What is Exposure Therapy?
Exposure therapy si the most effective psychological treatment for anxiety. Exposure means “facing your fears” and is the opposite of avoidance. When we avoid something that we fear, the fear only gets stronger; by avoiding we don't get to learn anything about our ability to cope. If we confront our fears and learn that we can cope then we become more able to manage similar situations in the future. Exposure can be done to real situations or to imagined ones. In psychological terms exposure leads to the “extinction of a learned fear response”.
How Exposure Works
One helpful way to think about how exposure works is to consider memories. A scary event creates a “fear memory” linking the object, event, or situation with a feeling of a fear. Reminders activate this fear memory and make you feel afraid. It is not possible to get rid of old memories, but it is possible to create helpful new ones which will outnumber the old ones. Exposure therapy creates new memories linking the feared object, event, or situation with feelings of control, safety, or achievement. With successful exposure, whenever you are reminded of the object, event, or situation your mind learns to recall a good memory and you feel ok.
Lets consider an example:
Step 1: Learning to be afraid of something
Bob is involved in a car crash. He feels very frightened at the time. A memory is created in Bob's mind which links cars with feeling afraid.
Step 2: The problem of fear
Reminders of the crash activate Bob's fear memory and make him feel afraid. His fear means that he avoids traveling in cars or on the road. This avoidance means that he doesn't get to learn how safe traveling by car normally is.
Step 3: Exposure therapy
As part of his treatment, Bob is gradually exposed to cars in a variety of different situations. Nothing bad happens so he begins to feel safer around cars. He starts driving again.
Step 4: Anxiety reduced
Exposure doesn't make the fear memory go away, it just creates new “safe” memories. In potentially scary situations the old fear memory and the new safe memories “compete”. Whenever a reminder comes along Bob can be reminded either of the old fear memory or the new safe memory. The more exposure therapy he has done the more positive memories he will have to rely on and the more capable he will feel.
Graded Exposure
Graded exposure is a gentler way of facing your fears. Fears are faced in order of increasing intensity, starting with something that is not too scary. Steps for graded exposure:
Identify a ladder of increasingly fearful situations
Starting with the easiest, confront the object, event, or situation and stay there until you fear reduces
Don't move up the ladder under you feel comfortable at each step
It's natural to want to avoid things that you fear. The purpose of fear is to alert us to when we are in danger and need to do something to protect ourselves. However, when our fear response is going off at the wrong time (when there is no danger or very little danger), the fear response itself becomes a problem. In this type of situation, avoidance leads to worsening anxiety, and prevents you from learning that the things you fear are not as dangerous as you think.
An important step in managing anxiety involves facing feared situations, places, or objects, so that you can learn through experience that these situations are not as dangerous as your body thinks. The process of facing fears is called exposure. Exposure involves gradually and repeatedly putting yourself in feared situations until your fear levels drop. Exposure is not dangerous to your health. After repeated exposures to a situation, your anxiety will naturally lessen.
It's important to start with small goals, with things that are not too frightening or overwhelming. After repeatedly facing things that are mildly scary, you will build confidence in those situations and will feel ready to gradually face more challenging situations over time. For example, if you have a fear of dogs, a first exposure goal might involve looking at pictures of dogs. Once you have done this repeatedly, any anxiety you have when looking at dogs will naturally lessen. Next, you could move on to watching videos of dogs on the internet, and keep doing that exposure activity until it no longer triggers much anxiety, and so on.
Exposure is very effective, but it takes planning patience to make it work for you. Many individuals with anxiety have doubts about trying exposure. You might have tried it in the past and found it didn't work. However, you might have tried to face something too scary too soon, which can be overwhelming. Or, you might not have had a chance to practice repeatedly in order to get the benefits of exposure. Be willing to try again!
The following steps can help you make exposure work for you:
Step 1. Make a List
Make a list of situations, places, or objects that you fear. If we go back to the example of dogs, the list might include looking at pictures of dogs, watching videos of dogs, standing across the park from a dog on a leash, standing in the same room as a dog on a leash, standing a few feet from a dog, or petting a puppy. If you're afraid of social situations, the list might include saying hi to a coworker, making small talk with a cashier, going for coffee with coworkers, or calling a friend on the phone.
