I am an exposure therapist. This is how I confront patients with their greatest fears.


In 2013 I obtained my Master of Arts in Professional Counseling. I was as unprepared as any intern would be, to be thrown into a world I didn’t get to know until grade school. I quickly realized that being a traditional “talk therapist” didn’t appeal to me. I haven’t found my specialty or ideal customer. I felt inadequate.

I worked with individuals in traditional settings and dealt with the traditional things people seek treatment for: depression, work problems, parenting and relationship problems, and life dissatisfaction. This isn’t to say that these issues aren’t serious or not worthy of advice, but dealing with those issues just wasn’t right for me.

I tried working in other settings, such as 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 an offer for a position that would provide on-the-job training at an anxiety center, I was intrigued, even though it wasn’t in my area. I applied for the position and was offered the job. So I moved halfway across the country to try something new: using an approach under the cognitive behavioral therapy (CBT) umbrella called Exposure and Response Prevention (ERP) to specifically treat anxiety disorders and obsessive-compulsive disorder. Working with clients with OCD.

ERP is used to break the negative reinforcement cycle by encouraging the person to encounter stimuli that cause distress. I am for the treatment of specific phobias such as agoraphobia (fear of leaving your home), emetophobia (fear of vomiting or vomiting), aerophobia (fear of flying), nosophobia (fear of contracting chronic diseases), fear of driving, fear of natural I use ERP. teasing, and even the fear of demons under the bed.

When working with clients with OCD, I use it to describe different subtypes such as contagion (obsessions about contracting diseases or spreading germs), sexual obsessions, obsessions that harm (intrusive thoughts or images about self or others). about doing harm), perfectionism, relationship obsession, checking. behaviors, cleaning/washing rituals, mental compulsions, “perfect” obsessions (thoughts or feelings that something isn’t right), feelings of disgust, and more.

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ERP may 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 took me out of the office, increased creativity and confidence in the therapeutic relationship, and delivered measurable results.

My working days look very different from my internship days. Now my day depends on my client’s fears. If they are afraid to drive, we drive. If they’re afraid of social judgment, I can ask them to order a coffee, ask someone a stupid question on the phone, or stop by the neighborhood.

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

These behavioral changes allow the brain to distinguish between real and perceived danger. As the client develops anxiety tolerance, the intensity and duration of his or her anxiety decreases over time.

I often give my clients homework that I call “experiments”. These experiments allow the client to build confidence in themselves and to tolerate feelings of insecurity and fear. Experiments can range from leaving the front door open to resisting the compulsion to turn off the stove when they go around the block.

Some exposures require more creativity. One of my favorite parts of being an exposure therapist is helping clients create their own experiments for their OCD/anxiety. For example, a client with a fear of flying asked to be locked in a closet to mimic the feeling of being trapped. Another client descended with me into a creepy basement to face her fear of contracting leptospirosis. (The fear was based on uncertainty whether there were rats in the basement that could carry the disease.)

To build stress tolerance, we increased the time we spent in space on a weekly basis. As a result, the customer’s fear has disappeared and they can now enter other places they previously feared, such as tunnels and parking garages.

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If a client challenges their magical thinking, we can watch traffic go by and imagine cars colliding with each other, or I can ask them to hope I show up for work. Will get hurt when you go home. When these things don’t happen, it challenges their belief that their thoughts have power and can create or change results.

Some of these experiments are challenging even for me. For example, while I don’t experience emetophobia (fear of vomiting) myself, spitting in the toilet with pea soup, white vinegar, and crackers in my mouth was definitely an inconvenience I could live without. But I think what makes me a successful exposure therapist is my willingness to experience discomfort with my clients.

One of the first things I say to them before I get into performance work is, “I won’t ask you anything that I wouldn’t do myself.” This helps the client build trust in me and build 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 a little guidance, insight, and desire, patients have been able to increase their tolerance and live lives in line with their values.

It amazes me to see someone go from “I don’t think I can do it” to “Meh, it’s not such a big deal anymore,” and I get a little bit of excitement every time it happens. The process of overcoming fear teaches the patient that his values ​​are more important than his fears. When a person is able to live in harmony with what is important to them instead of worrying, the world begins to open up.

Unfortunately, stigma, misinformation, and high rates of misdiagnosis can delay a person’s treatment. Obsessive-compulsive disorder is a relatively common disorder, but it is one of the most difficult to diagnose and treat. I usually see clients when they have experienced intrusive thoughts, compulsions, and avoidance behaviors for years.

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When a patient first comes into my practice and is told about exposure therapy, they are often anxious and hesitant. Sometimes they have had bad experiences with therapy, been told exposure therapy doesn’t work, or confused it with “inundation” (also called implosive therapy).

Flashback occurs when a person is exposed to their fear at maximum intensity for a long period of time. This type of treatment is not recommended because it can be traumatic for the individual, especially if their fear stems from a site of trauma and is not just an overactive fear response.

Exposure and response prevention involves gradual exposure to the fear using a fear hierarchy built during the session. It’s the difference between being thrown into a pool and being forced to swim, and being gradually introduced to the pool and learning how to swim.

Part of what I love about this job is being able to provide psychoanalysis to clients and their families or partners. When a person understands what is happening in their mind 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 a treatment.

So often I see clients’ worlds are small and closed, unable to go where they want to go, spend time with their children or engage in leisure activities. When exposure therapy is successful, they can get back what the fear took away from them. The strength and resilience of people is what drives me to work every day.

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