Exposure therapy is a type of cognitive behavioural therapy that is incredibly well-supported for the treatment of many anxiety-related disorders. Exposure therapy involves systematically facing feared situations, people or things, both during therapy sessions and in-between session exercises.
Despite the massive evidence showing that exposure therapy is highly effective, safe, and tolerable, it is not widely used by mental health providers. So, why aren’t therapists using one of the most powerful therapeutic tools available?
The answer is likely complex but relates in part to several pervasive misconceptions about the nature of the treatment.
Patients can’t handle exposure
Exposure therapy can lead to a temporary increase in symptoms for some people, but any such increases are temporary (i.e., gone a session or two later). Studies have also shown that the rate of dropout for exposure therapy is similar to the dropout rate for non-exposure cognitive behavioural treatments. Treatment seeking clients with anxiety-related problems are, by definition, already experiencing frequent distress. Practising exposure is not introducing distress to their lives. The kindest thing a therapist can do for their clients is provide fast and safe symptom relief, and exposure therapy is a great way to do this.
‘Complex’ patients won’t benefit
The vast majority of studies on exposure therapy have included patients with a number of co-occurring disorders, community-based populations, and treatment-seeking individuals. Research has shown that exposure therapy is safe to use with all kinds of ‘complex’ clients, including those at risk for suicide, those with active psychosis who are stable on medication, those with symptoms of borderline personality disorder, and those in treatment for alcohol and substance use disorders.
Clients need a lot of preparation before starting exposure
Most clients are tough, brave, and not fragile. Studies have shown that additional procedures are not necessary before clients begin exposure. In fact, additional preparation raises an ethical concern, due to the added time and costs that will prolong clients’ recovery.
What clients do need is a strong and compelling rationale for exposure therapy, and a provider who is confident in their ability to concur their fears.
Exposure therapy is rigid and impersonal
One of the cornerstones of exposure therapy is a strong, collaborative, therapeutic alliance with the patient. Exposure is an adaptable approach that only works when it’s carefully tailored to the client’s specific and idiosyncratic fears and needs. Specific exposures are created and planned in a highly collaborative fashion.
When therapists buy into these misconceptions, they may be less likely to use exposure therapy at all, or they may try to implement exposure in an overly cautious, nervous, or unnecessarily rigid manner. This leads to worse outcomes because the client will pick up on the provider’s lack of confidence. Then when this client doesn’t do well or drops out, the provider’s negative expectations have been realized. It’s a self-fulfilling prophecy.
The solution? More therapists should be trained to competence in delivering exposure therapy and have support (consultation) when first using the treatment. Information alone will do little to shift therapists’ misconceptions relative to having an actual success experience helping a client recover with exposure therapy. Therapists who have been trained in exposure should implement it with all the confidence that it’s evidence base deserves.
Carmen McLean, PhD is a clinical psychologist at the VA Palo Alto Health Care System and a clinical associate professor (affiliated) at Stanford University.