What Is Exposure?

Defining Exposure

Much of my time as a therapist is spent contemplating exposure. When I say that word, I’m sure all sorts of connotations come to mind – maybe photography, media presence, the way a building is oriented, even illicit activities. It is a broad term that doesn’t immediately give away its meaning and I usually spend a lot of time explaining it to individuals and families (as I have said before, historically, scientists - not great marketers).

So what does it mean in the context of therapy? In mental health treatment, exposure is a practice in which an individual encounters the things that they fear or that cause discomfort, typically at a slow pace, so that they can start to learn that these objects and situations are not as dangerous as they think that they are and that they can tolerate them. Basically, it follows the ethos of the familiar idiom “face your fears” but in a way that makes it more manageable and with much more support. The truth is – it’s hard to face your fears! There’s a reason we don’t all just do this on our own on a regular basis. When we practice exposure, we are asking someone to challenge the booming voice inside their head that says “No, stop, don’t do this, it’s not safe - let me list out all the ways this could go horribly wrong for you!!” It takes a lot of bravery and commitment and encouragement along the way and an experienced therapist to plan the gradual exercises to make sure clients are not too overwhelmed.

Why It Works

But there’s also a really important reason we do it – it works. There are many randomized controlled trials (basically the most rigorous form of scientific testing that we have) that show that exposure (often as part of a package of a larger treatment called cognitive-behavioral therapy) leads to better outcomes than other forms of treatment or no treatment. Please see the end of the post if you would like to learn more by reading specific articles (although, I warn you, they are dry).

Exposure is most typically used for anxiety disorders because it directly challenges the impulse to avoid, which is what keeps anxiety going. Anxiety is kind of like a misguided assistant – its intention is to direct us to danger and keep us out of harm’s way by alerting us to potentially dangerous situations. However, it tends to overdo it on the alerts and, in response, we are more likely to cut out the experiences that help us to grow and feel more confident in our ability to handle challenges. In many cases, avoidance of uncomfortable or feared things isn’t a big deal. If someone who is fearful of or uncomfortable with blood decides to not watch shows that have gory medical scenes, that has a pretty small impact on their life (although they are missing out on The Pitt, which is great!). But, if that same person refuses to get a necessary blood test or skips important health appointments, then it could be preventing that person from getting lifesaving information and taking steps to lower their risk of disease and it really becomes a problem.

Exposure shifts that tendency to avoid to one of approaching fears head on. As we get used to doing things that scare us, they start to feel much less overwhelming and become easier to do. We keep doing the things that we need to do and that, without exposure, we might have otherwise avoided. We may even do things we never thought we would be capable of (like seeing someone initially afraid of heights embrace skydiving). Although it is most closely associated with anxiety, exposure is also used to treat some aspects of trauma and related disorders, eating disorders, co-morbid anxiety and depression and is a major part of treatment for obsessive compulsive disorder (OCD).

What It Looks Like

What does exposure look like in treatment? Let’s use an example. Meghan is a 16-year-old girl who loves going to the beach and hanging out at friends’ pools but is afraid of putting her hear underwater. She worries that, if she dips her head underwater, water will enter her lungs and she will drown. She is able to get in the pool up to her shoulders and puts her feet in the ocean so she has typically been able to participate when her friends hang out at the beach or at a pool and she hasn’t felt pressured to go underwater when they do. However, she recently found out that she needs to complete a swim test at the high school she will be attending in the fall and is seeking out treatment so that she can prepare for that test ahead of time.

After some psychoeducation about anxiety and dispelling some of her inaccurate beliefs about what happens after submerging her head underwater, Meghan and her therapist create a list of the situations that she is afraid of and rates how anxious they make her (some therapists use a 0-10 scale, others use 0-100 – it doesn’t really matter so long as Meghan can indicate which ones are pretty challenging for her versus which ones seem more manageable). Once they have a good list together, they will start with doing some of the items with lower ratings that are easier for Meghan to do and then work their way up over multiple sessions where Meghan’s therapist can assess how quickly they can keep moving through the list.

In this case, they might start by looking at images or watching videos of people swimming with different strokes, dipping their heads underwater, dropping quickly into a dunk tank, and lead up to videos of scuba diving. Meghan’s therapist finds that her fear of drowning is higher the deeper the water and the longer the period of time underwater so watching someone scuba dive is a good challenge. Watching someone free dive without any equipment is even harder.  

