Exposure Therapy: How It Works & What to Expect

What Is Exposure Therapy?

Exposure therapy places the client in situations with the source of their distress. It illustrates the idea that exposure, not avoidance, is the path to decreased anxiety symptoms and increased comfort in a variety of situations and experiences. Meaningful progress is often reported after one extended session of three hours or three one-hour sessions.¹

Through exposure therapy, people learn that:²

• Fear and stress can be tolerated without the need for avoidance and escape
• Fear will naturally reduce over time with exposure
• The imagined worst-case scenario will not come true during exposure

How Does Exposure Therapy Work?

Exposure therapy uses the concept that feelings of fear and anxiety are formed from faulty thoughts and avoidant behaviors, so learning to access more accurate thoughts and healthier behaviors will shift the feelings.

Experts believe that exposure therapy helps address symptoms in four distinct ways:^3,4

• Habituation: After repeated experiences or time in contact with a stimulus, the reaction to the stimulus reduces. A person entering a hot tub will feel like the water is burning hot, but as their exposure to the environment lengthens, the temperature becomes more comfortable. The water temperature does not change, but the brain’s perception of the temperature changes.
• Extinction: The anxiety becomes “extinct” when contact with the feared stimuli does not result in the projected consequence. If a person spends time around a spider without being bitten, the lack of the projected consequence will permit the fear to shrink and face extinction.
• Self-efficacy: Rather than being interested in reducing fears, self-efficacy involves the person feeling more in control and capable in their environment. This process is essential as most people with high anxiety tend to diminish their ability and skills in the face of demanding situations. With increased self-efficacy, people are willing to put themselves in riskier environments.
• Emotional processing: Fear, stress, and anxiety have the ability to distort someone’s thinking and create a system built around danger. Through emotional processing skills learned during exposure therapy, a person finds new ways to view and understand situations. Instead of seeing dogs as wild creatures that will bite, the person can view dogs as fun and faithful companions.

How Long Does Exposure Therapy Take?

Exposure therapy is usually brief in nature, but that doesn’t necessarily mean it’s time limited. This is because the length of treatment will often depend on a variety of factors, including the condition being treated, intensity of symptoms, presence of a concurrent disorder, the type of exposure technique employed, and complications arising throughout the course of treatment. That said, exposure therapy generally lasts between 6-12 sessions with 50-minute weekly sessions for milder psychological conditions, while longer-term treatment may be necessary for more severe cases.^5,6

What Can Exposure Therapy Treat?

Overall, disorders that create high stress and worry, like most anxiety disorders, respond well to exposure therapy. Studies have demonstrated it to be helpful as the sole treatment or as a component of a larger treatment plan with additional interventions.

Some of the specific conditions effectively treated with exposure therapy include:³

• Specific phobias like fear of spiders, heights, or bridges
• Panic disorder
• Social anxiety disorder (social phobia)
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Generalized anxiety disorder

While exposure therapy is a wonderful tool for these diagnosed mental health disorders, its principles can be applied to many situations as well as symptoms that do not yet meet the criteria for a full diagnosis. Because of this, exposure is a useful tool for a variety of mental health concerns.

How Avoidance Plays Into Anxiety

People with anxiety typically invest a great deal of effort avoiding people, places and things that may elicit unpleasant feelings and fear. Although it is normal to want to avoid such distress, over time, this dysfunctional way of coping will only worsen the anxiety—leading to increased avoidance coping and becoming a never-ending, self-destructive cycle.³

This is where exposure therapy can assist people in breaking the pattern of avoidance and distress. This intervention consists of exposing the client gradually and systematically to the anxiety-producing stimuli in a safe and controlled environment. It has been proven to be effective in treating an array of anxiety-related disorders which is why it’s so widely used.³

Exposure Therapy Types

Some exposure therapies involve presenting the anxiety-provoking situation to the client, while others focus on using technology or imagination to create the exposure. In general though, exposure therapy uses a variety of techniques to help alleviate symptoms and create a sense of comfort and confidence when faced with anxiety triggers. A therapist would choose to employ a different type of exposure therapy based on what is most appropriate for the situation at hand.

Here are the types of exposure therapy you may encounter:

In Vivo Exposure Therapy

In vivo (in a living thing) exposure occurs when a person is directly facing the object, situation, or activity that creates anxiety. If a person is afraid of snakes, they will handle a snake. If they are afraid of bridges, they will cross bridges. If they are afraid of walking down dark alleys, they will walk down dark alleys.

