EExposure Therapy

Victoria M. Follette and Alethea A. A. SmithKeywords: exposure, cognitive processing therapy, PTSD, stressinoculation training

Exposure therapy has increasingly been found efficaciouswith a variety of anxiety-related disorders including pho-bias, generalized anxiety disorder, and posttraumatic stressdisorder. Originally developed using concepts from basiclearning theory, concerns about enhancing the efficacy ofexposure therapy have led to the enhancement of this tech-nique with additional components. The primary augmenta-tion has been the integration of cognitive techniques. Ascognitive conceptualizations of various forms of psy-chopathology, particularly anxiety and depressive disorders,became dominant, the integration of cognitive and exposurestrategies grew to be routine practice.

Based in learning theory, exposure techniques havebeen conceptualized to function as a form of countercondi-tioning or extinction. In an early form of exposure therapybased on counterconditioning, Wolpe (1958) used systematicdesensitization, the pairing of relaxation with confrontinganxiety-producing situations, to weaken anxiety responses.Mowrer’s two-factor theory (1960) represents yet anotherearly conceptualization of behavior problems. In Mowrer’smodel, fears are acquired through classical conditioning

processes and maintained by means of operant conditioning.Specifically, the conditioned stimulus (CS) is paired with anunconditioned stimulus (UCS), which elicits a fear response.Through avoidance of the CS, the fear is maintained by neg-ative reinforcement. Several significant therapeutic advanceswere generated from this seminal work. One of the mostnotable of these was the development of implosive therapy,which used exposure to interrupt the fear process throughextinction (Stampfl & Levis, 1967).

Exposure therapy for anxiety disorders has continued tobe elaborated and comprises a set of techniques designed tohelp patients confront their feared objects, situations, memo-ries, and images in a therapeutic manner. Commonly, the corecomponents of exposure programs are imaginal exposure(i.e., repeated visualization of images or action or repeatedrecounting of memories) and in vivo exposure (i.e., repeatedconfrontation with the feared objects or situations). Programsmay also include psychoeducation, relaxation training, pro-cessing of the exposure sessions, or combinations of each ofthese elements.

While exposure alone does have strong empirical sup-port across a variety of anxiety-related disorders, there havebeen several consistent concerns regarding this approach.First, studies using exposure often report high attrition ratesin the exposure treatment group which is sometimes inter-preted as a sign that it is difficult for clients to accept expo-sure as a treatment modality. Second, the use of exposurewith victims of traumatic events has been criticized as unnec-essarily increasing patient suffering and even exacerbatingPTSD and anxiety symptoms. Third, some clients, particu-larly those with a trauma history, have difficulty with basicskills including emotion regulation, distress tolerance, andinterpersonal relationships and are thus seen as not havingthe capacity to complete an exposure program. Finally, it hasbeen suggested that exposure should be enhanced in order to

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address additional problems, such as negative appraisalsincluding guilt and shame. Client concerns such as anger anddissociation may also require adjunctive treatments.

Cognitive–behavioral therapy has incorporated basiclearning theory along with cognitive strategies to addresssome of the above concerns. One early integrative exampleis stress inoculation training (SIT) which uses modifiedforms of exposure and cognitive techniques (Meichenbaum,1974). In addition to exposure, SIT provides patients withmanagement skills to help them reduce anxiety (e.g., relax-ation training, controlled breathing, positive imagery, cogni-tive restructuring, and distraction). Cognitive processingtherapy (CPT; Resick & Schnicke, 1992) takes a differentperspective, using information processing theory as its theo-retical foundation. While somewhat modified in form, itdoes merge features of cognitive and exposure therapies.Clients spend time writing about trauma experiences andworking to restructure core schemas such as safety and trust.

In some cases, therapies are developed that can be con-ceptualized as incorporating cognitive and exposure strate-gies, although they do not explicitly address theseconstructs. A prototypical example of this is acceptance andcommitment therapy (ACT; Hayes, Strosahl, & Wilson,1999). In this approach, efforts are made to reduce experi-ential avoidance which generally involves changing theclient’s relationship to language as well as exposure tofeared experiences by engaging in behaviors consistent withvalued life goals. Eye movement desensitization and repro-cessing (EMDR) is another example of a treatment thatincludes cognitive and exposure components, while espous-ing a different theoretical foundation. This therapy consistsof a form of exposure therapy that involves processing thetraumatic event while engaging in saccadic eye movements(Shapiro, 1995). Patients are also asked to replace negativethoughts with more positive or adaptive ones. While thetreatment remains somewhat controversial, particularly withrespect to the mechanism of change, some data suggest thereis utility in the approach.