Then they might start to actually practice in water. Meghan works with her therapist to get into the pool and slowly starts to submerge herself under the water first up to her shoulders, then up to her chin, up to her mouth, up to her nose, up to her eyes and so on, leading up to putting her whole head underwater. She might then work up to putting her head underwater for increasing amounts of time (5 seconds, 10 seconds, 15 seconds leading up to perhaps 30 seconds).

Once she feels comfortable with being underwater, they might move on practice exactly what is needed for the upcoming swim test. She might learn how to swim the freestyle stroke and start to swim across longer and longer distances of the pool. Then she might start to work on treading water in the deep end and slipping into the pool from the edge of the deep end before trying to jump into the pool from different heights.  

It is helpful for Meghan’s therapist to take it even further than what is need to prepare for the swim test so that Meghan is overprepared and feels very confident putting her head underwater in many different types of scenarios. Her therapist might have her do dives into the pool from a higher diving board, snorkel at varying depths of water, and practice the above exercises in other bodies of water like the ocean or a lake.

The overall goal of exposure here is for Meghan to learn that whatever she expects to happen when she puts her head underwater does not happen. Before each exposure, her therapist might ask her to predict what she thinks will happen (e.g., if she is concerned about water entering her lungs, they might ask “After how long do you think the water will start to enter your lungs?”) and then test that during the exposure and contrast it with what actually happened after the exposure is over. The goal is not to remove all of Meghan’s anxiety. In fact, it’s a great thing that she is attentive to water safety and is alert to potential dangers in the water. The goal is for her to understand that anxiety’s expectations are often incorrect and that she has the power to prove those expectations are wrong or inflated by challenging herself to do it anyway.

After several months of doing exposures, Meghan feels confident to do her swim test and also finds that she has started to go to school early to swim laps because she enjoys the exercise. She asks her friends to go to the pool more often and is even considering a job as a lifeguard this summer because several of her friends will be doing the same thing. She admits that she continues to feel nervous right before getting in the water and then she tells herself she has done this over and over and knows how to be safe. Her anxiety is not completely gone but she is able to move through it and do the things she needs to do.

Note: This is just one way to do exposure and simplifies the other elements that a therapist might do in exposure-based cognitive behavioral treatment. There is also some research to suggest that you can practice more challenging situations earlier in treatment and that it is beneficial to do so.

Selected Research Articles that Support the Use of Exposure

Butler, R. M., & Heimberg, R. G. (2020). Exposure therapy for eating disorders: A systematic review. Clinical Psychology Review, 78, 101851.

Cassiello-Robbins, C., Southward, M. W., Tirpak, J. W., & Sauer-Zavala, S. (2020). A systematic review of Unified Protocol applications with adult populations: Facilitating widespread dissemination via adaptability. Clinical Psychology Review, 78, 101852.

Ehrenreich-May, J., Rosenfield, D., Queen, A. H., Kennedy, S. M., Remmes, C. S., & Barlow, D. H. (2017). An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents. Journal of Anxiety Disorders, 46, 46-55.

Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of clinical psychiatry, 69(4), 621.

Longley, S. L., & Gleiser, T. S. (2023). Efficacy of the Unified Protocol: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology: Science and Practice, 30(2), 208.

McLean, C. P., Levy, H. C., Miller, M. L., & Tolin, D. F. (2022). Exposure therapy for PTSD: A meta-analysis. Clinical psychology review, 91, 102115.

Piacentini, J., Bennett, S., Compton, S. N., Kendall, P. C., Birmaher, B., Albano, A. M., ... & Walkup, J. (2014). 24-and 36-week outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). Journal of the American Academy of Child & Adolescent Psychiatry, 53(3), 297-310.

Papola, D., Miguel, C., Mazzaglia, M., Franco, P., Tedeschi, F., Romero, S. A., ... & Barbui, C. (2024). Psychotherapies for generalized anxiety disorder in adults: a systematic review and network meta-analysis of randomized clinical trials. JAMA psychiatry, 81(3), 250-259.

Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., ... & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753-2766.

Whiteside, S. P., Sim, L. A., Morrow, A. S., Farah, W. H., Hilliker, D. R., Murad, M. H., & Wang, Z. (2020). A meta-analysis to guide the enhancement of CBT for childhood anxiety: exposure over anxiety management. Clinical child and family psychology review, 23, 102-121.