Overview

Exposure Therapy is a powerful tool that helps people confront and conquer their fears, anxieties, and discomfort associated with challenging internal experiences including emotions, bodily-sensations, and mental processes (such as thoughts, predictions, imagery and memories that can otherwise cause distress). Exposure is a well-established psychological treatment, grounded in decades of research, and it has helped countless people regain control over their lives. This guide will walk you through the basics of Exposure Therapy, its history, success, and benefits. We’ll also provide a step-by-step guide to creating an exposure hierarchy and introduce complementary skills like mindfulness, self-regulation, and urge surfing that enhance the effectiveness of this therapy. 

 

What is Exposure Therapy?

Exposure Therapy is a type of cognitive-behavioral therapy (CBT) that involves gradually exposing a person to the source of their anxiety or fear in a controlled and systematic way. The goal is to help them confront these situations or memories in a safe environment, reducing their fear and avoidance over time.

 

A Brief History

Exposure Therapy has its roots in the early 20th century, emerging from the work of behaviorists like Ivan Pavlov and John B. Watson. The technique was further developed by psychologists such as Joseph Wolpe, who introduced systematic desensitization in the 1950s. Since then, it has evolved into a cornerstone of modern CBT, supported by a robust body of research demonstrating its effectiveness in treating anxiety disorders, phobias, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and more.

 

Success and Benefits

Research consistently shows that Exposure Therapy is one of the most effective treatments for anxiety-related conditions. By facing their fears in a controlled setting, individuals learn that their anxiety decreases over time, and the situations they feared are not as dangerous or unmanageable as they once believed.

 Key Benefits:

 

• Reduction in Anxiety: Exposure Therapy helps decrease anxiety levels by allowing individuals to experience the feared situation without the expected negative consequences.
• Increased Confidence: As individuals successfully confront their fears, they gain confidence in their ability to manage anxiety-provoking situations.
• Improved Quality of Life: By reducing avoidance behaviors, people can engage more fully in life activities, leading to greater satisfaction and well-being.

 

Creating an Exposure Hierarchy

An exposure hierarchy is a tool used in Exposure Therapy to systematically confront fears, starting with less anxiety-provoking situations and gradually working up to more challenging ones. Here’s how you can create your own exposure hierarchy:

1.     Identify Your Target Fear: Start by identifying the specific fear or situation you want to address. Identify what your mind is predicting (be honest with yourself can be as detailed as possible). Write this down. 

2.     List Scenarios: Next, brainstorm different scenarios related to your fear, from least to most anxiety-provoking. For example, if you have a fear of public speaking, your list might include:

• Speaking in front of a mirror.
• Recording yourself speaking.
• Speaking in front of a trusted friend.
• Speaking in a small group.
• Giving a presentation to a larger audience.

3.     Rank the Scenarios: Assign each scenario a number from 0 to 100 based on how much anxiety it causes you, with 0 being no anxiety and 100 being the most anxiety. 

4.     Start Small: Begin with the scenario that causes the least anxiety. Practice this situation until your anxiety decreases significantly, then move on to the next one. Sometimes this can require you to stay in a situation for longer and longer periods (you can time yourself and aim for longer and longer periods). For experiences that happen quickly, ‘longer time’ in the experience might not be possible. In such case, repeat the exposure several times until you feel more comfortable in yourself. 

5.     Gradually Progress: Continue working through your list, gradually facing more challenging scenarios as your confidence and comfort grow. Ideally you should aim to work withing your Window of Tolerance, which means you are challenged but not overwhelmed. A general guide is to choose challenges that are within the 40-70 range. Any less, and it will be too easy. Any greater than 70 and you may find it too challenging.  

 

Complementary Skills

Often, when embarking on a program of Exposure Therapy, your feelings may become more intense. Although the intention behind starting small is to build confidence, depending on what you may be working on you may still feel some discomfort. This is normal and to be expected and the more able you are to tolerate discomfort the more likely you will succeed. For this reason it can be helpful to build and incorporate skills that can help you stay within your Window of Tolerance so that you can succeed. Here are some complementary practices:

Mindfulness: Mindfulness involves staying present in the moment and observing your thoughts and feelings without judgment. Practicing mindfulness during exposure can help you manage anxiety and stay grounded.

Self-Regulation Skills: Learning to regulate your emotions is crucial for managing anxiety. Techniques like deep breathing, progressive muscle relaxation, and grounding exercises can help you stay calm during exposure exercises.

Urge Surfing: Urge surfing is a technique used to ride out intense urges or emotions without giving in to them. By acknowledging and observing the urge without acting on it, you learn that these feelings will pass, and you don’t have to avoid the situation.

Self-Compassion skills: Compassionate-Mind Training involves a set of skills that are motivated by a caring mentality that are useful for helping us  understand and accept the challenges of what we may be feeling while also encouraging us to endure difficulties despite any setbacks we may encounter along the way. 

Combining psychological skills with Exposure Therapy will enhance your capacity for challenges that may arise. Being able to remain calm and present while experiencing situations that challenge you, will make exposure therapy easier and will ensure that you can succeed. Ultimately this is about helping you broaden and remain within your Window of Tolerance, which will make any Exposure Therapy you do a more comfortable and confidence-inspiring experience.

 

 

Applying Exposure Therapy to Different Areas

In combination with the Complimentary Skills listed above, Exposure Therapy is versatile and powerful – it can be applied to a wide-range of experiences that you ultimately find challenging.  Below are some examples of how someone might use exposure therapy to gain more comfort about bodily sensations that can otherwise give rise to a panic attack, exposure to challenging emotions, and overcoming procrastination. 

