Do You Fear Exposure and Response Prevention?

Elizabeth Spencer

Fear of Causing Pain:
We clinicians went into our profession to help people; we are often natural caretakers. One of the paradoxes in training clinicians to do CBT with clients is the perception that exposures are painful for clients. We helpers don’t want to cause pain! This can result in tentative clinicians and clients who pick up on this ambivalence and therefore are only partially invested in trying exposure as a part of therapy.

I think about Anne, a therapist who has worked for 15 years at a community mental health center and has seen an enormous range of children who have suffered trauma and loss, such as refugees, who need long-term services. Anne decided to get training in CBT for anxiety disorders after she saw a child who ended up in the hospital because she was self-harming due to severe anxiety. Anne knew the child could be treated as an outpatient, but didn’t have the skills herself and there was no one in her network who she could refer the child to see.

After taking the course, Anne started working with me for case consultation. She was very uncertain about this new way of working with clients. I think Anne is a hero. She got the training despite her own anxiety and lack of self-confidence because she was determined to help anxious children who had nowhere else to turn.

Play to your Strengths:
I encouraged Anne to start with her clinical strengths, foremost of which is her tremendous ability to connect with her young clients. The soft skills needed to empathize and form a team with an anxious child are crucial to success as a CBT therapist, something Anne had not understood prior to our work.

Therapists think like Clients:
Like our anxious clients, Anne has a tendency to look at a hierarchy of exposures she and her clients develop in all or nothing terms. On the one hand she think she won’t be able to handle the hardest part that will need to be done, and on the other that the smallest steps are useless. Do you recognize how she is discounting the positives?

Recently we talked about a child she works with who has a fear of bugs. His hierarchy is skewed at both ends: dead bugs are zero anxiety, and live bugs are 8 and up. She remembered an example I told her about in an early conversation, and said “I know you brought in a spider in a jar for one of your clients, do I have to catch a bee to help this boy? I don’t want him or me to get stung!” She and I brainstormed several possible exposures, like drawing pictures of bugs; making bug puppets with Popsicle sticks; and writing stories about bugs. With a new enthusiasm, she said there are large cicadas now in her area, and she thought she would ask her client what his anxiety would be about her bringing in a cicada in a jar.

Be a Hero:
It is a pleasure working with Anne — seeing her flourish and knowing how she is bringing this enthusiasm to her young clients. I can see how she is able to be the healer she always has been and also teach her clients that they can be brave in the face of anxiety, just as she has been brave to get this new training
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