Exposure

Description of the Strategy

Since the 1960s and 1970s, it increasingly has been recognized and accepted that the common ingredient of many, if not most, behavioral treatments that affect anxiety is exposure to anxiety-provoking stimuli. Through repeated prolonged exposure to the offending agent, whether situation, event, person, sensation, or place, anxiety, fear, and other intense, associated negative emotions are reduced. In layman terms, exposure is essentially similar to “Facing one's fear” or “Getting back on the horse.” No matter what idiom is used, the implication remains the same: Persons are exposed to that which makes them feel afraid, and through facing such fears repeatedly, the reaction of anxiety is reduced.

Although anxiety is a naturally occurring phenomenon and is a normal and adaptive experience in genuinely threatening situations (i.e., it possesses survival value), when anxiety and fear occur within an anxiety disorder, it represents an overly intense, maladaptive, and inappropriate response to what would commonly be deemed a benign threat by others. In this fashion, anxiety-disordered individuals are reacting to nonthreatening or benign situations as if they were indeed genuinely threatening. Their perceptions facilitate a belief of threat where either one does not exist or the level of reaction is unwarranted. In fact, these perceptions guide reactions that are maladaptive and misplaced, since they represent inappropriately timed overreactions. Many anxiety-disordered individuals react in this fashion frequently enough so that they appear generally hypervigilant, which frequently leads to needing significantly less “threat” to react with anxiety and fear than their nonanxious counterparts (i.e., they are primed to react). In most anxiety disorders, this leads to a distinct and pervasive pattern of [Page 289]escape from—and eventually avoidance of—anxietyprovoking stimuli. Although this is a natural and common means for coping with threat in both humans and other animals, it prevents individuals from realizing that the stimulus is less threatening than imagined. In the absence of any contrary evidence, however, they do not learn that they have overestimated the threat. Hence, anxiety, fear, and other negative emotions recur each time the threatening stimulus is encountered, and it retains its provocative power. Escape and avoidance are negatively reinforcing, as they at least temporarily reduce perceived distress and therefore increase likelihood of a similar reactive behavior the next time the same or a similar stimulus is encountered. Without evidence to challenge their perceptions and beliefs about the stimulus, individuals cannot change their minds about the “threat,” and they remain anxious and fearful of it.

The basic principle of exposure operates exactly on this notion that the overreaction to the stimulus is maintained by continued avoidance and escape. Repeated, prolonged exposure to the stimulus, when combined with prevention of escape and avoidance, sometimes known as response prevention, puts the individual in contact with the realistic information about it, rather than the imagined information that has previously been encoded based upon negative reactions. When the stimulus is faced and the feared consequences of remaining in its presence do not occur, repeatedly, new evidence and information can be gathered about its realistic level of threat, and reappraisals can be formed. As the stimulus is repeatedly encountered and the feared consequences continue to not occur, the stimulus becomes viewed as less and less threatening, finally extinguishing the fear. Extinction of fear is typically possible only after habituation to the stimulus occurs. Such habituation process is akin to getting used to something over time, and in the case of anxiety and fear, it is like spending time with something that is thought initially to be dangerous until it is proven otherwise over time (e.g., after spending increasing amounts of time with a dog, the dog phobic comes to realize that it will not bite—a common fear amongst dog phobics—and the dog begins to take on more realistic levels of threat).

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