Exposure Therapy: A New Look at Conquering Cravings

By Dr. A. Tom Horvath 05/15/13

What actually takes place in addiction treatment? In the third of a three-part series, Dr. Tom Horvath shows exposure therapy in action as an alternative to avoidance in the treatment of cravings.

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People with substance use disorders often go to rehab partly to get away from the people, places and things that lead them back to using. Some rehabs even prohibit movies, music, and anything else that might serve as “triggers” of intense reminders of—and cravings for—alcohol or drugs. In this sense, rehab is a retreat from a dangerous environment and, ultimately, the real world. Sooner or later, however, a person has to return to the real world—and often to the very people, places and things formerly associated with using.

It’s not unusual for someone to relapse on the very day they are discharged. I had a client who didn’t make it out of the parking lot of a well-known facility. The day before discharge he called one of his former dealers. They used right in the car.

In order to help people learn to manage cravings, many programs encourage long-term stays in rehab or a move to a sober living facility. Extended retreat from the world certainly has its place. But a treatment approach that emphasizes exposure to, rather than avoidance of, triggers and other environmental stimuli that may result in cravings, “slips” and relapse can be effective, whether in rehab or the real world.

Exposure, a technical term in psychotherapy and CBT, is a foundation of treatment for anxiety disorders, PTSD and phobias. In exposure therapy, the client experiences, directly or indirectly, the very thing that’s feared in an effort to learn to gain control of the distress that it causes. The exposure can occur in gradual increments (often referred to as “desensitizing”) or all at once (often referred to as “flooding”).

In my practice, for a client who is terrified of heights, for example, I suggest that exposure take place in a nearby hotel that has an atrium 14 stories high, where you can hang your head over the balcony on each floor. After determining which method is best for the client, I advise that they either work their way up, floor by floor, or confront the entire drop from the 14th floor.

The crucial issue in the success of exposure therapy is for the client to remain in the anxiety-provoking situation long enough to calm down. For instance, their stress level might be seven on a ten-point scale when they enter the feared situation. If they stay until their stress level drops to five or less, they’re making progress. But if they leave before their stress level drops, the encounter is reinforcing their fear or anxiety, not resolving it. This may be harmful to the client, especially because it is taking place in the context of psychotherapy—an environment of trust. The therapist must take great care to ascertain that the client is ready. 

I have seen clients make big strides in recovery through the use of this technique, and I am convinced that addiction treatment could benefit enormously from the application of exposure therapy. What follows is an illustration of how exposure therapy can be put into practice with a client ("Carl" is a composite of several clients):


Dr. Horvath: You’re concerned that when you drive around town making sales calls, you’ll keep driving by bars. Eventually you’ll stop in one, maybe because you’ll likely know someone there. You’ll get to talking, and before you know it, you’ll be drinking. You don’t see how you can keep your job and not end up in a bar. You also don’t see how you can earn a living without this job. Am I summarizing correctly?

Carl: That’s it in a nutshell. If I work, I drink. If I don’t work, I starve. Either way I’m screwed.

Dr. Horvath: Not so fast! What if we blow up all the bars?

Carl: Doc, I know I’m important to you, but isn’t that a bit much?

Dr. Horvath: We’re facing a big challenge here. We need to be creative.

Carl: Could I visit some of them before you get rid of them?

Dr. Horvath: Isn’t that what led to this relapse?

Carl: Good point. So be serious. What am I going to do?

Dr. Horvath: I am being serious: We need to blow up the bar in your mind. Here’s how we could try to do it.

In exposure therapy, the client experiences the very thing that’s feared in an effort to learn to gain control of the distress that it causes. 

Later that week I met Carl outside his favorite bar, which was right in the middle of his sales territory. It was late afternoon. As we sat in his car I prepped him.

Dr. Horvath: Just to confirm: Is there any chance you’re going to drink, with me sitting next to you?

