Kimberly and I have spent the past three years training master’s level clinicians in person and online all over the country in evidence-based treatment for anxiety and OCD. Without exception, we find the hardest hurdle therapists face is in learning exposure and response prevention (ERP).
I was recently training a small group of clinicians on how to use ERP for phobias. They were great students – they listened attentively, and they asked thoughtful questions. When it was time for them to divide into small groups and design a beginning exposure for a case example I provided they did a terrific job. They picked appropriate exposures and clearly explained it to a person playing the role of the client.
Then I asked each group to design a hard exposure for the same client. The feeling in the room changed dramatically as the therapists struggled with what to suggest. I had shown examples of imagination exposures, photos, videos and apps I used with clients but something else seemed to be preventing them from being able to follow through with this step. I stopped the group and asked them instead to take out a piece of paper and write down their automatic thoughts about the assignment. Here is what some of them said:
1. Why would I want to make my client suffer?
2. Doing exposures triggers me, too, and I can’t stand that feeling.
3. It’s just too yucky.
Have you had these thoughts, too? It’s normal for therapists to have thoughts like this when starting to use ERP. We became therapists because we want to help people, not hurt them!
Remember that we need to use CBT ourselves to really understand how it works so we can teach our clients. Though this wasn’t what I thought we were going to be working on, leading a workshop is like working with with a client and sometimes we have to shift gears to make progress. This was a great chance to practice flexibility and stepping back to recognize automatic thoughts with these therapists.
What are the errors in these thoughts?
1. I realize the first question is really only confidently answered by a therapist who has worked with many, many anxious clients – the error is in thinking that the client will suffer less if we don’t do the exposure. Your client is suffering and stuck now. Exposures will let them move forward. Knowing this allows me to be confident guiding my client through hard exposures.
2. At this point in my career, I’m excited when an exposure triggers me because it doesn’t happen very often. One of my clients with emetophobia (fear of vomiting) got me last week with a video she brought in to watch in session, and she said, “that got you!” My response? I said, “Yes, it did! Great job!” We want to show our brains that we can do it, and I am always glad for a chance to do that myself. It also gave me a chance to model what I want my client to have as a goal for the future – looking for opportunities to practice.
3. Really? It’s yuckier for this client than to be missing things in life?
I have a wait list, and most ERP therapists do as well. Our clients get well, and they send their friends to get help from us, too. If you are feeling uncertain about starting ERP in general or any particular work with a client, talk to a colleague or get case consultation. Don’t let your automatic thoughts get in the way of helping your clients with this powerful form of therapy.