Exposure is a technique commonly used in cognitive-behavioral therapy, including the treatment of anxiety disorders (e.g., phobias). It involves exposing oneself to a situation that triggers anxiety, which one has been avoiding. For example, if someone is working on social anxiety (fear related to social situations – conversations with people, presentations, being in public places, etc.), a crucial element of therapy will be gradually entering social situations that evoke anxiety.

One of the most common maladaptive coping strategies in anxiety disorders is avoidance. Avoidance can be behavioral (not entering a situation that triggers anxiety), cognitive (“I don’t even want to think about it”), and emotional (suppressing emotions, e.g., with alcohol). Exposure allows breaking the pattern of avoidance. The goal of exposure is to learn a new response to a situation that was previously avoided.

During exposure, the habituation process occurs – a gradual reduction and fading of the reaction to the anxiety-inducing stimulus. In anxiety disorders, with each exposure, the experience of anxiety diminishes until the point where the stimulus no longer elicits anxiety. For habituation to take place, we must remain in exposure long enough until the anxiety starts to decrease.

There are various types of exposure. In real exposure (in vivo), we expose ourselves to the stimulus that triggers anxiety, e.g., in a fear of flying – getting on a plane. In imaginal exposure, we imagine a situation we are avoiding. It often precedes real exposure. In interoceptive exposure, we expose ourselves to physical sensations we fear – e.g., intense sweating in a social situation. In gradual exposure, we build a hierarchy of situations to be exposed to, starting with those causing the least anxiety and gradually progressing to more challenging ones.

If exposing oneself to difficult situations is an effective method for treating anxiety disorders, why do so many people struggle with fear? There are several reasons. For exposure to be effective, it must be well-planned, sufficiently long, and regularly undertaken. Entering a feared situation will involve experiencing significant discomfort. However, we often prefer to avoid it and use various “safety behaviors.” Moreover, if we find ourselves in an anxiety-inducing situation, we may use “neutralization” – not fully engaging in the situation and, for example, diverting attention from the anxiety-inducing stimulus. For instance, if I fear dogs, when encountering one, I might focus on the tail rather than the snout. Often, we also fail to draw healthy conclusions from the situations we face – we don’t notice that our catastrophic predictions did not come true. Choosing situations for exposure can be a lengthy and complex process. It is usually only one element of working with an anxiety disorder. Seeking the help of a cognitive-behavioral therapist is beneficial if planning exposure is challenging.

Readings: E. Bourne, “The Anxiety and Phobia Workbook”

D. Clark, A. Beck, “The Anxiety and Worry Workbook” (Based on Cognitive-Behavioral Therapy)

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