What is Exposure Therapy?

Introduction

Exposure therapy is a technique in behaviour therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger. Doing so is thought to help them overcome their anxiety or distress. Procedurally, it is similar to the fear extinction paradigm developed studying laboratory rodents. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalised anxiety disorder (GAD), social anxiety disorder, obsessive-compulsive disorder (OCD), post traumatic stress disorder (PTSD), and specific phobias.

Brief History

The use of exposure as a mode of therapy began in the 1950s, at a time when psychodynamic views dominated Western clinical practice and behavioural therapy was first emerging. South African psychologists and psychiatrists first used exposure as a way to reduce pathological fears, such as phobias and anxiety-related problems, and they brought their methods to England in the Maudsley Hospital training programme.

Joseph Wolpe (1915-1997) was one of the first psychiatrists to spark interest in treating psychiatric problems as behavioural issues. He sought consultation with other behavioural psychologists, among them James G. Taylor (1897-1973), who worked in the psychology department of the University of Cape Town in South Africa. Although most of his work went unpublished, Taylor was the first psychologist known to use exposure therapy treatment for anxiety, including methods of situational exposure with response prevention – a common exposure therapy technique still being used. Since the 1950s several sorts of exposure therapy have been developed, including systematic desensitisation, flooding, implosive therapy, prolonged exposure therapy, in vivo exposure therapy, and imaginal exposure therapy.

Medical Uses

Generalised Anxiety Disorder

There is empirical evidence that exposure therapy can be an effective treatment for people with generalised anxiety disorder, citing specifically in vivo exposure therapy, which has greater effectiveness than imaginal exposure in regards to generalized anxiety disorder. The aim of in vivo exposure treatment is to promote emotional regulation using systematic and controlled therapeutic exposure to traumatic stimuli.

Phobia

Exposure therapy is the most successful known treatment for phobias. Several published meta-analyses included studies of one-to-three hour single-session treatments of phobias, using imaginal exposure. At a post-treatment follow-up four years later 90% of people retained a considerable reduction in fear, avoidance, and overall level of impairment, while 65% no longer experienced any symptoms of a specific phobia.

Agoraphobia and social anxiety disorder are examples of phobias that have been successfully treated by exposure therapy.

Post Traumatic Stress Disorder

Virtual reality exposure (VRE) therapy is a modern but effective treatment of post-traumatic stress disorder (PTSD). This method was tested on several active duty Army soldiers, using an immersive computer simulation of military settings over six sessions. Self-reported PTSD symptoms of these soldiers were greatly diminished following the treatment. Exposure therapy has shown promise in the treatment of co-morbid PTSD and substance abuse.

Obsessive Compulsive Disorder

Exposure and response prevention (also known as exposure and ritual prevention; ERP or EX/RP) is a variant of exposure therapy that is recommended by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychiatric Association (APA), and the Mayo Clinic as first-line treatment of obsessive compulsive disorder (OCD) citing that it has the richest empirical support for both youth and adolescent outcomes.

ERP is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears, but refrain from engaging in the escape response or ritual that delays or eliminates distress. In the case of individuals with OCD or an anxiety disorder, there is a thought or situation that causes distress. Individuals usually combat this distress through specific behaviours that include avoidance or rituals. However, ERP involves purposefully evoking fear, anxiety, and or distress in the individual by exposing him/her to the feared stimulus. The response prevention then involves having the individual refrain from the ritualistic or otherwise compulsive behaviour that functions to decrease distress. The patient is then taught to tolerate distress until it fades away on its own, thereby learning that rituals are not always necessary to decrease distress or anxiety. Over repeated practice of ERP, patients with OCD expect to find that they can have obsessive thoughts and images but not have the need to engage in compulsive rituals to decrease distress.

The AACAP’s practise parameters for OCD recommends cognitive behavioural therapy, and more specifically ERP, as first line treatment for youth with mild to moderate severity OCD and combination psychotherapy and pharmacotherapy for severe OCD. The Cochrane Review’s examinations of different randomised control trials echoes repeated findings of the superiority of ERP over waitlist control or pill-placebos, the superiority of combination ERP and pharmacotherapy, but similar effect sizes of efficacy between ERP or pharmacotherapy alone.

