Exposure Therapy

Exposure Therapy is a psychological treatment that was adapted to help individuals confront their fears and ultimately cope with mental illnesses associated with such fears. In general, when humans are scared or fearful of something, they will try to avoid it at all costs. This so-called "something" can include a vast variety of things, such as specific objects, activities, situations, or even people or places. Many people hold various fears throughout their lifetime, but when the fear starts to impact their daily functioning then this becomes a mental health concern and needs specific attention.

A cognitive and behavioral approach that is used by clinicians to help individuals overcome fears and anxieties, exposure therapy aims at breaking the pattern of fear and avoidance. Although some avoidance to fears seems like a "normal" response and it may help reduce some feelings of fear in the short-term, the issue becomes this avoidance in the long-term can ultimately make the fear become much worse and more detrimental to the individual's well-being and overall functioning. In these cases, clinicians may recommend using exposure therapy in order to break this avoidance and fear pattern while in a safe environment to target the fears and break the cycle. The main objective of exposure therapy is to help reduce fear and decrease avoidance of the feared item.

As a behaviorist therapy, exposure therapy originated from the work of behaviorists like Ivan Pavlov and John Watson in the early 1900s. It's original roots can trace back to the principles of Pavlov's classical conditioning and then years later, in 1958, by behaviorist Joseph Wolpe in his development of systematic desensitization. Wolpe's systemic desensitization refers to a technique in which relaxation training, anxiety hierarchy, and exposure are all used to reduce an individual's sensitivity to situations that they may avoid or dislike. In the 1970s, psychologist Stanley Rachman developed exposure and response prevention while working with individuals experiencing various obsessions and compulsions. Rachman emphasized the importance of encouraging the idea of enhancing the obsessive thoughts and then the act of refraining from performing any of the anxiety-reducing compulsions or behaviors that the individual typical does to relieve the obsession.

Even further, the last thirty years has been revolutionary for exposure therapy with the advancements in technology and expansions in exposure and response prevention and systematic desensitization. For example, virtual reality devices has been a major technological advancement that can aid in exposure therapy by allowing access to potentially difficult situations that may be too challenging to recreate in reality. Research has shown that exposure therapy is a helpful and efficient treatment for a large range of mental health concerns, including phobias, panic disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder. The use of technology as well as greater knowledge on these disorders in general creates the perfect recipe for targeting the fears and establishing more appropriate and healthier reactions to the stimuli.

Exposure therapy has four main stages and approaches to conducting the exposure in a safe and efficient way. The first way is through emotional processing, where the exposure therapy helps you create realistic beliefs about a feared stimulus. The next way is through extinction, where the exposure therapy helps you unlearn negative associations with a feared object or situation. Habituation, the third way, refers to repeated exposure to a feared stimulus over time that helps decrease the fearful and avoidance reaction. Lastly, self-efficacy acts as the fourth way that helps show the individual that they are able to overcome the fear and manage the anxiety associated with the fear.

There are a wide number of fears that an individual could be suffering from. Some of the most common include, fear of spiders (arachnophobia), fear of needles (trypanophobia), and fear of flying (aerophobia). For example, if an individual is suffering from arachnophobia, this person will avoid being in contact with spiders at all cost, whether that is physically or literally. They would not want to see a spider in real life, in a book, in a picture, on a screen, and so on. Therefore, during exposure therapy, a clinician would safely and slowly expose the individual to those types of experiences that included interacting with spiders in order to get the individual to become comfortable with them in the long run. There are many benefits for incorporating exposure therapy into other evidence-based approaches, specifically cognitive behavioral therapy or dialectical behavior therapy.

**Exposure Therapy and the COVID-19 Pandemic**

The main characteristic of exposure therapy is presenting the client with the adverse stimulus and being present in order to help them cope with the stress of the exposure in health ways. In March of 2020 the COVID-19 Pandemic changed many aspects of life including Exposure Therapy. The field of psychology had to adapt to not being able to meet with clients in person because of the social distancing guidelines. There was a push for for all therapies, including exposure therapy to be conducted through telehealth and be more creative in their practices.One of the first adaptations is to include a session in order to provide education about telehealth to ensure a smooth transition to the new modality. Furthermore, therapist and clients need to be aware of the potential complication of conducting Exposure Therapy via telehealth.Therapists have to change their treatment plans with clients in order to comply with Center for Disease Control guidelines. One of the options therapist can utilize is waiting until there have been changes in the status of the pandemic to implement certain aspects of exposure treatment. While waiting is not an ideal option it can be a realistic one to ensure the specific treatment goals are met. An additional option for therapist is to adjust the focus of the exposure to focusing on topics like emotions and vulnerability. Clients are then able to work on improving their relationship with emotions and vulnerability that can be done through exposure therapy over telehealth or with others in their home.

