How can you overcome acute fears, such as fear of flying, spiders, public speaking, or speaking to strangers? If you've experienced these sorts of fears for a long time, you may think that this fear is something you'll simply have to live with forever. But there is a remarkably simple and scientifically-backed method that can help reduce these sorts of fears.
Exposure therapy is a form of cognitive behavioral therapy (CBT) designed to help people reduce the negative impact of their fears. People often avoid things or situations that provoke feelings of anxiety – which can provide short-term relief but ultimately re-entrenches the fear! There is significant empirical evidence of exposure therapy's effectiveness in treating phobias, as well as a range of anxiety disorders such as PTSD, OCD, and generalized anxiety disorder. In a meta-analysis of 33 experiments, exposure-based treatments for phobias "outperformed placebo conditions and alternative active psychotherapeutic approaches.”
We’ve broken down exactly how it works. If you or someone you care about experiences intense fear, we hope you'll find this information valuable.
How does exposure therapy work?
Imagine that you’re struggling with introducing yourself to strangers. Even thinking about going up to a stranger and introducing yourself makes your heart pound. You might even experience physical symptoms like lightheadedness or nausea.
A cognitive behavioral therapist might give you the following homework to do each week: go to a bar or event alone, introduce yourself to at least 5 people, and report back each session. At first, this is likely to be incredibly hard. Your brain might predict that each new interaction will spell doom. But as you push through them, and each fails to produce the terrible consequences you’re afraid of, you’ll get more and more evidence against the legitimacy of your fear. Your brain, which previously anticipated horrendous consequences in these circumstances, observes that nothing especially bad has happened and learns to predict less danger. Over time, it’s likely that your anxiety will significantly decrease.
This is just one form of Exposure Therapy, known as in vivo or “in real life.” During Exposure Therapy, you can face your fears in different ways, including virtual reality exposure, written exposure therapy (where you write about a traumatic event), and imaginal exposure (where you vividly imagine the feared situation). Each method can help significantly reduce fear responses.
How can you use Exposure Therapy to overcome your own acute fears?
First, if there is someone in your local area specializing in Exposure Therapy (or CBT broadly), and you can afford to work with them, this should be your first port of call. Having an expert walk you through the process and support you is really useful.
But, if you have sufficient motivation to improve, you can also apply Exposure Therapy yourself (however, if you have severe trauma, PTSD, or debilitating phobias, we highly recommend working with a Cognitive Behavioral Therapist rather than attempting this).
If you're ready to do Exposure Therapy yourself, how do you do it? We’ve broken it down into four key steps:
Step 1: Familiarize yourself with the true level of danger.
First, try and establish the facts about the thing you’re afraid of. If you're afraid of flying, read statistics on the actual level of danger per flight. If you're afraid of approaching strangers, talk to friends about how likely different bad outcomes truly are. If you're fearful of spiders, find out how many people truly die from spiders in your region each year and compare that to death rates from other things you are less afraid of, like falls and car accidents.
For most phobic people, this step alone will NOT cure their fear - because this fear typically comes from the brain's subconscious prediction that a situation is dangerous, not an explicit belief. But this step is still important to get your rational brain on board with the exposure. Additionally, if you (analytically) believe that the situation you fear is dangerous when it's not, then that belief about its danger can reinforce your subconscious fear.
This step is also important because Exposure Therapy should not be used for things that are truly dangerous. Fear is useful when it is proportionate to actual danger. When fear is extremely disproportionate, though, it can cause us to miss out on many valuable opportunities or, in extreme cases, even mess up our lives.
Step 2: Make a Fear Hierarchy.
This is a list of things that would make you afraid, rank-ordered from least fear-inducing to most. For example, imagine you have a phobia of spiders. You could sketch out a list of incrementally more anxiety-provoking exercises. This might look like:
(1) Being in a room with a plastic spider
(2) Looking at photos of spiders
(3) Looking at videos of spiders
(4) Looking at real-life spiders at the zoo
(5) Holding a (non-dangerous) spider for seconds or minutes
(6) Allowing a (non-dangerous) spider to crawl up your arm
You can rank each exercise by how much anxiety you imagine it will cause you. Depending on the severity of your fear, you can change up the starting point for your fear hierarchy, and how incrementally you want to move up the rungs of the ladder. A more incremental version of the hierarchy above could involve adding in extra rungs that expose you to photos or videos for different lengths of time, for example, or to footage of different types of spiders.