Techniques

Exposure therapy is based on the principle of respondent conditioning often termed Pavlovian extinction. The exposure therapist identifies the cognitions, emotions and physiological arousal that accompany a fear-inducing stimulus and then tries to break the pattern of escape that maintains the fear. This is done by exposing the patient to progressively stronger fear-inducing stimuli. Fear is minimised at each of a series of steadily escalating steps or challenges (a hierarchy), which can be explicit (“static”) or implicit (“dynamic” – refer to Method of Factors) until the fear is finally gone. The patient is able to terminate the procedure at any time.

There are three types of exposure procedures. The first is in vivo or “real life.” This type exposes the patient to actual fear-inducing situations. For example, if someone fears public speaking, the person may be asked to give a speech to a small group of people. The second type of exposure is imaginal, where patients are asked to imagine a situation that they are afraid of. This procedure is helpful for people who need to confront feared thoughts and memories. The third type of exposure is interoceptive, which may be used for more specific disorders such as panic or post-traumatic stress disorder. Patients confront feared bodily symptoms such as increased heart rate and shortness of breath. All types of exposure may be used together or separately.

While evidence clearly supports the effectiveness of exposure therapy, some clinicians are uncomfortable using imaginal exposure therapy, especially in cases of PTSD. They may not understand it, are not confident in their own ability to use it, or more commonly, they see significant contraindications for their client.

Flooding therapy also exposes the patient to feared stimuli, but it is quite distinct in that flooding starts at the most feared item in a fear hierarchy, while exposure starts at the least fear-inducing.

Exposure and Response Prevention

In the exposure and response prevention (ERP or EX/RP) variation of exposure therapy, the resolution to refrain from the escape response is to be maintained at all times and not just during specific practice sessions. Thus, not only does the subject experience habituation to the feared stimulus, but they also practice a fear-incompatible behavioural response to the stimulus. The distinctive feature is that individuals confront their fears and discontinue their escape response. The American Psychiatric Association recommends ERP for the treatment of OCD, citing that ERP has the richest empirical support.

While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms. Generally, ERP incorporates a relapse prevention plan toward the end of the course of therapy.

Mindfulness

A 2015 review pointed out parallels between exposure therapy and mindfulness, stating that mindful meditation “resembles an exposure situation because [mindfulness] practitioners ‘turn towards their emotional experience’, bring acceptance to bodily and affective responses, and refrain from engaging in internal reactivity towards it.” Imaging studies have shown that the ventromedial prefrontal cortex, hippocampus, and the amygdala are all affected by exposure therapy; imaging studies have shown similar activity in these regions with mindfulness training.

Research

Exposure therapy can be investigated in the laboratory using Pavlovian extinction paradigms. Using rodents such as rats or mice to study extinction allows for the investigation of underlying neurobiological mechanisms involved, as well as testing of pharmacological adjuncts to improve extinction learning.

Book: Mindfulness Workbook for Stress Relief

Book Title:

Mindfulness Workbook for Stress Relief: Reduce Stress through Meditation, Non-Judgement, Mind-Body Awareness, and Self-Inquiry.

Author(s): April Snow (LMFT).

Year: 2020.

Edition: First (1st).

Publisher: Rockridge Press.

Type(s): Kindle.

Synopsis:

Mindfulness is a powerful and proven method for reducing stress and its negative health effects. The Mindfulness Workbook for Stress Relief shows you how to relieve tension and find calm using soothing, restorative techniques like meditation, non-judgement, self-inquiry, and mind-body awareness.

Featuring helpful exercises and simple meditations, this hands-on stress management workbook delivers a wide variety of effective mindfulness tools that you can add to your self-care toolbox like breath awareness, body scans, mindful walking, and more.

The Mindfulness Workbook for Stress Relief includes:

  • Practical & actionable: This book has a beginner-friendly focus that covers a spectrum of everyday situations and science-based solutions.
  • Evidence-based approach: Explore engaging mindfulness-based exercises that are proven to help relieve stress, anxiety, chronic pain, and sleep issues.
  • Situational success: Learn how to address stress triggers in many areas of daily life like relationships, at work, and beyond.

Take a deep breath and begin your practice today with this evidence-based mindfulness workbook.

Book: The Mindfulness and Acceptance Workbook for Self-Esteem

Book Title:

The Mindfulness and Acceptance Workbook for Self-Esteem.

Author(s): Joe Oliver.

Year: 2020.

Edition: First (1st).

Publisher: New Harbinger, Workbook Edition.

Type(s): Paperback and Kindle.

Synopsis:

We all have stories we have created about ourselves-some of them positive and some of them negative. If you suffer from low self-esteem, your story may include these types of narratives: “I’m a failure,” “I’ll never be able to do that,” or “If only I were smarter or more attractive, I could be happy.” Ironically, at the end of the day, these narratives are your biggest roadblocks to achieving happiness and living the life you deserve. So, how can you break free from these stories-once and for all?

Grounded in evidence-based acceptance and commitment therapy (ACT), this workbook offers a step-by-step programme to help you break free from self-doubt, learn to accept yourself and your faults, identify and cultivate your strengths, and reach your full potential. You will also discover ways to take action and move toward the life you truly want, even when these actions trigger self-doubt. Finally, you’ll learn to see yourself in all your complexity, with kindness and compassion.

Book: Managing Depression with Mindfulness for Dummies

Book Title:

Managing Depression with Mindfulness for Dummies.

Author(s): Robert Gebka.

Year: 2016.

Edition: First (1st).

Publisher: Wiley.

Type(s): Paperback and Kindle.

Synopsis:

Rise above depression and build a positive future using mindfulness

If you suffer from depression, you know that it is not something you can simply snap yourself out of. Depression is a potentially debilitating condition that must be treated and managed with care, but not knowing where to turn for help can make an already difficult time feel even more harrowing. Thankfully, Managing Depression with Mindfulness For Dummies offers authoritative and sensitive guidance on using evidence based and NHS approved Mindfulness Based Interventions similar to Cognitive Behavioural Therapy (CBT) to help empower you to rise above depression and discover a renewed sense of emotional wellbeing and happiness. The book offers cutting edge self-management mindfulness techniques which will help you make sense of your condition and teach you how to relate differently to negative thought patterns which so often contribute to low mood and depression.

The World Health Organisation predicts that more people will be affected by depression than any other health problem by the year 2030. While the statistics are staggering, they offer a small glimmer of hope: you are not alone. As we continue to learn more about how depression works and how it can be treated, the practice of mindfulness proves to be an effective tool for alleviating stress, anxiety, depression, low self-esteem, and insomnia. With the tips and guidance offered inside, you′ll learn how to apply the practice of mindfulness to ease your symptoms of depression and get your life back.

  • Heal and recover from depression mindfully.
  • Understand the relationship between thinking, feeling, mood, and depression.
  • Reduce your depression with effective mindfulness practices.
  • Implement positive changes and prevent relapse.

Whether you are struggling with low mood or simply wish to learn mindfulness as a way of enriching your life, Managing Depression with Mindfulness For Dummies serves as a beacon of light and hope on your journey to rediscovering your sense of wellbeing, joy and happiness.

Are Mindfulness-Based Interventions Useful for Nursing Students?

Research Paper Title

The effects of mindfulness-based interventions on nursing students: A meta-analysis.

Background

Recently, mindfulness interventions have been extensively applied in the field of nursing education. However, no consensus has been reached on whether these interventions can reduce anxiety and depression in nursing students.

This meta-analysis was designed to determine the effect of mindfulness interventions on levels of depression, anxiety, stress and mindfulness for nursing students. It was a meta-analysis of randomised controlled trials.

Methods

The following Chinese and English databases were searched for relevant articles: Pubmed, Embase, Cochrane library, Web of Science, CNKI (China National Knowledge Infrastructure) and Wanfang. The search encompassed the establishment of these databases up until January 2020. Two reviewers separately entered the data into Review Manager Software 5.3.

Results

A total of 10 randomised controlled trials (RCTs) were reviewed. It was found that mindfulness interventions significantly lowered levels of depression (SMD = -0.42, 95% CI:-0.56 to -0.28, P < 0.001), anxiety (SMD = -0.32, 95% CI:-0.47 to -0.17, P < 0.001) and stress (SMD = -0.50, 95% CI:-0.65 to -0.35, P < 0.001) in nursing students. Furthermore, the interventions raised levels of mindfulness in this group (SMD = 0.54, 95% CI:0.33-0.75, P < 0.001).

Conclusions

Mindfulness interventions can significantly reduce nursing students’ negative emotions, helping them to manage their stress and anxiety. College nursing educators should consider adopting mindfulness interventions in nursing education to promote the mental health of students.

Reference

Chen, X., Zhang, B., Jin, S-X., Quan, Y-X., Zhang, X-W. & Cui, X-S. (2021) The effects of mindfulness-based interventions on nursing students: A meta-analysis. Nurse Education Today. doi: 10.1016/j.nedt.2020.104718. Online ahead of print.

Book: Mindfulness For Insomnia

Book Title:

Mindfulness For Insomnia – A Four-Week Guided Program To Relax Your Body, Calm Your Mind, and Get the Sleep You Need.

Author(s): Catherine Polan Orzech (MA and LMFT) and William H. Moorcroft (PhD).

Year: 2019.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback, Audiobook, and Kindle.

Synopsis:

Sleep plays a crucial role in our waking lives. While we sleep, our bodies are recharging with energy, damaged tissue is repaired, and our memories are stored. When we do not get enough sleep, we are tired, less positive, less motivated, less focused, and more likely to feel depressed. We may even experience more intense cravings for high-fat, sugar-rich foods. And yet, despite the myriad advantages of getting a good night’s sleep, countless people suffer from chronic insomnia. If you’re one of them, this book can help.

In this guide, a trained mindfulness expert teams up with a behavioural sleep specialist to offer evidence-based meditations and an innovative four-week protocol to address the emotional stresses and anxieties that lie at the root of sleep issues.

You’ll learn practices grounded in mindfulness-based stress reduction (MBSR), mindful self-compassion (MSC), and guided mindfulness and acceptance for insomnia (GMATI) to alleviate the mental, emotional, and physical suffering caused by insomnia. You’ll also learn to identify both internal and external factors that may be compromising your sleep, and develop a plan to address these issues.

There is nothing we can do to “make” ourselves fall asleep. In many ways, this is why insomnia can be so maddening. But what we can do is help create the conditions necessary for healthy slumber. The mindfulness tools in this book will help you do exactly that.

Book: Mindfulness for Everyday Living – A Guide for Mental Health Practitioners

Book Title:

Mindfulness for Everyday Living – A Guide for Mental Health Practitioners.

Author(s): Patrick R. Steffen (Editor).

Year: 2020.

Edition: First (1st).

Publisher: Springer.

Type(s): Hardcover and Kindle.

Synopsis:

This book presents practical approaches for integrating mindfulness principles into daily life. It examines how to incorporate mindfulness principles into interventions across various fields and with different client populations. In addition, the volume describes how to teach clients to integrate mindfulness techniques into daily living – from general stress reduction and compassionate positive living to working with children with medical conditions or autism to mindful parenting and healthy marriages.

The book explains key concepts clearly and succinctly and details practical daily approaches and use. Each chapter presents cutting-edge research that is integrated into effective, proven interventions that represent the gold standard of care and are simple and powerful to use, and concludes with recommendations on how each individual can create his or her own personalized mindfulness approach that matches his or her needs and situation. This book is a must have resource for clinicians, therapists, and health professionals as well as researchers, professors, and graduate students in clinical psychology, psychotherapy/counselling, psychiatry, social work, and developmental psychology.

Book: Managing Depression with Mindfulness for Dummies

Book Title:

Managing Depression with Mindfulness for Dummies.

Author(s): Robert Gebka.

