Caplan on Exposure Therapy

The idea is to get people to “face their fears.” … “Exposure therapy… involves deliberate and planned exposure to a feared stimulus, or representation of the stimulus, until the intensity of the person’s distress recedes.” … The Handbook [of Exposure Therapies] also reviews clinical evidence on exposure therapy vs. other talk therapies vs. drugs vs. nothing vs. combinations of the above.  …  In almost every case, they conclude that exposure therapy plus X is no better than – and other worse than – exposure therapy alone.  The zero or negative marginal benefit of drugs is awfully Hansonian:

With respect to short-run efficacy, a number of studies suggest that [some drugs] may enhance the effects of exposure-based CBT [cognitive-behavioral therapy].  However, an approximately equal number of clinical trials provide no support for this conclusion, and a meta-analysis of this literature indicates that combined treatment is no more effective than CBT alone. … On the other hand, clinical trials have consistently failed to support an advantage of combined treatment when long-term outcomes are considered.  In fact, the two largest and most well-designed trials of combined treatments provide unambiguous evidence that pharmacotherapy… interferes with the durability of exposure-based CBT.

More here.  Yes, exposure therapy probably does make people feel less stressed about particular fears.  But you can’t know if this is a good thing until you know how stressed people should feel on particular fears.  For fears that are over-blown, exposure therapy seems good, but for under-blown fears, it seems bad.

For example, exposing people to the real deaths of others may well make folks less stressed about, and accepting of, their own future death.  If you think people are not accepting enough of their death, you approve, but if you, like me, wish folks would more “rage against the dying of the light,” you disapprove.

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  • Psychohistorian

    I would be stunned to hear there’s experimental evidence that this works for death. I’d be pretty surprised if future experimental evidence found that this works for death. It’s just too big a category. The fears that get treated are mostly phobias, which are essentially irrational, which is why exposure works. If you’re deathly afraid of snakes, exposure to a real live snake in which you don’t get hurt at all can erode your fear. I’m not really sure how this could work for something as general as death.

    • 2999

      You beat me to it, it seems. Did you ever see that Youtube video where the woman has exposure therapy for her fear of snakes? Amazing.

  • 2999

    Exposure therapy is probably the most effective form of psychotherapy. Of course, some fears are useful, but Specific Phobias never are (by definition). Usually exposure is for phobias like heights, snakes, enclosed spaces, etc. which are debilitating and irrational.

    Usually the exposure therapy works over the course of a couple hours, and there are some maintenance exercises to maintain the treatment effect.

    I’ve never heard of exposure therapy for fear of dying, but I can’t imagine how it would work. (Fear of corpses is different.)

  • Arthur

    From experience I can say, that exposure therapy can be a great help overcoming phobia. I experienced this in the military, while crawling through a “fox-hole”. It was absolutely dark (almost space-black in my memory) and the ceiling was scraping on my helmet. The instructors were hitting the hidden exit door with a metal bar, which made it sound like the tunnel was going to collapse..I never liked enclosed spaces, but this situation like an exposure therapy to me. I would not say, that I overcame the fear of enclosed spaces, but now I can consciously observe the fear rushing through me, without loosing my mind.

  • Jay

    A side question: Why do you think people should be more fearful/ resisting of death than they are?

    Personally, it seems to me that many people, especially males, are eager to signal unconcern about death, but that when circumstances are actually immediately dangerous, they almost always act fearfully. 90% of soldiers in most armies, in actual enemy contact, don’t fight. The US Army does much better, thanks to the influence of literally generations of psychologists on our training processes.

  • John Maxwell IV

    Fear is only a desirable response if the situation really is fight or flight. If we’re talking about something like death that’s reasonably far away, the cognitive impairments associated with fear are *bad*.

  • Eric Johnson

    > 90% of soldiers in most armies, in actual enemy contact, don’t fight.

    Doubt it. Youre telling me that 90% guys in the American Civil War who were just crouching in the middle of a field with nowhere to hide, didnt bother firing on the enemy?

    Its true that soliders like to retreat and back-rank armed men have been used to force them not to run, at least sometimes.

    • Jay

      It surprised the heck out of me, too. Unfortunately, I no longer have access to the Army database I pulled that from.

      BTW, a lot of them fire, just very poorly. Quite a few people discharge their weapon in the general direction of the enemy (the so-called “Iraqui death blossom”), but that mostly just wastes ammo. It’s only about 10% of most armies (without sophisticated conditioning) that manage to choose a target, aim their weapon, and kill him.

      • student

        But is it not a good thing, that most soldiers hesitate to kill? I mean, is it not humane to hesitate? Afterall the “enemy” is a human being as well, born by a mother, raised by a family.

        I have served my time in the German military, before I started my studies at the university. I was very naive, but learned quickly, that we were trained to overcome this fear of killing. This is a very hidden process. First, they give you a gun, you learn to disassemble and reassemble it, then you learn to load it and unload it, then you shoot at normal “round” targets. When this phase is completed, the targets become more “human”-like. At the end, you shoot blanks at other human beings. I am sure, that most soldiers in my unit would have hesitated doing this, had they not been given this familiarization process beforehand. I have never been in a real combat situation, but the trainings seemed very real and vivid. I am ashamed to admit, that I was able to shoot at the enemy and I look up to the men and women who hesitate, even if it means bringing themselves in great danger. This is true courage.

        Afterall, we do not have an explanation for our existence. We are all here, on some rock flying through space. Still we don`t realize, that we have the potential to live together in harmony and peace, forever. We have plenty of time and ressources to find another earth-like planet, until the sun runs out. What a naive thing to say. But it still makes more sense to me than finding ways of sophisticated conditioning in order to train young men and women to overcome their fear of killing.

      • Jay


        I certainly think that peace is valuable, and that too many politicians are too eager to start wars. I wish America was less militarized, even though I worked for its army for years.

        But for a soldier in a firefight, broad policy questions are not relevant. Those decisions have been made. For him it’s best to win, win quickly, and keep as much of his team alive as possible.

    • TGGP

      I think 90% might be an exaggeration, but very high non-firing rates have been documented. Randall Collins wrote a lot about that in “Violence: A Microsociological Theory” which I quote heavily from here. It most certainly happened in the Civil War too. Many rifles were recovered from the battlefield, and not only did most have unfired rounds in them, a sizable number had MULTIPLE. The soldiers were just going through the motions of loading them without actually firing.

      Furthermore, even when soldiers do fire, it’s very often inaccurately (way too high, for example). These rates of incompetent firing have been greatly reduced in the modern era, partially because the military took note of S.L.A Marshall’s results and acted to counter them through a number of means, such as having soldiers trained to fire in chaotic conditions that more closely resemble the battlefield.

      • Yeah, 90% was too high. Checking Collins book I find that Marshall arrived at a figure of 75% for the best units in WW2. In Korea this rose to 55%, in Vietnam 80 to 95%.

        Here’s the quote on the Civil War: “In American Civil War battles, 90 percent of muzzle-loading muskets collected after teh battle of Gettysburg were found loaded, and half of those were multiply loaded, with two or more rounds on top of one another in the barrel; this implies that at leat half the troops, at the moment they were hit or threw away their arms, had been repeatedly going through the motions of loading, but without actually firing, time after time.”

  • Hansonian

    Now, that’s wanking.