Therapist Discomfort with Exposure Therapy

ACT-Informed Exposure for Anxiety is out May 1, 2023. Click here to preorder!

Exposure therapy is one of the success stories in evidence-based treatments. As potent as exposure therapy can be for anxiety and obsessive-compulsive and related disorders, therapists are often reluctant to use exposure because of their own discomfort with it (Scherr, Herbert, & Foreman, 2015). Additionally, when therapists do engage in exposure with clients, they may be overly cautious to a degree that undermines the effectiveness of the exposure. 

As therapists, we bring our own biases and areas where we feel more or less comfortable. This is very natural. If we’re unaware of where we hold back, however, it may undermine our exposure work. 

Some therapist reluctance comes from misunderstandings about exposure, that exposure therapy may be harmful for clients, or that clients are more likely to drop out. However, many therapist fears about exposure are rooted in myth. Dropout rates for exposure therapy may be over exaggerated in therapists’ minds. Ong and colleagues (2016) found in studies of exposure for OCD that dropout rates were not much different than for non-exposure treatments for other conditions such as CBT for depression. Additionally, research has found that exposure doesn’t cause clients to feel suicidal and, if anything, clients in exposure therapy become less suicidal. 

In sum, therapist fears about exposure are often unfounded. Fortunately, there is evidence that we can address therapists misunderstanding about exposure through education and deliberate practice (Farrell et al., 2016). 

Even if you’re on board with exposure, you may find there are particular types of exposure exercises you shy away from. Perhaps you’re reluctant to engage in interoceptive exposures because you don’t want to feel badly during your next appointment. Perhaps you experience discomfort addressing client noncompliance with exposure-based homework assignments for fear of bothering your clients, of a appearing like a scold or nag. 

In our book on delivering exposure using acceptance and commitment therapy (ACT), my coauthors and I recommend some strategies ACT-based for addressing our own avoidance around exposure.  

• Present-moment awareness: This may seem obvious, but it’s important to be mindful of our own avoidance habits. Bring a present moment focus to your exposure sessions and try to catch any urges to avoid discomfort. 
• Values: Contacting your values as a therapist can be motivating when therapy becomes uncomfortable. Exposure in and of itself may begin to feel like an exercise in torture at times but reminding yourself what exposure is in service of can be helpful in doing the hard work. 
• Connect with what’s working: It’s helpful to notice the times when we, as well as our clients, persist in values-driven behavior despite pain or discomfort. Paying attention to small treatment successes along the way can be helpful in strengthening our capacity to persist in doing difficult work as exposure therapists.  

Throughout the book, we have ACT-based exercises to help therapists clarify and work through any discomfort they have with exposure therapy. One benefit of ACT is that it can help increase therapist flexibility in doing things that are uncomfortable (Luoma & Vilardaga, 2013). Regardless, it’s important to be kind to yourself around your own avoidance. As we note in the book, “When we catch ourselves engaging in experiential avoidance we can let go of judgment and think- ‘Oh cool! I just caught myself doing that! Now I can be deliberate in making another choice right now.’” 

Author: Brian Thompson, PhD

If you liked this post, check out Dr. Thompson's upcoming workshop on ACT-Informed Exposure: A Practical Guide to Applying ACT-informed Exposure