Updated: Aug 21
Learn what exposure is used for, how it works, and get tools and worksheets.
It seems like the most logical way to protect yourself from a fear would be to avoid it. That makes a lot of sense in the short-term.
In fact, it’s an important defense mechanism that humans learned over thousands of years.
However, fears and avoidance can sometimes get out of hand, making a situation worse. For example, if someone spends most of their day worried they’ll run into a spider, they may not get much else done.
That’s where exposure comes in. Exposure therapies and techniques help people gradually face their fears so they no longer need to avoid or worry about them.
Such treatments help with phobias, anxiety disorders, post-traumatic stress disorder (PTSD) and more.
Need resources right away? Skip ahead to here take a look at our anxiety and PTSD bundle including common exposure techniques.
Here’s a look at common exposure techniques, what they’re used for, and specific treatments that include them.
There are several structured therapies that treat certain anxiety conditions with exposure. They all include all or some of the following techniques.
The most common treatment that includes exposure is called cognitive behavioral therapy (CBT). A key element of CBT is talking about thoughts, fears, and feelings.
I often find that simply talking through thoughts about a topic exposes people to their fears. For example, if someone is afraid of dogs, then talking through this fear can be a helpful first step of exposure.
Those with PTSD tend to push away thoughts and memories of their trauma. In CBT, we start to bring them back into our awareness by processing them. (Processing is simply talk therapy that’s focused on a specific topic.) This is typically the first exposure technique I use with my clients.
One of the most common exposure techniques is called “imaginal exposure.” This is done in various ways.
It’s more or less what it sounds like. The patient “imagines,” their fear. It’s also sometimes described as exposure to one’s own thoughts.
This might happen through thinking of a memory you’ve been avoiding, or imagining a worst-case scenario about the future.
Imaginal exposure may happen inwardly, out loud in therapy, or through written assignments between sessions.
In trauma-focused CBT, which is used with children and teens, it happens creatively. For example, kids may write a play about a bad memory, or create a piece of art that represents how they felt during a trauma.
The basic idea behind imaginal exposure is to allow the person to face the feelings that come up behind the fear. By understanding and working through these feelings, the fear and related anxiety will start to dissipate.
More details on these techniques are included below, within the therapies that use them.
In-vivo is French for “in real life.” If you’ve heard of exposure techniques or seen them portrayed in movies they were likely in this form.
If someone has a fear of heights, their therapist may assign in-vivo homework activities to face this fear. It could start as simply as standing on a short hill, and work all the way up to visiting a rooftop.
This doesn’t happen all at once, but will take place over several days, weeks, or even months. I’ve found that many clients take anywhere from a few homework activities up to several weeks worth to overcome fears.
The length of time needed depends on how set in the phobia is, how long they’ve been dealing with it, and how ready they are to complete the homework assignments.
In my experience, once people are ready to face their fears, they will overcome them – at least to the point where they no longer interfere with everyday life.
An exposure, or anxiety hierarchy, is a tool often used in in-vivo exposure. The chart includes a list of related fears, from lowest to highest. The person with the fear ranks them, or assigns a number, based on how strong the fear is.
Here’s an example of what an exposure hierarchy might look like for a fear of heights.
0=Little to no fear
10 - Climbing a mountain
8 - Standing on a rooftop
5 - Climbing a hill
4- Talking about heights
3 - Standing at the top of a staircase
Once the scale is developed, then we will develop homework assignments based on this hierarchy. We generally start with fears around the middle of the scale.
In this case, I would ask if my client would be ready and willing to climb a short hill at a local park. They would then try this activity between sessions.
If the activity is easy, then we will move on to something harder. If it’s too hard, then we will either slow it down, breaking it into smaller steps, or move lower on the hierarchy to something easier.
As the lower fears are faced, the higher fears often seem easier, and the scale will be updated accordingly.
These homework assignments can be done flexibly, by setting one goal per week and reporting progress back to the therapist.
Some people find it helpful to do this in a more structured way, and to use homework sheets to track their experiences. I use a combination of approaches, depending on the situation, our goals, and my client’s preference.
I’ve developed a worksheet that includes a simplified hierarchy and homework sheet. You can check it out here.
Sometimes exposure involves not doing something instead of doing it. For example, someone may have a fear that if they don’t repeatedly check the stove, then they will accidentally leave it on.
However, a stove only needs to be checked once to ensure it’s safe. With this type of exposure, the homework would involve not checking the stove. It’s sort of the opposite of other techniques, however it’s the same idea of facing a fear.
Now that we have an idea of the techniques used, let’s expand on the therapies that make a point to use exposure.
These therapies use exposure, along with other techniques to deal with PTSD or anxiety conditions. They are all organized a bit differently, but you’ll likely notice the overlap of strategies within each one.
Like the name sounds, this therapy is all about exposure. Prolonged Exposure (PE) is used specifically for PTSD. I find it to be one of the most effective, but also most intense, therapies out there.
This is no longer my go-to therapy for PTSD, due its intensity and a potentially higher dropout rate. I have found that my clients benefit from other therapies that work a bit faster and take a gentler approach.
However, it’s an important early therapy that influenced later treatments, and is still frequently used.
That being said, PE was the first PTSD therapy I learned, and all of my clients who completed it were glad they did so. I commonly heard them say that they thought everyone should do it.
I talk more about my experience with this therapy in my book, Finding Peace from PTSD.
