Core intervention: Exposure in vivo

What is exposure?
 

Exposure is an evidence-based treatment for anxiety disorders and an important component of Cognitive Behavioural Therapy. During exposure, a client systematically confronts the feared situation or stimulus with the main goal of investigating whether what they are afraid of actually happens. According to the latest insights, the emphasis in exposure is no longer on reducing anxiety, but rather on reflecting on the mismatch between anxious expectations and the actual outcome of an exposure exercise.

What is exposure in vivo?

In in vivo exposure, we examine which situations and/or stimuli from the outside world cause anxiety. This can range from a spider, car, or dog to a visit to the dentist or doctor, a bus journey, a job interview, or stopping the repetitive checking of the gas stove. Depending on the issue, it may be considered to pay extra attention to response prevention. It is important here to get a good overview of all anxiety-inducing situations.

How do you do exposure?

1. To prepare for your first session, send the article on exposure.
2. Begin by explaining the relationship between anxiety and avoidance, so that the client understands why they need to confront the fearful situation.
3. Identify which situations or stimuli trigger anxiety. You can create a non-hierarchical fear list for this. For example: 1. A quiet road, 2. Getting into the car, 3. A highway.
4. Determine the if-then expectation. An if-then expectation consists of a situation and a consequence. For example, "If I get into the car, then I will have an accident."
5. Next, create a feasible exposure exercise in which the client exposes themselves to one or more anxiety-inducing situations and make agreements about it. Make sure not to engage in the client's avoidance and also choose challenging exercises.
6. After performing the exercise, it is essential for the client to reflect on whether the if-then expectation came true.
7. Continue repeating the exposure so that the new association becomes dominant over the old if-then expectation.

How do you increase effectiveness of exposure?

There are three important conditions for effective exposure: debunking anxious expectations, independence from context, and stress tolerance. The following strategies can be employed to optimize the effectiveness of exposure:

• Debunking the if-then expectation: It is important that the exposure exercise thoroughly debunks the feared if-then outcome, creating the largest possible discrepancy between the anxious expectation and the actual outcome. Formulate a logical and testable if-then expectation (For example, not "I get startled by a dog," but "I get attacked and bitten").
   
• Deepened extinction: If there are multiple anxiety-inducing situations or stimuli, they can be combined. For example, in the case of social anxiety, giving a presentation while wearing a striking outfit.
   
• Occasionally reinforced extinction: Encourage your client to deliberately seek out the feared consequences. Clients can learn a lot from experiencing the anxious expectation and realizing that it's not as bad as they thought, such as experiencing rejection and finding that it's not as terrible as anticipated.
   
• Reduction of safety behaviours (response prevention): Safety behaviours limit inhibitory learning because they provide alternative explanations for the absence of the feared consequences. Not being rejected, for example, may be attributed to wearing a lot of makeup or exhibiting eccentric behaviour.
   
• Variation in context: Perform the exposure exercises in a variety of internal and external contexts (e.g., practicing in different moods, locations, days, and times). A diversity of new experiences leads to better generalization of the learning effect.
   
• Vary stimuli, duration, and intensity of the exercises: The situations that make a client anxious (previously organized in a hierarchy) are randomly traversed. This way, the arousal level and internal context vary. It teaches clients that they can confront the feared situation under various levels of anxiety.
   
• Label the emotions: Ask your client to verbalize their emotional reactions during the exposure. This can strengthen inhibitory learning as language processing activates brain regions that have a dampening effect on the brain's fear center (Affect labeling).
  
   

Recourses

1. Hofmann, S.G. & Smits, J.A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621-632. http://dx.doi.org/10.4088/JCP.v69n0415
2. Norton, P.J. & Price, E.C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease, 195, 521-531.
3. https://www.vgct.nl/vgct.nl/public/over-cgt/factsheets/factsheet-exposuretherapie-nieuwe-inzichten 
4. https://www.vgct.nl/themas/angststoornissen/de-nieuwe-inzichten-over-exposure-wat-moet-je-nu-anders-doen-als-cgter
5. Rijkeboer, M.M. & Van den Hout, M.A. (2014). Nieuwe inzichten over exposure. Gedragstherapie, 4(1), 2-19
6. Craske, M. G, Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B, (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy (58), 10-23.
7. https://www.psyxpert.nl/tijdschrift/editie/artikel/t/vermijdingsgedrag-veiligheidsgedrag-en-veilig-gedrag-bij-exposure-in-vivo#:~:text=Exposure%20in%20vivo%20en%20responspreventie,-Cognitieve%20gedragstherapie%20is&text=Exposure%20in%20vivo%20is%20de,ervaart%20dat%20het%20gevreesde%20uitblijft.
8. https://www.ggzstandaarden.nl/zorgstandaarden/angstklachten-en-angststoornissen
9. Greeven, A. & van Emmerik, A. (2020). Handboek exposure. Boom.