What is Exposure Therapy and Why Does It Matter?

What is Exposure Therapy and Why Does It Matter?

A few months ago, I received a call from a casting director looking for exposure therapists to conduct on-camera exposure for a reality TV show by the people who made Hoarders. I turned it down, of course—the ethics of it made me uncomfortable. However, the encounter suggested that exposure is becoming more widely known outside of professional circles.

Exposure has been hailed as one of the greatest success stories in cognitive behavioral treatment, and it’s currently going through a fertile period as clinicians and researchers are redefining what makes exposure work. There’s an enormous body of research on the use of exposure for things such as a panic disorder, worry, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder. I intend to devote time to exploring exposure research in greater depth across future posts.

What Is Exposure?

This is a good place to start: what is exposure? In a book chapter on exposure, Moscovitch, Antony, and Swinson (2009), offer a wonderfully succinct definition: “the repeated and systematic confrontation of feared stimuli.” But what does that mean? In essence, exposure involves having someone deliberately be with an experience that he or she would normally avoid. For example, having someone afraid of heights safely stand near the edge of a building. Often we think of exposure as a component in structured cognitive behavioral treatments. However, exposure doesn’t have to be so structured. Whether they realize it are not, therapists who ask their clients to sit with painful thoughts and feelings, as they come up in session, are using exposure too.

You’ll notice that the discussion of exposure in the paragraph above focuses on the procedure of exposure. It doesn’t tell us anything about how and why exposure works. The reason for this is that decades of research have proven exposure to be an extraordinarily effective treatment, but there is no consensus on its mechanisms of change.

Research on exposure began decades ago and was rooted in the early behaviorist perspective—classical conditioning (think, Pavlov’s dogs). Exposure was a way to undo a condition association between a neutral object or experience and a fear response. Several years later, cognitive therapists began using exposure as a way to challenge or disconfirm negative thoughts about feared outcomes. There is even a variant of exposure called implosive therapy in which therapists encouraged clients to imagine scenes with psychodynamic imagery as a way to facilitate exposure.

None of these theories used to explain exposure have been entirely satisfying. In addition, adding other interventions to exposure therapy  (e.g., relaxation, psychodynamic imagery) doesn’t appear to make it any more effective. Exposure seems to work on it’s own; however, without a theory to guide it, structuring exposure sessions can be tricky.

Who Uses Exposure?

Exposure is most often used by cognitive behavioral therapists, particularly those who specialize in anxiety disorders treatment. That said, there’s a lot of therapists who think exposure is a good idea, but who don’t use it in their own practices. Barriers include lack of training, fear that clients won’t tolerate it, and general discomfort with it. Exposure can be intense—for the therapists as well as the client! For example, the blog Psychotherapy Brown Bag has a nice post on the ethics of exposure therapy.

Clinicians seem especially reluctant to use exposure for posttraumatic stress disorder. Even though exposure is a gold standard treatment for PTSD, a survey of 207 licensed psychologists found that 83% never used exposure to treat people with PTSD (Becker et al., 2004). Another survey found that 84% of women with trauma would be willing to engage in exposure treatment after the rationale was explained to them. This suggests that clients are more willing to engage in exposure than therapists.

Why Am I Writing About Exposure?

For me, this series gives me an opportunity to delve into the exposure literature. My experience with exposure is that it can be a very potent intervention, but it requires thoughtful planning to successfully implement. There’s been some fascinating new research about exposure within the past 5 years. We seem to be going through a sea change in our understanding of it. My goal through these posts is increasing understanding of how we might better use exposure as therapists in clinical practice.

“Evidence-Based Psychotherapy” versus “Scientifically Oriented Psychotherapy”

“Evidence-Based Psychotherapy” versus “Scientifically Oriented Psychotherapy”

I just stumbled across a new paper by David and Montgomery (2011), who provide a novel system for categorizing psychotherapies in terms of their quality of evidence. One reason we named this blog Science-Based Psychotherapy, is to highlight some of the flaws in the current methods of evaluating evidence-based practice. I hope that some of the recommendations of David and Montgomery (2011) get adopted, because their guidelines would be a huge advance over the current state of affairs. As stated in the article:

…all the current systems of evaluating evidence-based psychotherapies have a significant weakness; they restrict their focus on evidence to data supporting (psycho)therapeutic packages while ignoring whether any evidence exists to support the proposed theoretical underpinnings of these techniques. (i.e., theory about psychological mechanisms of change; p. 90)

Evidence-based therapy lists ignore basic science and theory

One big problem of the current methods of evaluating evidence is the lack of attention to basic science and theory. The result is that therapy packages that are based on theories that have been clearly invalidated can still appear to be scientifically credible:

By ignoring the theory, the evaluative frameworks of various health-related interventions (including psychotherapy), technically (a) allow pseudoscientific (i.e., ‘‘junk-science’’) interventions to enter into the classification schemes and or (b) bias the scientific research in a dangerous direction (p. 90).

The danger of these kinds of incentives is that they push researchers to focus solely on outcome research at the expense of testing and refining the scientific theories that will allow for future advances in therapy.

…a consequence of current classification schemes (which consistently do not address underlying theories about mechanisms of change) is that as long as there are randomized trial data, the validity of the underlying theory is less relevant (p. 90).

The current evaluative systems focus on only one kind of evidence: outcome evidence based on the performance of particular therapy packages. This evidence is typically in the form of randomized controlled trials (RCTs). What David et al. add is a second factor that focuses on evidence for the underlying theory.