PE is a fairly simple therapy. Following a few introductory sessions, it settles into three main elements that are repeated until the client is better. These include:
At the beginning of therapy, clients learn about the basics of PTSD. Most therapies for PTSD are based on the idea that the condition is worsened by avoidance. Over time, trying not to think about feelings and memories relating to trauma makes it worse.
By facing these head on, the person can start to heal in a more natural way.
They will then develop some basic skills to manage anxiety and panic, such as slowed breathing or listening to music.
Following this brief stage, which may take one or more sessions, they move into the heart of the therapy.
Each week, the client will describe their memory of the trauma to their therapist. They are encouraged to imagine that they’re actually there, going through the experience again. They then record the session and listen to the exposure between appointments.
In-vivo exposure is another major piece of PE. As described above, the client completes an hierarchy and homework assignments to face fears between sessions.
In PTSD, the fears may or may not relate to the trauma itself. For example, if they experienced an accident while driving, they may gradually start to drive again.
Many people also have general fears that have nothing to do with the trauma, but still feel frightening and out of control. Common examples include a fear of crowds or busy restaurants. This is why many people with PTSD prefer to sit with their back to the wall.
After several weeks of PE sessions and the homework included, individuals become desensitized to their fears. The exposure also helps break down the walls that are holding back feelings that need to be felt and worked through.
This combination helps people overcome their PTSD.
Cognitive Processing Therapy
Cognitive processing therapy (CPT) is another therapy that includes exposure elements. The main parts of this therapy include:
Connecting thoughts, feelings, emotions
Processing and restructuring thoughts about trauma
Writing about the trauma (optional)
As I mentioned, simply talking about the trauma, even if you don’t go into specific memories, is a type of exposure. Since so much avoidance happens with PTSD, this is a major step towards dealing with the memories and feelings.
CPT also includes an optional element to write about the memory of the trauma. This is a type of imaginal exposure, in written form. The client writes about what happened between sessions, reads it over several times, and then reads it to the therapist.
This takes place over a handful of sessions. While not everyone needs to complete this step, my clients usually tell me that this was the most helpful part of the therapy. It allows people to take back control of the memory, rather than the memory controlling them.
As I mentioned, TF-CBT is used with kids and teens. It also includes imaginal exposure, and sometimes in-vivo exposure, if needed.
Here are the basic parts of this therapy, which spell out the word “practice.” You’ll likely notice many similarities between this therapy and the adult treatment of CPT.
P = Psychoeducation (learning about PTSD and trauma) + Parenting Skills for Caretakers
R = Learning relaxation skills
A = Affect regulation (managing emotions)
C = Cognitive coping and processing (challenging negative thoughts)
T = Trauma narrative (telling the story of the trauma, often through creative activities)
I = In-vivo exposure
C = Child and caregiver combined sessions
E = Enhancing safety during treatment and afterwards
Through this comprehensive treatment, kids and their parents or guardians learn multiple exposure techniques, as well as multiple other skills that support overall mental health.
TF-CBT is highly evidence based, with the majority of participants having improved symptoms.
Exposure and Response Prevention
Remember above when I mentioned that exposure sometimes includes not doing things? That’s the idea behind exposure and response therapy (ERP). This treatment is used specifically for obsessive-compulsive disorder (OCD).
Like with other therapies we’ve discussed, ERP includes imaginal exposure to triggers and things you’re avoiding. It also includes not participating in the compulsive behaviors that help you deal with these triggers.
You might recognize that the basic elements of exposure are all in place, they just work a bit differently due to the types of behaviors caused by OCD.
ERP is also an effective therapy, and is considered the best treatment for most people with OCD.
Eye movement desensitization and reprocessing therapy (EMDR) is another common treatment used for PTSD, anxiety, complex trauma, and several other conditions.
Many people familiar with EMDR wouldn’t think of it as an exposure therapy, and there’s quite a bit of debate about how and why it works. However, I find it similar enough to other treatments for PTSD that I’ve included it in this list.
The difference between this therapy and others is that the client can think about the memory internally, without needing to say it out loud. (See why this may be considered imaginal exposure?)
This is appealing to many people who avoid therapy because they don’t want to talk about what happened.
EMDR also combines other strategies, including bilateral stimulation (usually eye movement or tapping different sides of the body), and more recognition of the physical sensations of emotions.
Because EMDR is used for such a wide variety of issues, I recommend making sure your therapist has experience with PTSD specifically. The level of EMDR training can also vary, so find someone who has completed a structured, supervised training program.
Narrative Exposure Therapy
Narrative exposure therapy is a treatment most often used with refugees and other groups who’ve experienced ongoing trauma. It helps people work through their difficult memories, while putting them within the context of their broader story and mix of experiences.
This therapy includes exposure to memories of trauma. While it’s not used as frequently as those discussed above, it is an evidence-based program with research behind it.
Exposure Tools and Worksheets
Those who are struggling with ongoing symptoms of conditions like PTSD, OCD, or severe anxieties are most likely to benefit from seeing an experienced therapist. Anyone who’s facing immediate dangers or consequences due to their fears should definitely seek professional help.
In some cases, you may be able to work through phobias or fears on your own. By understanding the basics of gradual exposure, you can begin to take on the things you’ve been avoiding.
Below are a few of the worksheets we offer that are consistent with specific exposure techniques. These can be used along with therapy, or for self-help.
You can also get the entire bundle of CBT worksheets for anxiety and PTSD here. This kit, with 30+pages, includes exposure exercises along with other cognitive techniques.
In one way or another, exposure is used in nearly all treatments targeting PTSD and anxiety conditions. By understanding the basic elements, you can see more clearly how they’re used, and why they’re effective.
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