phobia exposure therapy

Phobias, or phobic anxiety disorders, are a category of anxiety disorders that describe intense anxiety related to specific situations or objects, even when there is little or no real danger is present. People with phobias often avoid the feared situations, or endure them with great distress, thinking “I need to get out of here”.

Three types of phobias

There are three main subtypes of phobias.

Agoraphobia is a fear of situations with no easy escape, Social Phobia (or social anxiety disorder), is a fear of social situations, and Specific Phobia, is a fear of specific objects or situations, such as animals, heights, darkness, small spaces, blood, air travel, and so on. These disorders sometimes have a substantial impact on a person’s life, affecting their work, relationships, social activities, and leisure time.

These phobias tend to be chronic without treatment, starting in childhood or adolescence and often persist throughout a person’s life. 

How common are phobias?

In a 12-month period, approximately 0.3 to 1.6% of people meet the criteria for Agoraphobia, 1.2 to 6.8% for Social Phobia, and 3.5 to 8.7% for Specific Phobia. These numbers are much higher in an individual lifetime prevalence, ranging between 0.9 to 3.4% for Agoraphobia, 2.4 to 7.8% for Social Phobia, and 7.7 to 10.1% for Specific Phobia. 

As many as 1 in 10 people meet the criteria for a Specific Phobia in their lifetime.

Exposure therapy for Phobias

Exposure therapy is considered the primary treatment for all anxiety disorders with very strong research evidence supporting its effectiveness. Exposure involves gradually facing fears over an extended period (several minutes to sometimes hours), repeatedly exposing the clients to the feared stimuli, while refraining from avoidance strategies, such as hiding or leaving the room.

Exposure to External vs. Interoceptive stimuli

Exposure can involve confronting external stimuli, such as heights, crowds, blood, spiders, or public speaking, either through imagination (with closed eyes, following and imagining a vivid story from the therapist) or real-life situations (called in-vivo). 

Interoceptive exposure, focusing on internal stimuli such as bodily sensations, is more applicable to panic disorder, and often combined with in-vivo exposure. Generalized Anxiety Disorder (GAD) treatment involves confronting both internal and external aspects of anxiety, including imaginal exposure and in-vivo exposure to everyday situations. 

Exposure therapy is highly effective, particularly for phobias, even when used as a standalone treatment. In-vivo exposure, exposing people to feared situations in real life, is especially useful for the treatment of Agoraphobia, Social Phobia, and Specific Phobia. 

How does exposure therapy work?

Exposure treatment relies on the core learning theories and involves habituation, extinction, correction of negative beliefs, and emotional processing. Inhibitory learning, as in, learning new behaviours in feared situations that can replace unhelpful ones, plays a central role in extinction learning. 

Habituation is a form of learning where an individual becomes less responsive to a repeated or constant stimulus over time.

It is a natural process that helps us filter out irrelevant from our environments (someone else’s phone ringing), allowing us to focus on new or potentially important stimuli (our own ringtone).

For example, we often notice new background noises, but soon stop paying attention to them as they remain constant and non-threatening. However, if we leave the environment for a long time, we notice the old noises again – and that is why exposure therapy needs repeated exposure, not just a single session.

Extinction is a process of reducing or stopping a learned response. In classical conditioning (think of the dog: bell=food), extinction occurs when a conditioned response (running away from a small spider) weakens and eventually disappears because the conditioned stimulus (a small harmless spider) is presented without the unconditioned stimulus (getting a painful bite from a spider). Importantly, extinction does not erase our memories; rather, it creates new learnings that can override the previous responses.

Exposure therapy is often integrated with other pieces of Cognitive-Behavioral Therapy (CBT) interventions, such as psychoeducation (explaining how fear is developed and maintained), cognitive techniques (looking at unhelpful thoughts more objectively), and relapse prevention strategies, depending on the specific disorder. 

While exposure therapy is highly effective in treating phobias, it is best done in therapy settings. When you are ready to face your fears, you can book a book a psychologist online.

Why isn’t exposure therapy used all the time?

While exposure therapy has a strong theoretical and clinical background, barriers to its widespread adoption in routine care include logistical and therapist-related obstacles. Often the therapist has time constraints, and a single session is not long enough to deliver the required amount of exposure time. Sometimes finance (insurance) issues get in the way. Some clinicians have negative attitudes toward exposure, thinking it is harmful or too stressful for the clients. 

