Exposure therapy is a wonderful and challenging form of treatment that can improve phobias and anxieties. This treatment modality works off the assumption that, by slowly and continually facing a fearful situation, we become less scared. Gradual exposure involves creating a formal list of tasks that are completed in order to build confidence in facing our fears. Repeating the exposure task helps us become desensitized to a scary object or event. Exposure therapy is based on cognitive-behaviour therapy wherein clients address their anxiety by challenging negative thought patterns and shifting their behaviours. If you have struggled for years with anxiety, exposure work could be the effective approach that helps meet your needs.
Anxiety and Avoidance
When we experiences anxiety, our natural reaction is to avoid whatever it is that is causing fear. For example, if you’re scared of heights, you may avoid climbing ladders or standing out on a balcony. If you’re scared of roller coasters, you may avoid amusement parks. If you live with social anxiety, you may feel distressed at the idea of speaking to strangers or participating in group work.
When our anxiety gets triggered, it tells us there is some form of imminent threat. The safest option is to get away from that threat. Avoidance is an effective strategy, and it can work for many years. However, if your fears are more common place (e.g. public speaking, taking tests, speaking to strangers), it becomes harder to avoid these fears all together. At some point, facing the actual fear becomes a necessity, and our desire and need to address these fears becomes stronger.
How avoidance makes things more complicated:
When we become anxious, we worry that something bad will take place if we actually face our fears. This belief is so strong and uncomfortable that the idea of confronting our fears is overwhelming. Unfortunately, we can spend years avoiding this fearful object or event because of this feared negative consequence. So, we listen to these problematic beliefs without testing whether it is accurate or likely to occur. We trust this belief without assessing whether we have any evidence to back it up.
Because our anxiety naturally feels better when a scary or distressing threat is taken away, we feel like we have managed this situation. However, the next time we are presented with the same threat, our anxiety comes back. As we get into these habits of avoiding, our anxieties become stronger. We stop trusting that we have the skills or ability to face our fears.
If you are struggling with a phobia, take a moment to consider: What would happen if you actually faced this fear? If you take public speaking, for example, the problematic beliefs could be:
- others will laugh at me
- I will make a mistake
- I will stutter and have a hard time being articulate.
Based on these beliefs, you may decide to avoid all forms of public speaking. While this makes sense, the unfortunate consequence is that we never actually test the validity of our belief. How likely is that you’ll make a mistake? If you do make a mistake, then what happens? Will you really be laughed at by your peers? Sometimes, we don’t quite know what would be so bad about these fearful consequences, but the sense of dread is so strong, we don’t want to test it out.
Starting Exposure Therapy
Exposure therapy is a gradual and systemic approach to facing our fears. By slowly placing ourselves in situations that make us fearful, we can start to challenge our fears and our problematic beliefs. We learn to assess whether our feared beliefs are valid. By taking a gradual approach, we can start at a pace that feels uncomfortable, but manageable. For example, if you have a fear of spiders, your exposure task may involve looking at pictures of spiders as a starting point. The task is not pleasant; however, it is much more manageable than actually touching a spider or being in the same room as a spider.
Gradual exposure is incredible in helping build our confidence. The more often we practice an exposure task, the easier it becomes because we learn that these problematic beliefs are either a) not happening, or b) not as bad as we initially believed. With an increased level of confidence, we can then move on to a more challenging exposure task.
Step One: Creating an exposure tasks
The first step to starting exposure therapy is to create a list of exposure tasks. A therapist can support you in creating a list where you consider every anxiety-provoking and avoidance-inducing scenarios related to this single issue. This list can be extensive, and it’s recommended that there are at least 15 exposure tasks to help give enough varied scenarios to build your confidence. For example, your fear of public speaking can include exposure tasks such as:
| Exposure Tasks |
| Providing a long presentation (10 min+) |
| Providing a short presentation (5 min+) |
| Introducing myself during ice breakers |
| Speaking in small groups |
| Speaking to strangers one on one |
| Having conversations with authority figures (e.g. boss, teachers) |
| Maintaining eye contact |
Step Two: Rating Distress Level
The therapist and the client then review the created list of exposure tasks and assess how uncomfortable, distressing or avoidant-prone the task seems. This is a subjective score, and the distress level depends on how the client perceives a situation. These items are then ranked from highest to lowest level of distress to create an exposure hierarchy.
| Exposure Tasks | How distress is it? |
| Providing a long presentation (10 min+) | 100% |
| Providing a short presentation (5 min+) | 90% |
| Introducing myself during ice breakers | 80% |
| Speaking in small groups | 80% |
| Speaking to strangers one on one | 75% |
| Having conversations with authority figures (e.g. boss, teachers) | 60% |
| Maintaining eye contact | 40% |
If you are looking for some examples of exposure hierarchies, here are some great examples from Anxiety Canada.
Step Three: Gradual Exposure
This is the hardest step of exposure therapy. Now that we have created a list of exposure tasks, we want to begin the actual behavioural work. The general principal with exposure therapy is to start with tasks that are mildly distressing (in the 30-50% range). This way, we begin with tasks that are challenging, but not so overwhelming that the individual wants to give up or is overwhelmed.
When you start exposure therapy, it’s best to do an exposure task enough times that the distress level goes down. You can stop the task when you are either at a point of habituation (you’re used to it), or to a point of extinction (the distress rating is at a 0% and the task does not bother you). When either of these factors happen, you can move on to the next task on your exposure hierarchy.
Some considerations to note when doing exposure work:
- Make sure you are actually focusing on the fearful experience. If your exposure task is to look at pictures of spiders, but you have music on in the background distracting you, this is preventing you from truly doing the work. The point is to practice being in that state of distress without any form of avoidance, so that you can recognize your own skill and ability to handle the situation. This is also part of the reason we start with an easier task when we begin exposure work.
- Who is with you? Are you able to do the task on your own or do you always have someone nearby? In the beginning, it is okay to practice doing an exposure task with another person. However, it’s important to try a task on your own so that you can gain confidence in your ability to manage the situation.
- Try and switch the length of time you practice exposure work. In the beginning, it’s okay to start for a small period of time, but as the days go on, see if you can lengthen your amount of time doing the work.
Step Four: Tracking using an Exposure Record
As you do these exposure tasks, it’s important to keep track of your distress level. Does it change over time? If not, it’s important to let your therapist know so that you can problem solve together, such as by creating additional steps to help bridge between a task that is manageable versus an overwhelming task. Keeping track of your distress level is also a great marker that tells you when you are ready to move on your exposure list to a task that is slightly harder. Your end goal is to ultimately face your fear in a variety of environments.
As always, everyone has their own specific and unique needs. If you have any questions about exposure therapy, or are looking for support, please feel free to reach out.
Cheers,
Kasi