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Written by David. B  Provisional Psychologist | PsychPhys™, BPsychSc(Hons), MPP

Anxiety motivates us to be vigilant; it is our bodies way of saying “be alert, pay attention, and be cautious, because something is wrong, and we need to be ready to act’. Everybody feels anxious from time to time. However, anxiety can also be highly unpleasant, and instead of helping us manage actual threats can stop us from doing what matters and stop us from being the people we want to be. Anxiety does influence us to avoid activities and situations that matter to us. While this avoidance might help reduce feelings of anxiety in the short term, this can paradoxically allow anxiety to continue and become amplified in the long term. This is because we learn that the only way we can stop feeling anxious is by avoiding anything that provokes anxiety. Therefore, we become more anxious so we withdraw from anxiety provoking situations.

Exposure therapy was developed as a way of teaching people that situations that provoke anxiety don’t necessarily need to be feared. This is achieved by introducing anxiety provoking situations that can not cause any harm. This allows us to become acclimatised to feeling anxious. Over time, we can learn to recognize when we feel anxious, what that feels like, what our anxious mind tells us, and how to respond more effectively.

Exposure therapy is based on behavioural principles of classical counter-conditioning, where a person’s emotion response towards something (e.g., feeling anxious in social situations) is changed by replacing it with a more favourable response. This method aims at habituation, where the original withdrawing/avoiding behaviours elicited when encountering an anxiety-provoking situation diminishes in intensity (or even disappear) over time. In traditional behavioural therapy this would involve providing a reward (e.g., praise, money, food) when a person engages in anxiety provoking situations without using avoidant behaviours (e.g., public speaking).

Joseph Wolpe expanded these ideas into systematic desensitization. Systematic desensitization involves pairing relaxation techniques with increasing anxiety provoking situations. This is based on the principle of reciprocal inhibition, which suggests an individual cannot be relaxed and anxious simultaneously. In systematic desensitization people create a hierarchy of fears, ranking anxiety provoking situations and stressors from least intense to most intense. People are then taught muscle relaxation techniques to use when they feel anxious to help calm them. Then, people use the relaxation techniques as they are exposed to anxiety provoking stimuli on this list, starting from the lowest and moving to the highest anxiety provoking situation. This gradually exposes people to anxiety provoking situations, which are made manageable by teaching them to relax when stressed. Once people begin feeling afraid or anxious, they use relaxation techniques to regain a sense of calm.

Systematic desensitization has also been used without relaxation strategies, in which case it is called gradual exposure. Research has suggested that it is the exposure to and success with managing fears sequentially that allows for reduced anxiety, rather than the relaxation techniques. Nonetheless, relaxation techniques can be helpful.

In cognitive behavioural therapy (CBT), cognitive approaches have also been incorporated into exposure therapy. In CBT, thinking and language alter how we interpret information and experiences. Therefore, in contrast to pure behavioural approaches that ignore mental behavioural, mental behaviours are also targeted in CBT. This typically involves a therapist helping a client identify and reframe unhelpful cognitions and identifying and labelling emotions and physiological sensations that accompany an anxiety provoking situation. In this way, CBT tries to reduce the amount of difficult unhelpful thoughts associated with anxiety.

There are several ways that exposure therapy can be undertaken. These include:

In vivo exposure: Directly facing an anxiety provoking object, situation, or activity in real life or during a psychology session. For example, someone with a fear of knives might be asked to handle a knife, or someone with social anxiety might be asked to give a speech in front of an audience.

Imaginal exposure: Vividly imagining anxiety inducing object, situation, or activity. For example, someone with PTSD might be asked to recall/describe their traumatic experience in order to reduce feelings of fear.

Virtual reality exposure: People can also be exposed to an anxiety provoking object, situation, or activity through the safety of virtual reality. For example, someone with a fear of crowds could visit a public place using equipment that provides the sights, sounds (and possibly smells) of a crowded venue.

Interoceptive exposure: Deliberately eliciting the physical sensations of anxiousness that are harmless yet feared. For example, someone with Panic Disorder may be asked to mimic the sensations of a panic attack by elevating their heart rate by ruining on a treadmill. This allows them to learn that this sensation is not always dangerous.