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Reducing Triggers to Prevent Relapse: Exposure Therapy for Trauma

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Some types of exposure therapy, such as exposure therapy for trauma, can be a part of alcohol addiction treatment.1 Exposure therapy changes how you react to triggers, which can reduce cravings and how much you drink by altering how you react in these situations.

What Is Exposure Therapy?

Exposure therapy is a behavioral therapy used primarily to treat anxiety disorders, including phobias, social anxiety disorder, and post-traumatic stress disorder (PTSD). It is used extensively to treat PTSD in veterans. Behavioral therapies work to alter how you deal with situations to reduce unwanted behaviors and increase healthy, productive, or desirable behaviors by altering the thoughts and emotions that cause them.2

In alcohol addiction treatment, exposure therapy alters how you react to your alcohol triggers to prevent relapse or reduce how much you drink.3 Exposure therapy can also be helpful and important if you are dealing with a secondary mental health condition—known as a co-occurring disorder or dual diagnosis. Anxiety and post-traumatic stress disorder (PTSD) are two common co-occurring diagnoses with alcohol use disorder. Not only are these disorders treated with exposure therapy, but treating them can help reduce alcohol use that is a coping mechanism for mental health symptoms.1

Exposure therapy for trauma works based on the idea that fear or anxiety in a situation continues, in part, due to avoidance. If you struggle with anxiety or a past traumatic experience, you naturally avoid whatever it is that triggers anxiety, memories of the experience, or other negative symptoms. While alcohol use may provide you relief in the short term, it also keeps you from overcoming the fear.

How Is Exposure Therapy Used in Addiction Treatment?

You may experience many types of triggers that can potentially lead to alcohol relapse. The simplest type is if you crave alcohol when exposed to a particular situation because you learned to connect alcohol with that situation in your mind at some point in the past. For example, if you used to drink heavily every time you went to a restaurant, you might still crave alcohol whenever you are in a restaurant.4

If you are abstaining from alcohol, you may feel you cannot eat out at restaurants or you may feel constantly on high alert while in restaurants because you experience cravings for and urges to order alcohol. Even if you do not order alcohol while in the restaurant, the craving may continue after you leave.

In this example, part of addiction treatment may involve exposure therapy to disconnect alcohol use from restaurants in your mind as part of your treatment plan.

Exposure therapy can also be a key part of treating some factors that may have contributed to the development of your alcohol addiction. Research shows that trauma, especially in childhood, is associated with a higher risk of misusing substances and developing a substance use disorder. Your therapist may use exposure therapy to treat trauma, which can positively affect alcohol recovery outcomes. 2

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One study found that participants who received medication treatment for alcohol addiction and exposure therapy for PTSD drank less alcohol six months later when compared to those who did not receive the exposure treatment.5

What Are the Types of Exposure Therapy?

There are different forms of exposure therapy. A therapist may recommend a particular method for you, depending on your unique situation and goals.2

In Vivo Exposure

In vivo exposure involves facing your triggers directly in real life. In the example of a restaurant, in vivo treatment would involve your therapist going to a restaurant with you and teaching you how to cope with your experiences while there.

Or, your therapist might instruct you to note the thoughts and feelings you experience the next time you go to a restaurant. In the next therapy session, you address those thoughts and feelings and learn how to deal with them the next time they come up.2

Imaginal Exposure

Imaginal exposure can be particularly helpful if your trigger isn’t a situation you can put yourself in now, for instance, traumatic memories of the past.2

When traumatic memories come up or PTSD flashbacks happen, you may also experience the thoughts, emotions, or physical sensations that you experienced at the time of the traumatic event. By avoiding sensations associated with the trauma, you temporarily protect yourself from those experiences. For example, you may avoid places, people, or even smells that remind you of the experience. Alcohol use may occur as a way to minimize anxiety, resolve sleep disturbances, or distract from distressing emotions.2

Imaginal exposure involves your therapist guiding you to imagine your trigger scenario and cope with the feelings and cravings that arise.

One common type of specialized imaginal exposure is eye movement desensitization and reprocessing (EMDR). EMDR is most often used to treat PTSD. EMDR focuses changing how a traumatic memory is stored in the brain.Exposure therapy for trauma may include EMDR.