They propose that each of these two factors are evaluated on three levels

a) empirically well supported;

(b) equivocal no clear data, which includes–not yet evaluated, preliminary data, or mixed data

(c) strong contradictory evidence (SCE; i.e., invalidating evidence).

Here’s their diagram showing how this breaks down:

One of the cool things about this framework is that it allows distinctions between therapies with both types of evidence and therapies that only have one form of evidence. They call those therapies with the highest levels of evidence “Scientifically Oriented Psychotherapies.”

Scientically oriented psychotherapies (SOPs) are those which do not have clear SCE for theory and package; the highest level of validation of a SOP is that in which both the theory about psychological mechanisms of change and the therapeutic package are well validated (i.e., Category I). A SOP seeks to investigate empirically both the therapeutic package in question and the underlying theory guiding the design and implementation of the therapeutic package (i.e., theory about mechanisms of change; p. 91).

A definition of pseudoscience

This allows for a pretty solid definition of a therapy based on pseudoscience.

Pseudoscientically oriented psychotherapies (POPs) are those that claim to be scientific, or that are made to appear scientific, but that do not adhere to an appropriate scientific methodology (e.g., there is an overreliance on anecdotal evidence and testimonial rather than empirical evidence collected in controlled studies; Lilienfeld, Lynn, & Lohr, 2003)…. We define POPs as therapies used and promoted in the clinical field as if they were scientifically based, despite strong contrary evidence related to at least one of their two components (i.e., therapeutic package and theory; p. 92).

One consequence of this approach is that it allows for the identification of therapies that have accumulated evidence of effectiveness, but where the theory on which they are based has been invalidated. If these therapies are promulgated based on the invalidated theory, they are classified as pseudoscientifically oriented psychotherapies (POP). Here’s an example from their article of a commonly utilized approach, neurolinguistic programming, that is based on a disproven theory:

An interesting shift from SOPs to POPs is illustrated by neurolinguistic programming. Once an interesting system (e.g., Category IV of SOPs, according to our classification), it is now seen largely as a POP (Category VII) because although its theory was invalidated by a series of studies (for details, see Heap, 1988; Lilienfeld et al., 2003), it continues to be promoted in practice based on the same theory, as if it were valid (p. 95).

Let’s break this down a little bit. While there is a general lack of evidence for the effectiveness of NLP, there is a greater consensus that the underlying theory contradicts basic research in neuroscience or psychology. NLP uses many scientific sounding but empty terms such as pragmagraphics, surface structure, non-accessing movement, metamodeling, metaprogramming, and submodalities. While these terms form the theoretical foundation for much of the  NLP techniques and sound scientific, they have not stood up to scientific scrutiny and thus the term pseudoscientific applies to this therapy.

Science cannot be stagnant. It is ever evolving and needs to be modifiable based on what the data suggest. In order for science to progress and produce effective treatments over time, good theory is needed. Theory is what allows scientists to make sense of the findings that are observed and guides new research. Brute force empiricism, without theory, leads to a lot of blind paths and wasted energy. I’m heartened to see a leading journal discussing alternate schemes for evaluating the scientific credibility of therapies that focus on mechanisms of action, theory, and incorporates understanding derived from basic science.

Reference:

David, D., & Montgomery, G. H. (2011). The Scientific Status of Psychotherapies: A New Evaluative Framework for Evidence-Based Psychosocial Interventions. Clinical Psychology: Science and Practice. Volume 18, Issue 2, pages 89–99.

What is Science-Based Psychotherapy?

What is Science-Based Psychotherapy?

Science-Based Psychotherapy is focused on educating therapists and the public about the role of science in the practice of psychotherapy.We will blog about topics such as:

1) How to use scientific thinking to inform the practice of psychotherapy

2) Particular psychotherapy methods that have been studied scientifically, and the evidence — either for or against — those models

3) New findings in basic and applied research that might have implications for psychotherapy practice

4) Research relating to training, supervision, professional well-being, and continuing to develop as a psychotherapist.

While psychotherapy is at its heart an interpersonal enterprise, this enterprise is best informed by scientific findings whenever possible. While we believe that the therapeutic relationship is very important for effective psychotherapy, and we strive to have a positive therapeutic relationship with every client we see, we also believe that psychotherapy is best guided by science. Fortunately, the evidence-base for psychotherapy has grown immensely over the last two decades and now we know a lot more about what works in therapy.

The name of our blog was inspired by the writers at Science-Based Medicine. Like them, we believe that good science is the best way to determine whether mental health treatments are safe and effective. This idea has been the core of the evidence-based psychotherapy (EBP)movement. While the EBP  movement has been a positive development in many ways and we are supportive of it, we also think that EBP proponents often focus too much on clinical trials as the primary (or sole) source of evidence for whether a mental health intervention is safe and effective. Lists of recognized evidence-based psychotherapies (for example, the APA Division 12 list) are often based solely on outcome research from clinical trials, and other kinds of applied or basic research are little considered. This is not optimal for the progress of science over time or for guiding therapists about what to do in therapy.

All the authors of Science-Based Psychotherapy are researchers, as well as active clinicians, with years of scientific study and clinical practice under our belts.

If you are looking for lists of evidence-based psychotherapies, here are some resources:

UPCOMING TRAINING EVENTS


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 11, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD

May 13th, 2022Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div, M.S.