Often during the exposure, the therapist will model desired responses to the stimuli and shape the client’s reactions. By guiding the experience, the therapist offers an alternative to the client’s current set of reactions. This form of treatment is highly effective, but it cannot reproduce all stimuli that create fear, anxiety, and stress, so it cannot be incorporated into every treatment plan.¹

Virtual Reality Exposure Therapy

Virtual reality exposure therapy is available for a variety of situations and stimuli. Some exposures will utilize a virtual reality headset to induce a sense that the person is in a different situation or location. For example, someone fearful of flying will view first-person images of an airplane with sounds that complement the setting.³

More sophisticated virtual reality exposures can add tactile feedback and even smells linked to the situation to heighten the exposure. Research shows that virtual reality exposure is very effective in treating flying phobias, fear of heights, and specific animal phobias, such as fear of spiders. A specially-designed virtual reality program created with the United States military replicates combat situations to reduce symptoms of PTSD in soldiers.⁷

Imaginal Exposure

In situations where in vivo exposure is impossible and virtual reality exposure is not available, imaginal (imaginary) exposure can be useful. Imaginal exposure uses the client’s imagination to trigger the anxious response.³ The therapist will assist by giving the client prompts and cues to deepen their imagination and incorporate all their senses. The client will be encouraged to remain in the memory or fear until exposure is completed.

Interoceptive Exposure

Rather than exposing the person to thoughts or behaviors connected to their feared scenarios, interoceptive exposure works to bring about certain bodily sensations. Sweating hands, shortness of breath, and rapid heart rate are common reactions to high stress, but they can also be brought about by normal actions.

After completing a few repetitions of jumping jacks, a client could increase their heart rate and become out of breath. Even though these sensations were associated with fear and anxiety, by separating the sensation from the stress, the person will begin to perceive the physical response as harmless or even healthy.³

Narrative Exposure Therapy

Narrative exposure therapy is a great tool for addressing trauma. The treatment encourages clients to complete a timeline of their life by filling in the important dates and details of significant events. The therapist helps the client work to process the thoughts, feelings, and behaviors related to these events to decrease their impact.⁸

Specific Exposure Therapy Techniques

Exposure therapy uses a number of techniques to help people reduce their symptoms and increase their quality of life. These techniques are used in different ways, yet each plays a role in decreasing discomfort and increasing coping skills. The techniques below are the most commonly used in exposure therapy.

Graded Exposure

This technique prompts the therapist and client to work together in creating a list of fears and exposures ranked from least to moderate to most difficult to achieve. They will begin to work together on these exposures, starting with the least triggering and making their way to more difficult exposures and situations.³

Flooding

In some cases, taking the opposite approach can work. In flooding, the client and therapist begin with the hardest exposure, fear, or situation on the list and work from there. Flooding is less common as it can be scary to consider facing one’s biggest anxiety or fear up front.³

Systematic Desensitization

In this technique, exposures or situations are approached with a combination of relaxation techniques (see more below) to increase the individual’s coping ability and create neural pathways that connect the fear with relaxation. Systematic desensitization may look like attending a public event while also practicing body scanning or breathing to eventually be able to use these coping mechanisms naturally without prompting.³

Prolonged Exposure (PE)

Prolonged exposure therapy (PE) is a specific manualized exposure therapy program typically used for PTSD. The theory behind this intervention holds that repeated exposure to trauma-related experiences can reduce their intensity, thus diminishing the sufferer’s distress. The overall goal is to teach clients to confront traumatic memories or repressed/avoided experiences safely and gradually.⁹

Exposure and Response Prevention

Exposure and response prevention (ERP) involves two parts:

1. Encouraging the client to become exposed to the anxiety-provoking trigger.
2. Preventing them from responding in a way that maintains or triggers the anxiety.

Rather than leaving the situation, using substances as an unhealthy coping tool or engaging in compulsive behaviors, the client sits with their anxiety. They learn that anxiety decreases over time and their unhealthy coping skills are no longer needed.

Incorporation of Relaxation Techniques

As mentioned above, relaxation and self-soothing techniques (body scanning, deep breathing, grounding, etc.) are combined with exposures in systematic desensitization. However, relaxation can be combined with most exposure therapy approaches or on its own to help manage physical symptoms of anxiety and fear. However, some researchers note that relaxation is not an active influence in fear or panic reduction and can even reduce the helpfulness of therapy in exposure.⁴

What to Expect at Your First Exposure Therapy Session

The first therapy appointment with an exposure therapist will likely resemble the first session for other forms of mental health therapy. The therapist will welcome you to the office and begin gathering information regarding your symptoms, your history, and goals to best formulate a treatment plan focused on improving your well-being.

During the first session, the therapist may offer education regarding the processes and techniques related to exposure therapy. In rare cases, the entire course of treatment can be condensed into just one session of exposure therapy, so your first session could also be your last.

What Are the Benefits of Exposure Therapy?

