Shanda Curiel, PsyD
OCD and Anxiety Psychologist & Primary Therapist
Resilience Treatment Center

When an individual experiences anxiety, the natural inclination might be to flee or minimize engagement in the situation. This can be very helpful in a real-life situation that entails a valid threat of danger. However, when one’s fear is pervasively out of proportion to, or completely irrational for, the context or societal norm, a repeated avoidant reaction can prove harmful in the long-term. In the realm of cognitive-behavioral and behavioral therapy, persistent avoidance that clinically impacts one’s life is conceptualized as a symptom of an anxiety disorder (American Psychiatric Association, 2013). Avoidance reinforces the idea that in order to achieve the same perception of safety, one must repeat this response each time the anxiety-induced stimuli presents itself.

Exposure is an effective therapy intervention used to address the pervasive avoidance symptoms of anxiety. This intervention entails a therapist guiding their patient towards facing their feared object or situation, in some form, to purposely invoke anxiety (Abramowitz, 2013). The same exposure is repeated until the patient habituates or the fear is extinguished (2013). In 1958, Joseph Wolpe originated systematic desensitization that entailed creating a hierarchy of anxiety-provoking situations, whereby individuals are gradually exposed to increasingly difficult stimuli, in addition to relaxation training (as cited in Exposure Therapy, 2015). James G. Taylor, was also a pioneer of exposure therapy (and response prevention) in the 1950s to treat fears of driving and contamination (as cited in Abramowitz, Deacon, & Whiteside, 2012). Franklin and Foa (2008) highlighted another early example of exposure from 1966 when Meyer’s Exposure and Ritual Prevention program attempted to prevent their patient with OCD from engaging in rituals, such as handwashing, by turning off the water; although this may have been successful, it would now be considered too forceful and not generalizable to natural situations where an individual may not have someone to disrupt the maladaptive process (as cited in Barlow, 2008).

There are three broad categories of exposure that include in-vivo, imaginal, and virtual reality (as cited in Exposure Therapy for Anxiety Disorders, 2011). In-vivo exposure entails placing the individual in a realistic scenario that they avoid due to fear. Imaginal exposure typically involves images or words to mentally create the frightening situation, including details that typically cause the individual anxiety (2011). This type of exposure can be very useful when a feared scenario cannot practically, or should not ethically or legally, be created (2011). According to Michaliszyn, Marchand, Bouchard, et al. and Meyerbröker and Emmelkamp (2010), virtual reality exposure entails a visually simulated feared experience (2011).

Notably, the above types of exposure can be further modified depending on the therapist’s therapeutic style, as well as what research indicates should be modified based on the type of anxiety condition. Upon examination of systematic desensitization by Telch, Lucas, and Schmidt, et al. (1993), the exposure component has shown to be more effective than relaxation (as cited in Exposure Therapy for Anxiety Disorders, 2011). According to Ost, Alm, Brandberg, and Breitholtz (2001) and Moulds and Nixon (2006), graded exposure maintains the gradual approach, whereas flooding immerses the individual in their feared scenario from the start of exposures; therapists typically utilize the former due to the level of difficulty of flooding (2011). Resick, Monson, and Rizvi (2008) highlight prolonged exposure for Posttraumatic Stress Disorder, where the individual is exposed to trauma-related stimuli or to recollections of trauma (Barlow, 2008). Franklin and Foa (2008) report that for Obsessive-Compulsive Disorder, therapy should entail prolonged exposure to stimuli that triggers OCD is paired with the omission of compulsions (2008). According to Michelle Craske and David Barlow (2008), interoceptive exposure is used with Panic Disorder, where one purposefully provokes the physiological sensations that create substantial discomfort during anxiety or a panic attack (as cited in Barlow, 2008).

Results of meta-analyses by Norton and Price (2007) and Tolin (2010) demonstrated exposure therapy as effective for anxiety disorders. Once an individual with an anxiety disorder understands the factors maintaining their condition (e.g. avoidance, compulsions) and the efficacy of exposure, they are more willing to confront their fears. Through exposure, they learn that what was once counterintuitive is actually fundamental for ultimate relief.

References:
Abramowitz, J. S. (2013.) The Practice of Exposure Therapy: Relevance of Cognitive-
Behavioral Theory and Extinction Theory. Behavior Therapy, 44, 548–558. Retrieved from http://jonabram.web.unc.edu/files/2012/07/Abramowitz-2013-practice-of-exposure-therapy.pdf
Abramowitz, J. S., Deacon, B. J., Whiteside, S. P. H. (2012). Exposure Therapy for Anxiety:
Principles and Practice. New York, NY: The Guilford Press.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders. (5th ed..). Arlington, VA.: American Psychiatric Association.
Barlow, D. H. (2008). Obsessive-Compulsive Disorder. In M. G. Craske Editor & D. H.
Barlow Editor (Eds.), The Clinical Handbook of Psychological Disorders (pp. 164-215). Retrieved from https://www.researchgate.net/profile/William_Trost/publication/6124095_Dialectical_Behavior_Therapy_for_Borderline_Personality_Disorder/links/00b4951adec520a7fb000000/Dialectical-Behavior-Therapy-for-Borderline-Personality-Disorder.pdf
Barlow, D. H. (2008). Panic Disorder. In M. G. Craske Editor & D. H.
Barlow Editor (Eds.), The Clinical Handbook of Psychological Disorders (pp. 1-64). Retrieved from https://www.researchgate.net/profile/William_Trost/publication/6124095_Dialectical_Behavior_Therapy_for_Borderline_Personality_Disorder/links/00b4951adec520a7fb000000/Dialectical-Behavior-Therapy-for-Borderline-Personality-Disorder.pdf
Barlow, D. H. (2008). Posttraumatic Stress Disorder. In M. G. Craske Editor & D. H.
Barlow Editor (Eds.), The Clinical Handbook of Psychological Disorders (pp. 65-122). Retrieved from https://www.researchgate.net/profile/William_Trost/publication/6124095_Dialectical_Behavior_Therapy_for_Borderline_Personality_Disorder/links/00b4951adec520a7fb000000/Dialectical-Behavior-Therapy-for-Borderline-Personality-Disorder.pdf
Goodtherapy.org. (2015). Exposure Therapy. Retrieved from
http://www.goodtherapy.org/learn-about-therapy/types/exposure-therapy
Psychiatric Times. (2011). Exposure Therapy for Anxiety Disorders. Retrieved from
http://www.psychiatrictimes.com/anxiety/exposure-therapy-anxiety-disorders
*Some information based on clinical experience and knowledge of patient symptomatology.