Exposure therapy

When something scares us, we usually stay away from it. Avoiding a fear brings quick relief. But over time, avoidance can make the fear bigger and your life smaller.¹

Exposure therapy is a way to turn that around. With a plan, you face the thing you fear in small, safe steps. You learn that you can handle it, and the fear often shrinks.¹ It is one of the main tools inside cognitive behavioral therapy (CBT).

How exposure therapy works

Fear is like a smoke alarm. It is meant to protect you. But sometimes it goes off when there is no fire, such as for a crowded store, an elevator or a racing heart.⁵ Each time you escape or avoid, your brain gets the message, "That was dangerous. Good thing we left." The alarm stays touchy.

Exposure therapy gives your brain new information. Experts think it helps in several ways:¹

• Getting used to it. Your fear reaction tends to fade when you meet the same situation again and again.
• Unlearning the link. The connection between the trigger and "something bad will happen" grows weaker.
• Confidence. You find out you can face hard things and cope with the feeling.
• New beliefs. You come away with a more realistic view of the risk.

Newer research adds an important idea. What matters most may be testing your prediction, not waiting for the fear to drop. Before a step, you say what you expect to happen. Afterward, you check what really happened. Your fear does not have to fall to zero for you to learn something.⁷

Types of exposure

Therapists choose the type that fits your fear. Many plans mix more than one.¹

There are also different speeds. Graded exposure, the most common, starts with easier steps and works up. Flooding starts with the hardest step. Systematic desensitization pairs each step with a relaxation skill, such as muscle relaxation.¹

What exposure therapy can help

What the research shows in plain numbers. A large review pooled 41 trials with about 2,800 adults who had anxiety-type problems. CBT, which often includes exposure, was compared with a placebo treatment. The odds of getting better were about 3 times higher with CBT.⁸ Results were largest for OCD and generalized anxiety, and smaller but still real for panic, social anxiety and PTSD.⁸

Exposure is hard work. In the PTSD studies, about 3 in 10 people dropped out of CBT, compared with fewer than 2 in 10 who got the placebo treatment. Dropout was about the same for the other problems.⁸ A good therapist will set a pace you can stick with.

Building a fear ladder, step by step

A fear ladder (also called a fear hierarchy) is the map for graded exposure.¹ Here is how it usually works. A therapist can help you build one, or you can try it alone for a mild, everyday fear.

1. Name the fear and your goal. Be specific. "I want to ride the bus to the senior center by myself" is better than "I want to feel less nervous."
2. List feared situations. Write down 8 to 12 situations linked to the fear, from a little scary to very scary. Include things you avoid and things you do only with a "safety" habit, like always sitting by the door.
3. Rate each one from 0 to 10. Zero means no fear. Ten means the worst fear you can imagine. Put the list in order from lowest to highest. These are your rungs.
4. Start low. Pick a rung you rate around 3 or 4. It should feel uncomfortable but doable.
5. Write your prediction. Before you start, write what you expect to happen. For example: "I will panic and have to get off."
6. Do the step and stay with it. Stay long enough to test your prediction. Try to drop safety habits, such as gripping a pill bottle or having someone hold your arm. These can block learning.⁷ Notice and name the feeling, such as "My heart is pounding. This is fear." Naming a feeling, without fighting it, may help.⁷
7. Check what happened. Did the bad thing happen? Was it as bad as you thought? How well did you cope? Write it down.
8. Repeat, then climb. Practice the same step several times, often on different days, until it feels easier. Then move up a rung. Practicing in different places and at different times may help the progress last.⁷

Short daily practice usually works better than one big effort once a week. Expect some ups and downs. A bad day does not erase what you have learned.

Is it safe?

Exposure therapy feels uncomfortable on purpose, but it is designed to be safe. You only face things that are not truly dangerous. A therapist creates a safe setting and goes at a pace you agree to.¹ Anxiety usually rises at first and then eases over time.⁵

Exposure therapy in later life

Treatment for anxiety and trauma works for people of all ages. The VA says it is never too late to heal from PTSD.⁹ Older adults may face fears that have grown over many years. Common examples include driving, leaving the house after a fall, medical tests or crowded places. Read about anxiety in later life and fear of falling.

Some practical tips can help older adults get the most from exposure:

• Tell your therapist about health problems, hearing or vision loss, and all your medicines. They can adjust the plan.⁹
• Choose smaller steps if stamina, pain or balance is an issue. Slower is fine.
• Write the ladder down and keep notes after each practice. This helps if memory is not as sharp as it used to be.
• Ask about video visits. Some treatment can be done by telehealth.⁹
• Bring a family member to a session if it helps, but plan to practice on your own over time.

How to get exposure therapy

Look for a therapist trained in CBT who says they use exposure, ERP or prolonged exposure. Ask, "How do you use exposure for my problem?" A good answer includes a step-by-step plan and practice between sessions.

For a simple phobia, treatment may be one long session or about 3 to 8 shorter ones.² For PTSD, prolonged exposure usually takes 8 to 15 weekly sessions of 60 to 90 minutes.⁶ For social anxiety, one well-known CBT plan uses up to 14 longer sessions over about 4 months.¹⁰

See how to find a therapist, paying for therapy and what Medicare covers for mental health. For other options, see treatment for anxiety and trauma-focused therapies.

Common questions

Will I be forced to face my worst fear right away?

No. In graded exposure, you and your therapist agree on each step, and you start with easier ones.¹ A good therapist will never trick or force you.

What if my anxiety does not go down during practice?

That is all right. Research suggests you can still learn even if the fear stays high. The goal is to find out whether your feared outcome comes true and that you can cope.⁷

Can I use relaxation or breathing during exposure?

Some plans pair exposure with relaxation or breathing skills.^1,3 Use them to help you stay in the situation, not to escape it. Try box breathing or grounding. If you notice you cannot face a fear without a certain habit, talk with your therapist about slowly letting it go.

Can I do exposure while taking anxiety medicine?

Many people do. Your therapist and doctor can plan together. Do not stop or change a medicine on your own. Talk with your doctor or pharmacist before changing anything. See medicines for anxiety.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.