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Exposure Therapy

SW 8350
Marla K. Ruhana, LMSW
School of Social Work

What is exposure therapy?

Exposure therapy encompasses various approaches

that involve some form of contact between the

client and the anxiety provoking object.
The rationale or logic behind exposure therapy
People avoid that which they feel anxious or fearful

Avoidance of the anxiety-provoking object perpetuates
By confronting the feared object through exposure one
learns that facing the feared object is not catastrophic.
Thus, the fear is overcome.

Exposure Therapy & Strategies

(Cormier et al.,

2013, Ch. 13)

Prolonged (repeated) imaginal exposure to a feared situation/event
Retelling the story in a cohesive, coherent and emotionally connected manner,
using I terms and as if in the present,
identifying and connecting with experienced emotions.
Exposure and Response Prevention (EX/RP) used to treat OCD.
Exposure + a different response than usual.
Virtual Reality Exposure
Computer generated imagery with therapist-controlled exposure to sensory
Interoceptive exposure used in the treatment of panic
Re-creation of physical symptoms (nausea, dizziness, shortness of breath, etc.)
Systematic Desensitization: Gradual exposure to feared stimulus +


Cognitive processing therapy: exposure through narrative.

Eye Movement Desensitization & Reprocessing

Exposure Strategies
Imaginal, in-vivo (live), in-vitro (in the office through role play)
Graduated exposure (gradual, hierarchical progression)
Flooding (full, intense and prolonged exposure in-vivo exposure
Implosive (full, intense & prolonged exposure imaginal


Particularly effective with anxiety disorders

Phobias (specific or social), PTSD, Obsessive-Compulsive Disorder, Panic.
Purpose or rationale:

Reduction or elimination of anxiety.

Exposure to the feared stimuli to counteract avoidance.
Modification of the usual response (i.e. avoidance, escape) &

development of effective coping response.

Emotional processing of the trauma (for PTSD).
Reframing of catastrophic projections associated with the trauma.

Factors to consider for exposure


Have enough time to perform the exercise and ensure

that the client does not leave the office in a high state of
Anxiety must be associated with a specific &

identifiable event or object

Client must have the ability/skill to:
Perform the specific task
Create vivid imagery
Informed consent from client***
Explain rationale
Discuss possible risks (i.e. discomfort, some anxiety) and benefits
Reassurance (e.g. Ill be with you every step along the way ).

Systematic Desensitization
A form of behavior therapy developed by Dr. Joseph Wolpe.
Based on the Pavlovian theory of Classical Conditioning

(i.e. conditioning by association)

Imaginal or in vivo
Graduated exposure to the feared stimulus. Involves:
Creating a hierarchy of steps from least to most feared/anxiety

Pairing relaxation with exposure to the feared stimulus until such
stimulus no longer elicits anxiety/fear.

Based on the principle of Reciprocal Inhibition where the

aim is:
To inhibit a response (i.e. anxiety) by creating another response

(e.g., relaxation that is incompatible with t he first one.

To condition the individual to respond with relaxation to a stimulus
that previously evoked anxiety or fear.

Systematic Desensitization
Preparation - Pre-scene presentation:
Discuss the rationale for the intervention.
Identify the specific anxiety-provoking situation or event.
Test clients capacity for imagery.
Build a hierarchy (10 to 15 scenes) from least anxious to most

Write them down.

Rank anxiety level connected to each scene on a SUDs scale (0-100)

Space scenes so that no more than 10 points separate them.

Train client in a relaxation strategy (e.g. diaphragmatic breathing,

progressive muscle relaxation, etc.).

Help client build a relaxing or neutral scene.

Systematic Desensitization Procedure


Lead client through relaxation process using

previously learned approach (i.e. diaphragmatic


Introduce the previously developed relaxing/neutral

scene (relaxation + imagery).


Hold scene for 30 seconds to allow relaxed mood to

set in


Introduce the first scene in the hierarchy of anxietyprovoking scenes.


The helper describes the pre-determined scene and asks the client to get
into it. The client signals when he/she is into the scene

Scene Presentation (cont.)


Let the scene set for 5 to 7 second



After the time elapses say stop the scene

Ask client to rate the anxiety level (0-100)


If anxiety > 10 repeat process (i.e., steps 1-5)

If anxiety < 10, repeat once more before moving to next

If after 3 tries the client has not been able to

reduce level of anxiety, stop the exercise and
assess/evaluate for possible problems, correct the
problem and try again.

Obstacles to Systematic Desensitization

Difficulties relaxing.
The target problem is not specifically defined.
Irrelevant hierarchies that do not address the issue.
Inability to create adequate imagery
Scene creates too much anxiety
Not enough scenes
Consider creating additional intermediate scenes to reduce
level of anxiety

Scenes for role play Systematic Desensitization:

The night before I am sitting in my office at home

thinking of asking my boss for a raise (Anxiety level =


In the morning I am getting ready to walk out the door

to go to work and I think that today is the day that I will

ask my boss for a raise (30).

I am driving to the office and I can see the office

building and I am thinking of what to say when I ask the

boss for a raise (50).

I arrive at my building and see that my boss is already

there. I see his car and realize that today is the day that
I will ask the boss for a raise (75).

Walking into my boss office and asking for a raise (95).