I'm An Exposure Therapist. Here's How I Confront Patients With Their Worst Fears.

"While I myself don’t experience emetophobia (fear of vomiting), making a concoction of split pea soup, white vinegar and crackers to put in my mouth and spit into a toilet was definitely a discomfort I could have lived without."
Photo Courtesy of Shanna Kramer

In 2013, I graduated with a Master of Arts degree in Professional Counseling. I was as unprepared as any intern would be, thrown into a world I’d only learned about in grad school. I quickly realized that being a traditional “talk therapist” was not appealing to me. I couldn’t find my specialty or ideal client. I felt inadequate.

I was working with individuals in a traditional setting, dealing with traditional things people seek therapy for: depression, work problems, parenting and relationship issues, and life dissatisfaction. It’s not to say that these issues aren’t serious or worth seeking counseling for, but treating those issues wasn’t the right fit for me.

I tried working in other settings, like a residential treatment center for traumatized children, where I loved the job, but the physical demands, secondary trauma and burnout were not sustainable for me.

So when I saw a listing for a position that would give on-the-job training at an anxiety center, I was intrigued, even though it was not in my area. I interviewed for the position and was offered the job. So I moved halfway across the country to try something new: working exclusively with clients with anxiety disorders and Obsessive Compulsive Disorder (OCD) using an approach under the Cognitive Behavioral Therapy (CBT) umbrella called Exposure and Response Prevention (ERP).

ERP is used to break the negative reinforcement cycle by encouraging the individual to confront stimuli that trigger distress. I use ERP to treat specific phobias like agoraphobia (fear of leaving one’s own home), emetophobia (fear of vomit or vomiting), aerophobia (fear of flying), nosophobia (fear of contracting chronic illnesses), fear of driving, fear of natural disasters, and even fear of monsters under the bed.

When working with clients who have OCD, I use it to treat variable subtypes like contamination (obsessions about contracting illnesses or spreading germs), sexual obsessions, harming obsessions (intrusive thoughts or images about harming self or others), perfectionism, relationship obsessions, checking behaviors, cleaning/washing rituals, mental compulsions, “just right” obsessions (thoughts or feelings that something is not quite right), feelings of disgust, and more.

ERP can also be indicated for school avoidance, social anxiety disorder, panic disorder and disordered eating.

Once I started successfully helping people face their fears, I knew I had finally found my specialty. ERP got me out of the office, allowed for more creativity and trust in the therapeutic relationship, and provided measurable outcomes.

My work days look much different than they did in my internship days. Now my day is dependent on my client’s fears. If they are afraid of driving, we will go driving. If they are afraid of social judgment, I might ask them to order me a coffee, ask silly questions to someone over the phone, or skip around the block.

If my day includes clients with OCD, we might try to conjure up images of perceived threats like knives or bridges. We might challenge fears like, “What if I steal something?” by going into a store, or throwing away a receipt.

These behavioral changes allow the brain to discriminate between real and perceived danger. As the client builds distress tolerance, the intensity and duration of their anxiety decreases over time.

I often give my clients homework that I call “experiments.” These experiments allow the client to build trust in themselves and their ability to tolerate uncertainty and feelings of distress. Experiments can be anything from leaving the front door unlocked while they go for a walk around the block to resisting a compulsion to check that the stove is turned off.

Some exposures require more creativity. One of my favorite parts about being an exposure therapist is helping clients come up with their own experiments for their OCD/anxiety. For example, a client with fear of flying asked to be locked inside a closet to mimic the feeling of being trapped. Another client ventured down into a creepy basement with me to face fears of contracting leptospirosis. (The fear was based on the uncertainty of whether or not there were rats in the basement who might carry the disease.)

In order to build distress tolerance, we sat in the space weekly while increasing the duration of time spent. As a result, the client’s fear lessened and they are now able to enter other spaces they’d previously feared like tunnels and parking garages.

If a client is challenging their magical thinking, we might watch traffic go by and think about the cars crashing into each other, or I might ask them to hope I get hurt on my way home from work. When these things don’t happen, it challenges their belief that their thoughts hold power and can create or change outcomes.

Some of these experiments are challenging for me as well. For example, while I myself don’t experience emetophobia (fear of vomiting), making a concoction of split pea soup, white vinegar and crackers to put in my mouth and spit into a toilet was definitely a discomfort I could have lived without. But I think what makes me a successful exposure therapist is a willingness to experience discomfort alongside my clients.

One of the first things I say to them before we engage in exposure work is, “I won’t ask you to do anything I wouldn’t do myself.” This helps the client build trust in me and build back trust in themselves. Many people with OCD and anxiety underestimate their ability to tolerate uncomfortable feelings.

The most rewarding thing about this job is seeing real, measurable change. With just a little bit of guidance, insight and willingness, patients have been able to increase their tolerance and live fulfilling lives that align with their values.

Watching someone go from “I don’t think I can do this” to “Meh, it’s not that big of a deal anymore” still amazes me, and I get a little thrill every time it happens. The process of overcoming anxiety teaches the patient that their values are far more important than their fears. When a person is able to live in line with what is important to them instead of letting anxiety run the show, the world starts to open.

Unfortunately, stigma, misinformation and high misdiagnosis rates can delay an individual’s treatment. Obsessive Compulsive Disorder is a relatively common disorder but is among the most difficult to diagnose and treat. I typically see clients after they have been experiencing intrusive thoughts, compulsions and avoidance behaviors for years.

When a patient first lands in my office and is told about exposure therapy, they are often reasonably scared and reluctant. Sometimes they have had bad experiences in therapy, have been told exposure therapy won’t work, or they have confused it with “flooding” (also called implosive therapy).

Flooding is when a person is exposed to their fear at maximum intensity for prolonged periods of time. This type of treatment is not recommended as it can be traumatizing to the individual, especially if their fear is coming from a place of trauma and not just an overactive fear response.

Exposure and Response Prevention involves gradual exposure to the fear using a fear hierarchy created in session. It’s the difference between being thrown in a pool and being forced to swim and gradually entering the pool and being taught to swim.

Part of what I love about this work is being able to provide psychoeducation to clients and their families or partners. When someone understands what’s happening inside their brain and what they can do to calm their fear center, hope is restored and their awareness increases.

There is no cure for OCD, but there is treatment.

So often I see clients’ worlds start out small and closed, unable to go where they want, enjoy time with their kids, or engage in leisure activities. When exposure therapy is successful, they are able to get back what anxiety has taken from them. The strength and resiliency of humans is what keeps me coming back to work everyday.

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