TIP: Group Fears Togther
Some people have a lot of different fears, so it can help to group similar fears or specific fear themes together. For example, if you have a fear of bugs and a fear of heights, make different lists for each of them.
Step 2. Build a Fear Ladder
Once you've made a list, arrange items from the least scary to the most scary. You can do this by rating how much fear you feel about each situations on your list: 0 (no fear) to 10 (extreme fear). Include a whole range of situations on your list: some that you can do with only mild anxiety, some that you can do with moderate anxiety, and some that would be too overwhelming to do right now. If everything on your list feels too overwhelming to do now, pick the least scary situation on the list and break it down into smaller, less overwhelming steps. Now your list has become a fear ladder.
TIPS:
When making a fear ladder, identify a specific goal (such as having a meal in a restaurant), and then list the steps needed to achieve that goal, eg:
1. Go to a restaurant and get coffee to go
2. Have a coffee at the restaurant and sit near the door
3. Have a snack at the restaurant and sit at a table in the middle of the room.
4. Have a full meal at the restaurant and sit near the door
5. Have a full meal at the restaurant and sit in the middle of the room.
If you're wondering how to break things on your list into smaller steps, consider changing one of the following factors:
1. Length of Time (eg: Talk to someone for one minute before trying five minutes)
2. Time of Day (eg: Go to the grocery store on a weekday morning before going on the weekend)
3. Environment (eg: Go swimming at a public pool before trying swimming in a lake)
4. Who you're with (eg: Go to the mall with a friend before going alone)
Step 3. Facing Fears (Exposure)
Starting with the situation that causes the least anxiety, repeatedly put yourself in that situation (eg: saying hi to the bus driver every day) until you start to feel less anxious doing it. If the situation is one that you can remain in for a prolonged period of time (eg: standing on a balcony), stay in the situation long enough for your anxiety to lessen (usually 20-30 minutes). If the situation is short in duration, try “looping” it, which means doing the same thing over and over again for a set number of times (eg: driving back and forth over a bridge until you start to feel less anxious).
If you stay in a situation long enough, or continue doing a specific activity enough times, your anxiety will start to lessen. The longer you face something, the more quickly you will get used to it and the less anxious you'll feel when you face it again.
TIPS:
It can help to track your fear level during exposure exercises and try to remain in those situations (or continue a specific activity) until your fear level drops by about 50%. For example, if you have a fear of needles, and you rated holding the needle as a 6/10 on the fear scale then you want to continue holding the needle until your fear level drops to 3/10.
It's important to plan exposure exercises in advance, so you feel more in control of the situation, and you can decide how much to challenge yourself.
Once you're able to face a specific situation on a several separate occasions without having much anxiety, you can move on to the next item on your fear ladder.
Don't rush! It can be very hard to face the things you fear. Be patient with yourself, and go at a pace that you can manage.
Step 4. Practice
Practice on a regular basis. The more often you practice, and the longer you practice for, the faster the fear will fade.
Don't forget to maintain the gains that you've made. Even after you become comfortable doing something, it's important to keep putting yourself in that situation from time to time to make sure your fears don't creep back.
Re-rate your fear ladder every once in a while, so you can see progress you've made, and identify the things on the ladder you still need to tackle.
Step 5. Reward Yourself
It's not easy facing your fears. Reward yourself when you do it. Rewards can be things you want for yourself (eg: book, treat, game), or things you enjoy doing (eg: seeing a movie).
Don't forget to give yourself credit for what you've done.
TIP:
Don't be discouraged if your fears start creeping back. This can happen from time to time, especially during stressful periods or transitions, such a starting a new job or moving. This just means that you need to start practicing again, just like you would with any other skill.
Exposure Practice Exercise
Preparation
What am I afraid of (or what do I need to expose myself to)?
What do I fear will happen (or what is the worst that could happen)?
How likely is it that the feared outcome will happen? (0-100%)
How severe would it be if this happened? (0-100%)
Exposure
Expose yourself to the feared situation and record your Subjective Units of Distress (0 -No distress at all, to 100- As bad as it can get) every few minutes, or when you notice your distress shifting upwards or downwards, until you decide to end your exposure.
Outcome and Learning
What was the outcome of the exposure? What did you learn?
