What is Exposure Therapy and Why Does It Matter?
A few months ago, I received a call from a casting director looking for exposure therapists to conduct on-camera exposure for a reality TV show by the people who made Hoarders. I turned it down, of course—the ethics of it made me uncomfortable. However, the encounter suggested that exposure is becoming more widely known outside of professional circles.
Exposure has been hailed as one of the greatest success stories in cognitive behavioral treatment, and it’s currently going through a fertile period as clinicians and researchers are redefining what makes exposure work. There’s an enormous body of research on the use of exposure for things such as a panic disorder, worry, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder. I intend to devote time to exploring exposure research in greater depth across future posts.
What Is Exposure?
This is a good place to start: what is exposure? In a book chapter on exposure, Moscovitch, Antony, and Swinson (2009), offer a wonderfully succinct definition: “the repeated and systematic confrontation of feared stimuli.” But what does that mean? In essence, exposure involves having someone deliberately be with an experience that he or she would normally avoid. For example, having someone afraid of heights safely stand near the edge of a building. Often we think of exposure as a component in structured cognitive behavioral treatments. However, exposure doesn’t have to be so structured. Whether they realize it are not, therapists who ask their clients to sit with painful thoughts and feelings, as they come up in session, are using exposure too.
You’ll notice that the discussion of exposure in the paragraph above focuses on the procedure of exposure. It doesn’t tell us anything about how and why exposure works. The reason for this is that decades of research have proven exposure to be an extraordinarily effective treatment, but there is no consensus on its mechanisms of change.
Research on exposure began decades ago and was rooted in the early behaviorist perspective—classical conditioning (think, Pavlov’s dogs). Exposure was a way to undo a condition association between a neutral object or experience and a fear response. Several years later, cognitive therapists began using exposure as a way to challenge or disconfirm negative thoughts about feared outcomes. There is even a variant of exposure called implosive therapy in which therapists encouraged clients to imagine scenes with psychodynamic imagery as a way to facilitate exposure.
None of these theories used to explain exposure have been entirely satisfying. In addition, adding other interventions to exposure therapy (e.g., relaxation, psychodynamic imagery) doesn’t appear to make it any more effective. Exposure seems to work on it’s own; however, without a theory to guide it, structuring exposure sessions can be tricky.
Who Uses Exposure?
Exposure is most often used by cognitive behavioral therapists, particularly those who specialize in anxiety disorders treatment. That said, there’s a lot of therapists who think exposure is a good idea, but who don’t use it in their own practices. Barriers include lack of training, fear that clients won’t tolerate it, and general discomfort with it. Exposure can be intense—for the therapists as well as the client! For example, the blog Psychotherapy Brown Bag has a nice post on the ethics of exposure therapy.
Clinicians seem especially reluctant to use exposure for posttraumatic stress disorder. Even though exposure is a gold standard treatment for PTSD, a survey of 207 licensed psychologists found that 83% never used exposure to treat people with PTSD (Becker et al., 2004). Another survey found that 84% of women with trauma would be willing to engage in exposure treatment after the rationale was explained to them. This suggests that clients are more willing to engage in exposure than therapists.
Why Am I Writing About Exposure?
For me, this series gives me an opportunity to delve into the exposure literature. My experience with exposure is that it can be a very potent intervention, but it requires thoughtful planning to successfully implement. There’s been some fascinating new research about exposure within the past 5 years. We seem to be going through a sea change in our understanding of it. My goal through these posts is increasing understanding of how we might better use exposure as therapists in clinical practice.