Exposure Therapy:
How To Face Fears And Overcome Phobias

What Is Exposure Therapy?

It’s a type of behavioral therapy specifically developed to help people face their biggest fears.

For many, being afraid of something - whether it’s a spider, large groups, or public speaking - means avoiding it altogether. Going out of our way to dodge any place a spider might be hiding, sidestepping events that draw in too many people, and declining all invitations to public speak.

Over time, avoiding a stressor becomes a pattern- one that gets exponentially harder to break. And while continuing to avoid spiders as much as possible may not have too much of an impact on your life, avoiding other fears may cause you to lose out on new opportunities and personal growth.

Figuring out how to stop your avoidance pattern and begin to face your fear is exactly where this type of comes into play.

With the help of a behavioral therapist, you create a plan and an environment that allows you to “expose” yourself to the very thing that scares you.

Sounds counterintuitive, doesn’t it?

If you’re so afraid of something that you do whatever it takes to stay away from it- why would you force yourself to face it head-on?

The answer is simple:

By exposing yourself to your stressor over time and in a set pattern, you minimize your feelings of anxiety and reduce how often you avoid it.

Licensed therapist Katie Lear shares:

“Exposure Therapy is based on the idea that repeatedly facing your fears will make them less scary and overpowering. I often compare it to being like an allergy shot: if you were to be exposed to a ton of an allergen all at once, it would overwhelm your system. However, if you get just a little bit of that irritating substance each week for a long period of time, your body will gradually learn how to defend against it. Exposure therapy works the same way: you’ll gradually approach your fear in a safe, methodical way that will help you feel less anxious over time.”

Exposure therapy is a treatment that can be helpful for quite a few different conditions, including:

• Social anxiety
• Panic disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• General anxiety disorder
• Phobias

How Does Exposure Therapy Help?

It allows you to take action over something that’s causing you stress or anxiety, allowing you to move forward, reach goals that were previously out of reach, and seek new opportunities. Rather than letting your fear stand in your way, you’re able to get past it.

Research has found that this type of therapy helps you face your fears in several different ways.

Most notably:

Habituation

You tend to create habit patterns in how you manage stressors.

If you’re scared of speaking up in a big meeting, maybe you find yourself pretending to read over notes so no one calls on you. Or if you’re afraid of large groups, you tend to make an excuse for not going to a big social event.

This therapy practice helps you replace avoidance and any other bad habits with new patterns. Over time, you’ll see your stress decrease, and your response to coming up against your fear change.

Extinction

By facing the very thing that scares you the most over and over again, you’ll find that the old associations you gave that fear begin to minimize and eventually even go away.

In essence: The connection you’ve made between a certain situation and a bad outcome slowly dissipates.

Self-efficacy

When we are fearful of something, we often begin to think we simply can’t handle the thing we fear. We underestimate our ability to manage the symptoms of anxiety we feel and to find a way to face our fear full on.

Exposure therapy shows us that we can, in fact, get past our anxiety and any symptoms that arise and learn to stand up to stressors.

Emotional Processing

It’s not unusual to have unrealistic or exaggerated views around fear. For instance, if you’re afraid of public speaking, you might begin to believe that you’ll fail or be laughed at if you dare to speak up.

Exposure therapy helps you begin to recognize which of your beliefs are unrealistic and replace them with those that are more realistic or even helpful.

However, Lear notes that, while this process may be helpful to many people in many different situations, it isn’t necessarily the right answer for everyone:

“I typically recommend exposure therapy to people whose fear is very specific and intense. For example, it can be very helpful if someone is terrified of public speaking or someone who has a phobia about spiders. It might not be as good of a fit for someone whose anxiety is very general, or who wants to explore the roots of their anxiety in the past. Exposure therapy is different because it’s not interested in finding the source of your anxiety; the only goal is to fix it in the present.”

In Vivo

This may sound like a fancy term, but “in vivo” simply means real life.

In in vivo exposure therapy, you face a stressor or a stressful situation directly in real life. If you’re scared of public speaking, you’ll speak in front of a group. If you’re afraid of a mouse, you’ll be present in a room with a mouse.

