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Exposure Therapy is a cognitive behavioral therapy technique for reducing fear and anxiety responses, especially phobia. It is similar to Systematic desensitization, though it works more quickly and produces more robust results. It is also very closely related to Exposure and response prevention, a method widely used for the treatment of Obsessive-compulsive disorder. It based on the principles of habituation and cognitive dissonance.
A typical example of the use of Exposure Therapy might be the treatment of a person with a phobia of snakes. The subject experiences an extreme revulsion when they encounter a snake; this would often not be associated with any feared consequence (so they don’t think it’s going to bite them) but rather with an evaluation of it as ‘horrible’ or ‘slimy’. The sight of a snake triggers an unthinking state of arousal, which can be relieved by escaping from the situation. Such escape behavior (or, more precisely, the habit-strength of the arousal-escape connection) is thus reinforced, but it also strengthens the link between snakes and arousal (the stimulus-arousal connection). Thus, the next time a snake is encountered, the arousal response may be stronger or the stimulus may not need to be as powerful to evoke the same degree of arousal – it might be, for instance, that a photograph of a snake might have the same effect that a real snake had previously.
Exposure Therapy would consist of the client (instructed and guided by the therapist) exposing themselves to progressively stronger stimuli and thereby experiencing habituation.
How to do Exposure Therapy
Some of the rules for constructing a good program of Exposure Therapy are:
- The subject should have a final goal which should represent non-phobic behavior. This might be (for example) to hold a large snake and rub it against their cheek for several minutes.
- They should also have in mind a series of intermediate steps such that once they have partially habituated to one step the next is close enough to it that they can readily move on. Such a sequence is called a hierarchy. It may be explicit, in the form of a list of increasingly challenging tasks, or implicit, in the form of a set of principles for escalating the exposure. The therapist will decide which of these will be more useful for the subject. (A useful way of constructing such a hierarchy is the Method of Factors.
- At every stage the subjects self-exposure should be completely voluntary - a criterion that may be derived from the theory of cognitive dissonance. One important corollary of this principle is that, at every moment, the subject must have an easy way of terminating the exposure. By choosing not to escape - and therefore practising a competing response - the subject thereby weakens the arousal-escape connection.
- The arousal experienced at any point should be the maximum that the subject is prepared to accept (this is the main difference between Exposure Therapy and Systematic desensitization). It's useful if at each stage the subject asks themselves "is there anything more I could do?" By considering which factors they can manipulate they should be able to keep moving smoothly up their hierarchy.
- Research by Marks and Rachmann[How to reference and link to summary or text] demonstrated that optimum results are obtained with daily practice lasting at least an hour; and that the daily session should be ended by allowing the level of arousal to fall off to around half its peak value. For this reason it's useful for the subject to keep a note of their arousal level on a 0-8 scale (where 0=no arousal and 8=intolerable arousal). Before this fall-off phase the level of arousal should be maintained at an uncomfortable but tolerable level.
Potential problems with Exposure based therapies
What are the side effects of exposure based therapy? As with any form of psychotherapy, there may be a temporary increase in distress; distressing and unresolved memories may emerge; some clients may experience reactions during a treatment session that neither they nor the administering clinician may have anticipated, including a high level of emotion or physical sensations Subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories feelings, etc., may emerge.
Possible contraindications for exposure based therapy Bryant & Harvey (2000) suggest that caution be exercised and the use of exposure be seriously questioned when the acutely traumatised client presents with one of the following problems: • extreme anxiety • panic attacks • marked dissociation • borderline personality disorder • psychotic illness • anger as a primary trauma response • unresolved prior traumas (e.g. refugees) • severe depression or suicide risk • complex co-morbidity • substance abuse not in stable remission • marked ongoing stressors (e.g. medical procedures) • acute bereavement - Patients living in dangerous circumstances - health problems that preclude exposure to intense physiological arousal - severe organicity - limited cognitive capacity, - pending litigation - compensation seeking - stage of change
There are a number of contraindications for using traditional hypnotic/trance techniques: In the rare cases of individuals who are refractory or minimally responsive to suggestions, hypnotic techniques may not be the best choice, because there is some evidence that hypnotizability is related to treatment outcome efficacy. Some PTSD patients may be reluctant to undergo hypnosis/trance, either because of religious belief or other reasons. If the resistance is not cleared after dispelling mistaken assumptions, other suggestive techniques can be tried, including emotional self-regulation therapy (ESRT), which is done with open eyes and uses sensory recall exercises rather than a hypnotic/trance induction.