EMDR works by using bilateral stimuli because it engages both the left and right parts of the brain. For example, your therapist may prompt you to follow a moving object you’re your eyes from one side of your vision to the other, which is where the name “eye movement desensitization” comes from. Therapists may also use other bilateral stimulation, such as sound or touch.

EMDR takes place in multiple stages, eventually leading to sessions in which your therapist guides you through recalling a specific experience while using bilateral stimuli. By stimulating both parts of the brain while you recall the memory, the intensity of the experience of the event reduces.6

EMDR for addiction helps to reduce the intensity of trauma symptoms, in turn helping you to reduce alcohol use to cope with related symptoms.

Interoceptive Exposure

Interoceptive exposure is used in the treatment of concerns such as panic attacks and chronic pain, such as those with co-occurring anxiety disorders. Individuals with conditions that have conditions with intense physical symptoms—such as rapid heart rate, shortness of breath, and acute pain—behaviors may be adopted to try and avoid these symptoms.

In interoceptive exposure treatment, you and the therapist work to simulate a manageable version of these sensations in your body. While doing so, you have the support of your therapist’s presence in the room to help you experience the unwanted sensation in your body without becoming overwhelmed. Over time, interoceptive exposure may help you become able to tolerate these sensations with minimal anxiety.2

Your therapist may also recommend other therapeutic modalities for physical symptoms, such as somatic experiencing (SE) therapy.

In addiction treatment, the goal is to learn to deal with distressing physical symptoms without using alcohol as a coping mechanism.

Virtual Reality Exposure

Virtual reality exposure treatment (VRET) uses computer simulations of the real world. VRET is particularly helpful if in vivo exposure is not easily accessible in the real world for triggers, such as if you have a fear of flying. It can also be a way to prepare you for in vivo exposure.7

What Can I Expect in Exposure Therapy?

Exposure therapy is paced based on your symptoms and needs. Usually, exposure therapy involves first exposing you to the lowest intensity of your trigger and slowly working at higher intensities. You and your therapist work together to identify what these levels are for you.2

For example, someone in imaginal exposure therapy who experienced childhood abuse may first be guided through imagining through an experience they can recognize as abusive but that does not cause a profound fear reaction, such as being criticized by their abuser. Their therapist will help them identify increasing intense experiences their therapist can guide them through to process.

In EMDR for addiction, part of the process is also identifying a safe mental space you can use if the therapeutic process becomes too intense.

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Flooding is another way to pace exposure therapy which works particularly well in phobia treatment. Flooding involves exposing you to your fear trigger at the most intense level, which can be in vivo or imagined. Flooding may be most suitable when there are not many intensity levels you can access.

In the example of the restaurant, you may not experience triggers when simply driving past a restaurant. You may need to sit down for a meal at the restaurant for those feelings to come up. Therefore, instead of using an intensity scale, your therapist would instruct you to eat at a restaurant and practice coping strategies you learn beforehand while there.2

Your therapist or care team at an addiction treatment program can help you determine if exposure therapy is an appropriate component of your treatment plan.

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  1. Craparo, G., Ardino, V., Gori, A., & Caretti, V. (2014, July 21). The relationships between early trauma, dissociation, and alexithymia in alcohol addiction. Psychiatry Investigation, 11(3), 330-335.
  2. American Psychological Association. (2017). What is exposure therapy?
  3. Lee, J., Kwon, H., Choi, J., & Yang, B. (2007, October 10). Cue-exposure therapy to decrease alcohol craving in virtual environment. CyberPsychology and Behavior, 10(5).
  4. Hone-Blanchet, A., Wensing, T., & Fecteau, S. (2014, October 17). The use of virtual reality in craving assessment and cue-exposure therapy in substance use disorders. Frontiers in Human Neuroscience, 8.
  5. Foa, E.B., Yusko, D.A., & McLean, C.P. (2013). Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. JAMA, 310(5), 488-495.
  6. American Psychological Association. (2017, July 31). Eye Movement Desensitization and Reprocessing (EMDR) Therapy.
  7. Botella, C., Fernandez-Alvarez, J., Guillen, V., Garcia_Palacios, A., & Vanos, R. (2017, May 24). Recent progress in virtual reality exposure therapy for phobias: a systematic review. Current Psychiatry Reports, 19(42).
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