What is meant by the term exposure therapy?
Exposure therapy is one of the classic methods of cognitive behavioral therapy. It is also called confrontation therapy and is often used to treat anxiety. In this method, you learn to face what scares you, step by step. This requires a lot of courage and can even seem almost impossible at first.
But the good thing is that you don't do exposure therapy alone; it is part of psychotherapy. This means that you prepare and carry out the exposure therapy together with your therapist.
Therapy process: Establishing a fear hierarchy
At the beginning of exposure therapy, you and your psychotherapist will create a so-called “fear hierarchy.” This means that you consider which situations trigger fear in you. Most people experience fear in several situations, not just one.
For example, for people who are afraid of crowds, both a visit to the mall and a ride on a crowded subway can trigger anxiety. To begin, write down all the situations that trigger anxiety. Then rate them on a scale of 0-10 (0 = no fear at all; 10 = very fearful).
Example of a fear hierarchy
This is what a fear hierarchy for fear of crowds ( agoraphobia ) could look like:
2 – stand in the longest line at the
supermarket
4 – walk to the metro and stand on the platform
5 – walk over a long bridge and look down
7 – take the elevator
9 – go to the shopping center on the weekend
10 – take the subway
Once you have created a fear hierarchy, the question is of course what level of difficulty exposure therapy should begin with. Most often, people start with a medium level of difficulty and then gradually increase the level.
In exposure therapy, such a gradual approach, in which one begins with a level of mild or moderate difficulty, is also called "gradual exposure." If one begins directly with the highest level of difficulty, however, this is referred to as "flooding."
We know from experience that many people find it easier not to start with the most difficult task. Tackling a moderately difficult task is already a big step.
Why does exposure therapy work?
Many people who are offered exposure as part of psychotherapy initially react with rejection: Why should I face my biggest fears? I don't want them to get any bigger, I want them to go away!
This attitude is understandable. After all, it makes sense to stay away from something that scares us and not to move towards it intentionally. And let's be honest - just the thought of facing the fear can trigger anxiety in the moment and lead to physical reactions.
Many people expect that when they enter fear-inducing situations, their fear will increase to an unfathomable level, and that they may even go crazy, die, or be harmed. It is true that fear initially increases when we encounter it. However, contrary to our expectations, it also decreases again if we stay in the situation long enough.
Of course, it is important that the situation does not pose any real danger. This is exactly the case with many fears. Often, a situation that is actually harmless (such as riding in an elevator) or a harmless physical reaction (such as an increased heart rate) is assessed as dangerous by people who suffer from an anxiety disorder, and fear arises.
So it is completely normal for fear to arise in the fearful situation at first. This is actually important, because it is the only way it can subside on its own if you face the situation long enough. And we know from practice: It works. Exposure therapy is one of the most effective methods available in psychotherapy for anxiety disorders.
The meaning of fear
Fear is actually there to help you: it is supposed to show you when something that is very important to you is in danger. This way you can react quickly and solve the problem. But if fear sounds the alarm when there is little or no danger, it can limit you more than it helps you.
In many cases, fear once served us an important purpose. Perhaps we were bullied at school, for example, and it was therefore very important for us to be careful not to behave "wrongly." Fear reminded us to constantly observe our behavior and correct it if necessary. As adults, however, we have grown out of this stressful situation. We must understand that bullying says much more about our classmates than about ourselves. In order to recognize that fear is unfounded today and is doing us more harm than good, we must face this fear. By stopping constantly controlling ourselves and allowing ourselves to make "mistakes" now and again, we may be able to recognize that we are liked just the way we are.
Plan the exposure well
As soon as you and your therapist have decided which situation you want to face at the beginning, it's all about creating a plan. Successful exposure requires good preparation. When should the exposure take place and where? How exactly do you want to face your fear during the exposure? When doing the first confrontation exercises, it is advisable to do them with your psychotherapist at your side. Later on, it may also be possible and useful to face certain situations alone.
Before exposure therapy, you will also consider together which methods you normally use to distract or calm yourself down from the fear during the situation. Because that is exactly what you should avoid in exposure therapy. Even if distraction or calming down sounds good at first:
The point of exposure is to face your fear until it goes away on its own.
If you distract yourself or use certain calming agents before the anxiety subsides on its own, this can lead to the anxiety subsiding in the short term but remaining there in the long term. This is because your brain registers that you distracted yourself or used calming agents to deal with the anxiety. This leads you to continue to assume that the situation is dangerous and should be avoided at best.
Possible distraction and calming strategies could be:
- Distract yourself by listening to music, using your smartphone, reading a magazine or book
- other people involved in a conversation
- imagine being somewhere else
- Bring calming items such as water bottles, emergency numbers or energy bars
- Be near an exit, toilet or medical assistance
However, through exposure therapy, you learn that you can tolerate the fear and that it will subside on its own if you stay in the situation long enough. You may also then notice that your worst fears are not coming true and that the situation is less dangerous than you initially thought.
Keep going
In most cases, repeated exposure is needed for the fear to diminish. This only seems logical when you consider how long the fear has probably existed. You can imagine it like this: If you take the same route to work every day for years, but one day it is blocked off by construction work, it will probably take a few times before you get completely used to the new route. You might drive down the old route a few times at the beginning and only remember when you see the construction work that it is currently closed to traffic. After a while, however, the new route becomes your usual route and you drive along it automatically.
It's the same with fear. You first have to get used to no longer automatically avoiding situations that scare you. This way you can master the situations and experience the fear slowly subsiding. So it's worth sticking with it. Over time you can increase the difficulty level of the exposure exercises and thereby master all the situations in your fear hierarchy step by step.
When is exposure therapy useful?
Exposure therapy is used to treat various illnesses in which fears and avoidance behaviour play a role and impair daily life. These include, for example, social phobias, specific phobias such as spider phobia, but also a so-called generalised anxiety disorder, in which many different worries and fears come together. Because fears and avoidance also play a major role in obsessive-compulsive disorder or post-traumatic stress disorder, exposure therapy can also be helpful here. Exposure therapy has also proven to be very effective in panic attacks.
However, it is important to note that exposure is usually only one component of therapy. It is well prepared and not carried out in the first few therapy sessions.
In addition to confrontation therapy, you will also learn a lot about how the fears arose in cognitive behavioral therapy. You may practice a relaxation technique or learn a new way of dealing with negative thoughts, unpleasant feelings or accompanying panic attacks.
When is exposure therapy not useful?
For most people, exposure therapy can be carried out without any concerns. Even though anxiety symptoms such as heart palpitations, dizziness or trembling often feel very dangerous for the body, they usually are not. However, exposure therapy may not be suitable for some physical and mental illnesses such as epilepsy, schizophrenia or bipolar disorder. However, you should always clarify this with a doctor and psychotherapist in advance as part of your psychotherapy.
Effective digital exposure therapy
Confrontation therapy is now not only carried out in traditional therapy sessions, but is also part of online therapy programs. The Empowerment Avenue Panic program, for example, can effectively reduce panic attacks and uses classic methods of cognitive behavioral therapy.
Just like in on-site psychotherapy, the online therapy course uses texts and videos to prepare for confrontation and to create a fear hierarchy. You will then be instructed to face your fears step by step in so-called "courage projects". In addition to confrontation therapy, the course also teaches you to take a closer look at your thoughts and find new, helpful thoughts. And the best part? The Empowerment Avenue Panic online therapy course is paid for by your statutory health insurance. All you need is a prescription from a doctor or psychotherapist. The best thing to do is to take a look at our course page.