EMPIRICAL FINDINGS

There are several studies that support the combinationof exposure therapy with other cognitive–behavioral thera-pies. Resick, Nishith, Weaver, Astin, and Feuer (2002) com-pared CPT with prolonged exposure (PE) and a wait-listcontrol for the treatment of PTSD in female rape victims.Analysis indicated that both 12 sessions of CPT and 9 ses-sions of PE were effective in reducing PTSD symptoms incomparison to a minimal-attention wait-list control group.At posttreatment, CPT and PE patients showed an averagereduction in PTSD symptoms of 72 and 67%, respectively,

and these results were maintained at a 9-month follow-up.One difference between the two treatments was that CPTproduced better scores on two of four guilt subscales.

Foa et al. (1999) compared the efficacy of PE alone,SIT alone, and a combination of PE and SIT. After ninetwice-weekly sessions, PTSD symptom severity decreasedan average of 55–60% for both the PE and PE/SIT groups.Results for both groups were maintained at a 12-monthfollow-up. Blanchard, Hickling, and Devineni (2003) alsoused a combined PE/SIT protocol and compared it to sup-portive counseling for patients with PTSD following motorvehicle accidents. At posttreatment, individuals in thePE/SIT group showed an average reduction in PTSD symp-toms of 65% compared to 38% for those in the supportivecounseling group and 18% in a wait-list control. Resultswere maintained at follow-up.

Several studies have been conducted to evaluate the effi-cacy of EMDR and the role of the eye movements; severalreviews suggest that compared to no treatment or nonspecifictherapies for PTSD, EMDR is successful. However, a meta-analytic review found EMDR less effective than other expo-sure therapy programs (Davidson & Parker, 2001). Inaddition, Devilly and Spence (1999) compared EMDR to amodified version of combined PE and SIT. At posttreatment,PE/SIT reduced symptom severity by 63% versus 46% in theEMDR condition and 3-month follow-up showed an averagesymptom reduction of 61% for PE/SIT and only 12% for theEMDR condition.

A different approach has been to introduce another CBTcomponent separate from the exposure intervention. Cloitre,Koenen, Cohen, and Han (2002) randomly assigned womenwith PTSD related to childhood abuse to either a two-phasecognitive–behavioral treatment or a wait-list control. Thefirst phase of the treatment consisted of 8 weeks of skillstraining in affective and interpersonal regulation. The secondphase consisted of 8 weeks of modified PE. Compared tothose on the wait list, participants in the skills/PE conditionshowed significant gains in affect regulation, interpersonalskills deficits, and PTSD symptoms. Gains were maintainedat both 3- and 9-month follow-ups. Furthermore, Cloitreet al. showed that Phase 1 negative mood regulation skillsand therapeutic alliance measures were predictive of successin reducing PTSD symptoms during Phase 2.

Finally, several studies have examined the effect ofaugmenting exposure therapy with other CBT techniques.Most of these studies show very little augmenting effect.The Foa et al. (1999) study discussed above showed no sig-nificant differences between the PE condition and a condi-tion combining PE and SIT. Foa (Foa, Rothbaum, & Furr,2003) reports on a study comparing PE to a combination ofPE and cognitive restructuring (CR) and a wait-list control.In this study the PE condition showed an average symptom

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reduction of 78% while the combined PE/CR conditionshowed an average symptom reduction of 62%. In both ofthe above studies, Foa and her colleagues suggest that theCBT therapies may not be augmenting the exposure therapydue to increased demands on the patients. The PE conditionalone is more efficient and more time may be needed to successfully implement a combined approach.

Marks, Lovell, and Noshirvani (1998) also conducted astudy comparing exposure and CR. In this study they had anexposure alone condition, a CR alone condition, a combina-tion exposure/CR condition, and a relaxation control. Theexposure used in this study consisted of five sessions of imag-inal exposure followed by five sessions of in vivo exposure.Results of the study are mixed. At follow-up, there were nosignificant differences in PTSD severity between any of thegroups including the relaxation control condition with anaverage severity reduction between 35 and 50%. At 6-monthfollow-up, the conditions that received exposure alone or CRin combination with exposure seemed to show furtherimprovement while the CR alone condition did not.Reductions in symptom severity were 81, 53, and 74% for theexposure alone, CR alone, and combined exposure/CR condi-tions, respectively. These findings do not support the hypoth-esis that CR augmented exposure. However, exposure didseem to augment CR at least for the follow-up assessment.

