This week we are going to go big-picture and compare the best treatments for anxiety disorders in adults. Specifically, we are going to look at which is better, exposure therapy or cognitive therapy. As we’ll see, the answer is not so simple.
As a guide for this discussion, I will be reviewing a review article by Edna Foa, one of the leading researchers in the PTSD field. Here is the citation:
In other articles we have covered what cognitive behavioral therapy (CBT) is. As a refresher there are two components to CBT: Cognitive and behavioral. Cognitive therapy works on cognitions in order to change emotions and behaviors, whereas behavioral therapy works on behaviors in order to change emotions and cognitions. What happens if you combine cognitive and behavior therapy? You get CBT! There are many forms of CBT treatments in the literature to treat every anxiety disorder, and they emphasize the cognitive or behavioral parts differently. I call those that emphasize the behavioral part of treatment cBT (CBT with a big B). cBT for anxiety disorders is just called exposure therapy. I call treatments that emphasize the cognitive part of treatment CbT (CBT with a big C). CbT for anxiety disorders is really just cognitive therapy.
The authors wrote the above paper to review how good exposure therapy and cognitive therapy are for anxiety disorders. It’s unclear how they chose they went about this review, as it’s a fairly brief article rather than a comprehensive overview. However, it is a good summary of the literature to date based on my knowledge of the literature, and from other literature reviews that exist. Plus, it’s written by Edna Foa who, as I mentioned earlier, is someone who really knows her stuff!
What did they find?
Here’s a table summarizing the review. Green boxes mean the evidence that it works is compelling, orange boxes mean that the evidence is mixed:
The discussion provided by the authors was excellent, I’d highly recommend you read the article. Let’s go through some discussion points to really understand the research. I’ll then include a table on what treatment I would recommend for someone based on this article.
It’s very clear that we are pretty good at treating anxiety disorders. If you have difficulties with anxiety, there is a good chance you can be helped by evidence-based treatment. In particular, exposure therapy seems to be the dominant treatment. As long as treatment, whether behavioral or cognitive, includes an element of exposure, you should be helped. However, the authors made an interesting point that perhaps exposure therapy has been unchallenged given its dominance. What they mean by this is that researchers may not have looked enough at other treatments because exposure therapy has proven so good.
The reason this is important is because they argue that exposure treatment has not been shown to be consistently better than cognitive strategies. Few studies exist comparing “pure” CT to exposure therapy. So, perhaps cognitive strategies could be really good if they were only studied more. This could be true, but don’t start thinking about them as equals because of this. For example, if I play one round of golf where I get an average score of 72, and Tiger Woods has an average of 73 based on 1000 rounds of golf, you wouldn’t say that I am better, or even equal to, Tiger. You would instead say to me that I need to play a lot more golf in order to make conclusions about how good I am at golf. My first round could have been a complete fluke! To this end, it’s hard to make conclusions because exposure therapy is waaaaaay more studied than cognitive therapy. In addition, there are even more reasons why exposure therapy may not be shown to be consistently better than cognitive therapy. A big part of this is because they employ many similar strategies. Let’s dig deeper!
The Problem with Comparing Exposure and Cognitive Therapy
This study is great in that it tries to separate out exposure and cognitive therapy to really help us understand whether they affect treatment differently. In just doing this research, and thinking about the issues involved, there is a fundamental assumption that exposure has a different mechanism of action to cognitive therapy. Let’s think about this for a second and return to the descriptions for each:
Exposure Therapy: Changes behavior in order to change thoughts/feelings
Cognitive Therapy: Changes thinking in order to change behavior/feelings
Sometimes, because of this assumption, people can think that exposure and cognitive therapy treat different things:
If exposure and cognitive therapy treat different aspects of anxiety, wouldn’t you expect exposure therapy plus cognitive therapy is better than either one alone? Perhaps it would get better and faster progress? Yet that is not what we see for the anxiety disorders. The authors give an example using the PTSD literature. There are studies comparing exposure therapy to exposure therapy + cognitive therapy. Which do you think did best? If you’re understanding me, you’ll guess that this is a trick question and both do equally.
The key is that exposure and cognitive therapy are not really acting on or treating different aspects of anxiety. Although the mechanism of change is meant to be different, it’s not all that different. To this end, cognitive therapy includes various techniques that are indistinguishable from exposure therapy. Remember how I broke down different types of CBT at the beginning of this article (CBT with a big B and big C)? That will be important to keep in mind. Let’s use an example to explain this more clearly.
