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.