Exposure therapy is used mostly with anxiety disorder. The idea is that people who suffer from anxiety disorders—who get anxious when they confront safe situations or objects—are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of. So if the fear is a normal fear—like the fear of driving on the track when you see the train whipping by very fast—you don’t want to teach people to get over it. You don’t want to change people’s fear of driving over the track just in front of the train, because normal fears protect people from doing things that will harm them.

The idea behind exposure therapy is that the therapist helps patients to confront or approach what they’re afraid of, because the things they’re afraid of are intrinsically not dangerous. Through exposure to these situations, they learn that there is no reason to be afraid of these situations. The disaster they expected does not occur.

Originally, exposure therapy was derived from animal studies. In these experiments, scientists condition a mouse to become afraid of a red light by pairing the light with electrical shock. And after a certain numbers of pairings, the mouse will start showing fear responses when the red light is presented, even when it’s not paired anymore with shock. We call this response a conditioned fear. Then if we want to eliminate the mouse’s fear of red light, we present it with a red light without the shock. After repeated presentation of the light without shock, the animal stops showing the fear reaction to the light. That’s called extinction.

In the ’60s and the ’70s, several experts, in England and the United States, translated the animal results to human beings and said, "Let’s suppose that the anxiety disorders—such as claustrophobia or fear of heights—are like a response that was conditioned. The person was conditioned to be afraid of elevators even though being in an elevator is not dangerous. So how do we eliminate the fear of elevators? We instruct the person to ride on an elevator many times until the fear is extinguished."

Well, it’s called flooding if the therapist conducts the exposure very abruptly. And it’s called systematic desensitization if the therapist is doing the exposure very slowly in small increments, and if he pairs the exposure with relaxation. There were big debates in the '60s and the '70s about what works better, and whether flooding is dangerous. Some experts, like Wolpe, thought it was dangerous to do flooding because the person will actually become more rather than less fearful.

No, not really. According to some theories, flooding should make the patient feel worse. But according to other theories, abrupt exposure should extinguish the patient’s fear more quickly, so it is actually more efficient.

Well, it depends. Not necessarily. Let’s say that somebody is afraid of going to the supermarket. People with panic disorder, you know, are afraid of going to places where they cannot escape quickly, like sitting in the first row at the movies. It takes longer to get out from the first row than from last row. Experts did abrupt exposure, getting patients to sit in the front seat from the start of the therapy, and other experts said, "Let’s do it incrementally—let them sit in the last row first, and then in the row before the last, and then two rows before the last, and then five rows before the last."

Exactly. Gradual exposure gets patients used to each one of those stages, and eventually the patient will sit in the first row. Now, studies have found that doing abrupt exposure is as effective as doing gradual exposure, except that the patients in the gradual exposure suffer less. But flooding doesn’t really make them worse, as Wolpe thought. So we know now that we can do flooding, or we can do systematic desensitization. Both work. Today, experts don’t quarrel about this issue anymore; all therapists use more or less a gradual exposure, but not as gradual as systematic desensitization, because that takes too long and is unnecessary.

So that’s what exposure is. Now, how does exposure work? It works because of a mechanism that we call extinction. Extinction is not unlearning what you learned, but rather it’s learning something new—it’s learning that what you were afraid of is not dangerous. Some experts say that the mechanism is the reduction of the anxiety—that gradually you’re less and less fearful. This is called habituation. But habituation is not an explanation for why patients get less fearful with exposure therapy.

My theory is that exposure reduces fear and anxiety because the patient learns that the bad thing he thought would happen to him does not happen. Therefore, it’s very important to plan in a way which will ensure that the thing the patient is afraid of will not happen during the exposure. Let’s say after being raped a woman starts to be afraid of going anywhere by herself after dark. The therapist then plans exposures to places that are not safe after dark, and she is attacked again. That’s not a good exposure, because it doesn’t teach the patient that what she was afraid of does not happen.

Exactly, it reinforces rather than extinguishes the fear. So that’s the way exposure works. In order to implement therapeutic exposure, the therapist has to find out what the person is afraid of, then make a list of these things and organize this list from the not-so-fearful situation to most fearful situation, in a kind of hierarchy. In order to create a good hierarchy, the therapist teaches the patient to assign a number, on a zero-to-one-hundred scale, to each situation. This number signifies how much fear the patient would have if he would be confronted with this situation. It is important that the therapist makes sure that the situations on the list are not really dangerous.

The therapist chooses a situation by saying to the patient, "Let’s choose a situation that is about forty on the scale. Which of these situations do you think you are able to do for homework next week or in the session with me?" The patient selects a situation and begins to practice approaching it, staying in the situation until he feels that the anxiety goes down and realizes that the fear is not realistic.

So exposure works through two mechanisms. The first is that the situation elicits the patient’s fear—there is a match between the situation that the therapist is presenting to the patient and the patient’s own internal fear. The second mechanism is that the exposure situation contains information that is incompatible with the information that the patient has in his mind. In the example I gave you about the dog-phobic, if the patient is afraid that large dogs will bite him and the therapist presents him with a large dog that, over several instances, does not bite, the patient will cease to be afraid of big dogs. Patients don’t really need to be in the situation a long time—they don’t need to wait until the anxiety dissipates completely. They just need to be in the situation long enough to realize that what they feared would happen does not happen.

Yes. First of all, we need to realize patients with OCD have diverse fears and diverse compulsions, which are behaviors they do again and again to prevent bad things from happening. So the therapist needs to find out what the OCD patient is actually afraid of and what ritualistic behaviors he does. Is he afraid of being contaminated by germs, let’s say if he’s touching doorknobs in the restaurant? Is he afraid he’s going to catch a disease or germs that will make him sick, and that’s why he washes his hands all the time? Or is he or she afraid of making a mistake, and that’s why they check things repeatedly? Is she afraid that while driving, she will hit a pedestrian and without realizing it will leave the injured person bleeding to death, so she goes back and checks the road again and again to make sure that she didn’t hit somebody?

The most established and studied treatment for OCD is called exposure and ritual prevention. The exposure component changes according to the specific concerns that the patient has. Let’s consider the patient who is afraid she will hit a person while driving. Exposure in her treatment will include asking her to drive in a busy street with many pedestrians. The ritual-prevention component is to instruct the patient to avoid looking at the mirror and to not check and recheck the road. What the patient learns during exposure and ritual prevention is that her anxiety does not stay forever despite the fact that she did not check. In fact, she finds out that her urge actually diminishes with time. Second, the patient learns that even if she does not check the road again, it is highly unlikely that she will hit a pedestrian without realizing it.

Some patients are afraid that if they don’t run away from the situation they’re fearful of, or if they don’t avoid the situation altogether, they will have a panic attack, and they will die from a heart attack. Exposure for these patients includes going to the places where they think they will get panicky and will have a heart attack, like driving in tunnels in one-way streets because in case they get a panic attack they won’t be able to turn around.

Yeah, or not as fast they want to. So for them exposure includes driving on one-way roads or on bridges, because you can’t turn around and drive back on a bridge or a one-way street. These exposures teach them that even if they have a panic attack, they don’t get a heart attack from it.

Well, Sometimes. Here’s an example of something we might do. Let’s say a patient is afraid of being around knives because they are concerned that they will have the urge to take the knife and stab someone. The therapist puts a knife in front of the patient and says, "Okay, pick up the knife and come close to me, and let’s see if you stab me." Because we know that obsessive-compulsives are afraid of things they want to do--I wouldn’t do it with a schizophrenic--the probability that an OCD patient will actually stab someone is close to zero. And that is what the patient finds out: that he is not going to do what he is afraid of doing.

That’s right. What happens to these patients during the session is that they have a cognitive shift. So exposure therapy, in my opinion, is a very good cognitive therapy. It does exactly what cognitive therapy does, but a lot of times, it does it faster.

In PTSD, again, we have different kinds of fears. Here a person was traumatized, and after a traumatic event like, let’s say, being in Iraq and seeing horrible ways that people died when a suicide bomber came close or when an IED exploded in the road. They may get injured or see other people injured, or both. And then they start to get flashbacks and nightmares, and they start avoiding many situations that remind them of the trauma. When they come back from Iraq, they won’t drive on highways because of fear that there would be a bomb on the highway. Or they drive on the highway and see on the side of the road some item that looks suspicious to them, and then they drive very quickly and will not stop until they’ve passed this item. Clearly it’s important to be careful in Iraq, because those things happen. In the United States, the probability that there would be a bomb on the road is very low. Behavior like driving extremely fast to avoid an imaginary bomb can be dangerous, because the person with PTSD may swerve around something that is not dangerous, and then put themselves and other people in danger because they are not driving carefully; these people are driven by their fear rather than by reality.

The other fear that people with PTSD have is that "I am a different person since the trauma, and I will not be able to tolerate the stress involved in facing the situations I’m afraid of. So maybe nothing bad will happen, but I will fall apart."

Yes. With PTSD patients the therapist needs to make sure that two things don’t happen during exposure therapy for PTSD: that exposure does not lead to a disaster like being attacked or raped again; and that the patient does not feel, during exposure, that she is losing control or falling apart. For patients with PTSD, it is important to select situations the patient is able to tolerate rather than run away from. So the therapist says to the patient, "Okay, when you drive on the highway the first time, go with your wife and your brother in the car. And then when you feel more comfortable, less anxious, you can drive on the highway by yourself."

So exposure to feared situations with patients who have chronic PTSD is gradual, just like with patients who have OCD or panic disorder. But with PTSD patients we use another type of exposure, imaginal exposure, which involves revisiting the traumatic memory. People with PTSD feel extremely anxious and distressed when they are reminded of their trauma. So they try not to think about the trauma, they push their thoughts away from their mind, but the thoughts come back; then they push them away again. This is why they do not process their trauma. So after years, they don’t even know exactly what really had happened during the traumatic event because they have their own story. Their story is basically true, but the details and the interpretation may be totally wrong. In treatment for PTSD, we ask the patient to do two types of exposure. One is the in vivo exposure, which is the same as the exposure we do with OCD and panic disorders, as we talked about before. We create a hierarchy of situations that they avoid because those situations remind them of the trauma, but not because the situation is really intrinsically dangerous. And we also do what we call imaginal exposure, which is basically saying, "I’m going to ask you now to invite the traumatic memory and describe it aloud," and then we tape their narrative of the trauma. We then ask them to listen to it at home.

Yeah. And they find out two things. First of all, they find out that they can spend forty-five, fifty minutes telling the story, being in the presence of the memory, and they don’t fall apart and go crazy like they thought they would. So that’s one thing they learn. The other thing they learn is that being in the presence of the memory is not the same as being in the situation itself. A lot of times, people with PTSD feel like they’re back in the trauma when they think about it.

Yeah, but that’s a concern that’s totally unfounded. We’ve done studies in which we actually looked at this issue. Among about 130 patients who did prolonged exposure, including both imaginal and in vivo exposure, none got worse. Some patients didn’t get better for one reason or another. Eighty to 85 percent of patients do really well, which is not bad. While we are not successful with everybody, we also don’t see patients getting worse with exposure. So exposure therapy does not re-traumatize the patients. Exposure therapy helps patients with PTSD process the traumatic event, learn exactly what happened during the event, and learn to view the traumatic event from the perspective of the present, rather than the perspective of the past when the trauma happened. A good example is the rape victim who all those years thought the rape was her fault because she didn’t really say to the rapist, ’Leave me alone, I don’t want this"—she was too afraid to say that. But all these years she blamed herself because if she only had said, "Stop it," they would stop. Now as she recalls the rape in telling the story of how it happened, she also remembers that the person said, "If you don’t do what I’m telling you to do, I will shoot you."

Exactly. After revisiting her traumatic memory several times, the patient says, "Of course I didn’t tell him to stop because he would have shot me." So now she realizes, "I was smart not to fight the person, because this way I’m here, and I’m not dead."

We don’t use soothing self-talk or other relaxation methods with most patients because we think it will prevent them from realizing that they are strong and can cope with their traumatic memories. We use relaxation only with the very few patients who are so overwhelmed when they remember their trauma that they start to feel as if they are losing control. But that’s very rare. In general, we say to patients, "You are a strong person. You can do it. You don’t need gimmicks for your fear to go away." Relaxation can be perceived by the patient as the reason why they were able to cope. And then they say to themselves, "I could engage with the memory and nothing happened to me only because I was relaxed. What will happen if I’m in the middle of a situation in real life and I forget how to relax? Then I will really be in trouble." So we want to show the patients that they don’t need relaxation.

Yeah, they’re coaching them. If they cry, for example, we say, "You’re doing great. I know it’s difficult, but this is the way to process the trauma and to get better." And if they do not feel emotional—it’s important to be connected to the emotion during the revisiting—then the therapist coaches them: "I want you to tell me how you feel now. What’s happened to you now? What do you see?" We coach them to get all the parts of the traumatic event into the working memory.

There are some dropouts, but the dropout rate from a prolonged exposure is not higher than from cognitive therapy. And, in fact, some patients prefer exposure to cognitive therapy because cognitive therapy involves writing down what you’re thinking and what you’re feeling, and they don’t like to write things down.

Now, some patients don’t like exposure therapy. So the way to convince them to do exposure is to say, "Look, we’re working together. I’m not here to tell you what to do. And even if I want to make you do things, I won’t be able to. The control is in your hands. We will always decide together what you will do in treatment." And we give them the rationale for exposure—how the treatment works and why it works. And we also tell them, "Look, it really is a treatment about courage. And you are a courageous person." That works really well with combat veterans.

We say to them, "If you were not courageous, you wouldn’t have chosen to be a soldier."

Well, the advice is to start exposure with patients whose cases are not very severe, and to see how it works on them. Another piece of advice is to actually take a course where you learn how to do prolonged exposure. A lot of therapists are saying they’re not doing treatment with cognitive therapy or exposure therapy because they do not have enough experience or they were not trained enough. So the advice is to get training. And then if you feel you’re still uncomfortable, get supervision.

In that book, we explain in great detail how to do this treatment, so that also helps therapists to get over their reluctance. But a lot of therapists just don’t like manualized treatment, and they don’t like treatments that are structured.

You’re welcome.