Exposure therapy is a psychological treatment developed to alleviate phobias and fear related behaviours. Exposure therapy is based on the fundamental reasoning that individuals avoid what they fear. Although avoidance is seen by many survivors of trauma to be helpful, it can actually compound the fear over the long-term. Exposure therapy is said to break the pattern of avoidance to fear related situations or activities by creating a safe environment in order to gradually expose patients to the things they fear and avoid. This exposure is this said to reduce fear and decrease avoidant behaviour and coping strategies.
Exposure therapy has been found beneficial with regards to phobias, social and generalized anxiety, OCD and PTSD. Varied in nature, exposure therapy uses different exposure types depending on the individual need whether that be; imagined exposure, VR exposure or interoceptive exposure. As techniques vary, exposure therapy can also vary in pace - again depending on the individual. Exposure can be gradual and paced, working through minor fears and eventually using those tools to face larger insecurities. This can also be reversed (facing biggest fear first); which is termed as 'flooding'; with or without the addition of relaxation exercises as appropriate (systematic desensitization)(2).
Over time, patients who are introduced to exposure therapy find their reactions dull or decrease as previously learnt associations are weakend. Exposure therapy has also been seen effective in making the patient aware of their capabilities in confronting difficult and fearful situations whilst simultaneously managing their symptoms of anxiety or fear. During exposure therapy, patients learn to assign new, positive and realistic meaning to those situations, objects or activities perceived as fearful or anxiety producing. This allows the individual to become progressively more comfortable with the actual experience of fear.
Exposure therapy has received criticism over the years. therapists have been criticised due to failing to encourage patients to approach the most distressing situations common using the wrong exposure type, encouraging distraction (and in some cases reliance on dissociation occurs), feeling to address core fears and not handling patients mental compulsions appropriately (3).
Trauma theorists have shown exposure therapy to be beneficial in single event trauma. However with regards to complex interpersonal relationship trauma or childhood developmental trauma; exposure therapy requires more research and analysis in this area.
Clinicians are often hesitant to use exposure therapy due to the belief that it is not effective in treating multiple event trauma and is viewed by theorists to be counterindicative to individuals suffering PTSD (4). Researchers recommend that in complex cases with severe comorbidity an integrated trauma-informed approach is necessary; while simple PTSD has been found to be associated with a decrease in such comorbidities and can be effectively used in such cases (4). Studies in the US show that only 17% of clinicians use prolonged exposure therapy and similar European studies show even fewer therapists using this therapy type (5). These studies show the main reason for not using prolonged exposure therapy with PTSD patients was a fear of exacerbating both PTSD and comorbid symptoms. More importantly; prolonged exposure therapy approaches which are based primarily on memory processing is inappropriate for cases of complex PTSD (5). This is due to the fact that clinicians believe any kind of dissociation as a contraindication for prolonged exposure therapy. It would ultimately mean a huge proportion of trauma survivors would be excluded from qualifying for this type of therapy (7). It is said that dissociation may hinder the fear activation and thus interfere with an individual's ability to process emotionally.
Research has also shown that PTSD patients can be successfully and safely treated with prolonged exposure therapy even with the addition of other comorbidities.
New research has identified a potential for PTSD improvement with prolonged exposure therapy. The University of Texas published a study in March 2019 which identified a way to improve current treatment for PTSD by changing the way the brain learns to respond to stressful conditions.
Researchers at the University of Texas have found potential for improvement within exposure therapy. Currently one of the preferred PTSD treatment models in the US which helps trauma survivors gradually confront their memories and related emotions in a safe setting.
Dunsmoor stated that "replacing expected adverse events with neutral and unexpected events, even a simple tone, is one way to capture the attention so that the brain can learn to regulate fear more effectively" (1).
During this study; researchers measured 46 participants brain activity when presented with fear conditioned pictures and progress to measure emotional responses to the threat or notion that they may receive an electric shock based on volume of sweat produced on participants hands. Participants were divided into two groups - those who had the shock turned off and those who had the shock replaced by a neutral tone. Both groups were then exposed to a picture of a face paired with a shock symbol. The groups were exposed to the same pictures, either using no tone or using a neutral tone in place of a perceived shock. Both groups were measured the following day in terms of behaviour activity and emotional reactions to the set of pictures. Results showed that replacing shocks with a neutral tone was associated with stronger the PFC activity (the area critical in survival response and perception of fear). Replacing the shop with tone participants emotional response on the second testing using the same photos.
Larger controlled studies are required regarding the effectiveness of prolonged exposure therapy with regards to complex trauma and developmental trauma. As is norm, I can find a plentiful supply of research regarding OCD, anxiety, depression and some PTSD; but with regards to severe trauma occurring due to multi events or during the developmental period, there seems to be a gap in research waiting to be filled.
Our research group can be found here;
(1) University of Texas at Austin. (2019, March 18). New research identifies potential PTSD treatment improvement. ScienceDaily. Retrieved July 28, 2020 from www.sciencedaily.com/releases/2019/03/190318144315.htm
(2) Deprince, A. P. (2001). Trauma and posttraumatic responses: An examination of fear and betrayal. Dissertation Abstracts International: Section B: The Sciences and Engineering, 62(6-B), 2953.
(3) Gillihan, Willaims, Foa (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD, published online 2012, May 30. Retrieved Jul 28 from; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423997/
(4) Minnen, Harned, Mills (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. Published online 2012, july 25. Retrieved jul 28, 2020 from; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406222/#!po=59.9057
(5) Hendriks L, de Kleine R, van Rees M, Bult C, van Minnen A. Feasibility of brief intensive exposure therapy for PTSD patients with childhood sexual abuse: A brief clinical report. European Journal of Psychotraumatology. 2010;1 5626, doi: http://dx.doi.org/10.3402/ejpt.v1i0.5626.
(6) Cloitre M, Courtois C. A, Charuvastra A, Carapezza R, Stolbach B. C, Green B. L. Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress. 2011;24:615–627
(7) Foa E. B, Hembree E. A, Rothbaum B. O. Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York, NY: Oxford University Press; 2007