Imagine someone who suffers from social anxiety. We know that they worry about people thinking badly about them so they avoid interactions as much as possible. Exposure therapy would have them do social interactions to get new learning to take place: For example, chatting with people and learning that often they are friendly, or that mistakes seem to go unnoticed. Cognitive therapy would have them challenge beliefs to get new learning to take place: For example, changing the belief that everyone judges them or that it’s a disaster if you make a mistake. Either way though, by the end of it the person should be socializing more because they have learned the same thing in real world situations: For example, that people are friendly, mistakes are uncommon, or that mistakes are tolerable. You can look at it in two ways: By the end of treatment they are engaging in the feared behavior and they are having more helpful/realistic thoughts about the feared behavior.
Ultimately then, exposure therapy and cognitive therapy are working in a very similar manner, and the mechanisms of change are not all that different. They are affecting behaviors and thoughts in the same way. As such, I think more studies to understand whether cognitive therapy is equally helpful to exposure therapy may not be the best use of time. A green apple and a red apple still taste the same. Therefore, instead of questioning how they are different, and doing studies to understand these differences, let’s ask how they are the same.
How are Exposure and Cognitive Therapy the same?
Exposure therapy is CBT, and cognitive therapy is CBT. They both work on cognitions AND behaviors. It’s just that exposure therapy is typically more behavioral focused (cBT). But they are not as different as many people assume.
Exposure therapy is effective because it creates new learning. For example, that spiders are mostly safe, that people don’t say mean things to me during a presentation, or that my family didn’t come to harm even though I deliberately didn’t tap the door handle six times. But how does it create that learning? The first step is that exposure should have a learning goal: The thing you are testing (e.g. If I am in the same room as a spider, will anything bad happen?). Second, the exposure should be designed to violate the expected/feared outcome. Third, following the exposure there should be a focus on the question “what did you learn?” in order to help consolidate that learning. So, if the spider did nothing the person might learn that it is safe to be a room with a spider. Hopefully they leave the session now thinking less catastrophically about what it might mean to be in a room with a spider. If they are leaving the room thinking in new ways, exposure is clearly changing cognitive beliefs in the same way that cognitive therapy would hope to achieve.
If exposure is changing cognitions, then how does cognitive therapy create new learning? A major piece of cognitive therapy is the idea of experiments. For example, if you’re worried that someone in a store will be mean to you if you ask, you can challenge the accuracy of this belief, generate more helpful/realistic thoughts, and also test it out in order to collect data. Perhaps go to 10 different stores to collect evidence about how many times people are mean or nice. Doesn’t that sound very similar to elements of exposure therapy? In many ways, yes.
This is a key point: Exposure therapy and cognitive therapy both change behaviors AND cognitions. Because of this, it’s very unlikely that modern day cognitive therapy that includes behavioral experiments will differ from exposure therapy too much. But don’t forget, and this is critical for anxiety disorders, it’s likely because they both share exposure techniques. It’s apparent that this seems to be the active mechanism of change. As such, if the focus is too cognitive it is likely to be a little less effective. In studies of cognitive therapy that involve very little behavioral focus, the outcomes are not as good as exposure therapy for the anxiety disorders.
Exposure therapy and cognitive therapy both get a person to approach the feared situation more often. This explains why some exposure vs cognitive treatments don’t have different outcomes. They are often not really all that different. In fact, they just employ different ways of helping you to do the same thing. Really, all that matters is which of them is going to get you to the point that anxiety isn’t a problem anymore! As long as they are getting you to engage and face the feared stimulus, the treatment has a great chance of working. All the research shows is that for the average person, certain routes/strategies seem to be more helpful than others in doing this. Specifically, more often than not, starting with exposure therapy first is shown to be the most robust method of reducing anxiety. It’s the path of least resistance!
Which is the Most Effective Route?
So, which of them can get you to master each anxiety disorder the best? For the average adult, what would the literature recommend you seek out as the first line of treatment? Below are my summarized treatment suggestions based on this article. Note, this is for adults, does not include medications, and is not intended as treatment advice, merely a summary of what I think the literature shows.
So that’s it. If you’re trying to manage your anxiety, you should be looking for a treatment that includes at the bare minimum some level of exposure. It seems to be the best route for most people who want to master their anxiety. If you see someone who does provides CBT, make sure they are familiar with some of these issues so you can be helped the best way we know at this point. They should probably know what exposure therapy is, and have a good answer for why they would begin with something else. It’s possible that this isn’t true for you, your individual situation, or your style of learning. However, I’m always a fan of at least starting with the treatment that is most likely to work, so if you want the highest chance of success then start with this.
Thanks again for reading 🙂
If you enjoy these articles, please follow me on Facebook for more!