Carl: No, it’s not going to happen.

Dr. Horvath: Any chance you’ll knock me out so I won’t be looking at you when you’re drinking?

Carl: Will you ever get serious?

Dr. Horvath: Seriously, are you in control of your behavior or not?

Carl: I won’t knock you out or anything else.

Dr. Horvath: I knew that, but it’s good to hear you say it out loud.

We went inside and sat down at the bar. Within minutes, a craving of nine on a ten-point scale came over Carl. There were beads of sweat on his upper lip. He couldn’t sit still; he kept glancing around the bar. He was already on his second diet Coke.

We talked about many things for about half an hour. I asked about parts of his history I knew he liked to talk about. We talked about sports. He told stories about his children. I told every joke I could remember. I tried to provide him with the experience of having a normal conversation and even some fun in a bar—this place of great anxiety and craving for him—while not drinking.

Dr. Horvath: We’ve been here about 30 minutes. How is that craving level?

Carl: Just like you said, it’s gone, maybe a one. How did that happen?

Dr. Horvath: What have I been teaching you about craving?

Carl: This is a test, isn’t it?

Dr. Horvath: Yes. What three facts did I suggest that you remember whenever you have a craving?

Carl: One is that a craving is time limited—they go away if you wait long enough. Another is that a craving can be very uncomfortable and distracting, but I can survive it—it won’t do any permanent damage. The last is that it can’t make me drink. I still have a choice. So, if I wait it out, I’ll be OK.

Dr. Horvath: Did your experience in the last 30 minutes support the validity of these three facts or not?

Carl: I didn’t really believe them until now.

We went back to his car and talked about what might happen if he had another craving on the way home. We also had pre-arranged to have some engrossing activity scheduled at home that evening, so that he would be highly motivated to stay home rather than return to the bar. When I left him, he was confident that he could make it back home safely and stay there.

At our next session a week later he told me that he had driven only a block and a half before he had to pull over.

Carl: A craving came on like I’ve never had before. It started at my toes. Can you imagine that? At my toes! In 20 seconds, in slow motion, it moved up my entire body. I had to sit for another 30 minutes before I felt safe to drive. But I kept reminding myself about those three facts. Thanks for drilling them into me. Since then, I’ve had some little cravings, but it feels like a fever broke. Now I know I can handle them.

A standard part of any relapse prevention plan is how to deal with “high-risk” situations. The goal is to have the confidence that you can cope with cravings. In the beginning of recovery, avoidance of dangerous triggers may make a lot of sense. But at some point, it is likely time to face cravings head-on, and that may require exposure therapy.

Many exposures are not as straightforward as moving up floor by floor as in the case of fear of heights. The therapist must work with the client to establish “safety factors” to protect against overwhelming feelings or a surrender to the craving. Yet exposure therapy can often work in a short period of time. Once someone has “survived” a few big cravings, they’re likely to be confident—often for the first time—about future experiences. And I am confident that if rehabs adopted the practice of exposure therapy for appropriate clients, these people would be much better prepared to return to the real world.

A. Tom Horvath, PhD, ABPP, is the founder and president of Practical Recovery in San Diego, CA, a self-empowering addiction treatment system including sober living, outpatient services and two residential treatment facilities for alcohol and drug abuse. He is also the president of SMART Recovery, an international nonprofit offering free, self-empowering, science-based, mutual-help groups for addiction recovery. A past president of the Society of Addiction Psychology, he is the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions. 

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A. Tom Horvath, PhD, ABPP, is the founder and president of Practical Recovery in San Diego, CA, a self-empowering addiction treatment system including sober living, outpatient services and two residential treatment facilities for alcohol and drug abuse. He is also the president of SMART Recovery, an international nonprofit offering free, self-empowering, science-based, mutual-help groups for addiction recovery. A past president of the Society of Addiction Psychology, he is the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions. Follow Dr. Horvath on Linkedin.

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