Transcription:
What is Exposure Therapy?

Dr. Anne Walters: In scary situations, a little bit of fear is normal. It protects us from harm. In some cases, it helps us to make the safer choice when about to do something that could be dangerous. However, this feeling of fear can sometimes take over when the thing that you are about to do isn't that dangerous at all? For some, it's speaking in public. For others, it could be a fear of dogs or even fear about leaving the house.

If it seems as though fear is ruling your child's life, there are treatments that can offer a helping hand. Today, we're going to be talking with Dr. Joshua Kemp, a psychologist at Bradley Hospital who performs a treatment modality called exposure with children and teens every day, helping them to learn strategies to cope with their fears and not let fear stand in the way. Welcome, Dr. Kemp.

Dr. Joshua Kemp: It's great to be here. Thank you for having me.

Dr. Greg Fritz: So this is Mindcast: Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, leaders in mental healthcare for children. I'm Dr. Greg Fritz with my colleague, Dr. Anne Walters. Josh, welcome to Mindcast.

Dr. Joshua Kemp: Thank you for having me.

Dr. Greg Fritz: When we were brainstorming topics for our upcoming podcast, this topic of exposure and response prevention rose to the top. As with a lot of therapies, people want to know in some detail what it is, how do we do it and how does it work. Sometimes it seems like magic. But like all therapy, of course, it isn't. So we're thrilled that you accepted our challenge today to talk with us and deconstruct some of the mystery around this therapeutic modality. Let's take it from the top. What is exposure therapy with response prevention?

Dr. Joshua Kemp: Yeah. So I can kind of provide a broad overview. Exposure can look very different depending on a person's presenting concerns. And exposure works for a variety of anxiety concerns. So what it exactly looks like for each individual, I'm sure we'll have time to get into a few examples. But generally speaking, exposure involves confronting feared items or situations in a planful, gradual, progressive kind of way such that you're confronting whatever it is you're afraid of without doing any sort of avoidance. So you're kind of letting yourself stay in the situation long enough to gain some kind of new learning about that situation, either that it's safer than you thought it was or that it's more tolerable than you thought it was. Then with that new learning, you head into another feared situation, feeling a little more confident, a little more able to tolerate those kinds of situations.

Dr. Greg Fritz: So avoidance is the response that's being precluded.

Dr. Joshua Kemp: Yes, exactly. So that's kind of how most anxiety concerns are maintained, is through avoidance. So people tend to have some kind of anxious belief, something like if I were to, you know, approach some kind of dog, that dog might be dangerous and might bite me, so that's somebody with like a dog phobia. And in that case, most times, a person is kind of scanning for things on the horizon, somebody walking a dog or somebody has a dog in the backyard. And by paying attention to those things, then they can be alert and try to avoid those things. And so they don't have to feel those fears quite as much, they don't have to face the dogs that they're afraid of, but they also don't get any new safety learning that would ever change that anxious belief. So, the avoidance might make a person feel better in the moment. But unfortunately, over time, it ends up preserving that anxious belief and keeps somebody stuck and feeling anxious about whatever that feared item is.

Dr. Anne Walters: So what would you say are the conditions that we see in children that respond most effectively to this type of treatment?

Dr. Joshua Kemp: Yeah, like I said, exposure's very broadly applicable across a number of different presenting concerns. Basically, if a person's presenting concerns are fear-based, so they're avoiding things because they're afraid of something bad happening, if there's anxiety and fear at the core of what's going on, then exposure's a good fit, again, because it's set up such a way that you confront things you're anxious about and you gain some kind of new learning about the safety and tolerability of that situation. So most anxiety concerns, including social anxiety, panic concerns, separation concerns, even OCD, it would also respond quite well to exposure.

So we have all of the fear-based kinds of conditions, but there are some instances like when somebody has more of a discussed kind of reaction, exposure can still be a good fit for discussed and some types of sensory sensitivities. It doesn't work quite the same way to approach sensory kinds of concerns with exposure. You're not gaining any new learning about its safety, because you're not really afraid of that sensory necessarily, but you are learning something about your ability to tolerate that discomfort associated with that sort of sensation. So sometimes, it works well for people that just kind of don't like the way their shirt fits or the way that their socks feel or things like that. If you slowly confront those things without avoiding, without stopping, you can start to feel more and more comfortable with those situations.

Dr. Anne Walters: Or people who are super sensitive to loud noise or who don't like chewing or other sorts of noises like that you might use this to address.

Dr. Joshua Kemp: Exactly.