This is seen as one of the most effective methods for tackling fear, as it shows you that you are capable of managing the things and situations you fear by actually doing them.

For example, Maika spent years battling an eating disorder. After nearly half of a decade working with her doctors, she was finally to overcome it and have normal eating patterns. However, despite this win, she realized she’d begun to feel incredibly uncomfortable eating in front of other people.

The coping mechanisms she relied on weren’t all that helpful. She began avoiding dinner parties and even pretended to not be hungry when she was out with friends. But the constant avoidance became harder and harder.

To help her overcome her social anxiety, her therapist began to have Maika eat small snacks in front of others like a few almonds and work her way up closer to a full meal over time.

Imaginal

Imaginal exposure therapy sounds just like what it is: to imagine a fear.

In this type of therapy, you’ll be asked to recall something that scares you in vivid detail and even imagine yourself handling that stressor to decrease your anxiety.

Sanjay was in a car accident about two years ago. It was a bad accident; his car was totaled and a passenger in another car involved was severely injured. Since that day, Sanjay has developed an intense fear of riding in cars.

For the most part, it actually hasn’t made too much of a difference in his life. He lives in a downtown area with decent public transportation, and his office is even close enough he can walk most days.

But calling an Uber when he’s out with friends or just trying to take a cab to the airport is increasingly becoming a problem. Sanjay is well aware that he can’t spend the rest of his life completing avoiding car rides.

Talking with his therapist, they decided hopping right into a car to get over his fear wasn’t the best path forward.

Instead, he attends sessions where he begins to walk through a car ride in his imagination with as much detail as possible- calling the car, walking up to the car, seeing the color of the car, feeling the metal handle of the car as he opens the door - all of the way until the ride is complete.

Eventually, his therapist and he will work on him moving on to an in vivo treatment.

Interoceptive

Interoceptive exposure therapy is often used for people who fear the feelings they experience when they’re scared or highly stressed. It’s often used for patients experiencing PTSD or panic disorder.

The idea is to purposely bring on the sensations you experience that create a feedback loop and make you even more afraid. For instance, let’s say the feeling of your heart rate increasing tends to spiral you into a panic. Your therapist may ask you to jog or do an aerobic exercise to increase your heart rate and show you that this sensation alone isn’t dangerous or always a sign that something bad is happening.

When Ashley was about twelve years old, she was playing in her family’s front yard when a neighbor walked by with their dog. Ashley loved dogs and wanted to be in contact with one every chance she got.

She ran straight up to the dog as she had dozens of times before. But this time, the dog bit her hard on her arm.

Ashley wasn’t seriously injured, but it was enough to make her completely terrified of dogs…all dogs.

Since that day, she would be terror-stricken every time she passed one. Each time she saw a dog, big or small, her heart would begin to race. She was convinced the dogs could feel her fear and she somehow believed this made them even more likely to attack.

She so badly wanted to be able to take a walk or even just pass by a dog in her apartment building without falling into a panic.

Her therapist had her begin to get used to the first sensation of her panic attacks: a racing heart.

She would put her on a treadmill to get her heart rate going to show her she could regain control of her body without allowing her adrenaline to spiral out of control.

Virtual Reality

The idea of virtual reality exposure therapy is to create an experience that’s very close to in vivo exposure when a real-life experience may not be possible or practical.

For instance, let’s say you have a deep, intense fear of flying. Getting you on a plane right away is probably not the best idea. So instead, your behavioral therapist may choose to simulate the experience of flying to help you get started in facing this fear.

Preston was incredibly claustrophobic- always had been. It was weird though- it felt like his anxiety around small spaces had never been consistent.

Standing in a packed crowd didn’t seem to bother him, but an elevator- even an empty one, would cause his adrenaline levels to surge.

And it was getting worse over time. So much so, that he was no longer able to take the elevator up the four levels he needed to get to his apartment at night. Walking the four flights didn’t seem that big of a deal- except when he had someone over with him or he was carrying an armful of groceries.

His therapist had recommended exposure therapy, but Preston shut down the idea almost immediately. The idea of getting into an elevator, even to ride up one floor, was just too much.