If you were to expose yourself again:
How likely is it that the feared outcome would happen? (0-100%)
How severe would it be if the feared outcome happened? (0-100%)
Exposure therapy si the most effective psychological treatment for anxiety. Exposure means “facing your fears” and is the opposite of avoidance. When we avoid something that we fear, the fear only gets stronger; by avoiding we don't get to learn anything about our ability to cope. If we confront our fears and learn that we can cope then we become more able to manage similar situations in the future. Exposure can be done to real situations or to imagined ones. In psychological terms exposure leads to the “extinction of a learned fear response”.
How Exposure Works
One helpful way to think about how exposure works is to consider memories. A scary event creates a “fear memory” linking the object, event, or situation with a feeling of a fear. Reminders activate this fear memory and make you feel afraid. It is not possible to get rid of old memories, but it is possible to create helpful new ones which will outnumber the old ones. Exposure therapy creates new memories linking the feared object, event, or situation with feelings of control, safety, or achievement. With successful exposure, whenever you are reminded of the object, event, or situation your mind learns to recall a good memory and you feel ok.
Lets consider an example:
Step 1: Learning to be afraid of something
Bob is involved in a car crash. He feels very frightened at the time. A memory is created in Bob's mind which links cars with feeling afraid.
Step 2: The problem of fear
Reminders of the crash activate Bob's fear memory and make him feel afraid. His fear means that he avoids traveling in cars or on the road. This avoidance means that he doesn't get to learn how safe traveling by car normally is.
Step 3: Exposure therapy
As part of his treatment, Bob is gradually exposed to cars in a variety of different situations. Nothing bad happens so he begins to feel safer around cars. He starts driving again.
Step 4: Anxiety reduced
Exposure doesn't make the fear memory go away, it just creates new “safe” memories. In potentially scary situations the old fear memory and the new safe memories “compete”. Whenever a reminder comes along Bob can be reminded either of the old fear memory or the new safe memory. The more exposure therapy he has done the more positive memories he will have to rely on and the more capable he will feel.
Graded Exposure
Graded exposure is a gentler way of facing your fears. Fears are faced in order of increasing intensity, starting with something that is not too scary. Steps for graded exposure:
Identify a ladder of increasingly fearful situations
Starting with the easiest, confront the object, event, or situation and stay there until you fear reduces
Don't move up the ladder under you feel comfortable at each step
It's natural to want to avoid things that you fear. The purpose of fear is to alert us to when we are in danger and need to do something to protect ourselves. However, when our fear response is going off at the wrong time (when there is no danger or very little danger), the fear response itself becomes a problem. In this type of situation, avoidance leads to worsening anxiety, and prevents you from learning that the things you fear are not as dangerous as you think.
An important step in managing anxiety involves facing feared situations, places, or objects, so that you can learn through experience that these situations are not as dangerous as your body thinks. The process of facing fears is called exposure. Exposure involves gradually and repeatedly putting yourself in feared situations until your fear levels drop. Exposure is not dangerous to your health. After repeated exposures to a situation, your anxiety will naturally lessen.
It's important to start with small goals, with things that are not too frightening or overwhelming. After repeatedly facing things that are mildly scary, you will build confidence in those situations and will feel ready to gradually face more challenging situations over time. For example, if you have a fear of dogs, a first exposure goal might involve looking at pictures of dogs. Once you have done this repeatedly, any anxiety you have when looking at dogs will naturally lessen. Next, you could move on to watching videos of dogs on the internet, and keep doing that exposure activity until it no longer triggers much anxiety, and so on.
Exposure is very effective, but it takes planning patience to make it work for you. Many individuals with anxiety have doubts about trying exposure. You might have tried it in the past and found it didn't work. However, you might have tried to face something too scary too soon, which can be overwhelming. Or, you might not have had a chance to practice repeatedly in order to get the benefits of exposure. Be willing to try again!
The following steps can help you make exposure work for you:
Step 1. Make a List
Make a list of situations, places, or objects that you fear. If we go back to the example of dogs, the list might include looking at pictures of dogs, watching videos of dogs, standing across the park from a dog on a leash, standing in the same room as a dog on a leash, standing a few feet from a dog, or petting a puppy. If you're afraid of social situations, the list might include saying hi to a coworker, making small talk with a cashier, going for coffee with coworkers, or calling a friend on the phone.
