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Principles and practice of exposure

Exposure has been defined as: ‘facing something that has been avoided because it provokes anxiety’. The term ‘exposure’ covers a number of different processes that may be applied in practice. In-vivo exposure refers to exposure ‘in real life’, where the client is actually in the presence of the feared stimulus or situation. Flooding is used to denote the process in which the client faces the stimulus or situation that is the most anxiety-provoking.

Imaginal exposure is where the client is asked to produce mental images of the feared stimulus, situation or object. Implosion techniques are the imaginal equivalent of flooding, where the client is asked to produce an image or mental description of the most feared situation. Interoceptive exposure techniques are used where the feared or avoided stimuli are internal physical sensations perceived by the client. Virtual reality exposure uses technology that provides stimuli that may be perceived as similar or equivalent to real-life situations but where in-vivo exposure methods may be impractical – as in the case of flying phobias. Systematic desensitization  is a term used to describe a particular therapeutic procedure that is based on Wolpe’s theory of ‘reciprocal inhibition’, that states that one cannot be anxious and relaxed at the same time. Modelling procedures are those in which the therapist demonstrates the exposure task in front of the client.

The majority of the exposure-based treatments discussed in this section are those that involve in-vivo exposure, imaginal exposure and modelling techniques. As can be seen from the range of anxiety disorders identified in DSM-IV, a wide range of situations or stimuli can trigger an anxiety response. Some of these may be external, such as specific objects or places, and some may be internal, such as specific thoughts, physical symptoms or memories. When planning an exposure programme, careful assessment will reveal the range of internal and external stimuli that reliably elicit an anxiety response.

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