Exposure therapy: a proven therapy for anxiety and PTSD

Anxiety disorders are some of the most common mental health disorders, affecting nearly 18.1% of adults in the United States. Anxiety symptoms can cause you significant distress and impair your quality of life (Boeldt, 2019).

Fortunately, there are scientifically proven therapies available to help. Exposure therapy is one such therapy, shown to be effective for treating anxiety, post-traumatic stress disorder (PTSD), and several other mental health conditions. 

Here’s what you need to know about how exposure therapy works, what conditions it treats, and its potential risks.

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You’ve probably heard the phrase, “Face your fears!” before—that could be the tagline for exposure therapy. 

Based on Ivan Pavlov’s work, exposure therapy is a type of psychotherapy or behavior therapy that involves repeatedly confronting a situation that causes anxiety or fear. The goal is to eliminate or reduce that emotional response over time. You might also hear it called systematic desensitization (Craske, 2014).

Exposure therapy usually involves multiple sessions with a therapist and “homework” assignments to complete on your own. With this treatment, you eventually learn that your worst fears generally won’t come true, which lessens or removes the fear (Craske, 2014).

There are two main theories as to why exposure therapy works: 

Emotional processing theory (EPT)

According to this theory, there are “fear structures” in your memory that help you identify and avoid danger. Usually, these are helpful—for instance, if you run into a bear while hiking, that fear is pretty important. Occasionally, though, these fear structures can make inaccurate associations, leading you to have a fear response where one isn’t needed. You then begin to avoid situations that aren’t dangerous, which maintains the cycle of fear (Cooper, 2017).

This theory also maintains that traumatic stress can disrupt how we process memories of that traumatic event. Our fear memories then become more disorganized and fragmented, making it more likely that we associate those fear memories with situations that aren’t dangerous (Cooper, 2017). 

Fear inhibition learning models

These models are based on Pavlov's classical learning theories. They show that conditioned fears can be stopped but also that they tend to return over time. Our minds connect the fear-provoking situation with whatever our senses were taking in during the event. So, for instance, if a predator attacked a person in a laundry room, the smell of laundry detergent might provoke a strong fear response (Cooper, 2017). 

This response is similar to how Pavlov conditioned his dogs to drool when they heard a bell. The dog had attached the sound of the bell to the memory of being given dinner. So the dog’s mind anticipated food and reacted when it heard the sound, even when there was no food. In this same way, our minds can react as if there is danger, even if none exists.

Scientists have found that our minds can’t completely erase these connections once they’ve been made. Instead, repeatedly exposing yourself to the fearful situation without anything bad happening can help your mind create a new connection to compete with the old one. You can make this new connection stronger through repeated exposure. Eventually, it can become more potent than the original fear association. The old fear makes way for the new, stronger association (Cooper, 2017).

The type of exposure and response prevention used in the course of treatment looks different for each person. Your treatment plan will depend on your condition, the resources available, and the therapist’s experience (Craske, 2014).

Your therapist can customize your sessions in the following ways  (Craske, 2014):

• The number of sessions: Short-term versus a prolonged course of therapy

• The intensity of exposure: Graduated versus intense (also known as flooding therapy)

• The types of exposure: Imagined exposure versus real-life exposure versus virtual reality exposure

Virtual reality exposure therapy

Researchers are exploring how they can use virtual reality technology in exposure therapy. Virtual reality exposure therapy (VRET) has successfully treated multiple conditions, including (Boeldt, 2019):

• Social anxiety

• PTSD

• Panic disorder

VRET has some advantages over standard exposure therapy. Using virtual reality, the therapist can see and control what the client sees. In contrast, in standard exposure therapy, the therapist can’t see the client’s mental images. The client may picture a situation that is too intense for the level of exposure that is taking place in that session. With VR therapy, the provider can control the level of intensity (Boeldt, 2019).

You can also use VRET to practice exposure to feared objects or situations that otherwise wouldn’t be possible in a real-world office setting. This can include situations like being at a party or on an airplane. One downside to this approach is that virtual reality equipment is expensive and requires special programming to provide a realistic experience. Not everyone can access this technology (Boeldt, 2019).

Exposure therapy has been well studied over the years to treat some common mental health conditions.

Anxiety

Many studies have looked at treating anxiety-related disorders with exposure therapy, cognitive-behavioral therapy (CBT), or a combination of both with good results. In one study, participants with social anxiety disorder were treated with VRET. The researchers found that this worked as well as group cognitive behavioral therapy (Emmelkamp, 2020). 

PTSD

The Veterans Health Administration has extensively studied exposure therapy for PTSD, concluding that it should be a primary treatment for veterans. Protocols involving prolonged exposure effectively reduced PTSD symptoms, and the type of traumatic event or the number of events didn’t matter (Rauch, 2012).  

Exposure therapy can also reduce other symptoms that people with trauma frequently report, such as (Rauch, 2012):

• Anger

• Guilt

• Depression

• Negative thoughts about your health

Phobias

One of the best-known uses of exposure therapy is to reduce the fear associated with specific phobias. These are intense, irrational fears of something that poses little or no actual danger. Common phobias include fears of heights, spiders, closed spaces, or any other fear.

Randomized, controlled trials (RCTs) are among the strongest types of research that we have. In one study, people with spider phobia were enrolled in an RCT and assigned to receive either exposure therapy or progressive muscle relaxation (PMR) training from a clinician. The results showed that the exposure therapy group reported less fear and expectation of danger than the PMR group at follow-up visits (Lange, 2020).

Eating disorders

Scientists found mixed results when they first looked at exposure therapy as part of treatment for eating disorders in the 1980s. Since then, our knowledge about exposure therapy and anxiety has significantly improved. Therapists are now using this new research to create treatment routines that are much more promising in targeting anxiety and behaviors related to eating disorders (Reilly, 2017).

The main risk associated with exposure therapy is that it may not work for everyone. Exposure therapy is very effective for treating certain conditions, but like any therapy, some people won’t find it helpful. Additionally, some people who experience relief of their fears after treatment might later have their symptoms come back (Craske, 2014).

Researchers think this is because people with anxiety disorders might also have differences in how their brains process information. These differences might be what caused the fear and anxiety in the first place. Researchers are looking at ways to compensate for these changes to make exposure therapy work well for more people (Craske, 2014).

Another concern is for people who have both PTSD and substance use disorders (SUD) at the same time. Some therapists expressed concern about using exposure therapy for these clients. They worried that there was a risk of making their symptoms worse before they got better. This might make the client more likely to turn to drugs or alcohol for symptom relief (Lancaster, 2020).

However, a small study of military veterans seeking treatment for both PTSD and SUD found that this wasn’t as much of a concern as previously thought. The veterans were randomly assigned to receive 12 sessions with either prolonged exposure or general relapse prevention therapy. Researchers found that symptom flare-up was minimal and about the same for both groups. The participants in the non-exposure group experienced slightly more episodes of symptom flare-up (Lancaster, 2020).

If you or a loved one is struggling with the symptoms of anxiety, PTSD, or any other mental health problems, resources are available. Contact your healthcare provider for assistance. They can help you rule out any physical health problems and provide referrals to local mental health services.

You can also call the Substance Abuse and Mental Health Services Administration’s national helpline. This free, confidential, 24/7 service is available in both English and Spanish. They can provide educational information and referrals to local treatment facilities, support groups, and community-based organizations.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

Current version

June 30, 2021

Written by

Ellyn Vohnoutka, BSN, RN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.