Paunovic and Ost (2001) were also unable to find sup-port for augmenting PE with CR in a population of Swedishrefugees with PTSD. Comparing PE alone to a combinedPE/CR condition, PTSD symptoms were reduced by 53%and 48%, respectively. Similar patterns were maintained at 6-month follow-up and across measures of depression andanxiety.

One study that did find an augmentation effect (Bryant,Moulds, Guthrie, Dang, & Nixon, in press) compared con-ditions of imaginal exposure, imaginal exposure with a cog-nitive component, and supportive counseling. Symptomreduction at treatment end was 48%, 67%, and 22%, respec-tively, and this pattern of results was maintained throughfollow-up. While this does give support for an augmentationeffect, it is also important to note that this study did notincorporate an in vivo exposure component, which is foundin all of the previous studies.

SUMMARY

Exposure therapy has increasingly been used in con-junction with other cognitive–behavioral therapies in a vari-ety of formats and techniques, particularly in the treatmentof anxiety disorders. Reasons for the addition of cognitiveenhancements to exposure therapy include concerns for

client well-being and/or an interest in increasing client will-ingness to engage the treatment. Other newer therapies suchas CPT, ACT, and EMDR, while based in differing theoreti-cal paradigms, incorporate cognitive and behavioral strate-gies that are consistent with exposure and cognitive change.

Several empirical studies support combinations ofexposure and other cognitive–behavioral therapies.However, studies evaluating a possible augmenting effect ofother CBT components have generally shown equally prom-ising effects with exposure alone and exposure combinedconditions. Further research is needed to more fully under-stand which components of other cognitive–behavioral ther-apies are most helpful in addressing concerns of usingexposure therapy alone, and the manner in which exposuretherapy can be most effectively integrated.

See also: Panic disorder, PTSD, Severe OCD

REFERENCES

Blanchard, E. B., Hickling, E. J., & Devineni, T. (2003). A controlled eval-uation of cognitive behavioral therapy for posttraumatic stress inmotor vehicle accident survivors. Behavioral Research and Therapy,41, 79–96.

Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., & Nixon, R. D. V.(2004). Imaginal exposure alone and imaginal exposure with cognitiverestructuring in treatment of posttraumatic stress disorder. Journal ofConsulting and Clinical Psychology, 71, 706–712.

Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills trainingin affective and interpersonal regulation followed by exposure: Aphase based treatment for PTSD related to childhood abuse. Journalof Consulting and Clinical Psychology, 70, 1067–1074.

Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitizationand reprocessing (EMDR): A meta-analysis. Journal of Consultingand Clinical Psychology, 69, 305–319.

Devilly, G. J., & Spence, S. H. (1999). The relative efficacy and treatmentdistress of EMDR and a cognitive–behavioral trauma protocol in theamelioration of posttraumatic stress disorder. Journal of AnxietyDisorders, 13, 131–157.

Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., &Street, G. P. (1999). A comparison of exposure therapy, stress inocu-lation training, and their combination for reducing posttraumatic stressdisorder in female assault victims. Journal of Consulting and ClinicalPsychology, 67, 194–200.

Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape. NewYork: Guilford Press.

Foa, E. B., Rothbaum, B. O., & Furr, J. M. (2003). Augmenting exposuretherapy with other CBT procedures. Psychiatric Annals, 33, 47–53.

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change.New York: Guilford Press.

Marks, I., Lovell, K., & Noshirvani, H. (1998). Treatment of posttraumaticstress disorder by exposure and/or cognitive restructuring: A con-trolled study. Archives of General Psychiatry, 55, 317–325.

Meichenbaum, D. (1974). Cognitive behavior modification. Morristown,NJ: General Learning Press.

Mowrer, O. A. (1960). Learning theory and practice. New York: Wiley.

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Paunovic, N., & Ost, L. (2001). Cognitive–behavior therapy vs. exposuretherapy in treatment of PTSD in refugees. Behavior Research andTherapy, 39, 1183–1197.

Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002).A comparison of cognitive processing therapy with prolonged expo-sure and a waiting condition for the treatment of chronic posttraumaticstress disorder in female rape victims. Journal of Consulting andClinical Psychology, 70, 867–879.

Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy forsexual assault victims. Journal of Consulting and Clinical Psychology,60, 748–756.

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Stampfl, T. G., & Levis, D. J. (1967). Essentials of implosive therapy: Alearning based psychodynamic behavioral therapy. Journal ofAbnormal Psychology, 72, 496–503.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA:Stanford University Press.

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