Exposure Therapy: Types, How It Works and What Trials Show

Exposure therapy is a type of cognitive behavioral therapy (CBT) in which a person spends brief periods in a supportive setting learning to tolerate the distress caused by certain objects, ideas or imagined scenes, continuing until the fear tied to them goes down^[1]. The National Institute of Mental Health lists it among the elements of psychotherapy, for use with anxiety disorders^[1].

The target is avoidance. Avoiding a feared object or situation lowers fear in the short term but can make the fear worse over time, and exposure therapy is designed to break that pattern^[2]. Prevalence figures for the conditions it treats sit on our any mental illness page and the condition pages linked below.

The deepest trial evidence for exposure therapy comes from PTSD. A 2022 meta-analysis of 65 randomized-trial studies (4,929 patients) found large effects for exposure therapy compared with waitlist and treatment as usual^[4].

Exposure therapy varies in how the feared thing is encountered. The American Psychological Association's Society of Clinical Psychology describes four formats^[2]:

• In vivo exposure: facing a feared object, situation or activity in real life, such as a person with social anxiety giving a speech to an audience^[2].
• Imaginal exposure: vividly imagining or describing the feared situation, such as a person with PTSD recalling and describing the traumatic event^[2].
• Virtual reality exposure: a simulated version of the feared situation, used when real-life exposure is impractical, such as a virtual flight for fear of flying^[2].
• Interoceptive exposure: deliberately bringing on harmless but feared body sensations, such as running in place to raise the heart rate in panic disorder^[2].

Exposure can also be paced in different ways. Graded exposure works up an exposure hierarchy, flooding starts with the most difficult items, and systematic desensitization pairs exposure with relaxation exercises^[2].

Several named treatments are built on exposure. Prolonged exposure (PE) for PTSD combines repeated, recorded retelling of the trauma memory with step-by-step approach to avoided situations^[6]. Narrative exposure therapy (NET) builds a coherent life narrative around traumatic experiences and is often delivered to small groups over 4 to 10 sessions^[3].

Exposure and response prevention, which adds resisting compulsions to exposure, is covered in our ERP therapy guide.

The APA's Society of Clinical Psychology describes four ways exposure is thought to help^[2]:

• Habituation: reactions to the feared object or situation decrease over repeated contact^[2].
• Extinction: the learned link between the feared thing and a bad outcome weakens^[2].
• Self-efficacy: the person learns they can confront the fear and manage the anxiety^[2].
• Emotional processing: the person attaches new, more realistic beliefs to the feared thing and becomes more comfortable with the experience of fear^[2].

In PTSD the same logic applies to trauma reminders. The VA's National Center for PTSD explains that avoiding trauma-related feelings and situations helps in the moment but keeps people from recovering, and that facing safe but avoided situations and talking through the trauma reduces symptoms^[6].

Exposure therapy has been shown to help as a treatment or a treatment component for six conditions, according to the APA's Society of Clinical Psychology^[2]:

• Specific phobias (see our list of phobias)
• Panic disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Generalized anxiety disorder

For PTSD, the APA's clinical practice guideline recommends offering three first-line interventions, all variations of CBT: cognitive behavioral therapy, cognitive processing therapy and prolonged exposure^[3]. EMDR, cognitive therapy and narrative exposure therapy received conditional recommendations^[3].

For social anxiety, exposure is one component of a broader CBT package; trial results are summarized in our post on CBT for social anxiety.

The broadest pooled analysis reviewed here is a 2022 meta-analysis in Clinical Psychology Review covering 65 studies of randomized trials and 4,929 adults with PTSD^[4]. Exposure therapy showed large effects compared with waitlist and treatment as usual, a small effect compared with non-trauma-focused therapies, and a negligible difference compared with other trauma-focused treatments or medication^[4]. Most effects held at follow-up, and the individual exposure therapies studied were similarly effective^[4].

