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(p. 1) Introduction: Making a Case for Personalized Exposure Therapy 

(p. 1) Introduction: Making a Case for Personalized Exposure Therapy
(p. 1) Introduction: Making a Case for Personalized Exposure Therapy

Jasper A. J. Smits

, Mark B. Powers

, and Michael W. Otto

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date: 17 January 2020

1.1. What Is Exposure Therapy?

The beauty of exposure therapy is that it is anchored in theory, simple in principle, but rich in clinical innovation. And it works. Most clinicians would agree that it makes sense to reintroduce a patient to avoided and feared cues when the goal is to help that individual rid himself or herself of anxieties and return to a fulfilling life. The goal is to create a renewed sense of safety around once-feared cues, helping the patient recognize that harm is unlikely and be willing to take minor “risks” because doing so yields a life that is more rewarding.

Some sort of exposure is always part of successful treatment of anxiety and related disorders, because patients eventually need to re-enter avoided situations to return to full engagement in life. As compared to naturalistic exposure, exposure therapy is a well-designed procedure for maximizing the therapeutic learning of safety that comes from successful exposure. In exposure therapy, patients learn anew the safety of situations and events, as well as their own ability to cope and thrive in these situations. There are a variety of ways of learning safety. Some clinicians prefer a cognitive approach that relies on the careful evaluation of thoughts. Yet, even richly cognitive approaches are not conducted in a vacuum; they are instead conducted in the context of active monitoring of ongoing experience.

This experience is exactly what is provided by exposure therapy. Exposure is programmed experience, plain and simple—guided experiences to help individuals undo the faulty, maladaptive, and anxiogenic beliefs; vigilance to harm; and avoidance that characterize anxiety and related disorders. Exposure therapy is an especially malleable approach and can provide a “where the rubber meets the road” addition to almost any therapy. That is, regardless of whether clinicians see themselves as leading therapy with an eclectic, supportive, humanistic, or cognitive therapy approach, as long as the clinician is willing to facilitate active learning episodes, exposure therapy can be integrated within treatment and can speed a therapeutic response.

For such a straightforward concept, exposure therapy has garnered a wide range of misconceptions in its years of use. To clarify our understanding of (p. 2) exposure therapy, we review what we believe are the top five misconceptions about exposure interventions. In no particular order, these misconceptions include:

  1. (1) Exposure is a brain-dead process that relies on simple repetition and that makes little use of my patients’ abilities as engaged and thinking individuals. Research over the last two decades has made it clear that exposure-based learning (fear extinction) does not involve the successive weakening of fear associations; instead it is an active process of learning safety in response to fear cues. As an active learning process, full engagement of a range of strategies for creating and setting-in memories of safety is important. Safety learning, like other learning processes in humans, engages both automatic (unconscious) and strategic (conscious) cognitive processes, and results in learning outcomes that rely on both automatic and effortful behavioral outcomes.

    • In this book, we pay attention to safety learning that occurs as part of both of these—automatic and strategic—processes. Indeed, Chapter 2 is entitled “Thinking through Exposure” not just because it provides a conceptual overview to clinicians on how to think about exposure, but because it guides clinicians on how to help their patients think actively before, during, and after the exposure exercises. The exposure session provides a core opportunity for safety learning in the context of ongoing experience, but this learning is enhanced by active engagement of cognitive resources to help consolidate and extend these gains.

  2. (2) Exposure is a one-size-fits-all procedure that may not be appropriate for my particular patients. It is true that exposure relies on a one-size-fits-all core principle, because the principle of fear extinction has been validated repeatedly across not only thousands of individuals but across multiple species. However, it is not true that the exposure interventions (used to engender fear extinction) are unitary across patients. Part of the thrust of this book is to show the importance of tailoring the exposure exercise to an individual’s core fears and the particular contexts that modulate these fears (i.e., case formulation). Quite easily, a clinician may never do exposure practice the same way twice, given how important it is to fit the exposure exercises to the specific safety learning needed by a particular patient. In addition, surveys of clinicians have revealed deep misgivings about treatment manuals, with complaints such as “manuals may not be appropriate for the complex and unique patients in a particular clinical practice,” “a fixed 16-session approach is too rigid,” “a fixed approach is difficult to incorporate into ongoing treatment with a patient,” “manuals don’t give guidance on what to do if the session unfolds differently (p. 3) than what is depicted in the manual,” or “manuals stifle creativity and innovation.”

