Guest Post: Exposure Therapy for Anxiety: Faithful Old Dog, Clever New Tricks

Editor’s Note: Today’s post is written by New Harbinger author Timothy Sisemore, PhD.

In the world of pet owners, I’m a dog lover. I’m not too sure why, but I enjoy the enthusiastic welcome when I come home, the companionship of a devoted animal lying next to me, and the fulfillment of teaching a companion a few tricks. Of course, the old folklore is that you can’t teach an old dog new tricks. I don’t know that I agree with that for dogs, but I know I disagree with it when it comes to some aspects of psychotherapy.

In the history of psychotherapy, exposure therapy (ET) is a pretty old dog that can be traced to a few really old dogs – those of Ivan Pavlov. The new trick for those old critters was to salivate at the sound of a bell, even if no dinner was yet in sight. They taught psychology about classical conditioning when they learned this trick. We took those ideas and learned how to train a fear in a person, and then how to relieve those fears. 

While this “old dog” has evolved, ET still holds a solid place as an effective treatment for anxiety, even with the recent push for evidence based therapies. It is a faithful treatment. As therapists, it is easy to enjoy playing with the “puppies” of new therapies and overlook the loyal dependability of old companions like ET.

Why do we avoid ET, even though we know it has a good evidence base? I offer a few suggestions.

First, there is often the inclination to medicate anxiety. Most anxious persons talk with a physician before they consult a mental health professional. Even many mental health counselors tend to refer for medication quickly when anxiety is the problem. Yet, research suggests we have tools that are as good as – if not better than – medications. Likely one of the underlying reasons for this mentality is our “quick fix” culture prefers the easier, less demanding approach to problem solving.

A second reason we may overlook the “old dog” of ET is that it goes against our grain as therapists. Most of us really prefer to offer comfort and support rather than invite our clients into activities that are unpleasant even if effective. Yet, we know in physical health that if one wants to better one’s conditioning, the motto of “no pain, no gain” is true. I often explain to my clients that just as sweating is an expected discomfort of working out, so some of the unpleasantries of ET are what it takes to move past anxiety.

For some therapists, ET is overlooked because it is hard to fit into our standard practice. Many forms of exposure encourage the therapist to get out of the office and into the “real world” to join clients exposing themselves to malls, bridges, or elevators. That doesn’t fit well into tight schedules and limits of insurance reimbursement policies. 

But for many therapists, the primary hindrance to using ET is simply a lack of knowing how to do it well. It is certainly more than just toughing it out and staying with an anxious situation or thought. Clients need to understand the logic of deliberating exposing themselves to feared situations or thoughts and how escape and avoidance serve to perpetuate the fears even as they offer immediate, albeit very temporary, relief. So, ET starts with psychoeducation. The intervention itself is theoretically very simple: one needs to expose oneself to the anxiety until the anxiety subsides naturally. Typically, therapists guide clients through a hierarchy of situations relevant to the fear, from less to more threatening, staying at one level until it produces less anxiety, then moving to the next. For example, a person afraid of heights might begin by looking at pictures taken from tall buildings, proceeding to looking down from the upper floor of the buildings themselves. At heart, ET is behavioral, assuming that the exposure creates new learning through habituation.

But this old dog has developed new tricks, showing it can be adapted into newer forms of therapy. The most established of these is using exposure in the “B” of CBT, a behavioral technique ensconced in cognitive therapy. Here ET is improved by helping the client focus on proper thinking during exposures, and more explicit work on maladaptive cognitions that are related to, if not part of, the feared item itself. Moreover, exposure serves to confirm the cognition that the feared situation was indeed safe after all.

Another “new trick” for ET is in Dialectical Behavior Therapy. Rather than simply being used to treat a specific symptom, ET is a technique that facilitates the broader skill of distress tolerance which in turn is part of the even broader skill of emotional regulation. ET thus serves to help clients develop the skills to manage feelings rather than be managed by them.

Finally, ET finds utility in Acceptance and Commitment Therapy. Here ET is subsumed under the idea of acceptance, or willingness, where clients learn that some suffering in life is inevitable as they pursue life goals. One must, for example, endure the anxiety of a job interview if one hopes to get the job. So, avoidance behaviors compromise pursuing valued goals and miss the fact that some suffering is necessary to move toward those. This context adds meaning and motivation to the basics of purely behavioral ET.

So, ET is not only effective, it is remarkably flexible and adaptable. Maybe this “old dog” deserves a second look by mental health professionals. For a helpful overview of ET and its applications, including a detailed menu of ideas for exposures, consider my new book, The Clinician’s Guide to Exposure Therapies for Anxiety Spectrum Disorders.

Timothy Sisemore, PhD is the author of The Clinician’s Guide to Exposure Therapies for Anxiety Spectrum Disorders: Integrating Techniques and Applications from CBT, DBT, and ACT, the first guide to offer specific exposure exercises for clients’ individual fears and phobias, and tools for overcoming common roadblocks that arise during exposure therapy. A clinical psychologist for more than twenty-five years, Sisemore specializes in treating anxiety disorders. He is also the author of I Bet I Won’t Fret: A Workbook to Help Children with Generalized Anxiety Disorder, and Free From OCD: A Workbook for Teens with Obsessive-Compulsive Disorder.