Should OCD Therapists Participate in Exposures?

by stuart miles

by stuart miles

I’ve written a lot about exposure and response prevention (ERP) therapy and how to evaluate your therapist. I’ve said that many good therapists will tell you,“I won’t ask you to do anything I wouldn’t do myself.”

But do these therapists actually go ahead and do these things? Do they, or should they, participate in exposures with you?

In my son Dan’s case, as far as I know, his therapist at his residential treatment program worked on creating a hierarchy with him, but never directly participated in any exposures. The same is true for Dan’s later therapist whom he connected with after residential treatment. Perhaps this was due to the fact that Dan was 100% committed to ERP therapy and didn’t need that type of encouragement. I’m not really sure. There are those, however, who struggle more with ERP and could use all the help they can get.

I have heard from parents who were frustrated because their children were at residential treatment programs, yet refused to participate fully in ERP therapy. One mom described how her daughter just stared out of the window all day because she couldn’t tackle her exposures. “Why couldn’t a therapist have done them with her, at least in the beginning?” this mom wanted to know. She felt that would have been especially helpful for her child. Instead, time and money were wasted, and her daughter returned home with the same severe obsessive-compulsive disorder she went in with.

There are healthcare providers who do exposures along with their clients. Some make house calls, others go out into the world with their patients, and still others participate in exposures in their office. One woman wrote to let me know how helpful it was that her therapist touched a toilet seat in a public restroom while encouraging her to do the same.

But I don’t get the impression that this is the norm. And as difficult as it is to find a good OCD therapist, my guess is it’s even harder to find one who has the flexibility to do all kinds of exposures with you. Indeed, many times it’s just not possible logistically. For example, if some of your triggers occur in your workplace, it might not be feasible for your therapist to accompany you to work.

I do wonder if some therapists don’t participate in exposures because they might believe it offers their clients reassurance (“Look, I did it, and I’m okay”). According to a study (which I highly recommend reading) conducted by Dr. Seth Gillihan, providing reassurance is one of the most common mistakes OCD therapists make. ERP therapy can get complicated, especially for new therapists, and there can be a fine line between encouragement and reassurance. A good therapist acts as a coach and provides gentle yet firm encouragement – not reassurance.

Good ERP therapy is individualized, and my guess is participating in exposures might be appropriate for some clients and not for others. Certainly if you feel this might be helpful in your fight against OCD, you should discuss it with your treatment provider. I’d also love to hear from those who have had their therapists take part in exposures with them and how you felt, and feel about it.



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8 Responses to Should OCD Therapists Participate in Exposures?

  1. Lorre Leon Mendelson says:

    YES! I was diagnosed with OCD in 1996, thank goodness! To find out there was a name for what I had and not alone was an amazing relief to me. Dr. Grayson responded to a question on where to start “you have to make a decision to live a life of uncertainty”. What an amazing feat for each of us with OCD. I was surrounded by therapists and psychiatrists and educators who believed that it was very important therapists work with people individually on their treatment plans. It was seen as a unique type of therapy as they were not viewed as “enabling” in the alcohol treatment sense but helping people with OCD learn how to perform ERP and CBT. I was in a group, as well as individual therapy and once my therapist had a piece of candy in his mouth and then passed it to each one of us in the group to put in our mouths. And I believe he ended with putting it back in his mouth. VERY powerful. Another therapist worked with me on carpet issues and a bathroom. I think an OCD therapist must work hands on with people with OCD. AND, in finding a treatment program or therapist, I think part of the screening is learning what type of therapy they provide and how they provide it.
    Best, Lorre

  2. Hi Janet. Thought provoking post. I definitely participate in exposures with my patients. This is especially true in the early stages of treatment as I’m modeling and teaching how to do a proper exposure. If I want a child or adult to go home and practice doing exposures, I want them to truly know how to do it to get the most benefit. There’s also a lot to be said for building trust as we do these together. And, if need be, I go on site (some rituals just cannot be targeted in the office). There are some exposures, though, that is it better that I not participate in because my patients do find the experience provides reassurance, which defeats the purpose of the exposure. So, basically, I have to be careful and really communicating with my patient about the exposure and what it is accomplishing. Often, as therapy goes on, my patients begin designing their own exposures and come in to session telling me about the new thing they’ve done! At that point, they start showing me that they don’t need me, or my participation, so much anymore – which is really the goal we are aiming for!! 🙂

    • Thanks for your insight, Angie. All I can say is your patients are lucky to have you for a therapist. It sounds as if you really try to individually evaluate each exposure situation and do what you feel is best for each particular patient. I like what you say about doing exposures together as a way to build trust – that makes a lot of sense. Thank you so much for commenting. I think people will find your thoughts helpful.

  3. Thanks for another thoughtful post, Janet. I would echo what Angie said, that as an ERP therapist I’ll generally do exposure with a person to begin with (if it’s possible), and then homework will involve the person’s repeating the exposures on his/her own, as well as doing ones outside the office that we can’t do during sessions (like shower-related exposures). Sometimes my “presence” will be via video conference when that’s helpful.

    Happy belated Thanksgiving!

    • Thanks for sharing, Seth, and I hope you had a nice Thanksgiving. Sounds as if you’re on the same page as Angie. I’m glad you brought up video conferencing because it seems as if that would be a viable option for support when appropriate. Your client are lucky to have you!

  4. Sarah Nelson says:

    I am a behavioral specialist who specializes in treating people with OCD, anxiety, and mood disorders. I myself have created many hierarchies and have also completed many, many exposures with my patients. I believe that doing the exposure with them initially, helps build a therapeutic relationship and trust. There are people who will get some reassurance from their therapist’s presence. In that case, it’s benificial to know your patient well enough that you would know whether or not it was reassurance. Knowing your patient well enough is also part of having that individualized treatment plan, that I for one, believe is key to each person’s success.

    • Thanks for your insight Sarah and I think you bring up a very important point – that it’s all about knowing your patient well and individualizing treatment. OCD is definitely not a “one size fits all” disorder when it comes to therapy. Thanks again for sharing!

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