    • In response to concerns like these, we have not written a treatment manual. We have instead written a principle- and procedure-based guide for the delivery of exposure therapy that encourages exposure planning around the unique fear characteristics of an individual patient. Our book is not organized around diagnoses, instead, it is organized around (a) the case formulation that leads to the identification of a specific set of fears, concerns, behaviors, and contexts that will be the target of safety learning and (b) the development of exposure experiences that are guided by principles and examples but are unique to each patient. These exposure interventions can be added on to any program of ongoing treatment. As such, this book is designed to help clinicians bring state-of-the-art exposure interventions to whatever stage of therapy a clinician may find himself or herself with a patient.

  3. (3) Exposure is too hard on patients; don’t a lot of patients drop out of exposure treatment? Ongoing study shows that exposure therapy is an especially tolerable treatment, with strong retention of patients in treatment relative to both medication alternatives as well as the attrition rates observed in open-treatment care networks. We believe this occurs because exposure-based treatments start with a clear rationale, provide incremental treatment benefits, and can be readily modified should patients face barriers to progress. Moreover, when clinicians ask for an initial investment of a fixed number of sessions and engage patients in the active monitoring of treatment outcome, treatment benefits are especially palpable relative to a patient’s investment in therapy. Indeed, examination of session-by-session outcomes shows that initial benefit is realized by many patients in the very first session, with continued benefit thereafter. In addition, in exposure therapy, some patients experience sudden gains (when they achieve over 50% improvement across a single week of treatment) that are driven by a reconceptualization of their fears and their resilience following a single exposure session. Accordingly, both incremental and sudden gains provide patients with anxiety relief, a return to more functional activity, and motivation to continue with the methods that work. Each of these gains provide motivation for continued work with exposure therapy.

  4. (4) Exposure therapy is so challenging, patients need to be on medication first. This misconception about exposure therapy should be considered in relation to its psychosocial analogue, “When a person feels anxious, doesn’t this mean that he or she needs more coping responses?” We will consider both forms of these concerns together, because they share the same root concern—that the patient needs to be protected from his or (p. 4) her own experience of anxiety. We agree that being afraid of one’s own emotional responses is an especially debilitating and overwhelming condition, and this condition needs good treatment. This treatment, we believe, is not to engage the patient in additional avoidance of his or her own emotional experience, but to intervene to reduce the aversiveness of his or her experience of anxiety as a first step toward decreasing the frequency and intensity of anxiety. Chapter 5 emphasizes the transformation in the personal meaning of anxiety that comes from exposure interventions targeted specifically to the experience of anxiety/panic itself (interoceptive exposure). This approach ensures that coping responses are learned in relation to making anxiety more tolerable, while patients are learning safety. Furthermore, it is the role of personalized treatment planning to ensure that any of the “steps” in safety learning to feared cues are not so large that the patient feels exposure practice is not possible. Exposure practice always starts where the patient is and steps forward in a reasonable way from that point. It is true that anxiety medication may be chosen by some patients to aid their entry into therapy, but this represents a personal preference rather than a desirable treatment strategy for the following reasons: (a) there is not supportive evidence that the addition of medication to exposure improves treatment adherence, perhaps due to the complicating factors of medication side effects; (b) considering the “need” for medication to ease the process of exposure, there is evidence that treatment with antidepressants and benzodiazepines, while offering benefits on their own, may in fact slow treatment benefit from exposure-based treatment and add substantially to the costs of treatment; (c) the addition of medications to exposure-based treatment also appears to detract from the staying power of the exposure; when medications are later discontinued, the risk of relapse is dramatically higher unless the exposure-treatment is reinstated before, during, and after the medication taper period. Indeed, medication combination issues are so complex that we devoted Chapter 8 to elucidating strategies to best manage combination treatment strategies.

