Climbing Over Obstacles in Exposure Therapy

Kimberly Morrow

Have you ever struggled to help a client through an exposure while doing exposure therapy? Treating anxiety and OCD means that you will be doing a lot of exposures with your clients. Some of them will be planned, others spontaneous. Usually exposures are short in duration, lasting as long as it takes for a client’s anxiety levels to decrease by 50%, which is often about 30 min. The most recent research suggests that it is more important to help your client develop anxiety tolerance than it is to have their SUDS level decrease. One way to help your clients develop anxiety tolerance is to have them do exposures to the anxiety symptoms themselves. I often have my clients rate their perceived anxiety tolerance as well as their symptoms of anxiety. We then go to work on increasing their tolerance of the most challenging symptoms through inducing the symptoms and changing their self talk.  Once they have increased their anxiety tolerance, they will have more success doing Exposure and Response Prevention to the their triggers/fears.

Another area that can be difficult for therapists is when an exposure takes a long time to accomplish. I have a client whose OCD kept convincing her that she didn’t actually have OCD, but rather she was a potential murderer which left her feeling horrified, ashamed, and believing that she would go to Hell. One day she came to me saying she believed she was being called to run an OCD/Anxiety support group in her church. She asked if we could put that on her ERP list as it triggered all of her fears! We started working on this exposure 2 years ago. There have been many obstacles which triggered her fears including the elders of her church not being comfortable with having a support group for mental illness in their church, the pastor telling her she could only use the bible to offer support, and the secretary refusing to put OCD in the title of the support group. Often we both wondered if she was really suppose to run this group. I watched her backslide with her symptoms every time an obstacle was put in place. But she continued to persevere-climbing over, under, and around every obstacle.

This week she held the first support group at her church. 10 people showed up! None of them had ever heard of CBT or ERP. She chose to speak about the treatment she has received even though it went against her church’s policy.  She found some middle ground by reading a prayer at the end of the group. Most importantly she learned about what she is capable of and that her fears did not represent the truth. She found how much she loves holding a space for others who are suffering and how much compassion she has to offer others. She felt the cheering of her friends surrounding her and her husband even showed up to support her.

I think it’s important for us to remember that helping clients walk through these challenging exposures will always bring out our own fears and insecurities. However, if you are persistent, it can also bring about growth and interesting experiences to process together. Each obstacle brings about an opportunity to learn something new about their fears and develop a new skill to move forward. When you feel yourself ready to give up on an exposure, I hope you reconsider and help your client recommit to the task at hand: facing their fears.

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