TIP: Group Fears Togther
Some people have a lot of different fears, so it can help to group similar fears or specific fear themes together. For example, if you have a fear of bugs and a fear of heights, make different lists for each of them.
Step 2. Build a Fear Ladder
Once you've made a list, arrange items from the least scary to the most scary. You can do this by rating how much fear you feel about each situations on your list: 0 (no fear) to 10 (extreme fear). Include a whole range of situations on your list: some that you can do with only mild anxiety, some that you can do with moderate anxiety, and some that would be too overwhelming to do right now. If everything on your list feels too overwhelming to do now, pick the least scary situation on the list and break it down into smaller, less overwhelming steps. Now your list has become a fear ladder.
TIPS:
When making a fear ladder, identify a specific goal (such as having a meal in a restaurant), and then list the steps needed to achieve that goal, eg:
1. Go to a restaurant and get coffee to go
2. Have a coffee at the restaurant and sit near the door
3. Have a snack at the restaurant and sit at a table in the middle of the room.
4. Have a full meal at the restaurant and sit near the door
5. Have a full meal at the restaurant and sit in the middle of the room.
If you're wondering how to break things on your list into smaller steps, consider changing one of the following factors:
1. Length of Time (eg: Talk to someone for one minute before trying five minutes)
2. Time of Day (eg: Go to the grocery store on a weekday morning before going on the weekend)
3. Environment (eg: Go swimming at a public pool before trying swimming in a lake)
4. Who you're with (eg: Go to the mall with a friend before going alone)
Step 3. Facing Fears (Exposure)
Starting with the situation that causes the least anxiety, repeatedly put yourself in that situation (eg: saying hi to the bus driver every day) until you start to feel less anxious doing it. If the situation is one that you can remain in for a prolonged period of time (eg: standing on a balcony), stay in the situation long enough for your anxiety to lessen (usually 20-30 minutes). If the situation is short in duration, try “looping” it, which means doing the same thing over and over again for a set number of times (eg: driving back and forth over a bridge until you start to feel less anxious).
If you stay in a situation long enough, or continue doing a specific activity enough times, your anxiety will start to lessen. The longer you face something, the more quickly you will get used to it and the less anxious you'll feel when you face it again.
TIPS:
It can help to track your fear level during exposure exercises and try to remain in those situations (or continue a specific activity) until your fear level drops by about 50%. For example, if you have a fear of needles, and you rated holding the needle as a 6/10 on the fear scale then you want to continue holding the needle until your fear level drops to 3/10.
It's important to plan exposure exercises in advance, so you feel more in control of the situation, and you can decide how much to challenge yourself.
Once you're able to face a specific situation on a several separate occasions without having much anxiety, you can move on to the next item on your fear ladder.
Don't rush! It can be very hard to face the things you fear. Be patient with yourself, and go at a pace that you can manage.
Step 4. Practice
Practice on a regular basis. The more often you practice, and the longer you practice for, the faster the fear will fade.
Don't forget to maintain the gains that you've made. Even after you become comfortable doing something, it's important to keep putting yourself in that situation from time to time to make sure your fears don't creep back.
Re-rate your fear ladder every once in a while, so you can see progress you've made, and identify the things on the ladder you still need to tackle.
Step 5. Reward Yourself
It's not easy facing your fears. Reward yourself when you do it. Rewards can be things you want for yourself (eg: book, treat, game), or things you enjoy doing (eg: seeing a movie).
Don't forget to give yourself credit for what you've done.
TIP:
Don't be discouraged if your fears start creeping back. This can happen from time to time, especially during stressful periods or transitions, such a starting a new job or moving. This just means that you need to start practicing again, just like you would with any other skill.
Exposure Practice Exercise
Preparation
What am I afraid of (or what do I need to expose myself to)?
What do I fear will happen (or what is the worst that could happen)?
How likely is it that the feared outcome will happen? (0-100%)
How severe would it be if this happened? (0-100%)
Exposure
Expose yourself to the feared situation and record your Subjective Units of Distress (0 -No distress at all, to 100- As bad as it can get) every few minutes, or when you notice your distress shifting upwards or downwards, until you decide to end your exposure.
Outcome and Learning
What was the outcome of the exposure? What did you learn?
If you were to expose yourself again:
How likely is it that the feared outcome would happen? (0-100%)
How severe would it be if the feared outcome happened? (0-100%)
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