Dr. Greg Fritz: So a lot of people are familiar with cognitive behavioral therapy. Put this exposure in the context of CBT, cognitive behavioral therapy. How are they related?

Dr. Joshua Kemp: Yeah. So cognitive behavioral therapy is kind of an umbrella term. It stands for a lot of different psychotherapies that involve some proportions of both cognitive and behavioral components. That might be looking at a person's thought patterns and evaluating just how truthful some certain kinds of anxious beliefs might be. That might be the cognitive part. And then, the behavioral part is the actual facing certain situations, going out and doing some of these things. So exposure fits under that broad umbrella, along a number of other psychotherapies. But exposure in terms of all of the different psychotherapies that fall under that umbrella is probably much more on the behavioral side. So we're still talking about a person's anxious belief. If we circle back to the dog example, somebody who's afraid that a dog might be dangerous and therefore they're avoiding that dog, that might be the cognitive part. But most of the intervention involves the behavioral part. Confronting slowly and progressively different situations that put you more and more in contact with a dog and you get to test more and more that thought. Is a dog really that dangerous? Is it really that intolerable to sit with this anxiety? So it's under that umbrella, but way more on the behavioral side, I would say.

Dr. Greg Fritz: Yeah, that's useful.

Dr. Anne Walters: So sometimes when we first start talking to children about what exposure would be like, they think it sounds absolutely horrifying and there's no way they're going to, you know, be able to do that ever. So can you walk us through what a treatment session would look like, what could a child expect when they were coming to work on some of these fears?

Dr. Joshua Kemp: Yeah. I think that's really good to talk about. I think if we could do it over again, we'd probably rename exposure something else, because when you hear it, it sounds like some kind of Fear Factor thing, you're jumping into the deep end.

Dr. Greg Fritz: Or worse.

Dr. Joshua Kemp: Yes, exactly. And so sometimes, those first few visits is just addressing some of those exposure myths and talking about what exposure really is. So once we're up and going and doing exposure for a particular fear, a typical session might look like coming in, talking about how the past week has gone and reviewing any kind of homework that was assigned or that's not the best term either, we try to use bravery practice in the context of exposure, but things that people might have been working on between our last meeting time and when we're meeting in terms of challenging those beliefs and doing exposures on their own.

And so once we talk about that and find out kind of where are you at in terms of your feelings about facing this feared item, we start to pick up with wherever we left off from the last week. And then, if a person's having a particularly tough week, sometimes people come in on a day when it hasn't been the best day. So you can always back up a little bit and try something a little bit easier and then move your up through where you left off last week and then move on to the next thing. So typically, we'll talk about a situation that will try in the office or try to replicate someplace around the hospital. If it were somebody with a fear of spiders, maybe we would go outside and look in the shrubs and the bushes, see if you could find a spider and work on getting as close as we were last week. And then, all throughout that process, we're asking somebody, "What number are you at right now? How anxiety-provoking is this for you?"

And typically, we're trying to stay in this kind of Goldilocks zone of like medium hard. So if it's really easy and you're doing your exposure, you're probably not learning too much about your ability to confront a spider in this situation. Or if it's really hard, a person's just extremely anxious, they're not really processing what's happening while they're doing this exposure. All you learn at the other end of that is I can survive a very difficult situation. Instead, we want to be kind of medium difficulty and we're asking people what number you're at right now using like a zero to 10 scale or something like that to keep an eye on just how anxious they are and trying to stay in that medium difficulty range. And as they continue to confront whatever it is, a spider in this case and that anxiety starts to go down, then we might try to increase their approach. Let's take one more step forward or what if we put our hand out just a little bit toward the spider. And as they make more and more progress, progressing closer to the spider until we're reaching the end of our session, we'll come back and talk about, "How did that go? What did we learn? How confident are you feeling now that you might be able to handle various spiders if you were to see them in the house or outside?" or something like that.

So that's what a typical exposure session might look like. They can look very different depending on a person's particular concern. Sometimes it's riding out one big exposure. Sometimes it's doing a lot of little ones. If it were like social exposures, you might go and talk to a lot of different people. So exposure, I think that's one of the things that makes it so fun, is you can change it up based on a person's presenting concerns and you can really tailor it to people's needs.

Dr. Anne Walters: Can you say a little bit about distraction in that? I know that a lot of times therapists have differing opinions about children using distraction when they're confronting a difficult situation. What's your stance on that?