So his therapist then suggested virtual reality therapy (VRET). There was a specialized office not too far away that could create virtual simulations for him. He could watch a virtual version of an elevator until he built up the confidence to try facing his fear in a real one.

Graded Exposure

In graded exposure, you work with your therapist to grade or rank feared situations in order of difficulty.

The idea here is to get a better understanding of your stressor and the best way to approach it.

Your behavioral therapist will build out your exposures so you start with situations that are only a little scary and build up to scarier ones.

Let’s say you’re afraid of heights. Your therapist might start naming off a list of different scenarios that expose you to different heights. You’ll work together to rank these based on how challenging or scary each scenario sounds to you. From there, you’ll create a plan and order which challenge to do first.

For instance, you’ll talk through going to the top floor of a skyscraper that’s fully inside versus going to a lower floor on a different building that has an outdoor balcony to go out on.

Which would be more of a challenge for you?

Graded exposure is a technique that Lear regularly relies on for many of her patients:

“I usually teach some relaxation and deep breathing exercises to clients before we begin exposure. We then create something called a fear hierarchy, which is a list of situations that would trigger their fear or anxiety, ranked from least to most intense. This serves as a roadmap for exposure therapy, helping us decide what to focus on first and what to save later. I have the client rate each situation on a 1-10 scale from least to most triggering. As we move through therapy, I’ll ask them to revisit this scale and see if their ratings have changed. Often clients are surprised to notice that their ratings drop right away.”

Flooding

Flooding is the opposite approach to graded exposure. Rather than working your way up from minor situations to more challenging circumstances, flooding involves starting with the scariest situations right off the bat.

Flooding is often used in in vivo exposure therapy as the idea is to expose you to your fear directly from the start.

For instance, let’s say mice terrify you. Anytime you see one, even when it’s in a cage, you completely freak out. Maybe it’s gotten to the point where you can’t even be within sight of one.

If you’re looking to tackle this fear, your therapist may suggest in vivo exposure using flooding- or putting you in the same room with a mouse straight away.

It’s important to point out that flooding can be very intense and may even be traumatic for some. To help you through this, your therapist will provide relaxation techniques to help you get through it. Flooding should only be done alongside a trained, experienced therapist to ensure it’s done safely and effectively.

Systematic Desensitization

In systematic desensitization, therapy is combined with relaxation practices. For many, using common relaxation techniques like breathing exercises or meditation can help make the exposure exercises feel more approachable and less daunting.

It also helps you maintain control over your anxiety as you work through different exposure scenarios.

Let’s say you’ve experienced trypanophobia, or the fear of needles, for as long as you can remember. You realize there’s no rational reason for your fear- but you can’t help it.

Even seeing a needle on TV causes your entire body to tense up. Your head begins to spin and you even feel a little nauseous.

Your therapist may recommend incorporating relaxation practices through systematic desensitization.

Before you even think about exposing yourself to needles, whether in real life or a virtual setting, you and your therapist work on relaxation. Since you tend to tense up, you start by practicing muscle relaxation. This is followed by practicing deep breathing exercises to help you fight off any nausea or head spins.

Once you’ve mastered these techniques, you’ll start approaching situations where needles are present. Your therapist will be there in these moments to remind you to call on the relaxation practices you’ve worked to master as your tool to fight off any anxiety that spikes.

Prolonged Exposure

Prolonged exposure is a specialized form of exposure therapy that’s generally used for someone trying to overcome past trauma or experiencing PTSD.

It includes a much more gradual approach to overcoming fear. For many, treatment may last for as long as three months with weekly one-hour to ninety-minute sessions.

It’s important to point out that prolonged exposure is a specialty and needs to be done under the care of someone who is experienced in this area as it can be very anxiety-provoking.

To complete prolonged exposure, a behavioral therapist will likely draw on various practices including imaginal and in vivo exercises. The exact layout of the program will vary and will be designed specifically with the patient and past trauma being addressed in mind.