Exposure therapy offers many significant benefits. Anyone considering the treatment should consider the following strengths:

• It’s effective. Exposure therapy works for many conditions.
• It has a solid history of research.
• It’s widely available as many therapists are well-trained in its use.
• It produces results quickly. In some cases, exposure treatment can be completed in one day.
• It provides lasting results. Once treated with exposure therapy, symptoms may not return

Limitations of Exposure Therapy

Even though exposure therapy can be very beneficial for many, others may experience some drawbacks or undesired results.

Here are some of the potential limitations of exposure therapy:^5,10,11

• Emotional distress: Since exposure therapy involves deliberate exposure to anxiety-producing stimuli, it often intensifies emotional distress. Some individuals may struggle with tolerating the increased discomfort experienced in therapy.
• It doesn’t always treat the underlying issues: Sometimes anxiety or fear may be symptoms of an underlying mental health concern. Thus, other interventions in combination with exposure therapy may be necessary to target the core problem as well.
• Initial worsening of symptoms: It’s not unusual for symptoms to briefly worsen before getting better. This initial strain can be off-putting for some people, and they may need extra guidance from their clinician.
• Not the best fit for trauma survivors: Because some exposure techniques can reactivate disturbing memories, those with a history of trauma run the risk of becoming re-traumatized.
• High dropout rates: Exposure therapy can be mentally and emotionally taxing which is why some people struggle to finish therapy and may suddenly stop, negatively impacting treatment outcome and progress.

Does Exposure Therapy Work? Evidence of Effectiveness

Though many therapeutic techniques provide mixed or inconsistent results, exposure therapy is one of the most consistently effective treatment options available. Of course, the treatment is not recommended for all mental health conditions, but if a person is experiencing anxiety, panic, phobias, PTSD, or OCD, exposure therapy is a great choice.

Here are some results of studies regarding the efficacy of exposure therapy:⁴

• After a single session of in vivo exposure, 90% of people noted less fear, less avoidance, and less overall impairment, even years after the treatment
• 65% of people seeking treatment for a specific phobia noted exposure therapy eliminating their disorder after one session
• People using exposure therapy show better ability to maintain progress months after treatment ends when compared to medication-only and exposure plus medication groups
• 86% of people with OCD who received exposure therapy displayed lower obsessive and compulsive symptoms, compared to only 48% of people who received medication only

When Is Exposure Therapy Not Recommended?

As with other forms of therapies, exposure therapy may not be appropriate in certain cases because it requires a level of awareness, determination, and distress tolerance. For this reason, exposure therapy is often not recommended if someone is in crisis or having self-harming or suicidal thoughts. Equally, people with an unmanaged chronic psychological condition, psychotic features, dissociative symptoms, or a co-occurring mental disorder are not adequately prepared to get the most out of this therapeutic approach.

Exposure therapy is also not suggested for anyone with a history of violence or substance use issues, since the excessive emotional stimulation or re-processing of trauma in sessions can trigger a decline in their wellbeing.^5,10,11

Risks of Exposure Therapy

Perhaps the greatest risk encountered with exposure therapy is that symptoms worsen during the treatment. That may be because the client does not allow the procedure to unfold long enough to habituate to the process, or because the treatment is not the correct approach for their needs. Some people with PTSD have reported that exposure therapy resulted in violence, depression, and suicidal thoughts.¹²

Criticisms of Exposure Therapy

The potential risks of exposure therapy fuel some of the biggest criticisms of the treatment. Some experts believe that the treatment creates more issues for participants, and since the therapy is uncomfortable, the dropout rate can be up to 50%.¹²

Others believe that retelling or re-experiencing the traumatic events is ineffective because of the brain changes that trauma produces.¹² It should be noted, though, that most of the criticisms of exposure therapy are related to the treatment of PTSD, while exposure therapy for other disorders seems universally positive.

Exposure Therapy Examples

Exposure therapy effectively addresses many mental health disorders, such as social anxiety disorder and specific phobias, but since treatment is tailored to the client’s exact needs and skills, one person’s exposure could look different than another’s. Though differences exist, the theme of putting people in contact with their fears, in real, virtual, or imagined ways, is the focus of any exposure therapy treatment plan.

Exposure Therapy for Social Anxiety

Social anxiety disorder is marked by people feeling extreme fear or anxiety in social situations. Usually the fear is driven by ideas of being judged or scrutinized by others. As anxiety grows in these social situations, people will avoid the anxiety by staying home and isolating from friends and loved ones.¹³

Exposure therapy for social anxiety disorder will begin with the therapist building an understanding of the anxiety, its triggers, and the timeline of symptoms. Then, the client and therapist will work together to create a fear hierarchy that ranks situations based on how stressful they seem. Next, using the hierarchy, the treatment team will begin with a series of in vivo or imaginal exposures aimed at triggering increased anxiety. By starting with items that create little anxiety and increasing to more feared items, the treatment gradually addresses distress.

