Is all therapy exposure therapy?
Exposure is a lifestyle — for clients, and for their therapists.
Happy December! I’m The Overthinker and this is The Big Q. This week I’m diving deep into common factors across all kinds of therapy.
There are at least 20 major psychotherapeutic modalities practiced in the US today, from Jungian depth psychology to dialectical behavior therapy (DBT) to EMDR for trauma. Each one can incorporate dozens — even hundreds — of discrete techniques, from free association to behavioral activation to self-monitoring.
Clinicians love to talk about how their practice is “evidence-based” (and how their professional nemesis’ practice isn’t). Sometimes, this differentiation is urgently needed, like when it helps us say definitively that conversion therapy is not therapy, or emboldens us to ban “rebirthing therapy,” which in 2000 killed an American child. Other times, though, it’s just a petty game of one-upsmanship.
This is unfortunate, because there are actually key similarities between all legitimate therapeutic modalities, from psychodynamic work to cognitive behavioral therapy (CBT). These include the “common factors” — those squishy qualities like a strong therapeutic alliance and a client’s motivation to change. But they also include “common elements” — specific strategies like psychoeducation, rewards for engagement, and, yes, exposure.
All therapy is exposure therapy
Technically speaking, “exposure therapy” refers to a behavioral intervention that emerged out of the work of Ivan Pavlov. We all know from psych 101 that Pavlov taught dogs to associate the ringing of a bell with food — such that they began to drool when they heard the familiar ding. But what is often forgotten is that Pavlov also taught those same dogs to stop the very same behavior. How? Pavlov found that if he presented the bell over and over and over, without presenting the food, the dogs would eventually cease to associate the bell with the food. Eventually, it was just another noise.
Today, a client with a discrete phobia — say, riding an elevator — would work to systematically delink a stimulus (an elevator!) from their typical response (a panic attack!). Like Pavlov’s dogs, they would do this through escalated exposures — touching the bell, stepping inside the elevator and stepping out, riding up a floor, riding up 20 floors — until their brain learned that they actually can tolerate riding in an elevator and their worst fears are not likely to come true. With some effort, the previous association (elevator = plummeting to your death) is overpowered, and the client can ride to the Top of the Rock without fear. This premise underlies behavioral therapy for anxiety disorders, OCD, post-traumatic stress, and more.
So that’s formal “exposure therapy.” But if we talk about exposure more broadly, well, I see it everywhere in therapy:
Talk therapy, at its best, exposes us to ourselves, by asking us simply to name our desires, our needs, and our pain, even — or, perhaps, especially — when what we feel seems socially unacceptable.
DBT is built on what Marsha Linehan calls “informal exposure” — in this case, to one’s own emotions. The job is to identify in every situation the “primary emotion” (often sadness) and the “secondary emotion” we use to hide it (often anger) and refocusing on the primary emotion until it can be really felt.
CBT treatments like “behavioral activation” are just exposures specific to depression!
There’s even some reason to think that psychedelic-assisted therapies include an element of exposure!
And what is meditation if not exposing oneself, over and over again, to the innate human feeling of dissatisfaction with reality?
But not all exposures are equal
Now, that’s not to say that all of these types of exposure are interchangeable. We know, for example, that talk therapy is contraindicated for individuals with OCD, because talking with a therapist can just become another reassurance-seeking ritual that keeps their obsessions locked in place. And we know, too, that someone who is experiencing generalized anxiety, without any ritualizing, does not need formal exposure and response prevention (ERP) like an OCD client does. They’d probably be better off with some relaxation exercises.
The real takeaway here is that we all engage, to some degree, in experiential avoidance — essentially, an unwillingness to simply tolerate distressing internal experiences. And experiential avoidance seems to propel many a mental illness. That means therapists, no matter what modality they use, and no matter what patient population they see, should keep exposure top of mind. Are you helping your clients approach the things they fear, in slow, safe, and steady ways? Or are you aiding and abetting their avoidance? Are you doing the (often aversive!) things you need to do to help your client in the long run? Or do you find yourself walking the path of least resistance, week after week?
If these questions make you squirm, it might be time for some exposure!
Strong feelings about this issue of The Overthinker? Leave a comment below.