Dr. Joshua Kemp: Yeah. Distraction sometimes is just inevitable. When you're doing a long exposure, you're having somebody sit and look at a spider, let's say, for a long period of time to see that they can sit there and tolerate it and nothing too bad happens. And as time goes by, it's hard not sometimes to engage in other kinds of conversations, so that might be kind of distracting. But in general, we try not to distract at all or to engage in any sort of coping behaviors when you're doing exposures.

And a good way of thinking about that is if you get to the other side of that exposure, if it goes well and nothing bad happens, and you find that you're able to tolerate it with some distress and you've been doing some other kind of coping or distraction the whole time, you don't know for sure if you could just simply handle that situation or did you get through it and did it go the way it did because you were using the distraction. You kind of have to share the success of that situation with that coping skill. And so we advocate as much as possible to do exposures without any sort of coping or distraction. And that's not to say that those skills don't have value in other circumstances for individuals. So you might be working on a particular exposure that's of a certain difficulty. But if somebody isn't ready to take on something that's beyond what you're doing right now, that coping can still be helpful in their day to day life for the things that they're just not ready to do yet. But when it comes time to do exposure to a particular situation, you want to pick an exposure a person can do with moderate difficulty that they don't need to do coping to get through. That way, when it goes well, they get to own 100% of the success of that situation.

Dr. Anne Walters: That makes a lot of sense.

Dr. Greg Fritz: So there's tons of evidence, good empirical evidence, millions of journal articles, and so forth supporting the effectiveness of exposure. But nonetheless, it remains, you could say, highly underutilized. Why is that? Why isn't it more utilized than it is at present?

Dr. Joshua Kemp: Yeah, that's a really good question. One that a lot of my research to date has actually focused on. I think there's a lot of reasons initially. In the literature, the prevailing thought was that we are just not doing enough training. If more people are trained in exposure, more people would be doing it out in the community and it would just be that much more accessible to the anxious individuals that might really benefit from this really effective treatment. And we've found more recently in the last decade or so, that's not necessarily the case. Approximately half the people who get trained in exposure actually go on to use it. And so, it's really an implementation issue. Getting people who are trained in it to actually go on and use it and trying to figure out why that's the case. So many could be trained and yet half of them don't go on to use this really effective treatment, was something I thought was quite interesting and seemed like a good place to focus some of my research efforts.

And so what we found is that a lot of therapists who get trained, but don't go on to use exposure, tend to harbor especially high rates of these negative beliefs or negative attitudes about exposure, which if you dig into what those are all about, it's typically therapists having some kind of reservation about if I were to deliver exposure with my patients, I'm worried that either something bad could happen or they might get upset with me or it would ruin our therapeutic rapport or things like that. Because most people get into the field of mental health because they want to make people feel better. When people come in to see me, I want to do everything I can to make you feel better today. And so it can seem kind of counterintuitive to do this approach that calls for people to be temporarily more distressed in the service of learning that maybe their fears are not as accurate as they might have thought.

And so, for some people, it's just not a good fit that way. And on the surface, it doesn't sound like something that's going to fit easily into their approach and their rapport. And so they end up not using that treatment. And so we've been doing a lot of research on training approaches that can better address those therapist level reservations and hopefully help individuals feel more confident and have a training that they can go forth and do this intervention with their clients, that they are going to respond quite well in that even though they might feel temporarily distressed, the progress that people make with this kind of intervention easily offsets any of that temporary distress. And that's just further supported by surveys that we've done with patients and parents asking them their opinions about exposure.

So when you look at therapist's perception of what they think their patients and families might think about exposure and the actual impressions that patients and their families have, therapist tend to predict that their patients will find it way more worse than they actually do. And I think that has a lot to do with the fact that these patients and families are experiencing this every single day. It's not new to them to face things that make them very anxious and to feel distressed. And to them, they feel like, "If I could do that in a way that makes me feel more confident on the other end, then I'm on board with trying that because I'm going to, just by moving through my world, experience exposures every single day in my life. But if I can figure out how to do that in a way that ends up making me feel more confident on the other end of each of those experiences, that is of interest to me." So I think for those reasons, it actually is quite well received by patients and families.

Dr. Greg Fritz: Is a tune up or a booster session, is that generally part of the program? Is that usually expected that'll be needed down the line?

Dr. Joshua Kemp: Yes. So anxiety, it goes up and down and things come up in a person's life. What's nice is exposure is a type of skill that a person has. Once you learn how to do exposure for yourself and look for opportunities for exposure in your life, it's easy to apply. I shouldn't say easy to apply, but it's easy to know what the principles are and how a person could go about approaching some kind of feared items. It's not always easy to make it happen. Sometimes you're busy or you miss the opportunity.