The therapist may prompt the client to spend increasing time out of the house, enter a store, speak to a stranger, attend a party, or partake in other anxiety-provoking behaviors. Exposure therapy requires the final exposure to be very intense, so a person with social anxiety may be asked to give a speech in front of a group of people. When they complete the task and realize their fear was unnecessary, treatment can conclude.³ This method of graded exposure therapy may be completed in a series of three to eight one-hour-long therapy sessions.¹

Exposure Therapy for Phobias

At times, exposure therapy is a slow and gradual process, but depending on the circumstances and the fear, a quicker route may be used. People with a specific phobia, like fear of driving or fear of animals, may respond well to a different form of exposure called flooding. In flooding, the client begins their exposures with items high on their fear hierarchy.³ Rather than thinking about a mouse or looking at a picture of a mouse, the person will move into direct contact with a mouse.

The therapist may provide a situation where the client could touch a mouse, hold a mouse, or even lay down while several mice crawl over them. A vital aspect of flooding is the client’s willingness and ability to perform these tasks. If they were to abruptly end or avoid the treatment, symptoms could actually worsen, so their commitment to the process is invaluable.

Due to the nature of flooding, the treatment can occur in less time. It is possible to address specific phobias in only one three-hour-long therapy session.¹

Exposure Therapy for PTSD

Although there are other treatments, like EMDR for PTSD, exposure therapy can be quite helpful. Like other exposure therapies, the process begins by meeting with a therapist to determine the root of the symptoms and the best course of action to manage the disorder.

Someone with PTSD from their time serving in the military may participate in a treatment protocol devised by the Department of Defense called Virtual Reality Exposure Therapy (VRET). VRET utilizes a headset to transport the person into a situation that mirrors the site of their trauma. They may hold a rifle while feeling like they are walking in a foreign land, or they could have the sensation of riding in an armored vehicle, complete with changing weather and terrain.⁷

VRET and other forms of exposure therapy for PTSD usually takes eight to 15 weekly sessions to create the desired effects. Each session lasts between one and 1.5 hours.¹⁴

Exposure Therapy for OCD

Exposure and response prevention, a specific type of exposure therapy, is the standard therapy style for OCD, and it creates desired levels of change quickly. For this example, the client has an issue with contamination where they frequently wash their hands.

During exposure therapy, the therapist will encourage the client to touch increasingly dirty or contaminated objects and then prevent them from hand-washing (compulsions). Like all exposure treatments, this process leads to short-term anxiety and long-term relief. The therapist will encourage the client to no longer engage in compulsive behaviors at home.

How to Find a Specialist for Exposure Therapy

Many therapists will have some expertise with the process and protocol to reduce fears through exposure. People looking for an exposure therapy specialist may consider completing an online search or referencing an online therapist directory to narrow down their options. It can also be helpful to ask your doctor for a referral, or consult your insurance company for a list of covered providers.

Who Can Provide Exposure Therapy?

Exposure therapy does not require any advanced training or additional certification to perform, so any licensed mental health professional will be able to offer the treatment. However, just because they can does not mean they should. Only professionals with education, experience, and supervision related to exposure therapy should offer the treatment.

How Much Does It Cost?

Exposure therapy generally costs between $50 and $150 per session, with some providers or programs charging more. Fortunately, in the majority of cases, mental health insurance will fully cover these therapy sessions as they would any physical health treatment.

One study found exposure therapy to be a cheaper and more favorable option when compared to medication for anxiety. On average, exposure therapy costs about $1,600 less than medication used for PTSD.¹⁴

Key Questions to Ask a Therapist When Considering Exposure Therapy

Starting with a new mental health professional can feel unnerving, so people should always come prepared with questions about the therapist’s experience and process.

Here are some potential key questions to ask an exposure therapist:

• Is exposure therapy a suitable treatment for my symptoms?
• How long have you been providing exposure therapy?
• Are you currently receiving consultation or supervision from an expert?
• Will the exposure use graded or flooding techniques?
• Will I use in vivo, imagined, virtual reality, or a combined exposure technique?
• How long will the course of treatment last?
• Will I learn relaxation techniques along the way to manage my stress?
• Will exposures only take place during sessions, or will I be expected to engage in exposures in between sessions?
• How will we establish my goals?
• Will my fears return after my course of treatment is over?

Can I Do Exposure Therapy on Myself?

Independently, making a list of your fears (these can be situations, items or animals, etc.) and approaching the least difficult of these in small steps can be helpful.² However, going beyond this would not be in your best interest. In exposure therapy, you and your therapist will be working together to identify your fears, the influences behind them (emotions, neural connections, traumatic experiences, etc.), and even processing these influences by potentially digging into some difficult areas of your history.

Due to the intensity of this work, it is not recommended to begin this process on your own as it can be dangerous to get into these things without a knowledgeable person who can support and help you through this process.