Step 3: Expose yourself to something safe that you fear
Start with the easiest items on your fear hierarchy. While doing so, make sure not to engage in any coping behaviors – behavioral defenses aimed at reducing your anxiety levels, which make the exposure less effective. For example, if you are terrified of flying and you're using going on planes as your exposure, but before flying, you always research the safety features of the plane, you may be undermining the exposure. Your brain will learn that you’re safe only if you check the safety features beforehand, whereas you actually want your brain to learn an unconditional rule: “I’m safe on planes”. During the exposure, stay in the situation until your anxiety falls a bit before you leave it (or as long as the situation naturally lasts). Leaving too early can end up being a coping behavior, which can reinforce your fear - your brain might think something bad really was going to happen if you hadn't gotten out of there!
As an exception to the "no coping behaviors" rule, using deep breathing or progressive muscle relaxation techniques during the exposure is generally considered to be okay to use if they help you stay in the situation that you fear. These techniques, unlike other coping behaviors, are always available to you and don't tend to reinforce false beliefs like "I'm only safe if I do XYZ."
Remarkably, if you stay in frightening situations where nothing too bad is happening, your anxiety will tend to fall after a little while, naturally, even if you literally do nothing. To understand this intuitively, consider that most people have at least some fear of snakes. This makes sense since some snakes are dangerous. Having to lie in a casket of totally harmless snakes would be frightening for most people. But if you had to lie in that casket for 5 hours, chances are your terror would eventually turn into boredom. Since nothing bad was happening to you, and nothing was changing, you'd eventually start thinking about other things (e.g., what you're going to do the next day), even though you're in a casket of snakes! This is a key insight into understanding exposure therapy – with enough exposure to something that's not dangerous, your fear will "burn itself out"!
If you're bold, as with the snake example, you can also do exposure by jumping right to the top of your fear hierarchy instead of working your way up. This is known as "flooding." This may be more efficient, but it is also much more frightening and has the drawback that you may succumb to fear and exit the situation too early.
If you exit too early, then, as mentioned, you may end up reinforcing your fear in a counterproductive manner. So, only try flooding if your rational brain is confident that the scenario is truly not dangerous, and you're also confident you can get yourself to stay in the scary situation without leaving. Moving gradually up a fear hierarchy tends to be easier than flooding, for most people.
Exposure therapy can also be applied even in situations where it's challenging or impossible to expose yourself to some of the feared triggers. To do so, you can use "imaginal exposure" - where you vividly imagine something you fear. The visualization has to be so vivid that it actually makes you afraid. By doing so, you can treat the imaginal exposure just as if it were a real exposure. Virtual reality exposure can also be useful in some situations where in-person exposure is not feasible.
Step 4: Keep repeating step 3
While a single long exposure can sometimes cure people (for example, someone phobic of spiders allowing a harmless spider that terrifies them to crawl on their arm for two hours straight), typically, quite a few exposures are needed to see substantial improvement. Once one step on the fear hierarchy begins to feel easier, try exposures at the next step on the hierarchy. If you fail at one step, simply go back to the prior (easier) step on the hierarchy and work on that until it becomes even easier, then try going up a step again.
A helpful additional part of the method is tracking your "Subjective Units of Distress" (SUDs) on a 0 to 100 scale before, during, and after each exposure. This can help you observe your progress and calibrate what challenges you are ready for.
Exposure therapy works best for specific fears with clear triggers. While success with one trigger may partially transfer to related situations, you often need separate exposure practice for different triggers. For example, mastering public speaking with notes doesn't guarantee comfortable speaking without them. For best results, vary your exposure practice across different scenarios you might realistically encounter in daily life.
Additionally, it’s worth noting that periodic exposure "refreshers" may be needed to overcome flare-ups or temporary setbacks, which are a normal part of treatment.
Before we wrap things up, here's a reminder: Self-guided exposure therapy can carry risks, particularly for people with severe trauma, PTSD, or debilitating phobias. While many people can benefit from applying exposure techniques on their own, it’s important to carefully consider whether this approach is right for you. If you are struggling with extreme distress, avoidance, or past trauma, working with a licensed therapist can provide essential guidance and support to help ensure the process is safe and effective.
Now that we’ve been through the steps, you can decide whether exposure therapy is something you want to try for yourself!
In addition to helping cure specific fears, Exposure Therapy has a deep lesson for us: when we are afraid of things that are not dangerous, we need not let that fear stop us from taking valuable actions. We can act even though we are afraid and still get that value - and this often leads to less fear in the long run.
That's exposure in a nutshell! The process is difficult but incredibly simple. If you have an acute fear that is making your life worse, you can likely overcome it. You may want to give exposure therapy a try!