Imaginal exercises will include being guided through past trauma, detailing the experience. For instance, your therapist may ask you to write down the memory in detail or speak it out loud. As you walk through the trauma, your therapist will help you identify the thoughts and feelings you experience. By processing these emotional touchpoints, you’ll later be able to understand your triggers and be aware of what to look out for.

You’ll also make a list of things that you tend to avoid due to a trauma memory- things like specific sounds, certain smells, or specific places.

Based on all of this information, your therapist will start to build an exposure hierarchy to help you slowly approach these things over time and help you become more comfortable.

Benefits & Limitations Of Exposure Therapy

Exposure therapy is an effective treatment technique that is helpful to those experiencing a fear-based condition.

To start, it can help you become less sensitive to the objects and situations that tend to cause your anxiety levels to rise. By exposing yourself while in a safe environment to these stimuli, you become less sensitive and more comfortable with them over time.

Exposure therapy can also help you break the negative associations you have around certain things and situations. You tend to associate something that scares you with a bad outcome. It helps show you that just because something is scary, doesn’t mean it’s going to cause something bad to happen.

Finally, exposure therapy helps you understand the amount of power you actually have over a situation. Anxiety can make you feel powerless in a situation; therapy shows you that’s not the case.

According to Lear:

“The biggest benefit of Exposure Therapy is that it may help to alleviate your symptoms more quickly than other forms of therapy that are more focused on exploration or self-reflection. Because it has been heavily researched, you can also feel confident knowing that you’re trying a form of therapy that has been proven to be safe and effective for many people.”

While there are many benefits to this type of therapy, there are some drawbacks just as there are with any treatment option.

First off, in some cases, it’s been shown that symptoms can return later on after treatment has been suspended. So while you may temporarily experience improvement, it is possible to find your fear and anxiety returning at a later point. For many, this may be a signal that an alternative treatment is needed.

Additionally, Lear notes:

“Exposure Therapy is limited in that it isn’t likely to help you discover the root cause of your anxiety or address any deeper underlying issues if they exist. For example, if you are very afraid of loud noises due to previous traumatic experience, you may get some benefit from exposure at some point in treatment, but you’ll also need other techniques to help you process your trauma.”

Finally, in some cases, people experience such severe fear around the subject of their therapy that they struggle to make it through the exercises.

When this happens, a doctor may prescribe a beta-blocker like Propranolol to minimize the physical symptoms of the fear they experience. So instead of allowing a racing heart, shaky limbs, and intense breathing to send alarm bells off, they’re able to remain physically calm and focus on the exercise at hand.

Exposure Therapy Vs. Mindfulness

As you’re reading through this, you may recognize that a lot of what makes up exposure therapy sounds very similar to mindfulness.

And you’re not wrong. In fact, mindfulness is often incorporated as part of therapy.

But to be clear, while mindfulness may be incorporated into this type of treatment, the two are actually separate and very different.

As Lear notes:

“Part of mindfulness is being aware of–and radically accepting–your feelings and bodily reactions in a given moment. In that way, exposure therapy is similar to practicing mindfulness. During exposure, you may monitor and really observe your anxiety response, but there’s no attempt made to diminish or change it in any way. In fact, using relaxation techniques and coping skills designed to reduce anxiety are usually discouraged during an exposure activity. Many people view mindfulness as a way to relax and alleviate stress, and that’s not the short-term goal of exposure therapy. The activities are designed to gradually increase the intensity of your anxiety over time to build tolerance, rather than taking it away.”

How To Get Started

If you decide that exposure therapy might be a suitable option for you, there are several places you can start.

You can start by reaching out to your primary care doctor and asking for a referral. If you have insurance, you might also be able to get in touch with a representative to find a doctor.

If you don’t have insurance, you can use online search tools to find a behavioral therapist in your area, including:

• Psychology Today
• ABCT
• NACBT

Lear points out that it’s important to not just settle on any behavioral therapist:

“Look for a therapist who says that they practice cognitive behavioral therapy and specialize in anxiety. These are the therapists who are likely practicing exposure therapy day in and day out and will have a good idea of how to help you create a program of exposure experiences that gradually increase in intensity. Feel free to mention to them that exposure therapy is something you might be interested in, and ask them if they think this technique could be a good fit for you.”