When I first heard about exposure therapy I was early in my graduate career sitting on a bench with a professional mentor who told me that her son had a needle phobia and was in treatment to reduce his fear so that he could be vaccinated.
She described the therapist showing pictures and watching videos of the use of needles. I recoiled at the thought of intentionally causing distress in a client. It was hard for me to reconcile causing someone distress.
Years later, I was walking across campus with a fellow psychologist. He was not sure where to go, so I walked with him leading him in the right direction. He practiced exposure therapy and suggested that I attend a training session on it.
A year later, I touched base with him to see if the offer still stood. I attended the Prolonged Exposure Therapy training at the Center for the Treatment and Study of Anxiety (CTSA) at the University of Pennsylvania. It seemed daunting. I asked to volunteer and treat patients so I could learn the treatment. My request was accepted.
All therapists were required to videotape the therapy sessions, which were subsequently viewed by all practicing clinicians in group supervision and consultation with the CTSA clinic.
It was an anxiety provoking situation to say the least. I made mistakes. I was corrected. I was thrilled that my clients were getting better. I felt a very real potential for failure. I was being evaluated by leaders in the field of exposure therapy.
While I received a lot of constructive criticism, it was criticism nonetheless. I was sure the expert clinicians would tell me that I needed to stop volunteering there due to my own perceived inadequacies.
Staying true to the principles of exposure therapy, I decided to keep going until my feared outcome came to fruition. I decided that I would keep volunteering and treating patients until I was essentially fired from the volunteer job. Much to my surprise, the exact opposite happened. A week later, I was offered a job.
When people are impaired by anxiety and it gets in the way of performance it is usually because of two maladaptive coping mechanisms. Either they are avoiding something completely or they are behaving in a way to make them feel safe from whatever outcome they are scared of.
By exposing oneself to the feared outcome by approaching it either in their mind (imaginal exposure) or in real life (in vivo exposure) they typically learn that the thing they are afraid of is very unlikely and even if it did happen they would be able to cope.
CTSA trained me in exposure therapy. I learned how to treat all anxiety disorders, including exposure and response prevention therapy for OCD. I received extensive amounts of supervision. I learned how to successfully treat individuals because I took a chance and took an opportunity that was offered and I kept going despite a fear of failure. That is exactly what I ask my clients to do.
Exposure therapy training is offered typically in four day-long intensive training programs. CTSA offers these programs twice a year. Other programs are offered by reputable centers as well, including the Beck Institute and the Center for Anxiety and Behavior Therapy. Experts at these centers offer consultation to providers looking to hone their skills. It is also possible to find other experts for consultation. I now provide these services myself.
Practicing exposure therapy is a rich, rewarding and fun experience for client and clinician. It requires the ability to tolerate distress by both the therapist and client.
You start exposures by approaching fears in a way that clients can tolerate and get through without relying on avoidance or safety behaviors. You end when clients are able to tolerate their most distressing fears. They learn that they can tolerate distress and are able to adequately cope when confronted with difficult situations.
Their world has a tendency to open and expand in a very short period of time.
Elizabeth A. Ellis Ohr, Psy.D., is a licensed clinical psychologist with a private practice in Portsmouth, N.H., specializing in Cognitive Behavioral Therapy and Exposure and Response Prevention. Her email address is: firstname.lastname@example.org.