Person-Centered or Exposure Therapy?

My portrait according to one of my young patients

I don’t remember how long ago this was but sometime post-grad I was introduced to and trained in providing exposure and response prevention therapy (ERP). I really like the ‘idea’ of this treatment. Most psychotherapy has an intangible quality. It can be hard to measure its effect. I remember asking a friend of mine who was trained as a therapist, “How do I know if I am helping someone?” He asked me, “Do they come back?” I thought that was a pretty good answer but still, I was left with a lot of uncertainty about what changes people.

ERP is much more directive compared to my usual approach. I am still getting used to that since I was trained to adapt, respond, and respect the clients’ direction in the therapeutic process. The way to measure the outcome with ERP was much more specific and clear. Was the patient expressing that they were feeling a significant reduction in anxiety? Was the patient clearly less reactive upon exposure to triggers? Was the disorder causing less interference with day-to-day activities? Compared to measuring self-esteem or even reduction of depression, it was so much clearer. I really liked that. Often problems are talked about for a long time without appreciable improvement – at least to my eyes. I am not objecting to that process at all. I am just saying it was nice to have a very measurable process. Generally, it was less time-consuming as well. (Psychotherapy can get pricey.) I suppose some part of this was due to the very single-minded focus. Treatment was about symptom reduction and not so much about insight.

In theory, ERP seemed like such a good idea. But when I started using it, that was a different story. One of my patients was worried he was a sexual deviant. We devised a script that included, “I might be a pervert.” That was terrifying. Of course, I didn’t think that was relevant to my patient, but it seemed strange to not argue with it – I mean employ cognitive behavior disputation. Another patient was afraid she would kill her children. Imagine writing a script (imaginal exposure) that included details on stabbing her children to death. While we drafted the story that was in her head (we didn’t make up something, just chronicled what the OCD was saying). It was quite terrifying. I had her record it, go home, and play it over and over. This was about once a day for a couple of weeks. While we wrote the script, her SUD score was 8. (I use a scale of 10.) That was really high, but she was willing to keep going. Of all the sorts of OCD, people with violent intrusive thoughts are very motivated. They hate the thoughts and want them GONE. After a week (maybe two, I can’t remember) the SUD score was around a 3. I don’t know who was more relieved, the patient or me! Of course, the patient but I was the most relieved. However, secretly I was praying, “Please make this work, please, please.” I was definitely relieved.

That was a long time ago and now I have hundreds of hours (and patients) using exposure and response prevention. It is strikingly effective. Of course, nothing always works. I guess my main point with the post is to tell clinicians who are just beginning to use exposure to go slow but don’t stop. I have known clinicians who have been very deliberate in choosing to NOT do ERP. It is not for the faint of heart. Don’t expect instant results; if your patient is willing, keep going even if you don’t see huge changes right at first. I am, of course, assuming there has been quality training before starting this. This treatment is head and shoulders better than standard psychotherapy for anxiety disorders – at least in my experience. I still practice psychotherapy with different modalities. I am just recommending for anxiety disorders (only) consider using ERP.

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