The secret to overcoming the avoidance of doing exposures

Exposure therapy can feel very scary at first. You are asking clients to do the things that scare them most. They may even do things they’ve never done or haven’t done in a very long time. Below are some guidelines to make exposure therapy more approachable for our clients.

1. Give yourself at least a full session or two to give psychoeducation on Obsessive Compulsive Disorder (OCD) and Exposure and Response Prevention (ERP).

In order to get buy in, clients need to fully understand the rationale behind treatment. Three of the most important parts of psychoeducation on ERP are that:

a). Compulsions and avoidance perpetuate the cycle of OCD.

b). The distress from doing exposures, while very difficult, is only temporary.

c). Eventually, the things that scare us become less scary with exposure. If that’s not the case, clients will ideally feel that they are more equipped to handle their fears when they arise.

During the psychoeducation sessions, leave time for clients to ask questions to ensure that they full understand what to expect out of ERP.

2. Help the client identify their core fear.

a). According to Elna Yadin (2005), there are five main core fears that people can experience:

b). Being a bad person, dying, suffering, ruining one’s life, and being alone

Understanding these core fears will allow therapists to create more sophisticated exposures that appropriately target the client’s fears.

3.Work collaboratively with the client to create the fear hierarchy.

a). We may be experts in ERP but our clients are experts in their own experiences. Only they can tell us what it’s like to confront the fear and anxiety that arises from their OCD symptoms.

b). The client can give you an idea of what obsessions and compulsions should be targeted first.

c). They can also tell the therapists what exposures may or may not be helpful for them.

4. Have your clients identify their values.

a). When clients have a good understanding of their values, it will be easier to align their actions with what truly matters to them.

Let’s go through an example. Someone with OCD may avoid their friends because they are scared of doing something embarrassing. As a result, they may start to notice that their friendships fizzle out. If this person values friendship and close connection, they will be more inclined to limit their avoidance.

5. Teach clients core tenets of Acceptance and Commitment Therapy (ACT).

a). Cognitive defusion will teach clients that they are separate from their thoughts. Thoughts are not facts and should be treated as something that we experience but not a way to define ourselves.

b). Clients with OCD can also benefit from acceptance of their thoughts. Our goal is not to change the thoughts but rather acknowledge them non-judgmentally.

Lastly, a friendly reminder to meet clients where they are. Exposure therapy can feel scary! For many clients, even coming to session feels like an exposure. They are doing the right thing by seeking treatment with an OCD specialist.

References

Foa, E.B. et al. (2012). Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder: Therapist Guide (2nd edition).

Twohig M. P., Hayes S. C., & Masuda A., (2006a). “Increasing willingness to experience obsessions Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder,” Behavior Therapy, 37: 3-13.