Flooding therapy is a more intense and accelerated form of exposure therapy used to treat anxiety disorders, phobias, and OCD. In flooding therapy, people are encouraged to face their biggest fears early on in treatment, as opposed to working up to them slowly. Today, gradual exposure is more commonly recommended over flooding exposure therapy approaches because it is less distressing and equally effective for most people.1,2,3,4
What Is Flooding Therapy?
Flooding therapy is a type of exposure therapy used to help people face their biggest fears and triggers in order to overcome them. Sessions are typically intense, involving real ‘in-vivo exposures’ and ‘imaginal exposures.’ These are performed through seeing photos, videos, or guided visualization. More recently, virtual reality has also been used to create realistic exposures in therapy.1,4,5
The goal of these sessions is to ‘flood’ the person and cause intense feelings of fear and panic, which the therapist instructs the client to fully accept and experience. The flooding therapy technique sometimes involves much longer and more intense sessions that can last several hours. The exposure continues until the person’s fight-or-flight response naturally stops. This may be repeated again in a future session if needed or assigned as homework between sessions.2,4
How Does Flooding Therapy Work?
Exposure therapy works by reconditioning the fear and stress response in the brain, body, and nervous system to become less sensitive to certain feared objects or situations. All exposure techniques (including flooding) also help reduce avoidance coping, which is often a big part of what makes these disorders so debilitating. By facing their fears, people are able to practice skills that help them feel more confident in stressful situations, while also reprogramming learned fear responses.1,6
Flooding Vs. Gradual Exposure in Exposure Therapy
Flooding therapy was originally developed in 1967 by psychologist Thomas G. Stampfl who was among the first to use exposure therapy techniques in practice. Flooding was part of an ‘implosive flooding’ or ‘implosion therapy’ that Stampfl developed to help his clients face and overcome fears, compulsive behaviors, and a variety of other psychological issues.4,7 Stampfl’s original flooding methods were similar to modern-day exposure techniques, but involved longer and more intense sessions where clients faced their biggest fears first.
Since then, exposure therapies have been adopted under the cognitive behavioral therapy (CBT) umbrella and refined. For example, modern gradual exposure focuses on preparing clients for sessions by teaching them relaxation and coping skills. It also begins with addressing smaller triggers before working up to bigger ones.1,4 Today, flooding in therapy is something therapists try to avoid, as it can overwhelm the client and indicate a need for a slower pace.1,4
Key differences between flooding therapy and gradual approaches in exposure therapy include:1,2,5,7
| Diagnosis & issue | Gradual exposure example | Flooding therapy example |
|---|---|---|
| Specific phobias Specific phobias involve situations where a person’s anxiety is focused on one specific feared object or situation that the person goes out of their way to avoid | Spending several sessions preparing for exposures with coping/relaxation skills training and education about the treatment Developing a fear hierarchy where smallest fears they avoid are at the bottom and biggest fears they avoid are on top Starting from the bottom (smallest fears) and repeating exposures until the person is ready to move up the pyramid Using a SUD scale to ‘rate’ the level of anxiety a client feels during exposures to ensure they don’t get flooded and pausing or pulling back when anxiety is too high | Providing brief assessment, treatment planning, and basic information about the approach before starting exposures Identifying a person’s biggest fear and the situations that evoke the strongest fear responses Conducting real or imaginal/VR exposures to the biggest fear in the beginning of treatment, while providing minimal coaching and guidance on skills to relax Encouraging the person to remain in the exposure for as long as it takes for the fear response to become ‘extinct |
| Claustrophobia Someone with claustrophobia has an intense fear of small spaces who copes by avoiding them at all costs | Helping the client identify their treatment goals & timeline and make a plan to achieve them Helping them identify triggers for claustrophobia and rate them according to how anxious they make them Helping them do exposures in session by closing the office door or moving to a smaller office and coaching them through skill use to relax Assigning repeats of this exposure as homework until the client feels ready to move up to face a bigger fear | Providing brief assessment of the phobia and general information about the exposure and flooding techniques Helping the client tackle their biggest fears (on the top of the pyramid) in the second or third session Providing minimal guidance, support, and skill coaching during the exposures in order to not interrupt the natural desensitization process Using a SUD rating scale to ensure the client is maintaining their anxiety in order to maximize progress in each appt. |
