Exposure is a useful intervention when the client recognises that they are avoiding one or more situations, and that this avoidance is interfering with their progress towards valued goals.
Many people avoid situations that cause anxiety. According to learning theory, specific situations become paired or associated with fear or anxiety (e.g. interacting in a large group or going to school). As a result of this pairing, the individual avoids these situations in order to avoid feeling anxious.
Avoidance can include completely avoiding a situation altogether (e.g. dropping out of school and refusing to go back) or the use of safety behaviours which help to reduce the effects of the anxiety (e.g. not interacting with teachers or other students, or remaining silent).
Exposure is an intervention that aims to unpair or cut the connection between anxiety and the situation. A key assumption is that if the person stays in the situation for long enough, the anxiety will eventually reduce, and they will come to learn that the situation is not necessarily fearful or that they can cope with the initial anxiety.
The concept of anxiety fatigue is important. Fatigue occurs when the physiological arousal involved in anxiety cannot be maintained over long periods, and so the anxiety passes. This should happen if the person stays in the situation for long enough and the feared event or consequence does not occur. This helps the person to decatastrophise the situation.
A key challenge is encouraging the client to expose themselves to the feared situation and to stay in it for long enough for the anxiety to reduce.
The process of graded exposure was developed to help achieve this. This involves breaking the feared situation down into a series or hierarchy of steps that vary in their degree of difficulty or in the amount of anxiety that they cause (e.g. mild, moderate and severe) and working through these steps one at a time.
The graded exposure hierarchy needs to be very specific to the client’s own concerns and capacities so it must be developed in collaboration with the client. The steps in the hierarchy need to be described in specific detail and rated personally by the client regarding their degree of difficulty.
Using the example of acute fear and anxiety around school, a hierarchy of steps might involve: (1) a short visit to the school grounds after school hours in the company of the worker; (2) a visit to the school grounds during lunchtime with the worker or a friend; (3) a visit to a friendly teacher; (4) sitting in on a class for 50 minutes in the company of the worker; (5) a formal meeting with the principal, facilitated by the worker, to discuss return to school; (6) attending 2 or 3 mornings per week for a period of time with debriefing / counselling after each attendance. In the longer term having access to ongoing support and mentorship from a trusted worker may be necessary to keep a young person attending school and working productively.
Key principles of graded exposure are to get the young person through each step with less anxiety at the end than at the beginning, and to build up confidence for the next step.
It may be useful to combine exposure with skills training such as problem-solving and communication skills to build actual competencies in dealing with the challenges inherent in the fearful situations, or relaxation skills to help reduce anxiety.
Imaginal exposure can be used instead of in-vivo exposure or real life practice when there is limited access to the feared situation. This may be appropriate for clients with PTSD who avoid any situations that may trigger memories of a traumatic event (e.g. an assault or accident) or potentially evolve into the feared situation (e.g. displays of anger or violence by another person).
Imaginal exposure can also be used as part of a graded exposure hierarchy if the client is too anxious for in-vivo exposure at the early stages.
Exposure to situations related to PTSD and trauma should only be delivered by mental health professionals with specialist training in trauma-focused interventions.
All exposure work should be closely supervised or undertaken with secondary consultation from a qualified practitioner.