  5. (5) If a patient has failed to get better with exposure on his or her own (or with a past clinician), doesn’t that mean that exposure won’t work and other interventions should be offered? It is true that many patients will have persisted for years, working to enter feared situations prior to finally coming to therapy. Indeed, in one of our studies, we documented that patients had struggled with their disorders for over a decade before coming to our treatment. These patients got better rapidly, raising the question about why their own persistence in the face of anxiety did not lead to a cure. The answer lies in how you approach exposure. Effective (p. 5) exposure is not a process of “grinning and bearing it” or of “cheating one’s way through a hard situation.” It is a process of evaluating what happens when subtle avoidance behaviors are eliminated in favor of testing how safe the situation truly is. These subtle avoidance behaviors are termed “safety behaviors” because they create a false sense of preventing feared outcomes, and thereby prevent a fuller learning of real safety in feared situations. Elimination of safety behaviors and a focus on objective evaluations of outcomes are some elements that differentiate toughing out feared situations and useful exposure. Also, there can be strong divergence in the types of interventions offered by those claiming to offer cognitive-behavior therapy or exposure therapy. Just as one would never conclude medications don’t work after trying one particular prescription, it does not make sense giving up on exposure therapy after trying one particular clinician.

By reviewing these misconceptions, we hope to communicate that exposure therapy can be delivered with all the richness and finesse that a clinician desires and that a patient needs. Exposure therapy can be added to any treatment where the clinician is comfortable taking a guiding role, helping patients learn what they do not know about psychopathology and the process of change. In exposure therapy, the clinician is a guide to teaching patients about some of the self-perpetuating patterns that characterize anxiety, its disorders, and their maintenance. Likewise, the clinician is a guide for showing patients how to approach phobic situations and events to be able to re-evaluate their relative safety. Finally, the clinician is a guide on how to process and consolidate these experiences to get the most out of exposure therapy.

1.2. The Art of “Playing” with Fear

It may be tempting for a clinician and patient to view reduced avoidance as an outcome that follows anxiety reduction rather than a primary therapeutic target in itself. Patients come to the clinic to feel better, and thus, to many, it feels counterintuitive to set up exercises that tackle avoidance head on and elicit fear and related emotions. Many clinicians are concerned that patients cannot tolerate the distress and/or translate these acts of courage during the session into meaningful improvements in symptoms. There is a sense that things can go badly, so why risk it? For example, one of our clinical trainees recently described her experience conducting prolonged exposure therapy with a new patient with posttraumatic stress disorder as stressful and draining. Seeing her patient upset when repeatedly recounting a memory of physical abuse had her wondering whether this (p. 6) exercise would really help the patient and prompted her to teach the patient a relaxation exercise instead. The patient welcomed the relaxation exercise as it matched her routine of fighting off fear, and the clinician left the session feeling reassured that she had done no harm.

This example is typical of our experience and reflects one of the challenges to conducting effective exposure therapy. In our own work in the clinic and the training of clinicians, we have found that exposure therapy becomes more appealing and effective when both clinicians and patients change their relationship with fear and related emotions as they arise during exposure therapy—from seeing distress as possibly problematic to viewing it as a positive signal for therapeutic learning. When you as clinicians trust that distress can be managed and that emotions are transient, you are in a better position to use exposure exercises as opportunities for new learning and consequent symptom improvement. When you believe fear activation signals that you are off to a good start, you can better model an adaptive response to distress. Instead of attempting to “rescue” the patient, you stay calm, offer support (“I know this is hard, but you are doing great”), and help the patient attend to and process the (safety) information that exposure exercises yield. In that way, you model the appropriate response to fear during exposure exercises: These emotional experiences reflect false alarms that, although producing discomfort, run their course when the patient and clinician act in ways that communicate that the patient is fine. Thus, an effective relationship with fear elicited during exposure therapy is evident when the clinician encourages the patient to embrace the discomfort (“anxiety is your green light; bring it on!”), helps them to resist the habitual avoidance and escape-oriented behaviors, and guides them to ride out the discomfort by doing “nothing.”