In cases where exposure is contraindicated, other techniques, including anxiety management, cognitive therapy or pharmacological intervention may be effective (Bryant & Harvey, 2000).
Potential obstacles to exposure therapy
• Excessive avoidance A common obstacle to treating ASD is the extent to which the person actively avoids confronting his or her traumatic memories or feared situations. Clients may engage in overt or covert avoidance strategies to minimise distress during exposure. For example, clients may think of less distressing aspects of the trauma to limit their distress. Rationale for exposure may need to be further discussed. Clients may feel more comfortable in doing exposure on less distressing aspects of the trauma before moving onto more distressing ones. NOTE: Exposure is based on the principle that avoidance is maladaptive. In the acute phase following a disaster, the therapist must be cautious in defining avoidance as maladaptive because avoidance can often be a useful coping mechanism. Research suggests that ongoing and pervasive avoidance tends to be problematic. Many avoidance tendencies observed in the acute phase will ease as time progresses.
• Dissociation Dissociation can impede activation of fear networks and preclude habituation because of limited emotional engagement. This may be overcome by directing attention to emotions that are accessible but be wary that the client may need this defence to avoid memories they are unable to currently manage.
• Anger Anger is a very common response after a traumatic experience. Anger responses are particularly prevalent in victims of violent crime. Research indicates that anger responses to trauma memories will not benefit markedly from exposure because these individuals do not experience elevated fear relative to their anger. Cognitive therapy may be a more beneficial approach in these cases.
• Bereavement/grief Grief is a very common condition after a traumatic event when a loss has occurred (Raphael & Martinek, 1997). Moreover, posttraumatic stress and grief interact to compound the clinical presentation (Goenjian et al, 1995). The use of exposure in the acute trauma phase should be exercised cautiously, if at all, with people who present with grief issues. Acute grief reactions may also be characterised by intrusive symptoms, numbing, and a degree of avoidance as described above, but these phenomena differ from those of traumatic stress reactions. The bereavement process requires time, however, and it may not be appropriate to provide the acutely grieving client with exposure when she or he is coming to terms with loss. Recognising the need for people to proceed through the grieving process often involves not overburdening clients with exposure in the acute phase.
• Catastrophic beliefs Repeated exposure may not benefit clients who interpret their memories in a catastrophic or overly negative way. Issues of guilt, responsibility, and blame may be particularly prevalent in these cases. Cognitive therapy should be actively pursued in conjunction with exposure.
• Ambivalence / low motivation Clients may not participate in exposure because of poor motivation to cooperate in this approach. They may require the rationale for exposure to be revisited and the client’s motivation for treatment to be re-evaluated.
Impact of assessment
The clinician should be sensitive to the impact of the assessment on the acutely traumatised, bereaved or affected person. In the initial month after a trauma, many people are highly distressed, are functioning in a chaotic environment, and are attempting to deal with many changes. In this context, the client often presents as fragile and is striving to retain some control over their turbulent environment. A poorly conducted assessment has the potential to place additional stress on a person if it is perceived as a continuation of the initial traumatic experience. In extreme cases, poorly conducted assessments may have contributed to suicidal attempts by fragile individuals. Accordingly, the assessment should commence with recognition by the clinician that material covered in the assessment may be distressing, and the client should be explicitly invited to communicate such distress to the person carrying out the assessment. The concept of a ‘therapeutic assessment’ should be the basis for this process. This means ensuring the assessment process ‘does no harm’, and that as far as possible it is: helpful to the person, timed to their individual reactions and takes their needs into account. The process of history-taking about their experiences, and the various stressors involved can commence the process of dealing with these in manageable ways. It can lead into and become the basis for therapy, if this is necessary. The clinician should also inform the client that the opportunity for respite during the assessment is available. Clinicians should be sensitive to the client’s responses to the assessment. Capacity to tolerate an assessment can be an important indicator of the client’s subsequent response to therapy. It is often useful to inform clients that they may experience an exacerbation of re-experiencing symptoms after the assessment and that this is part of the process of resolving the traumatic experience (Bryant & Harvey, 2000).