| Obsessive compulsive disorder (OCD) Someone with contamination OCD who fears germs, worries excessively about getting sick or contracting diseases; they compulsively disinfect surfaces and wash hands to avoid this feared outcome | Assessing the subtype of OCD, severity, compulsions and avoidance behaviors, and impairment to daily functioning Helping the client understand the principles of Exposure and Response Prevention (ERP) and it’s efficacy for OCD Helping the client create a list of triggers rated in order of which are causing the most anxiety and compulsive urges Starting with exposure to triggers that are less anxiety provoking, and gradually delay for longer times until they are ready to stop the compulsive behavior Repeating this with more distressing triggers and working with the client on skill building throughout the process | One or two sessions spent assessing OCD, identifying biggest triggers and compulsions, and avoidance coping methods they use Diving into intense exposure sessions where the client is encouraged to face a big fear without using avoidance coping For example, having the client rub their hands on surfaces in the office then touch their face or even put a finger inside their mouth and keep it there while thinking about the germs Not allowing them to wash their hands, use hand sanitizer, or disinfect surfaces in order to maximize and accelerate the extinction of the fear response |
When Are Flooding Therapy Techniques Used?
Flooding therapy is a faster and more intense version of exposure therapies that are commonly used today to treat different types of anxiety disorders, like specific phobias and panic disorder, which involve specific triggers, extreme anxiety, and avoidance behaviors.1,2,5 Other issues and disorders, such as OCD symptoms, are sometimes treated with flooding techniques, which may be blended with other therapeutic and exposure approaches.2,6,7
Historically, flooding therapy techniques have been used for treating PTSD symptoms including flashbacks and avoidance of trauma reminders. However, newer therapies (i.e. ART, EMDR, EFT tapping, and brainspotting) can achieve similar or better results in less time.2 Also, most of these newer types of treatment for PTSD are much less likely than flooding therapy to retraumatize the person or cause other adverse effects.1,8
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Pros & Cons of Flooding Therapy
Benefits of flooding exposure therapy may include faster progress, fewer sessions, and more dramatic improvements in anxiety and phobias. There are also potential drawbacks including higher levels of distress, more intense exposures, and longer, more draining sessions.1,3,4
Below are some of the potential pros and cons of flooding therapy:1,2,5
| Pros of flooding therapy | Cons of flooding therapy |
|---|---|
| Considered an evidence-based treatment | May spend less time preparing clients with relaxation and coping skills before exposure |
| Involves prolonged exposure to maximum anxiety-provoking triggers | Can be more triggering and distressing than gradual exposure therapy |
| Can be effective in treating anxiety, phobias, and specific fears | Alternative, more gradual methods of exposure therapy are just as effective |
| May provide faster results and improvements for some people | Does not provide substantial differences in the rate of progress compared to gradual approaches |
| Can be more cost-effective because of its short-term nature | Gradual exposure therapy can also be adapted for short-term treatment |
| Can be adapted for real life, imaginal, or virtual reality exposures | May be harder to find a therapist who is willing to use flooding over gradual exposure |
| Can be adapted and used to help people suffering from OCD | Is not advised for people with PTSD, as it can worsen symptoms |
Is Flooding Therapy Effective?
In general, exposure therapy is one of the most proven and effective types of treatment for certain types of anxiety disorders and obsessive compulsive disorder.1,9 When a person’s anxiety centers around a specific trigger, repeated exposure is proven to help desensitize them and possibly overcome phobias. Instead of needing to avoid their fears, exposure therapy helps them face their fears without experiencing intense anxiety or panic attacks.1,6
Flooding techniques were used primarily during the 1970s and 1980s, but have since become less popular and researched. Because of this, there are few studies comparing flooding techniques to gradual exposure, making it hard to determine which may be more effective. While exposure therapies help clients overcome phobias, anxiety disorders, and OCD, there isn’t proof that flooding therapy is a more successful approach.1,2,3
Is Flooding Therapy a Good Fit for Me?