Clinicians who trust that fear is an important part of the therapeutic process—those who are willing to “play with fear”—are less likely to hold back and therefore are better able to design and implement effective exposure exercises. Central to playing with fear is the development of a new relationship with the experience of anxiety. The anxiety signal becomes a herald for learning: It prompts an enquiring stance toward finding out what is accurate and what is false about this signal, and how this information can be used to enhance quality of life. Indeed, playing with fear implies that you (and the patient) are engaged and curious when you have found the (set of) cues that activate the patient’s fear. And, when you (both) are excited that you have created the optimal circumstances for therapeutic learning, you can focus on getting the most out of this learning. That is, rather than attempting to provide comfort and immediate anxiety reduction, playing with fear means asking the patient to lean into the feeling, tolerating the moment, while attending to new information that contradicts fearful expectations. This book is dedicated to the many strategies that can be used to achieve these goals.

(p. 7) 1.3. Personalized Exposure Therapy

We wrote this book to help make exposure therapy easier and more rewarding both for the patient and the clinician. It’s true that, in many cases, simply guiding patients through a hierarchy of feared situations is all it takes to reduce fears. It’s when such a manualized approach doesn’t yield the desired effects that clinicians may be turned off by the method or question its efficacy. Being comfortable playing with fear is essential to achieving optimal outcomes quickly, as is personalizing exposure therapy.

The personalized approach to exposure therapy presented in this book stresses the importance of case formulation. That is, it encourages you to first work with your patient to develop an understanding of the factors that maintain fears for the patient. Complementing your clinical interviewing with self-report measures that assess thoughts and habits helps to

  1. (1) determine the specific concerns—or appraisals of threat—driving the fears in situations; and

  2. (2) identify the avoidance and escape maneuvers—or safety behaviors—that the patient uses to manage his or her fears (see Chapter 9 for a list of measures that can be used to assess these maintaining factors).

These two variables—threat appraisals and safety behaviors—are logically linked together, such that patients tend to adopt specific coping strategies that they believe will greatly reduce the perceived threat. Because they are idiosyncratic, these compensatory behaviors can be subtle and easily overlooked.

In addition to using the case formulation to fine-tune the exposure exercises to increase the salience and importance of the therapeutic learning—specifically setting up exposures that disconfirm fearful expectations—personalizing exposure therapy also means attending to individual differences in the processing of new information. Patients and clinicians easily align on treatment goals as determined during the intake process (e.g., reducing anxiety, enhancing self-esteem, increasing quality of life), yet they often think differently about the process required to achieve these goals. Most patients enter therapy thinking of their weekly therapy session as the hour for disclosure and support. Despite having an adequate discussion of the exposure therapy rationale, patients may not easily shift from seeing the session as an hour aimed at venting and feeling better to approaching it as an opportunity for safety learning. Indeed, as we describe in Chapter 4, entitled “Assessing Success,” clinicians and patients may rate the value of the session using different criteria. Whereas the clinician will rate the session as successful when a patient recognizes that he or she overestimated perceived threats and is able to resist engaging in automated avoidance behaviors, a patient (p. 8) may rate session success by his or her sense of personal performance and anxiety level in an exposure practice. For example, we provide group treatment for social anxiety disorder that relies on repeated public speaking exposure exercises. We provide the rationale that repeated brief public speaking exposure exercises provide opportunities to respond differently to false alarms, allowing the fears to extinguish. Patients can articulate this model for therapeutic change—we know this because it is the topic of the first set of repeated speeches—but when processing the exposure exercises, many tend to focus on the quality of the speech. Patients who view the session as successful felt like they “nailed the speech.” Their focus remains on becoming a better performer rather than being less concerned about performance. It is our job as clinicians to help these patients learn to view interim therapeutic success as having performed poorly without giving in to any of his automatic avoidance behaviors, thereby learning that the feared outcome (performing suboptimally) was actually manageable.

We believe that the degree to which a patient approaches the session as an opportunity for safety learning influences the rate of progress in exposure therapy. It is understandable when a patient feels relieved at the end of an exposure session—it takes a lot of energy to do the work. Yet, when this relief turns into avoiding the homework exposure exercises and the next in-session exercises, it is clear that adjustments need to be made in the patient’s framing of exposure practice. In many cases, reframing is aided by a refocus on the exact learning goal for each exposure practice. The goal is not to “get through” the exposure, but to learn something specific from the experience of the exposure. Developing the right “dialogue” for this process is important. For example, a 33-year-old woman who presented with posttraumatic stress disorder in our clinic was able to articulate the treatment rationale for prolonged exposure therapy and showed excellent persistence in being able to repeatedly recount the memory of a rape that occurred when she was 27 years old. Yet, it wasn’t until the clinician described exposure therapy as a method to help rearrange our “collage of memories of major life events” (reducing the size of the image representing the memory of the rape) that she started attending to the meaning of the memory (awful but not dangerous) during and following the sessions. Getting the dialogue right for your patient requires that you tell stories and provide metaphors that patients can relate to and, importantly, translate into the right action. We provide exemplar scripts throughout the book to aid you in this effort.

