Exposure Therapy: Definition, Types, Approaches, and More

It’s normal behavior to want to avoid something that one feels afraid of. After all, avoidance can offer a sense of relief. Unfortunately, the more you avoid confronting your fear, the more it becomes reinforced. Exposure therapy aims to address this avoidance behavior.

Learn more about exposure therapy in this article. We’ll discuss how it works, different exposure therapy techniques, and the conditions it helps with, including its risks and limitations.

What is Exposure Therapy?

Exposure therapy is a type of cognitive-behavioral therapy (CBT) with a strong scientific basis to treat different conditions, such as generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, phobias, and panic disorder [*].

The techniques behind exposure therapy can be traced back to the experiments conducted by Ivan Pavlov, a physiologist who discovered classical conditioning. His experiments with dogs have shown how neutral stimuli (the sound of a bell) can be associated with food. This has led to the understanding that behaviors can be learned and modified over time [*].

Besides Pavlov, Mary Cover Jones (a behaviorist and student of John B. Watson) conducted experiments in the 1920s involving a young boy who suffered from a specific phobia. She helped him overcome his intense fear of white rabbits by pairing a rabbit with a pleasant stimulus which was food [*].

How Does Exposure Therapy Work?

In exposure therapy, a psychologist, exposure therapist, or counselor systematically exposes the client to their feared stimuli or situation. This exposure can be imaginal or the client confronts the stimuli in real life (also called in vivo exposure). In cases where in vivo exposure isn’t possible, virtual reality technology may be used [*].

Mental health professionals may implement an exposure hierarchy or a “fear ladder.” This technique entails starting the exposure using low anxiety situations and moving towards more challenging ones (higher level fears) based on the client’s comfort level.

For example, if a child or teen is fearful of social situations, such as public speaking, the exposure ladder involves watching videos of a child giving speeches. Next, they’ll be delivering a speech alone, until they agree to give a speech in front of others.

What are the Types of Exposure Therapy?

There are various types of exposure therapy based on the exposure technique used and their timing. Techniques include:

• In vivo exposure. The term “in vivo” means “within the living,” which implies that the feared object is confronted in real life. For example, if a child has a fear of dogs, in vivo exposure can involve watching dogs from a distance or across the street under supervision.
• Imaginal exposure. A professional provides a safe environment for the client to confront their anxieties and fears using guided visualization or imagination exercises. For example, the child who fears dogs may be asked to discuss their past experiences with dogs and describe their feelings.
• Virtual reality exposure. The client will be introduced to virtual reality (VR) technology. Here, the therapist creates a virtual environment with the client’s trigger (dogs, for example).
• Interoceptive exposure. This involves intentionally inducing symptoms and sensations caused by the client’s fear. Research shows that it can address anxiety sensitivity in panic disorder [*]. The goal of this exposure is to help the client understand that although they experience symptoms, they can be managed and are only temporary.

As for the different types of exposure therapy based on the timing of exposure, they include the following:

• Graded exposure. Also called “gradual exposure,” this approach involves rating their feared objects or situations according to their intensity or the level of fear they induce. Next, the therapist begins the client’s therapy, starting with mild exposures and then proceeds to moderately difficult ones.
• Systematic desensitization. For this approach, gradual exposure and relaxation techniques are combined. On that note, the therapist first teaches the client relaxation methods, such as deep breathing, progressive muscle relaxation (PMR), and guided imagery.
• Flooding .As the term suggests, flooding is an intense form of exposure in which the client begins with the most anxiety-provoking stimulus. There’s no gradual buildup of intensity unlike with graded exposure. It’s important to note that flooding isn’t appropriate for everyone, particularly clients who find their experience “too traumatic.”

What Conditions Can Exposure Therapy Help Manage?

Exposure therapy can be effective for a wide range of conditions affecting children and adolescents — not just adults. These conditions include [*]:

• Anxiety disorders (e.g., phobias, social anxiety disorder, panic disorder, separation anxiety)
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)

Keep in mind that in some cases, exposure therapy may be used as part of a comprehensive treatment plan. It may also be paired with cognitive restructuring, which involves noticing and changing unhelpful thoughts that increase anxiety [*].

How Long Does Exposure Therapy Take?

The duration of exposure therapy varies depending on the client’s unique situation and treatment plan. A few weekly sessions lasting an hour may be needed for clients to experience a reduction in their symptoms.

