When my son turned 3, we signed him up for ice skating lessons. It was my son’s idea. One of his favorite books at the time showed Charlie Brown and the Peanuts gang playing hockey on a frozen pond and he quickly informed us that he too wanted to learn to skate. I was skeptical given his age, but my husband informed me that as a Michigander, “once you can walk, you can learn to skate.” The first few lessons went well, and I was impressed to see the group of little kids, outfitted in their snowpants and bike helmets, inching along the ice like baby giraffes first learning to walk.
But when the lessons got harder, he didn’t want to go anymore. He was too afraid that he’d lose his balance and fall. When this attitude persisted, we decided to take a break from the lessons. In the meantime, he watched the winter Olympics, attended his first Red Wings game, and one day he said he wanted to skate again. Instead of jumping back into lessons, we went to the rink as a family. We went slow. We circled the ice holding hands, then he held onto the wall, and after enough time he said, “I can do it myself, mom!” I could see the smile in his face knowing that he had faced his fear.
The way my son took small steps to overcome his avoidance is the basis of exposure therapy, a type of cognitive behavioral therapy (CBT) that helps people confront their fears. As a psychologist in our Anxiety Disorder Program, exposure is a form of treatment we often recommend to our patients. Patients are sometimes reluctant, and understandably so. We know that treatment is more successful when patients understand what they are doing and why. Below I explain some important elements and misconceptions about exposure therapy. I hope this article can demystify exposure therapy and make you more confident about your ability to engage in it.
Exposure works!
Meta-analyses show that exposure-based treatments are helpful for a variety of anxiety-related conditions such as panic, social anxiety, health anxiety, and phobias (flying, heights, needles, etc.) obsessive compulsive disorder, (OCD) and trauma-related conditions such as post-traumatic stress disorder. For some conditions, like OCD, it may even be more effective than medications alone.
You’ve probably done exposure before, and you don’t even realize it
Can you relate to the example I gave of my son learning to skate? Even if you haven’t formally done exposure therapy with a provider, chances are you have experienced overcoming a fear at some point in your life. You can draw on this memory to give you more confidence in your ability to do exposure therapy.
The principles of exposure don’t just work for fear. Have you ever gone swimming and noticed that the water feels very cold when you first get in, but after some time the water feels warm? After enough exposure, your body acclimates. That is the same thing that can happen with feared situations.
Allergy treatment in another example. During immunotherapy, a patient is repeatedly exposed to gradually increasing amounts of an allergen until the immune system ‘gets used it to’ and is less likely to have an exaggerated response.
You can set the pace of exposure therapy
Just as my son took small steps to face his fear, exposure therapy is gradual. Working with a provider, you make a list of items, ranked from the easiest to the hardest, of steps toward your goal. For example, for someone trying to overcome a fear of driving, we wouldn’t recommend driving on I-94 during rush hour as the first step. Instead, you could start by siting in the car in your own driveway, without even turning the car on! Then once you are comfortable with that, try driving around the block or in a parking lot. Once a person works on those easier items, they often find that the ‘hard’ thing doesn’t feel as hard anymore.
The science is based on how the brain learns
Our brains are built to respond and adapt to the environment. A network of brain regions is responsible for detecting danger in the environment and setting off a ‘fight-or-flight’ response to protect ourselves. When we repeatedly confront our fears, our brain forms new expectations (“Wow, I can tolerate leaving the house without repeatedly checking the lock”) and beliefs about safety (“Giving a presentation is generally safe”), which can cause this danger system to alarm less often and less loudly than before. Some research even shows changes in brain function after exposure therapy.
Exposure can feel uncomfortable, but it’s not harmful
During an exposure, you will feel anxious or uncomfortable. We often say, “if you are feeling anxious, you are doing it correctly.” From an outsider’s perspective, it might seem odd or even mean to encourage our patients to experience these negative emotions. However, this discomfort is temporary, and research shows there are no long-term negative consequences of exposure-based therapy, even for trauma-based conditions.
It is normal for symptoms to temporarily worsen at the beginning of treatment, but research shows that most people experience a decrease in symptoms after a full course of treatment (typically at least 3 months of weekly treatment).
Think of it like organizing your house. The other day I rearranged the furniture in our family room because I thought the space would be more organized another way. However, if you came over to my house while I was in the middle of this process, the room would have looked like a mess. To make a neater space, I had to temporarily create what seemed like disorganized clutter. This is a bit like what happens in exposure therapy. To achieve your goal, you have to temporarily take items ‘off the shelves of your brain,’ which feels uncomfortable, even messy in the moment, but helps reorganize your mind with newer beliefs and behaviors that better fit your life.
Patients often feel more empowered after facing a fear. They know that they are calling the shots in their life, not anxiety.
We don’t pretend like danger doesn’t exist
Has someone ever told you, “You’ll be fine” or “nothing bad will happen?” While this may be true most of the time, during exposure, we acknowledge that real dangers do exist in the world. None of us can predict with 100% certainty what will happen in the future, such that everything in life involves some level of risk. If we doing an exposure to germs by touching door knobs, I don’t say to a client, “Don’t worry, you won’t get sick,” as a way to help them through the exercise. Instead, I say, “you could get sick” and let’s figure out how you would cope with that. We look danger straight in the eye and say, “I know you’re there, but I’m going to do this anyway, because anxiety is getting in the way of my life.” As a therapist, I show that I’m willing to take risks by participating in the exposure exercises too. At the same time, we use our common sense and don’t encourage entering situations with higher levels of risk, such as walking alone at night, driving without a seatbelt, or during the pandemic – going to the store without a mask.
Not everyone who has a fear needs to face it
Treatment is based on an individual's personal goals and values. There is no right or wrong thing to do exposure to. Instead, exposure is helpful when anxiety or fear is interfering with what’s important to you in life. In that sense, we hope that patients can see the bigger picture of the life they will gain when they are in the midst of a difficult exposure exercise.
It is also perfectly ok for someone with a fear of flying to choose to never fly, especially if that fear doesn’t bother them and it doesn’t impact their life at all. If instead, someone has always wanted to see The Great Wall of China, has a grandchild that lives far away, or can’t focus at work because they are spending too much time worrying about plane crashes, we might explore how exposure therapy could be helpful.
Conclusion
Exposure therapy is an evidenced-based treatment for anxiety for both children and adults. Talk to a provider if you have questions about if exposure therapy is appropriate for you or a loved one.
Citations
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.
Knowles, K. A., & Tolin, D. F. (2022). Mechanisms of action in exposure therapy. Current Psychiatry Reports, 24(12), 861-869.
McLean, C. P., Levy, H. C., Miller, M. L., & Tolin, D. F. (2022). Exposure therapy for PTSD: A meta-analysis. Clinical psychology review, 91, 102115.
Norman, L. J., Mannella, K. A., Yang, H., Angstadt, M., Abelson, J. L., Himle, J. A., ... & Taylor, S. F. (2021). Treatment-specific associations between brain activation and symptom reduction in OCD following CBT: a randomized fMRI trial. American Journal of Psychiatry, 178(1), 39-47.
Parker, Z. J., Waller, G., Gonzalez Salas Duhne, P., & Dawson, J. (2018). The role of exposure in treatment of anxiety disorders: A meta-analysis. International Journal of Psychology and Psychological Therapy, 18(1).
Teachman, B. A., White, B. A., & Lilienfeld, S. O. (2021). Identifying harmful therapies: Setting the research agenda. Clinical Psychology: Science and Practice, 28(1), 101.