Therapeutic gains require learning during the session but obviously heavily depend on the extent to which patients retain or consolidate this new learning. It is striking to see the differences in the recounting of previous session experiences across patients. We are excited when we hear that a patient with fears of contamination reports that the experiences during the previous session prompted her to throw away all unnecessary cleaning agents—the exposure exercise during that (p. 9) session chipped away at the belief that contamination is harmful and deserving of the amount of attention she gives it. It is disheartening when the patient who evidenced a large reduction in the fear of fainting in a session that involved repeated practice with voluntary hyperventilation returns the following week to tell the clinician that he has started listening to a series of audio recordings that help him regulate his breathing (an obvious safety behavior in this case). Even though he recognized that the exposure session clearly demonstrated that feeling faint does not lead to fainting, this new learning did not cement into useful awareness.

It may be fair to assume that most patients generally make good use of what they learn during a session, but the example of the patient presenting with a fear of fainting underscores the importance of attending to take-away messages. For this patient, the clinician may complement the end of session review of what he learned during the session with a discussion focused on how to translate this learning into real-life behavioral change. This discussion becomes the basis of specific homework exercises (e.g., journaling, discussing the exercise with a friend/partner, repetition of the exposure exercise at home) designed to make the learning stick.

1.4. How to Use This Book

Our focus for this book is on the principles and procedures that guide exposure therapy; this is a “how to” book. We further break this information into the specific steps you can take to prepare for and implement sessions, with lots of practical information that you can quickly review before starting a session. For many of the procedures, we provide scripts that you can use or easily adapt into the “language” you feel most comfortable using with your patients. The book is also full of figures, worksheets, and handouts that can be used during the session. To make it easier for you, we have made key materials available on a website that complements this text ( We seriously considered providing in-text citations, as this is the standard approach to giving credit to the people who have done the work informing this book. We ended up deciding to forego in-text citations, simply because we were concerned that doing so would result in another more technical and thus possibly less accessible and appealing book on how to deliver exposure therapy. We want to be clear though that the ideas that we present in this book have very much been shaped by the research conducted by our mentors, peers, and students as well as the conversations in clinical supervision with our fellow clinicians and trainees. We acknowledge several of them throughout the book and have provided a list of key references in the bibliography section.

(p. 10) The first section of the book, Chapters 2 to 4, provides a framework for conducting personalized exposure therapy. Specifically, Chapter 2 offers a “forest instead of the trees” overview of principles behind exposure therapy and the way in which new learning is integrated in memory structures. In short, we use a memory-centric view of exposure therapy that is designed to help clinicians identify what is likely to be learned from individual exposure sessions, and how to arrange exposures to provide fuller safety learning. Chapter 3 translates Chapter 2 into the general approach to conducting exposure therapy (i.e., how to implement it), highlighting case formulation, the principles of delivering exposure exercises, and the techniques that help ensure that the patient gets the most out of the session. Chapter 4 complements Chapter 3 by guiding you how to make decisions about treatment progression as it introduces “yardsticks” for improvement that you can use to determine whether you and your patient are on track.

The second section of the book, Chapters 5 to 8, describes the application of personalized exposure therapy to the core fear cues evident across anxiety and related disorders—emotions and physical sensations (Chapter 5), people (Chapter 6), thoughts, images, and traumatic memories (Chapter 7)—and discusses specific strategies for how to combine exposure therapy with medications (Chapter 8).

The third and last section of the book, Chapters 9 to 11, provides you with additional resources, including a list of assessment of strategies (Chapter 9), materials for patient education (Chapter 10), and some of the key references to research papers, chapters, and books that have informed the approach to exposure therapy that we discuss in this book (Chapter 11).