Interoceptive Exposure: Panic Attack Symptoms

Interoceptive exposure involves deliberately exposing yourself to physical sensations that are often associated with anxiety or panic, such as increased heart rate, dizziness, or shortness of breath. This type of exposure helps you become more comfortable with these sensations, reducing the fear and avoidance behaviors that can contribute to anxiety disorders, particularly panic disorder.

How it can Help:

Interoceptive exposure is particularly effective for individuals with panic disorder, generalized anxiety disorder, or those who experience significant anxiety about bodily sensations. By repeatedly experiencing these sensations in a controlled way, you learn that they are not harmful and that you can tolerate them without panicking or catastrophizing.

 

Example of an Interoceptive Exposure Hierarchy:

Mild Sensations:

• Spinning in a chair: Induces mild dizziness.
• Breathing through a straw: Mimics shortness of breath.
• Holding your breath: Causes a slight feeling of suffocation.

Moderate Sensations:

• Running in place: Increases heart rate.
• Hyperventilating for 30 seconds: Creates lightheadedness.
• Wearing tight clothing: Causes a sensation of chest tightness.

Intense Sensations:

• Spinning rapidly for 1 minute: Induces strong dizziness.
• Breathing through a straw while running in place: Combines shortness of breath and increased heart rate.
• Holding breath longer (up to discomfort): Mimics suffocation.

 

Start with the mildest sensations and gradually work your way up as your comfort increases. Repeat each exercise until your anxiety decreases significantly. 

 

Exposure to Challenging Emotions

Emotional exposure involves deliberately confronting and sitting with difficult emotions, such as sadness, anger, or fear, without trying to suppress or avoid them. This practice helps you become more comfortable with these emotions, reducing the need for avoidance or maladaptive coping strategies.

How it can Help: 

By repeatedly exposing yourself to challenging emotions, you learn that these feelings, while uncomfortable, are not dangerous and will pass. This can reduce the intensity of emotional reactions over time and increase emotional resilience.

 

Example of an Emotional Exposure Hierarchy:

Mild Emotional Triggers:

• Watching a sad movie scene: Induces mild sadness.
• Listening to a song that evokes nostalgia: Brings up a mix of emotions.
• Reading a news article on a challenging topic: Stirs mild anxiety or frustration.

Moderate Emotional Triggers:

• Revisiting a past conflict: Brings up feelings of anger or guilt.
• Reflecting on a personal loss: Elicits deeper sadness or grief.
• Discussing a sensitive topic with a close friend: Evokes vulnerability or fear.

Intense Emotional Triggers:

• Writing a letter to someone you have unresolved feelings towards: Induces strong emotions.
• Imagining a worst-case scenario: Triggers deep fear or anxiety.
• Engaging in a difficult conversation about personal boundaries: Confronts fear of rejection or anger.
• As with other types of exposure, start with milder emotional triggers and work your way up to more intense experiences. Practice sitting with the emotions without reacting or avoiding them.

 

 

Exposure for Overcoming Procrastination

Procrastination often stems from anxiety or fear related to the task at hand, such as fear of failure, perfectionism, or feeling overwhelmed. Exposure for procrastination involves gradually confronting these tasks in a structured way to reduce avoidance and build confidence in your ability to complete them.

How it Can Help: 

By facing the tasks you’ve been avoiding, you break the cycle of procrastination, reduce task-related anxiety, and build a sense of accomplishment. Over time, this leads to more productive habits and a greater sense of control.

 

Example of an Exposure Hierarchy for Procrastination:

Mildly Avoided Tasks:

• Opening the task list: Simply reviewing what needs to be done.
• Setting up your workspace: Preparing the environment without starting the task.
• Spending 5 minutes on a task: Committing to a very short period of work.

Moderately Avoided Tasks:

• Completing a small, straightforward task: Such as replying to an email or organizing files.
• Breaking down a larger task into smaller steps: Starting with the easiest step.
• Working for 15-20 minutes on a more challenging task: Building focus and momentum.

Intensely Avoided Tasks:

• Tackling the most daunting task on your list: Such as starting a big project or making a difficult phone call.
• Working on a task without stopping for an hour: Pushing through discomfort.
• Completing a task to the best of your ability without perfectionism: Allowing yourself to finish even if it’s not perfect.

Begin with tasks that you mildly avoid, gradually working up to those that cause more anxiety. The goal is to reduce avoidance by showing yourself that you can handle these tasks.

 

Conclusion

Exposure Therapy is a well-researched and effective method for overcoming fears, anxieties, and other challenges such as confronting situations that can evoke difficult emotions and sensations in the body. By systematically facing your fears in a structured and gradual way, you can reduce anxiety, build confidence, and improve your quality of life and enhance your overall well-being. Remember, this journey is about progress, not perfection. Each small step forward is progress, and over time, these small steps add up to significant change. As you take one step at a time, and celebrate each victory along the way. With courage and persistence, you can overcome your fears and live a fuller, more empowered life.

 

If you are experiencing difficulties with fear, challenging emotions or if you would like assistance with embarking on a program of exposure therapy, contact me below. I am a Clinical Psychologist with over 15 years experience. 

 

Further Resources

• Emotion Regulation skills: Understanding your Window of Tolerance
• Learn about your Brain’s Threat System
• Learn about the physiology of self-criticism
• Calm yourself quickly with Soothing Rhythm Breathing
• How to deal with negative thinking
• Learn about Anxiety and Anxiety Disorders
• A list of all articles I have written