For example, a client with PTSD may have sessions lasting 90 to 120 minutes during their initial treatment phase. As treatment progresses, these sessions can be as short as 20 minutes [*].

Regardless of the timeline involved, parents and caregivers supporting children should keep in mind that any progress is considered valuable.

What are the Risks of Exposure Therapy?

Although it is supported by research, clients may decide to drop out or stop going to therapy due to trauma reactions. Not being able to control their emotional responses during exposure exercises could interfere with their adherence to therapy.

Below is a list of potential risks to be aware of:

• Feelings of distress and discomfort during exposure
• Re-traumatization
• An increase in intrusive thoughts
• Concerns about potential harm, especially when conducted with children

Since clients who feel anxious normally engage in avoidance behaviors, therapists working with children can frame exposure exercises as “experiments” to test out their worries. They can, for instance, tell the child to imagine themselves as detectives who will examine their worries, and gather clues in the process [*].

What are the Limitations of Exposure Therapy?

Some people might ask, “When is exposure therapy not recommended?” It may not be an ideal option for those who are in acute crisis or having suicidal thoughts. Teens who have a history of violence or are struggling with substance abuse issues might get triggered during exposure.

That being said, exposure is not right for everyone. This is why it’s important for therapists to carefully evaluate a client. Besides their mental health condition, their intellectual ability, readiness, and willingness also influence the suitability of exposure therapy.

For clients who have received exposure therapy but are having limited progress, their provider may consider other alternative treatments. Dialectical Behavior Therapy (DBT) can be one alternative.

On the other hand, some psychologists vary in their beliefs about exposure therapy. A 2023 study found that not having enough theoretical knowledge or understanding of principles can prevent professionals from using exposure therapy on clients [*].

The Bottom Line

Research supports exposure therapy for treating different anxiety disorders, panic disorder, PTSD, and OCD. In this type of intervention, clients learn to tolerate their fears by getting exposed to them. If you are considering it for your child or teen, be sure to look for a therapist with background and specialized training.

Exposure therapy may be effective in reducing anxiety — but an experienced therapist and support from parents also influence the success of the therapy.

If you need resources and tools to complement your child’s exposure therapy, check out our Anxiety Collection and Trauma Collection.

References:

1. What Is Exposure Therapy? (2017, July 31). https://www.apa.org. https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy
2. Böhnlein, J., Altegoer, L., Muck, N. K., Roesmann, K., Redlich, R., Dannlowski, U., & Leehr, E. J. (2020, January 1). Factors influencing the success of exposure therapy for specific phobia: A systematic review. Neuroscience & Biobehavioral Reviews/Neuroscience and Biobehavioral Reviews. https://doi.org/10.1016/j.neubiorev.2019.12.009
3. Classics in the History of Psychology -- Introduction to Jones (1924) by A. Rutherford. (n.d.). https://psychclassics.yorku.ca/Jones/intro.htm
4. Wald, J., & Taylor, S. (2005, March 1). Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report. Cognitive Behaviour Therapy. https://doi.org/10.1080/16506070510010648
5. Ford, J. D. (2009, January 1). Treatment of Adults with Traumatic Stress Disorders. Elsevier eBooks. https://doi.org/10.1016/b978-0-12-374462-3.00007-1
6. Beidel, D. C., Neer, S. M., Bowers, C. A., Newins, A. R., Tuerk, P. W., Cunningham, C. A., Mooney, S., Hauck, H. N., & Jett, M. (2020, March 1). Trauma Management Therapy and Prolonged Exposure Therapy for PTSD in an active duty sample: Design and methodology of a randomized clinical trial. Contemporary Clinical Trials Communications. https://doi.org/10.1016/j.conctc.2019.100491
7. Gola, J. A., Beidas, R. S., Antinoro-Burke, D., Kratz, H. E., & Fingerhut, R. (2016). Ethical Considerations in Exposure Therapy With Children. Cognitive and behavioral practice, 23(2), 184–193. https://doi.org/10.1016/j.cbpra.2015.04.003
8. Moses K, Gonsalvez CJ, Meade T. Barriers to the use of exposure therapy by psychologists treating anxiety, obsessive-compuslive disorder, and posttraumatic stress disorder in an Australian sample. J Clin Psychol. 2023 Apr;79(4):1156-1165. doi: 10.1002/jclp.23470. Epub 2022 Nov 30. PMID: 36449416.