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

How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. 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.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC