The Science Behind Fear and Avoidance
Fear is a natural human response that once kept our ancestors alive, but for millions of people today, it becomes a prison that limits their daily experiences. When we’re afraid of something, we tend to avoid the objects, activities or situations related to it. This avoidance creates a vicious cycle where the fear grows stronger over time, making the avoided situation seem even more threatening than it actually is. This avoidance, in turn, can temporarily reduce anxiety but is not necessarily an adaptive way of coping with it. In this regard, patients’ avoidance behaviors can become reinforced – a concept defined by the tenets of operant conditioning.
What Gradual Exposure Really Means
“Graduated exposure” – gradually exposing the patient to increasingly vivid experiences that are related to the trauma, but do not trigger post-traumatic stress. Think of it like learning to swim – you don’t jump into the deep end on your first day. Fear is minimized at each of a series of steadily escalating steps or challenges (a hierarchy), which can be explicit (“static”) or implicit (“dynamic” – see Method of Factors) until the fear is finally gone. Most therapists understand that rushing the process can backfire, which is why the approach focuses on building confidence one small step at a time.
The Revolutionary Work of Joseph Wolpe
Systematic desensitization was developed by South African psychologist Joseph Wolpe. In the 1950s Wolpe discovered that the cats of Wits University could overcome their fears through gradual and systematic exposure. Although hardly a novel concept today, the idea of desensitization was very alien to the traditional psychoanalytic zeitgeist of that era. His groundbreaking research proved that fears could actually be “unlearned” through controlled exposure. Wolpe found that systematic desensitization was successful 90% of the time when treating phobias.
How the Brain Changes During Exposure
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. When you face your fears in a controlled environment, your brain essentially learns new information. This therapy aims to gradually remove the fear response of a phobia and substitute a relaxation response to the conditional stimulus using counter-conditioning. The patient is counterconditioned, taught a new association that is to counter the original behavior learnt. It’s like updating your brain’s software with more accurate information about what’s actually dangerous versus what just feels scary.
The Three Essential Steps of Treatment
Systematic desensitization involves a three-step process: Relaxation Training: The individual learns deep muscle relaxation techniques and breathing exercises to control anxiety and physical reactions to stress. Establishment of Anxiety Hierarchy: The individual and therapist collaboratively create a list of fear-inducing situations related to the specific phobia, ranking them from least anxiety-provoking to most. The list is crucial as it provides a structure for the therapy. Finally comes the actual exposure work. Gradual Exposure: Starting with the least anxiety-inducing situation, the individual is exposed to each item while employing relaxation techniques.
Success Rates That Give Hope
The numbers speak for themselves when it comes to exposure therapy’s effectiveness. Although people may experience mild to moderate discomfort and there is a potential risk of relapse, the success rates of prolonged exposure therapy are up to 80%. For specific conditions, the results are even more impressive. Those with OCD who underwent ERP therapy saw a 47.8% reduction in anxiety, a 44.2% reduction in depression, a 37.3% reduction in stress, and a 22.7% improvement in quality of life. Among OCD people who received remote ERP treatment via videoconferencing twice weekly, 30% no longer met diagnosis criteria for OCD, and 80% of people were rated as very much or much improved after a three-month follow-up.
Why Traditional Therapy Sometimes Falls Short
The success rate for treating phobias with in vivo exposure is high. Unfortunately, few phobics (less than 15-20%) ever seek treatment. This creates a troubling gap between what works and who receives help. Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. Many therapists themselves feel uncomfortable with exposure techniques, preferring to stick with talking therapies that feel safer but may be less effective for specific fears.
Long-term Benefits That Last
One of the most compelling aspects of gradual exposure is how well the benefits hold up over time. 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. This durability sets exposure apart from many other treatments that show initial promise but fade over time. Research from 2024 included a sample of people with PTSD who had multiple previous psychotherapies. They completed a treatment program combined with prolonged exposure therapy, eye movement desensitization and reprocessing (EMDR), and physical activity. The treatment response rates showed that 46% to 60% achieved recovery for PTSD symptoms and that 44% to 48% no longer met diagnostic criteria for PTSD.
What Makes Treatment Successful
The number of sessions for successful treatment was estimated at around 15.3 (SD = 6.0). But success isn’t just about showing up – it’s about active participation. Higher efficacy correlates with lower avoidance behaviours, and greater adherence to homework. The people who do best are those who push themselves to practice between sessions rather than just waiting for their next appointment. Advise the patient to continue each self-exposure until anxiety drops by at least 50%. If it doesn’t, it’s technically sensitization rather than desensitization.
When Exposure Doesn’t Work
Despite its impressive track record, gradual exposure isn’t a magic bullet for everyone. Systematic desensitization is highly effective where the problem is learned anxiety of specific objects/situations, e.g., phobias (McGrath et al., 1990). However, systematic desensitization is not effective in treating serious mental disorders like depression and schizophrenia. In the treatment of OCD, nonadherence affects between 31% and 65% of people. Some individuals struggle with the approach because they can’t create vivid mental images, while others find their anxiety actually increases rather than decreases during treatment.