While exposure therapy may be helpful for some individuals, flooding techniques can be intense and very triggering.1,3,6 People with PTSD and complex trauma are not advised to try flooding therapy because it can worsen symptoms.1,8 Due to the intense nature of flooding therapy, people with underlying heart or medical issues should consult with a doctor before considering this approach.1,8
Most clinicians who use exposure techniques do not practice flooding, and instead take a more gradual treatment approach. However, there may be certain individualized circumstances that may warrant the use of flooding therapy.1
Flooding therapy may be beneficial for populations, such as:
- People who need short-term therapy because of limits imposed by an agency, policy, insurance plan, or other external factors.
- Clients who are severely impaired by their symptoms of anxiety or OCD, and need immediate relief or faster results than gradual exposure provides
- Clients specifically request flooding be used and are informed about the differences between gradual and flooding exposure therapy treatment approaches
- Clients who do not respond well to gradual exposures
- Individuals who have completed exposure therapy in the past and have more skills and confidence in facing bigger triggers early in treatment
- Clients who have higher distress tolerance, resilience, or effective coping skills to help them regulate their emotions and responses to fear and stress
Alternatives to Flooding Therapy
There are several alternative approaches to flooding therapy. The most obvious alternative is traditional exposure therapy, which can be customized according to the needs and progress of each client.1 Other research-backed treatments differ depending on the type of disorder or problem a person wants to overcome.
Below are alternative approaches to flooding therapy for specific conditions:1,6,9
- Panic disorder: Exposure therapy techniques that use gradual exposure are highly effective in treating those with panic disorder or frequent panic attacks. Other effective treatments for panic disorder include cognitive behavioral therapy (CBT), applied relaxation therapy, and psychoanalytic therapy.
- Obsessive compulsive disorder (OCD): Exposure and response prevention (ERP) therapy is one of the most effective treatments for OCD. Other therapies include cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).
- Specific phobias: Exposure therapies are the most effective forms of treatment for phobias, but there is research to support the use of CBT and mindfulness-based approaches like ACT, which incorporates meditation techniques and relaxation training.
- Post-traumatic stress disorder (PTSD): Many therapy options for PTSD are highly effective and fast-acting. These include accelerated resolution therapy (ART), EFT tapping, and eye movement desensitization and reprocessing (EMDR). Cognitive processing therapy (CPT) and even CBT are longer-term trauma therapies that utilize more traditional approaches.
How to Find Treatment
Anxiety disorders are the most common type of mental health problem in the US, and can be debilitating. The good news is that they’re also highly treatable. Treatment can help people manage and sometimes even overcome their symptoms. Therapy is a frontline treatment approach for anxiety related conditions, but can also be combined with anxiety medications for those who want or need additional support.
Finding a therapist who is knowledgeable about your condition and utilizes an approach that works well for you is essential. Many people begin their search using an online therapist directory that allows them to narrow their search by location, insurance type, and areas of specialization. Becausing finding the right therapist is so important, many counselors offer free consultations to answer questions and provide information about their approach.
Final Thoughts
Flooding therapy is a form of implosive therapy used in the treatment of anxiety disorders, avoidance behaviors, OCD, and phobias.2,4,7 Since its development, there have been more gradual therapeutic approaches introduced to help people face smaller fears and work up to major stressors. Most therapists using exposure therapy recommend a gradual approach, but are willing to individualize the pace of treatment according to the needs of each client.1,3,4
For Further Reading
- What Is Exposure Therapy / APA
- Exposure and Response Prevention (ERP) / International OCD Foundation
- Phobias Fact Sheet / Association for Behavioral and Cognitive Therapies
Flooding Therapy Infographics
