Understand Exposure Therapy

Exposure therapy sounds terrifying, until you understand why it works.

What is Exposure Therapy?

Exposure with Response Prevention is the most well-researched and empirically supported therapy for Obsessive Compulsive Disorder.

As the name suggests, Exposure with Response Prevention involves two components: exposure—intentionally confronting something you are afraid of, and response prevention: not doing things that would help you avoid the thing you are afraid of.

For example, let’s imagine a hypothetical person “Sam” who is very anxious about the possibility of accidentally touching or ingesting chemicals. For Sam, an exposure might be going to a hardware store, walking through the paint aisle, and then not washing their hands or changing their clothes.

The underlying idea is that when you repeatedly face your fears and nothing bad happens, your brain starts to learn that thing you were afraid of is actually safe. Through their use of Exposure with Response Prevention, Sam teaches their brain to send them fewer anxiety signals because they don’t avoid chemicals (which shows their brain they are not “using” the anxiety signal it is sending) and because they don’t get poisoned by chemicals despite potentially being around them (which shows their brain the anxiety signal it is sending is too strong for how risky the situation actually is).

How to Start Exposure Therapy

When people learn about exposure therapy, they are typically quite hesitant to try it out. This makes sense – we go to therapy to feel less anxious, not more! The good news is that although exposure therapy is not exactly fun, it does not have to be overwhelming.

When you are doing exposures, it is actually not a good idea to push yourself way too hard—that’s called “flooding” and the reason it is less effective is because it is intolerably difficult. Any time we are building strength and skill, it helps to take our time. If you wanted to lift weights, it is better to start with 5 or 10 pounds and work up only when that becomes very easy. Exposure therapy is exactly the same.

At the beginning of therapy, you and your therapist will collaborate in creating a list of exposures ordered by how much anxiety they would cause you, ranging from mildly uncomfortable to very anxiety provoking. This is called an “exposure hierarchy”. In my work, I try to ensure that people feel that their hierarchy really reflects their experience—cookie cutter templates don’t work here.

For example, Sam’s hierarchy might look something like this:

Anxiety level

Exposure

Response prevention

1–3 Low

Walk through paint aisle

Do not wash hands

Do not change clothes

4–5 Mild

Order takeout

Drink filtered tap water

Do not ask restaurant staff if they use chemicals near food

Do not boil water

6–7 Moderate

Wash clothes with laundry pod included

Burn incense inside

Do not rewash clothes

Do not google incense ingredients

8–10 High

Use a can of spray paint

Use a mercury thermometer

Clean countertop with household cleaner

Do not wear gloves

Do not wash hands

Do not search internet

After making your hierarchy, you will choose some introductory exposures to do. These should cause, at most, low to mild distress. You will repeat these same exposures over and over until they become boring. Then you can consider moving on to the next “group” of exposures. Over time exposures that sounded really scary will start to seem only mildly uncomfortable.

This is a key element of exposure therapy that is often misunderstood. Although you are facing your fears, at any given time you are only really facing a moderate fear. Exposure works through repetition. When you repeatedly do a mildly to moderately scary activity until it is boring, it reduces the fear associated with all related exposures, even the ones that feel impossible to do. The exposures you are doing will change over time, but just like at the gym, your feeling of effort should stay relatively stable.

Keys to Successful Exposures

After 7 years of supporting people with OCD across inpatient and private practice settings, I have learned it is crucial to design exposure plans based around these principles:

1) You are in control

You get to decide what you are comfortable doing, and what you are not. Your therapist is there to brainstorm, advise, and collaborate when desired, but ultimately you call the shots.

2) Don’t sweat setbacks

At some point in treatment, you will almost certainly have a tough day where you go back to compulsions and safety behaviours that you thought you had stopped for good, or have an old fear come back again.

It is helpful to work with your therapist to understand why this setback occurred, but the setback itself is not dangerous.

Exposure therapy is about repetition, so you are not going to eliminate anxiety with one great day of doing a lot of challenging exposures or lose all your progress after one disappointing day of falling back to old habits. It is about the steady application of effort and willingness to tolerate uncertainty over time that leads to transformative change.

3) Response prevention is gradual too

I have worked with many people who tried exposure before meeting me and were unable to continue because they were told they had to do response prevention perfectly. Consider Sam again—if we asked them to not wash their hands at all after walking through the paint aisle, that’s a massive departure from how they live right now. If I was working with Sam, I would ask them—knowing what you know about yourself, how long could you wait to wash your hands? One minute? Five? Fifteen? An hour? The time itself is not important, what is important is creating a plan that is challenging enough that it helps shift neural connections, but easy enough that it is repeatable.

4) Work backwards from the life you want

Even when it is gradual, exposure therapy is not much fun. It’s like stretching or brushing your teeth. So, if you are going to do something unpleasant, it is important to have a compelling “why”.

Try to let go of judgements you or others may have about how you “should” think and act. Instead, ask yourself—where do you want to be in six months, a year, two years? What activities do you want to be doing? What are you going to need to be comfortable with in order for that to be possible? Then design exposures around that. That way, each exposure is not just an empirically validated way of feeling less anxious, it is a practical step towards your best life.

Dr. Andrew Hunter is a Clinical Psychologist at Laksman Doell Psychology. He has passionately pursued the intersection of mental health, business, and optimal performance throughout his career. In addition to his clinical work, he holds an MBA from the University of Toronto’s Rotman School of Management and has previous experience working in management consultancy. He is passionate about using his diverse skillset to collaborate with individuals pursuing transformative intrapersonal change, and to facilitate well-being at scale.