Exposure Therapy Quietly Grew Up

Twenty-five years ago, four patients with chronic low back pain sat down in a Dutch clinic and went through something new. Instead of teaching them to pace, rest, or build tolerance on quotas, their clinicians walked them into the activities they feared most. The study (Vlaeyen et al., 2001) used a replicated single-case experimental design. Four people. Fear of movement dropped. Catastrophizing dropped. And the change only happened during the exposure phase, not during graded activity.

That tiny study planted a seed.

A new paper in Behaviour Research and Therapy (Schemer et al., 2026) is the field's first coherent look at what grew from it. It's a meeting report from an international group of exposure researchers who gathered in Maastricht in September 2024 to answer one question: where is this work now, and where does it need to go?

If you work with pain this should be a paper that influences your practice

Exposure is no longer just about fear of movement

In the original fear-avoidance model, the target was clear. A patient predicts a movement will cause pain or harm, avoids it, and the avoidance itself drives disability. Exposure tests the prediction and helps the person build a new one.

But the 2026 report documents how the same approach is now being used for:

Irritable bowel syndrome, with exposure to feared foods and social contexts.
Tinnitus, with exposure to sounds and environments that amplify perception.
Post-concussion symptoms, with exposure to bright light, complex reading, and cognitive load.
Vulvodynia and chronic genitopelvic pain.
Post-myocardial cardiac anxiety, with exposure to interoceptive cues resembling a cardiac event.
Chronic neuropathic pain, including painful diabetic neuropathy.
Cluster headache, post-COVID syndrome, and more emerging applications.

The throughline isn't pain. It's dysfunctional avoidance driven by threat expectations, wherever it shows up. Whenever the person is overestimating harm and the they are organizing life around that prediction, exposure has something to offer.

This is a major reframe for pain clinicians. If you trained thinking of exposure as a specialty tool for kinesiophobia, the field has moved past that. It's now closer to a transdiagnostic intervention for avoidance-driven disability.

The mechanism shifted, and it matters clinically

If you learned exposure therapy a decade ago, you probably learned Emotional Processing Theory. Expose the patient long enough, the fear response habituates, a new memory forms, and the fear stays extinguished.

The field has moved on from that frame.

Inhibitory Learning / Retrieval Theory is now the dominant framework. Fear memories don't get overwritten. They get competed with. Successful exposure creates a new inhibitory memory that, under the right conditions, outcompetes the original fear memory. This is why fears return after context shifts or time passes. It's also why good exposure deliberately violates patient expectations as strongly as possible, across multiple contexts, with explicit strategies to enhance retrieval.

Relational Frame Theory and goal-directed accounts sit alongside it. Which is why the meeting report includes Acceptance and Commitment Therapy as an exposure-based approach. Mechanistically, a values-based behavioral experiment is a behavioral experiment. This is why we lean into ACT at Modern Pain Care as you will see it’s priniciples in new frameworks such as Cognitive Functional Therapy (CFT).

This is not a semantic change. It changes what clinicians actually do.

If you're running exposure as habituation, you care about duration and intensity. Stay in the water until the anxiety drops.

If you're running it as expectation violation, you care about what the patient predicted, what actually happened, and how different those two were. "You said three reps would lock up your back for a week. You did five. It's been two days. What do you make of that?"

Different mental model with different clinical actions and ideally different outcomes.

The goal is goal-directed action, not fear reduction

This is probably the biggest reframe in the paper.

Old exposure: help the patient tolerate fear until it drops. New exposure: help the patient pursue what matters to them, even when fear is present.

The practical consequence: exposure targets aren't selected by what scares the patient most. They're selected by what matters most. And the success criterion isn't "pain is gone." It's "I'm living the life I want, with or without the symptom."

This also quietly resolves a tension some clinicians have held for years. You don't have to choose between exposure and values-based work. They're the same thing, run from different sides.

Exposure should probably be early care, not last resort

Here's the line that should stick with every clinician who reads this paper:

"Rather than being a last resort when everything else fails, exposure could become part of standard early management."

We still treat exposure as something you try after ten other things haven't worked. Medications. Imaging. Passive care. Graded activity. General rehab. And then, finally, if the patient is disabled enough and desperate enough, maybe a referral to someone who does exposure.

The evidence base no longer supports that sequencing. Pain Reprocessing Therapy's randomized trial showed 66% of chronic back pain patients pain-free or nearly so post-treatment, with the effect largely maintained at 5 years (Ashar et al., 2022, 2025). That's not a rescue intervention. That's a first-line offering.

If you wait until the nervous system has had three years of threat learning and the patient has rearranged their life around the symptom, you've made the work harder and probably smaller.

What's still broken

The paper is honest about the gaps.

Most measures of pain-related fear don't meet recommended psychometric standards (Traxler et al., 2026). The tools we use to decide who needs exposure may not be measuring what they claim to measure.

Clinician drift is real. Training reduces negative attitudes, but often fails to change actual behavior in the clinic. Clinicians still default to what they were trained to do. And a recent study in a non-experienced team found fewer than half of patients responded favorably (Ummels et al., 2025). The protocol matters. So does the person delivering it. So the next time you are feeling the discomfort of trying something new, lean in instead of retreating to your clinical safety signal.

Matched care remains aspirational. The paper sketches five delivery settings: digital self-guided, psychologically informed physiotherapy, psychologist-led outpatient, joint outpatient delivery, and inpatient interdisciplinary. What we don't yet know is which patient needs which setting.

What to take into Monday

Three things you should be thinking of:

First, exposure is a transdiagnostic tool for avoidance-driven disability, not a specialty intervention for movement phobia. If a patient is avoiding something meaningful because they predict harm, and the avoidance is making their life smaller, you have a target.

Second, stop calling graded activity exposure. Graded activity is operant and quota-based. It's can be useful, but it's not exposure unless there is an explicit expectation being tested. Name the prediction. Run the experiment. Debrief what happened.

Third, aim for goal-directed action, not symptom reduction. Patients who live the life they want often end up with less pain too. But if you make pain reduction the target, you recreate the exact avoidance loop you're trying to interrupt.

The 2001 study had four patients. The 2026 report has twenty-plus authors, seven bodily symptom categories, and a matched care model. The underlying move is the same. Help people confront what they've been avoiding, notice what actually happens, and let the new information do the work.

Reference: Schemer, L., et al. (2026). Exposure-based interventions for chronic pain and bodily symptoms: A special interest meeting report. Behaviour Research and Therapy, 199, 104998. https://doi.org/10.1016/j.brat.2026.104998

Exposure Therapy Quietly Grew Up