Types of Exposure Therapy

Exposure therapy can be used to treat a wide range of anxiety disorders and phobias. Several types of exposure therapy include:

  1. In-vivo exposure involves real-life confrontation of the feared object or situation. For example, someone with a fear of heights would gradually expose themselves to bigger and bigger heights, gradually going to locations without fences or guardrails.
  2. Imaginal Exposure uses imagination and mental visualisation to confront the feared situation or object. It is effective for both phobias and traumatic memories. The therapist is delivering a vivid story that includes a feared situation, and the client, with closed eyes, imagines this story in their head.
  3. Virtual Reality Exposure Therapy (VRET) employs computer-generated videos to expose individuals to their phobic stimuli, such as heights or flying, in a controlled and safe manner. Especially useful when access to the feared stimuli is otherwise difficult (for instance, inside of an aeroplane).
  4. Interoceptive Exposure is used especially for panic disorder and involves exposing clients to sensations associated with panic, such as increased heart rate, shortness of breath, or dizziness, in a safe therapeutic environment.
  5. Systematic Desensitization involves a structured and gradual exposure followed by relaxation techniques.
  6. Flooding is an intense form of exposure where the individual confronts the most feared situation directly for a prolonged time, often without gradual steps. Sometimes flooding therapy takes an entire day, but by the end of the day, the client learned not to fear a certain object or situation.

Arachnophobia Exposure Therapy

Arachnophobia, the fear of spiders, is commonly treated using exposure therapy. When the fear is intense and paralysing, even one-session exposure therapy can reduce arachnophobia symptoms to the point that the person can function well at home without help.

Acrophobia Exposure Therapy

Acrophobia, the fear of heights, can be effectively addressed through exposure therapy. Typically it is easy to organise graded exposure to heights as there are plenty of opportunities in and outside of cities to gradually increase the “scariness” of the height, and allow the client to habituate.

Blood Phobia Exposure Therapy

Exposure therapy is a valuable approach for blood phobia treatment. A limited number of exposure sessions can significantly help the person with blood phobia. The exposure can involve watching videos with the therapist, using fake blood, and then visiting a hospital for a final session.

Claustrophobia Exposure Therapy

Claustrophobia, the fear of confined spaces, responds well to exposure. The therapy might be logistically difficult as it requires gradually making the exposure space smaller and smaller, and in some offices, this is simply not feasible. Regardless, exposure therapy can help to tolerate small, enclosed, crowded spaces without intense fears.

Dog Phobia Exposure Therapy

Exposure therapy is a well-established approach for dog phobia. Controlled, gradual exposure to (live) dogs for individuals with dog phobias can lead to substantially reduced fear, even after a few sessions. Dog phobias often develop in childhood if the child is not allowed to be around dogs due to the parent’s fear of the animals.

Exposure Therapy for Fear of Flying

Fear of flying, or aviophobia, can be effectively treated with exposure therapy. Virtual Reality Exposure Therapy is especially useful for aviophobia as logistically it is sometimes too difficult to expose the client to real-enough situations that would trigger their fears, which is required for the treatment to be effective.

VR Phobia Treatment

Virtual Reality Exposure Therapy (VRET) is a new approach to the treatment of anxiety disorders. In VRET, individuals are exposed to a feared situation or object in a virtual environment using computer-based VR technology, such as VR glasses or projection-based systems. This allows for a controlled and customizable exposure to feared situations or objects, which is sometimes hard with in-vivo exposure.

For instance, in VR treatment, the therapist can choose the exact size and colour of a spider, very gradually exposing the client to their fears. The VR approach is often both logistically and financially more viable. 

Research indicates that clients often prefer VR over in-vivo exposure, mostly because it is just too scary to face real stimuli in person.

In terms of how many people complete treatment, studies show that there is no significant difference between VR and in-vivo exposure.

Furthermore, studies show no evidence that VR exposure is less efficacious than in-vivo exposure in Specific Phobia and Agoraphobia, but with Social Phobia, a combination of VR exposure with other CBT cognitive interventions might be advantageous. 

Exposure Therapy vs. Systematic Desensitization

Exposure therapy and systematic desensitization share similarities, as both involve gradual confrontation of the feared stimulus. However, exposure therapy is a broader term encompassing various techniques, including in vivo exposure, imaginal exposure, and VRET. Systematic desensitization, on the other hand, is a specific technique that combines gradual exposure with relaxation training. The choice between the two may depend on the specific phobia or anxiety disorder being treated and individual preferences.

Please note that this blog post by Personal Psychology is not intended to provide professional advice. If you or someone you know is experiencing mental health difficulties, it is important to seek help from a qualified healthcare professional.