Another realm of Exposure Therapy that was challenged by the COVID-19 Pandemic was conducting exposures related to social anxiety with youth. Given the social distancing guidelines and the promotion of isolation by the CDC it made doing social anxiety exposure more difficult. Before the COVID-19 pandemic traditionally clients would do social exposures during and in between sessions.While the pandemic presents challenges to exposure therapy it still is one of the most effective methods in treating social anxiety which has encouraged therapist to find new creative ways to still continue to do exposures.One example of an adaptation that a therapist made to a traditional exposure was to change the exposure of go out in public in a silly hat and changed it to wearing a silly hat on a zoom call or when essential to go out in public with a silly mask. Another example is instead of opening a closed door at the clinic the client would FaceTime someone without giving them a heads up that they were going to call. While these new methods may not be empirically supported like the ones that predated them they still are able to provide an adapted form of exposure therapy.

**References**

1. ↑ 1.0 1.1 *What Is Exposure Therapy?*. https://www.apa.org. (2022). Retrieved 6 May 2022, from https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy.
2. ↑ 2.0 2.1 Rauch, S. A., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: a gold standard for PTSD treatment. *Journal of rehabilitation research and development*, *49*(5), 679–687. https://doi.org/10.1682/jrrd.2011.08.0152
3. ↑ *Exposure Therapy*. Goodtherapy.org. (2022). Retrieved 6 May 2022, from https://www.goodtherapy.org/learn-about-therapy/types/exposure-therapy.
4. ↑ Clark, R. (2004). The classical origins of Pavlov’s conditioning. *Integrative Physiological &Amp; Behavioral Science*, *39*(4), 279-294. https://doi.org/10.1007/bf02734167
5. ↑ 5.0 5.1 Davis, T., Ollendick, T., & Öst, L. (2009). Intensive Treatment of Specific Phobias in Children and Adolescents. *Cognitive And Behavioral Practice*, *16*(3), 294-303. https://doi.org/10.1016/j.cbpra.2008.12.008
6. ↑ 6.0 6.1 Foa E. B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. *Dialogues in clinical neuroscience*, *12*(2), 199–207. https://doi.org/10.31887/DCNS.2010.12.2/efoa
7. ↑ 7.0 7.1 Boeldt D, McMahon E, McFaul M, Greenleaf W. Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles. Front Psychiatry. 2019 Oct 25;10:773. doi: 10.3389/fpsyt.2019.00773. PMID: 31708821; PMCID: PMC6823515.
8. ↑ Sars, D., & van Minnen, A. (2015). On the use of exposure therapy in the treatment of anxiety disorders: a survey among cognitive behavioural therapists in the Netherlands. *BMC psychology*, *3*(1), 26. https://doi.org/10.1186/s40359-015-0083-2
9. ↑ 9.0 9.1 9.2 9.3 9.4 Guy-Evans, O. (2022). Simplypsychology.org. Retrieved 6 May 2022, from https://www.simplypsychology.org/exposure-therapy.html.
10. ↑ 10.0 10.1 Gaines, J. (2022). *Exposure Therapy: How Confronting Fears Can Help Clients Heal*. PositivePsychology.com. Retrieved 6 May 2022, from https://positivepsychology.com/exposure-therapy/.
11. ↑ 11.0 11.1 11.2 11.3 11.4 Khan, A. N., Bilek, E., Tomlinson, R. C., & Becker-Haimes, E. M. (2021). Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19. *Cognitive and behavioral practice*, *28*(4), 669–678. https://doi.org/10.1016/j.cbpra.2020.12.002
12. ↑ 12.0 12.1 https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
13. ↑ Wells, S. Y., Morland, L. A., Wilhite, E. R., Grubbs, K. M., Rauch, S., Acierno, R., & McLean, C. P. (2020). Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID-19 Pandemic: An Overview of the Research and Special Considerations for Providers. *Journal of traumatic stress*, *33*(4), 380–390. https://doi.org/10.1002/jts.22573
14. ↑ 14.0 14.1 14.2 14.3 14.4 Fina, Brooke A et al. “Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment.” *Cognitive and behavioral practice* vol. 28,4 (2021): 532-542. doi:10.1016/j.cbpra.2020.09.003