In 2013, I graduated with a Master of Arts in Career Counseling. I was as ill-prepared as any intern, thrown into a world I had only discovered in graduate school. I quickly realized that being a traditional “speech therapist” didn’t appeal to me. I couldn’t find my specialty or my ideal client. I felt insufficient.
I was working with people in a traditional setting, dealing with traditional things that people seek therapy for: depression, work issues, parenting and relationship issues, and dissatisfaction with life. That’s not to say these issues aren’t serious or worth counseling, but dealing with these issues wasn’t what I needed.
I tried working in other settings, like a residential treatment center for traumatized children, where I loved the work, but the physical demands, secondary trauma, and burnout were not sustainable for me.
So when I saw a listing 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 interviewed for the job and was offered the job. So I moved across the country to try something new: working exclusively with clients with anxiety disorders and obsessive-compulsive disorders (OCD) using an approach under the umbrella of cognitive-behavioral therapy. (TCC) called exposure and response prevention (ERP).
ERP is used to break the cycle of negative reinforcement by encouraging the individual to confront stimuli that trigger distress. I use ERP to treat specific phobias like agoraphobia (fear of leaving home), emetophobia (fear of throwing up or throwing up), aerophobia (fear of flying), nosophobia (fear contracting chronic diseases), fear of driving, fear of disasters, and even fear of monsters under the bed.
When working with clients with OCD, I use it to address variable subtypes like contamination (obsessions with contracting diseases or spreading germs), sexual obsessions, harmful obsessions (intrusive thoughts or images about harming oneself or others), perfectionism, relationship obsessions, checking behaviors, cleaning/washing rituals, mental compulsions, “just right” obsessions (thoughts or feelings that something wrong), feelings of disgust, etc.
ERP may also be indicated for school avoidance, social anxiety disorder, panic disorder, and eating disorders.
Once I started successfully helping people deal with their fears, I knew I had finally found my specialty. ERP took me out of the office, allowed for more creativity and trust in the therapeutic relationship, and provided measurable results.
My working days are very different from those of my internship days. Now my day depends on my client’s fears. If they are afraid to drive, we will go by car. If they’re afraid of social judgment, I might ask them to order me a coffee, ask someone silly questions on the phone, or walk 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 could challenge fears such as “What if I steal something?” when entering a store or throwing away a receipt.
These behavioral changes allow the brain to distinguish between real and perceived danger. As the client develops their distress tolerance, the intensity and duration of their anxiety decreases over time.
I often give my clients homework that I call “experiments”. These experiences allow the client to develop their self-confidence and ability to tolerate uncertainty and feelings of distress. Experiences can range from leaving the front door unlocked as they walk around the block to resisting having to check that the stove is off.
Some exhibits require more creativity. One of my favorite parts of being an exposure therapist is helping clients come up with their own experiences for their OCD/anxiety. For example, a customer with a fear of flying asked to be locked in a closet to mimic the feeling of being trapped. Another client ventured into a scary basement with me to deal with the fear of contracting leptospirosis. (The fear was based on the uncertainty of whether or not there were rats in the basement that might carry the disease.)
In order to develop distress tolerance, we sat in the space each week while increasing the amount of time spent. As a result, the customer’s fear has lessened and they can now enter other spaces they previously feared, such as tunnels and parking lots.
If a customer challenges their magical thinking, we can watch the traffic go by and think about cars crashing into each other, or I can ask them to hope I hurt myself on the 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 experiences are also difficult for me. For example, even though I don’t suffer from emetophobia (fear of throwing up) myself, making a mixture of split pea soup, white vinegar and crackers to put in my mouth and spit down the toilet was definitely a discomfort I could have done without. But I think what makes me a successful exposure therapist is the willingness to feel discomfort alongside my clients.
One of the first things I say to them before we engage in exhibition work is, “I won’t ask you to do anything that I wouldn’t do myself.” This helps the client to trust me and to regain confidence in himself. 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 guidance, insight, and willpower, patients were able to increase their tolerance and live fulfilling lives that matched their values.
Watching someone go from “I don’t think I can do that” to “Meh, it’s not that bad anymore” always amazes me, and I get a little chill 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 tune with what is important to them instead of letting anxiety run the show, the world begins to open up.
Unfortunately, stigma, misinformation, and high rates of misdiagnosis can delay an individual’s treatment. Obsessive-compulsive disorder is a relatively common disorder, but it is among the most difficult to diagnose and treat. I typically see clients after years of experiencing intrusive thoughts, compulsions, and avoidance behaviors.
When a patient first comes into my office and is told about exposure therapy, he is often reasonably frightened and reluctant. Sometimes they’ve had bad experiences in therapy, been told exposure therapy won’t work, or they’ve confused it with “flooding” (also called implosive therapy).
A flood occurs when a person is exposed to their fear at maximum intensity for prolonged periods. This type of treatment is not recommended because it can be traumatic for the individual, especially if their fear is coming from a place of trauma and not just an overactive fear response.
Prevention of exposure and response involves gradual exposure to fear using a session-created fear hierarchy. It’s the difference between being thrown into a pool and being forced to swim and gradually getting into the pool and learning to swim.
Part of what I love about this job is being able to provide psychoeducation to clients and their families or partners. When someone understands what is going on in 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.
Very often, I see clients’ worlds start out small and closed, unable to go where they want, spend time with their children, or engage in leisure activities. When exposure therapy is successful, they are able to reclaim what the anxiety has taken from them. The strength and resilience of humans is what keeps me coming back to work every day.
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