Specialist referral is necessary in some instances and should be carried out supportively. The problems outlined below need particular attention and referral to professional services specialising in these. • Extreme agitation, particularly if it leads to actions that are life-threatening to the self or others. • Overt psychiatric disturbance requiring care in its own right, for example, ‘psychotic’ decompensation where the affected person appears out of touch with reality and perhaps even responding to hallucinations or delusions. This is rare but may occur. • Prolonged denial of reality. Some shutting out of what has happened is natural initially but the person who continues, for example, to talk about somebody who has died as if he or she was still alive is likely to need specialist care. • Persons distressed by overwhelming bouts of anxiety, dread, or panic when the danger has long since passed. Some panic is natural in the beginning but when this does not gradually fade and lessen in intensity as the weeks and months progress, then specialised assistance is probably necessary. • Although some depression is very likely in the aftermath of trauma a picture of severe depression, accompanied by hopelessness, unremitting despair and a loss of belief in any worthwhile future indicates a severe response. In addition, if self-esteem is low, sleep severely impaired, there is marked weight loss and loss of interest in the world, and a general slowing-down in all activities, then a depressive illness should be suspected and specialist assistance sought urgently. • Although suicide is not that common after trauma, one should be alert to the possibility that feelings of hopelessness may be associated with this level of despair. Similarly a bereaved person preoccupied with thoughts of reunion with someone who has died should be of concern. • Body complaints particularly mild, ill-defined and chronic complaints such as listlessness and headaches, often accompanied by irritability and sleep disturbance, may reflect chronic, hidden and unresolved psychological distress that requires assessment, possible psychiatric illness, or a risk of developing physical ill-health. • Disturbed interpersonal relationships appear as a severe and prolonged disturbance of the capacity for interpersonal relationships (for instance in family or marital breakdown, rejection or the formation of only transient relationships). • Posttraumatic stress disorder. This is a serious and disabling condition and often becomes chronic unless treated early in its course and with the most effective forms of treatment (EMDR or Trauma Focussed CBT). People with such indicators should be referred to specialist professionals and services for assessment and care. People with PTSD are also at increased risk of other psychiatric problems such as severe depression or alcohol and other drug problems and thus may develop a series of chronic conditions needing care. • Alcohol or medication abuse may be another symptom of the person’s attempts to deal with unresolved psychological distress related to the trauma experience. Many attempt to shut out or numb painful experiences in this way, but such coping devices usually only lead to further difficulties. If this cycle cannot be broken by the support being provided, specialist referral is suggested.
However, it must be emphasised that exposure is not suitable for everyone, for example, the bereaved and torture survivors. There are a number of potential barriers to conducting exposure therapy and also certain groups with which this technique is contraindicated (Bryant & Harvey, 2000).
- Marks I (1979) Exposure therapy for phobias and obsessive-compulsive disorders. Hosp Pract. Feb;14(2):101-8.
- Marks I (1981) Cure and Care of Neuroses John Wiley & Sons Inc 0-471-08808-0
- De Silva P, Rachman S. (1981) Is exposure a necessary condition for fear-reduction? Behav Res Ther. 19(3):227-32.
- De Silva P, Rachman S. (1983) Exposure and fear-reduction. Behav Res Ther. 21(2):151-2.
- Cobb J. (1983) Behaviour therapy in phobic and obsessional disorders. Psychiatr Dev. Winter;1(4):351-65
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