Salene M. W. Jones Ph.D.
All About Cognitive and Behavior Therapy

KEY POINTS

• Exposure therapy is not right for all types of anxiety.
• Exposure therapy can look very different, depending on the source of the anxiety.
• Sometimes a way of coping with anxiety is a safety signal and sometimes a safety measure.

I recently published a post on myths about exposure therapy. As soon as it went live, I remembered several other myths I’d forgotten. But this happens to everyone. This post will cover those additional myths.

First, I see a lot of assumptions that exposure therapy should be used for any type of anxiety. This is not true. Anxiety is a normal part of life but becomes a problem when it becomes too intense or so frequent that it interferes with what a person wants to do. The everyday anxiety that most people experience does not necessarily need treatment. Anxiety can also be realistic or unrealistic. Realistic anxiety does not need exposure therapy. Unrealistic anxiety could benefit from exposure therapy, depending on the situation.

Whether anxiety is realistic or unrealistic is highly individual. A person who is perfectly healthy with no medical conditions and no risk factors for heart disease might have anxiety about exercising because it raises their heart rate. For this person, their anxiety is likely unrealistic. However, for people with severe heart disease, their anxiety about exercising too intensely could be realistic. It can be tricky to figure out if anxiety is realistic or not but looking at the evidence, similar to the cognitive side of cognitive behavioral therapy, can help.

In my previous post, I mentioned that exposure therapy involves a hierarchy of feared situations that are then slowly and gradually faced. Often patients might assume that once they have cleared a step in the hierarchy, they shouldn’t feel anxiety in that situation again. Backsliding or having to revisit a step on the hierarchy (or a revised step) is common, especially when someone is experiencing more stress in other parts of their lives. The improvement with exposure therapy is not always a straight line.

Exposure therapy can also take many forms. Sometimes it can be what is called in-vivo, meaning in real life, and includes engaging with the feared situation directly. But the actual feared situation or object might not be available. Sometimes it is because the fear is about something hypothetical and sometimes it is in the past or hard to find. In these cases, imaginal or written exposure might help. Imaginal exposure, as the name implies, means imagining the feared situation for a set period of time. Written exposure has the person write about the feared situation for a set period of time. It’s one of the reasons why journaling can be helpful; journaling can sometimes function as a form of written exposure, helping people engage with a feared situation. The different forms of exposure therapy can also be used to form a hierarchy. A person might be ready for written exposure but not imaginal or in-vivo exposure. After written exposure, they may then feel ready to try imaginal or in-vivo exposure. This is why working with a mental health professional, trained in exposure therapy, is key; it helps people discover which situations and forms work best for them.

The last myth I would like to tackle is about something called safety signals. These are sometimes called safety behaviors and are signs to the person with anxiety that they are safe but do not actually provide a significant amount of safety. Examples include anxiety medication, always having someone else present, or having some special object. The problem is that these safety signals prevent people with anxiety from fully facing their fears. This doesn’t mean that the person has to go headlong into a situation without them. Usually, a person can try facing fear with the safety signal and then try facing it without the safety signal.

There is a major exception to safety signals. What might look like a safety signal to others might actually be a safety measure. Safety measures are actions people take to reduce risk and are perfectly reasonable. In fact, we would not want people to go into certain situations without appropriate safety measures. Let’s take a nurse caring for a tuberculosis patient as an example. Tuberculosis is highly contagious and these patients are usually kept in a negative pressure room that prevents tuberculosis from leaving the room and infecting others. We would never want the nurse (or any health care personnel) to care for someone without this because it is a safety measure. Also, what is a safety signal versus a safety measure can vary for each person. Let’s take dairy allergies and lactose intolerance as examples. The person with lactose intolerance might just need an ingredient list without dairy as a safety measure but having something made in a dairy-free facility could be a safety signal. The person with a dairy allergy, however, would need food made in a dairy-free facility as a safety measure. It is important to not make assumptions about others, especially when you do not know their full health and situation, because what is a safety signal (or irrelevant) to you could be a safety measure to them.

I would like to reiterate my previous disclaimer that exposure therapy should only be attempted in collaboration with a mental health professional with training and experience in exposure therapy. Exposure therapy or similar tactics should never be forced on a person without their consent and people should not be coerced into exposure therapy. When conducted with an experienced mental health provider, exposure therapy can be quite helpful for those with anxiety.

To find a therapist, please visit the Psychology Today Therapy Directory.