How to conduct exposure therapy

Prior to conducting an exposure programme it is important that the client understands what is involved and the reasons for treatment. At this stage it is often useful to use examples from the client’s own life experience to illustrate the principle that ‘the more you do something the easier it gets’. Such an example might include learning to drive.

A careful assessment is conducted in which all situations that elicit anxiety are identified. In addition, all situations that the client avoids as a result of their fear are detailed. From this a detailed hierarchy of feared or avoided situations is compiled. Wolpe suggests identifying around ten steps when compiling a fear hierarchy, and also identifies two main types of hierarchy – conventional and idiosyncratic. Conventional hierarchies are those that may reflect typical behaviours common to the problem, for example, height in feet for someone with a height phobia or distance from home for someone with an agoraphobic problem. Idiosyncratic hierarchies on the other hand vary according to the individual, for example, ‘degree of hairiness of spider’ or ‘dirtiness of door handles’ in OCD. Once the hierarchy is complete the client is then asked to enter the feared situations or remain in the presence of the feared stimulus, situation or thought until their initial anxiety rating on entering the situation is reduced by 50 per cent. In practice, this generally takes around 50 minutes to one hour, but may vary according to individuals and the type of problem (for example, OCD problems may require sessions of up to two hours). It is important to select a stimulus that is rated as moderately anxiety provoking for the first set of exposure tasks, to help ensure that the client will habituate within the first session and to help demonstrate that anxiety does go away without escaping or avoiding the triggers. Earlier exposure sessions may be therapist assisted, so that the therapist can be on hand to prompt the client to attend to the stimulus without distracting, help collect anxiety ratings, reinforce progress and, where necessary, model approach behaviours to the stimulus. Once the client has gained experience, understanding and some confidence in the process homework tasks are devised. Homework involves the client engaging in self-directed exposure tasks on a daily basis to stimuli or situations identified on the hierarchy. Homework tasks should be clearly agreed and planned, and be done at a less stressful time of day when the client will be free from interruptions. Self-directed exposure tasks are generally as effective as therapist-assisted sessions, and have the additional benefits of ensuring that the therapist doesn’t become a safety signal for fear reduction and will enhance the client’s confidence or ‘self-efficacy’.

The role of the mental health practitioner in exposure-based treatments is to help the client work through the process of treatment for themselves, while providing guidance and support. It is important that the practitioner is able to let the client work at their own pace, while being aware that some prompting and encouragement may be necessary if clients are to achieve their desired aims. It is also important to monitor the client’s progress by looking for evidence of habituation within exposure sessions (i.e. did the client’s anxiety reduce from beginning to end?) and across sessions (i.e. does the same stimulus produce less initial anxiety each time it is faced?). This can usually be done by asking the client to complete homework diaries that detail the stimulus exposed to, the length of the session, and anxiety ratings and the beginning, middle and end of the session.