Year: 2016.

Edition: First (1st).

Publisher: Tyndale Momentum.

Type(s): Paperback and Kindle.

Synopsis:

If you suffer from depression, you know that it is not something you can simply snap yourself out of. Depression is a potentially debilitating condition that must be treated and managed with care, but not knowing where to turn for help can make an already difficult time feel even more harrowing. Thankfully, Managing Depression with Mindfulness For Dummies offers authoritative and sensitive guidance on using evidence based and NHS approved Mindfulness Based Interventions similar to Cognitive Behavioural Therapy (CBT) to help empower you to rise above depression and discover a renewed sense of emotional wellbeing and happiness. The book offers cutting edge self-management mindfulness techniques which will help you make sense of your condition and teach you how to relate differently to negative thought patterns which so often contribute to low mood and depression.

The World Health Organisation predicts that more people will be affected by depression than any other health problem by the year 2030. While the statistics are staggering, they offer a small glimmer of hope: you are not alone. As we continue to learn more about how depression works and how it can be treated, the practice of mindfulness proves to be an effective tool for alleviating stress, anxiety, depression, low self-esteem, and insomnia. With the tips and guidance offered inside, you′ll learn how to apply the practice of mindfulness to ease your symptoms of depression and get your life back.

  • Heal and recover from depression mindfully.
  • Understand the relationship between thinking, feeling, mood, and depression.
  • Reduce your depression with effective mindfulness practices.
  • Implement positive changes and prevent relapse.

Whether you are struggling with low mood or simply wish to learn mindfulness as a way of enriching your life, Managing Depression with Mindfulness For Dummies serves as a beacon of light and hope on your journey to rediscovering your sense of wellbeing, joy and happiness.

Book: Everyday Mindfulness for OCD

Book Title:

Everyday Mindfulness for OCD: Tips, Tricks, and Skills for Living Joyfully.

Author(s): Jon Hershfield (MFT) and Shala Nicely (LPC).

Year: 2017.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you have been diagnosed with OCD, you already understand how your obsessive thoughts, compulsive behaviour, and need for rituals can interfere with everyday life. Maybe you have already undergone therapy or are in the midst of working with a therapist. It is important for you to know that life does not end with an OCD diagnosis. In fact, it is possible to not only live with the disorder, but also live joyfully. This practical and accessible guide will show you how.

In Everyday Mindfulness for OCD, you will discover how you can stay one step ahead of your OCD. You will learn about the world of mindfulness, and how living in the present moment non-judgmentally is so important when you have OCD. You will also explore the concept of self-compassion; what it is, what it is not how to use it, and why people with OCD benefit from it. Finally, you will discover daily games, tips, and tricks for outsmarting your OCD, meditations and mindfulness exercises, and much, much more.

Living with OCD is challenging; but it does not have to define you. If you are tired of focusing on how you are living with OCD is and are looking for fun ways to make the most of your unique self, this book will be a breath of fresh air.

Book: Mindfulness for Everyday Living

Book Title:

Mindfulness for Everyday Living – A Guide for Mental Health Practitioners.

Author(s): Patrick R. Steffen (Editor).

Year: 2020.

Edition: First (1st).

Publisher: Springer.

Type(s): Paperback and eBook.

Synopsis:

This book presents practical approaches for integrating mindfulness principles into daily life. It examines how to incorporate mindfulness principles into interventions across various fields and with different client populations. In addition, the volume describes how to teach clients to integrate mindfulness techniques into daily living – from general stress reduction and compassionate positive living to working with children with medical conditions or autism to mindful parenting and healthy marriages.

The book explains key concepts clearly and succinctly and details practical daily approaches and use. Each chapter presents cutting-edge research that is integrated into effective, proven interventions that represent the gold standard of care and are simple and powerful to use, and concludes with recommendations on how each individual can create his or her own personalised mindfulness approach that matches his or her needs and situation.

This book is a must have resource for clinicians, therapists, and health professionals as well as researchers, professors, and graduate students in clinical psychology, psychotherapy/counselling, psychiatry, social work, and developmental psychology.