How does exposure therapy work?
The gold standard of evidence-based treatment for anxiety and related disorders is Cognitive Behavioral Therapy (CBT). CBT rests on the principle that our thoughts (cognitions), actions (behaviors), and feelings (emotions/sensations) reciprocally interact and influence each other. In CBT, we aim to intervene at the level of thoughts and behaviors. Anxiety disorders are maintained by mistaken or inaccurate thoughts, beliefs, and predictions, as well as by experiential avoidance. Experiential avoidance is defined as anything we do or don’t do (avoid) to try to escape or get rid of anxiety.
Sometimes avoidance is easy to identify because is is literally an action we are avoiding.
For example, someone with medical fears or anxiety might avoid going to the doctor. Someone with a needle phobia might avoid getting vaccinations. Someone with panic disorder might avoid drinking caffeine or exercising out of fear that an increased heart rate will trigger a panic attack. Someone with agoraphobia might order groceries online so they don’t have to be in a grocery store, stand in a line, or leave their house. Someone with generalized anxiety might skip out on a meaningful vacation out of fear of all the things that could go wrong.
But sometimes avoidance is a thing we are doing or a thing we are telling ourselves.
For example, someone with medical anxiety might constantly reach out to their doctor seeking reassurance or requesting additional tests. Someone with panic disorder might constantly check their heart rate or constantly say to themselves, “I’m safe. I’m not dying.” Someone with agoraphobia might always carry their Xanax prescription just in case they have a panic attack. Someone with generalized anxiety might spend hours and hours researching and preparing for every possible worst case scenario that could arise while on vacation.
Avoidance typically makes the anxiety decrease in the moment, but makes it increase over time.
Avoidance behaviors are a totally logical strategy to use to cope with anxiety because they do usually make you feel better in the moment. And that is incredibly reinforcing. The problem with avoidance is that although it tends to make anxiety decrease in the moment, it causes it to increase in the long run. When you continually avoid anxiety, you reinforce a few unhelpful beliefs:
you have to rely on avoidance to feel better
you can’t handle the experience of anxiety and therefore you have to do something to make it go away
the things you are afraid of are likely and you must work to prevent them
The more you reinforce these thoughts, the more you rely on avoidance, and the harder it becomes to encounter the situations and stimuli that elicit that anxiety. Essentially, over time, your world gets smaller and smaller as you increasingly depend on avoiding anxiety as your strategy for coping with it. Avoidance behaviors are part of how the temporary emotion of anxiety becomes a clinically significant anxiety disorder that causes distress and functional impairment.
Exposure therapy helps undo the avoidance cycle that maintains anxiety disorders.
Exposure therapy is a behavioral tool used in CBT (a.k.a. the B in CBT). It is the way that we start to counter avoidance and challenge the inaccurate anxious beliefs and predictions that avoidance has reinforced. When you start to slowly begin to encounter your anxiety without avoidance, you begin to learn based on your experience things that challenge those unhelpful anxious thoughts, including:
eventually, anxiety will subside on its own (anxiety will not continue increasing forever, it will eventually pass when you stop engaging in experiential avoidance)
you are far more capable of handling anxiety than you believe
the things you fear are often much less likely to occur than you believe, and if something you fear does come to pass, you are typically far more capable of handling it than you predict
When you engage in avoidance, anxiety decreases in the moment but increases over time. Whereas when you engage in exposures, you feel a temporary increase in anxiety, but over time your anxiety decreases as you learn that you don’t need to rely on avoidance to be okay.
Is exposure therapy as hard and scary as it sounds?
Exposure therapy is hard work that does require courage and practice, but it’s not a “throw you in the deep end and expect you to swim” kind of approach. After some initial psychoeducation on the particulars of your anxiety as well as the role that avoidance plays in anxiety disorders, you work with your therapist to build a hierarchy. A hierarchy is basically like a menu of different exposures activities, each of which are rated on a scale of 0-10 in terms of how distressing you expect that specific exposure to be for you. You can start wherever you are willing to start on the hierarchy, but most clients prefer to start off with an exposure that is around 3 or 4 out of 10.
Often you complete your first exposures (as well as subsequent ones) in session with your therapist, and you learn in real time how to refrain from your typical experiential avoidance, practice sitting with your anxiety, and then you process what you learned from the exposure with your therapist. You will typically be asked to repeat the same exposure for homework on your own. As you engage in lower level exposures with professional support and guidance, you begin to develop increased confidence in yourself and often as your anxiety decreases in those initial exposures, the harder exposures begin to feel more within reach and a little less scary than when you started.
Exposures are really about learning to sit with your internal discomfort more than anything.
Every hierarchy is unique and specific to that particular client. An exposure is any activity that will help you to practice getting more comfortable with discomfort, sitting with uncertainty, letting go of control efforts when they do not serve you, and allowing yourself to learn that you do not need to avoid the things that make you feel anxious. The best hierarchies involve at least some exposures that are clearly aligned with your personal values, that is, things that you want to be able to do but haven’t been able to do as a result of your anxiety.
Anxiety disorders can rob you of experiences that are important or meaningful to you. Exposure therapy can give you your life back.
Anxiety has a way of making you feel trapped, like anxiety is running your life. Exposures are meant to help put you back in the driver’s seat of your life. To help you choose the actions that are aligned with the kind of person you want to be and the kind of life you want to live. Exposures aren’t about finding the scariest or most painful thing we can think of. They aren’t about putting you in situations that are truly dangerous or that are out of line with your values. They are about figuring out where and how anxiety is holding you back and helping you lean into discomfort in service of a rich and meaningful life.