But usually when we're wrapping up, we've made a lot of the therapeutic gains that we wanted to make and people are heading out and just continuing the services. We'll spend a good amount of time talking about how do you maintain these gains? How do you keep using this skill out there in your life? And I will often talk about it like it's like weeding a garden. So if you look for all these exposure opportunities in your day to day life, and you're taking them as they come little bit by bit, just as you're seeing weeds pop up, you're taking care of those, you can keep these anxiety concerns in their place for the most part.

But if avoidance creeps in and you're not doing exposure, you find yourself avoiding more and more or anxiety just kind of sneaks up on you, it's easy for things, those anxiety concerns, to crowd themselves back in and a booster session could be really helpful for that. And people who come back for booster sessions, you tend to respond much quicker and they move through that content with much more ease than the first go-round. So it's clear that the skill is still there, but either more avoidance has been happening or it's presenting in a way that just on its face doesn't make as much sense. So that happens a fair amount with OCD where it's just a new domain, not quite sure what to do about this, a booster session can be a good fit for that.

Dr. Anne Walters: Are there children that you think this form of treatment is not effective for?

Dr. Joshua Kemp: I think for individuals that are presenting with avoidance, but underneath that avoidance, it's not really driven by anxiety. It's more of like a preference kind of thing, that's oftentimes what we're trying to assess for early on when meeting with new clients and families, is how much of this avoidance is really the anxiety-based versus a preference kind of thing and just don't want to do that thing. In which case, it's more of, you know, behavioral presentation. So in those instances where anxiety really isn't underlying a lot of that avoidance, those individuals might not be the best fit for exposure. And I think for others where inattention might be a significant issue, that's not that exposure isn't a good fit in that case, but it can help to add medication or do other kinds of behavioral strategies to help support attention because, ultimately, the learning you get from an exposure is tied to how well you're able to stay in a situation and attend to that feared item and really gain new learning about just how dangerous or intolerable is this situation. And so if it's really difficult to stay focused on that content and gathering that new information, sometimes that can make the learning not quite as robust as once you have those attention issues better addressed.

Dr. Anne Walters: So a child with ADHD, for example, might need another form of treatment to be able to truly access exposure effectively.

Dr. Joshua Kemp: Yeah. Or at least, it can be helpful to build in strategy to help a person concentrate. And maybe that involves augmenting the way that you're delivering the exposure, rather than trying to make these really long, drawn out exposure scenarios, trying to do shorter exposure scenarios in taking breaks and giving a person a chance to disengage and then come back to the exposure work. So I wouldn't say that exposure is not a good fit for people with attention issues. I think it just warrants additional adjustments in terms of making sure they're going to get the most out of that learning.

Dr. Anne Walters: So this type of therapy could truly give kids their lives back and, in turn, their family's lives back. If a parent listening is wondering if this type of therapy could help their child, what's the best way to connect them with a provider who can help?

Dr. Joshua Kemp: Yeah. So as we were talking about, unfortunately exposure is pretty underutilized out there in the community. And the best thing to do is either you can call into the Kids' Link number if you're here in Rhode Island, or you can look at various organizations that have a lot of providers that have more of an exposure background that belong to those organizations. Those are like the Association of Behavioral and Cognitive Therapies or the Depression and Anxiety association or the International OCD Foundation also has a pretty good directory of individuals who might be able to deliver exposure.

But I think as you're reaching out and talking to different providers, it's good to ask, "Do you provide exposure? I think my child's presenting with an anxiety concern." "Do you provide exposure? And you know, if so, what does that look like?" So some individuals might be delivering exposure, but it's still combined with an awful lot of coping. I think you want to look for somebody who's delivering exposure and they're talking about it as something where they're having somebody confront their anxiety in a prolonged and intensive way that's planful and collaborative. Those are all the earmarks of high quality exposure. So, don't be afraid to, if you're reaching out, ask people questions about what exposure looks like and if they use it. That can save a lot of time, I think, for somebody who has clear anxiety concerns who might go and do other interventions that aren't the best fit for anxiety specifically if you're really looking for exposure, which has the most evidence for anxiety. Those are some of the things you might want to ask about.

Dr. Anne Walters: Thank you so much for being here, Dr. Kemp. This was a great discussion and be sure to check out our entire Mindcast podcast library at bradleyhospital.org/podcast. Thanks for listening today.

Dr. Joshua Kemp: Thank you.