An earlier meta-analysis, published in 2010, focused on prolonged exposure alone^[5]. Across 13 studies with 675 participants, PE produced a large effect versus control on primary outcomes (Hedges' g = 1.08) and a medium-to-large effect at follow-up (g = 0.68)^[5].

Virtual reality has been tested as a delivery format. A 2019 meta-analysis of 30 studies with 1,057 participants, spanning specific phobias, social and performance anxiety, PTSD and panic disorder, found a large effect for VR exposure versus waitlist (g = 0.90) and no significant difference from in vivo exposure (g = -0.07)^[7].

The pooled numbers here lean heavily on PTSD trials. Exposure-based results for OCD are covered in our ERP guide, and broader anxiety results in therapy for anxiety.

Prolonged exposure for PTSD usually takes 8 to 15 weekly sessions of 60 to 90 minutes, so treatment lasts about 3 months, according to the VA^[6]. The APA's PTSD guideline describes PE as weekly individual sessions over about three months, with 60- to 120-minute sessions often needed to engage in exposure and process it^[3].

The VA describes the sequence this way. Early sessions cover an overview of treatment and a breathing technique, and around the second session the client and provider list people, places and activities avoided since the trauma^[6]. From around the third session, each session includes talking through the trauma in detail, and clients listen to a recording of that part between sessions^[6].

Homework is part of the design: practicing avoided activities, starting with manageable ones and working up to harder ones^[6]. For comparison, the APA guideline lists cognitive processing therapy at about 12 sessions and EMDR at 6 to 12 sessions^[3].

More sessions do not necessarily mean larger effects. In the 2022 meta-analysis, studies with fewer sessions were associated with larger effect sizes^[4].

The VA lists the main risk of PE as mild to moderate discomfort when engaging in new activities and talking about trauma-related memories, usually brief^[6]. A smaller risk it names is that a session recording could be heard without permission if it is not stored securely^[6].

Dropout is the larger practical issue. A 2020 meta-analysis of randomized trials of psychological therapies for PTSD found a pooled dropout rate of 16% (95% CI 14% to 18%), and therapies with a trauma focus were associated with greater dropout^[8]. The same review found no evidence of higher dropout in group formats or in studies limited to military personnel or veterans^[8].

Effect sizes also vary by who is treated. In the 2022 meta-analysis, effects were smaller in studies with more participants who had substance use disorder or were taking psychiatric medication, and in military samples compared with refugees and civilians^[4].

Individual therapy was associated with larger effects than group therapy^[4]. These are study-level associations, not predictions for any one person.

Exposure therapy is not a rival to CBT; the NIMH classifies it as a type of CBT^[1]. The more useful comparison is with other PTSD treatments.

In the 2010 meta-analysis, prolonged exposure did not differ significantly from cognitive processing therapy, EMDR, cognitive therapy or stress inoculation training^[5]. The 2022 meta-analysis likewise found a negligible difference between exposure and other trauma-focused treatments or medication at post-treatment, with a medium effect favoring exposure over medication at follow-up^[4].

EMDR differs from exposure therapy in method: it does not include extended exposure to the distressing memory, detailed descriptions of the trauma, challenging of beliefs or homework^[3]. Only two medications, sertraline and paroxetine, are FDA-approved for PTSD^[3]. More detail is in our posts on EMDR for PTSD and PTSD treatment options.

Exposure therapy is well supported but not always offered. In a 2021 survey of 155 licensed providers, 92.3% reported understanding of or training in exposure, but only 55.5% reported using prolonged exposure to treat PTSD^[9].

Clinicians with a CBT orientation, a doctoral degree and PE training reported greater likelihood of using exposure and fewer negative beliefs about it^[9]. The authors found that negative beliefs and misunderstanding of the exposure rationale persisted even among some trained providers who reported high use^[9].

Access looks different inside the VA. Almost all VA medical centers offer PE in their specialized PTSD programs, and smaller facilities may deliver it by videoconference^[6]. More on mental health in this group is on our veterans page, and provider credentials are explained in kinds of therapists.