled and safe environment, they are able to learn to tolerate the experience (Foa et al., 2013).
  • What this means is that each time a person practices coping with that anxiety, they may reduce the amount of anxiety they will feel next time. More importantly, they gain confidence that they can handle it, whatever happens.
  • Exposure therapy targets the emotions and behaviors which prevent people from experiencing long-term relief, such as avoidance and catastrophizing, so that people can break out of their avoidance trap and start living their life.

Myth #3: People with severe anxiety symptoms can’t handle exposure therapy.

  • This is false; exposure can benefit people with mild to severe symptoms with little risk of adverse side effects (Hendriks et al., 2010, Foa et al., 2013, Olatunji et al., 2009, Trivasse et al., 2020)
  • People with very severe symptoms may actually benefit from MORE intensive exposure therapy, such as in intensive outpatient or residential treatment for OCD.
  • People who struggle with substance use, self-injury or suicidal ideation, or dissociation may want to work on developing other coping skills prior to conducting exposures. For example, combining Dialectical Behavioral Therapy (DBT) with Prolonged Exposure (PE) is acceptable and more effective than DBT alone for people with PTSD and suicidal behaviors (Harned et al., 2014).

The Take-Home Points

Exposure therapy is very effective for all types of anxiety disorders. Of course, like any available treatment, exposure therapy won’t work for everyone. Also, depending on where you live and your insurance, it can be difficult to find an expert therapist. But given the hundreds of studies showing it is more helpful than control or placebo treatments, most people with anxiety disorders should seek this proven treatment.

I lead an exposure therapy group, and I’ll end this post the same way we end each group:

“Courage is not the absence of fear, but rather it is the judgment that something else is more important than fear” (James Neil Hollingworth PSEUDONYM AMBROSE REDMOON)

To find a therapist for exposure therapy, visit the Psychology Today Therapy Directory.

LinkedIn image: Prostock-studio/Shutterstock

References

Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3), 277–292. https://doi.org/10.1016/S0005-7967(03)00138-4

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006

Farrell, N. R., Deacon, B. J., Dixon, L. J., & Lickel, J. J. (2013). Theory-based training strategies for modifying practitioner concerns about exposure therapy. Journal of Anxiety Disorders, 27(8), 781–787. https://doi.org/10.1016/j.janxdis.2013.09.003

Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD. Psychological Science in the Public Interest, 14(2), 65–111. https://doi.org/10.1177/1529100612468841

Harned, M. S., Dimeff, L. A., Woodcock, E. A., & Contreras, I. (2013). Predicting adoption of exposure therapy in a randomized controlled dissemination trial. Journal of Anxiety Disorders, 27(8), 754–762. https://doi.org/10.1016/j.janxdis.2013.02.006

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7-17.

Hendriks, L., de Kleine, R., van Rees, M., Bult, C., & van Minnen, A. (2010). Feasibility of brief intensive exposure therapy for PTSD patients with childhood sexual abuse: A brief clinical report. European Journal of Psychotraumatology, 1(1), 5626. https://doi.org/10.3402/ejpt.v1i0.5626

Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S. (2009). The Cruelest Cure? Ethical Issues in the Implementation of Exposure-Based Treatments. Cognitive and Behavioral Practice, 16(2), 172–180. https://doi.org/10.1016/j.cbpra.2008.07.003

Trivasse, H., Webb, T. L., & Waller, G. (2020). A meta-analysis of the effects of training clinicians in exposure therapy on knowledge, attitudes, intentions, and behavior. Clinical Psychology Review, 80, 101887. https://doi.org/10.1016/j.cpr.2020.101887

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