Anxiety/OCD Research: Ethical Considerations in Exposure Therapy with Children
Dr. Jennifer Gola, a psychologist specializing in OCD and anxiety disorders at the Center for Emotional Health of Greater Philadelphia, in Cherry Hill and Princeton, NJ., talks about the article she and her colleagues published titled “Ethical Considerations in Exposure Therapy with Children.”
In short, what is this article about?
Exposure therapy, a type cognitive-behavioral therapy (CBT), has been well established as the evidenced-based psychological treatment of choice for anxiety disorders and OCD, but this treatment is underutilized by clinicians. In addition, many clinicians hold negative or false beliefs about this treatment. Our article addresses myths associated with exposure therapy, outlines ethical considerations therapists and patients should be aware of when conducting or engaging in this treatment and offers suggestions for the ethical use of this treatment. Our aim is to increase the use and effectiveness of exposure therapy.
What are some of the main points of the article?
Exposure therapy is not actually unsafe, rather it sets up situations in which the patient believes harm will occur or highly overestimates the risk. For instance, a patient with a fear of someone breaking into their home may practice leaving the door unlocked for a quick walk, but should not be encouraged to leave the door unlocked all day and night. Because of the seemingly contradictory nature of exposure therapy (reducing anxiety by increasing anxiety) there are unique ethical considerations in the treatment. For instance, people with anxiety disorders obviously want to avoid anxiety, thus it is important for them to understand the rationale for exposure therapy in order for them to be willing to engage in it. Thus, an exposure therapist should be sure a patient fully understands why and how exposure therapy works, allow patients to go at their pace while still constantly encouraging them to step out of their comfort zone, and plan for exposures adequately to increase the chance of success.
With children, there are additional ethical considerations. Children often do not want to attend therapy and may have trouble understanding the rationale for treatment. In addition, parents often play a role in unintentionally limiting the treatment effectiveness for a number of reasons; they may be anxious themselves about exposures, allow their child to avoid anxiety-provoking situations because they want to decrease their child anxiety, they may not believe in the treatment, they may be helping their children do exposure homework regularly, or they may have beliefs that child is being oppositional instead of anxious, to name a few. In addition, because exposures often have to be done outside of the office, therapists and patients have to consider confidentiality and risks associated with being outside of the office. One suggestion given is that a “cover story” should be prepared, in case, for instance, someone asks why you are riding the elevator over and over, or if you run into someone the patient or therapist knows.
How do we best ensure exposures are successful and not “harmful” or “too risky”?
There is no evidence that there is more harm inherent in exposure therapy than any other psychological intervention, but like all treatments, there are steps that should be taken to maximize success and minimize risk. First, exposures on the hierarchy should be collaboratively created between the patient, the therapist, and the family if working with a child. The first exposures conducted should be something that both the therapist and patient can agree will likely be successful. It should be something the patient is doing already with difficulty or know they can do with some anxiety.Choosing the next exposure item each session, and agreeing on goals and specifics should also be done collaboratively. The top of the hierarchy exposures should go above what is typically done intentionally and fully target the fear, without being truly unsafe, harmful, or outside of what is accepted in the patient’s culture or religion.
Examples of good “above and beyond” exposures include singing a song in public to treat social phobia, or eating off of the bathroom floor to target contamination OCD. Since there is much variability even among the non-anxious population on what is considered safe or reasonable to do, it can be helpful to poll others on their behaviors, have an open dialogue with the family about the appropriateness of the exposure, and gain information through research or speaking to other professionals to gain insight into the acceptable level of risk. Indeed, many clinicians actually deliver treatment in an overly cautious manner, which often reduces its effectiveness. Therefore, we mostly want patients and therapists to know that anxiety is not harmful, that learning to tolerate anxiety without anxiety-reducing methods is helpful, and that the more the patient can lean into anxiety, the more successful he or she will be.
Choosing the next exposure item each session, and agreeing on goals and specifics should also be done collaboratively. The top of the hierarchy exposures should go above what is typically done intentionally and fully target the fear, without being truly unsafe, harmful, or outside of what is accepted in the patient’s culture or religion. Examples of good “above and beyond” exposures include singing a song in public to treat social phobia, or eating off of the bathroom floor to target contamination OCD.
Since there is much variability even among the non-anxious population on what is considered safe or reasonable to do, it can be helpful to poll others on their behaviors, have an open dialogue with the family about the appropriateness of the exposure, and gain information through research or speaking to other professionals to gain insight into the acceptable level of risk. Indeed, many clinicians actually deliver treatment in an overly cautious manner, which often reduces its effectiveness. Therefore, we mostly want patients and therapists to know that anxiety is not harmful, that learning to tolerate anxiety without anxiety-reducing methods is helpful, and that the more the patient can lean into anxiety, the more successful he or she will be.
How do I find a competent exposure therapist?
Look for a therapist that specializes in anxiety disorders and OCD, and who specifically is well trained and well versed in exposure therapy. Many therapists who treat anxiety disorders or OCD say they do CBT, but do not actually do exposure work, the key ingredient of anxiety treatment. ABCT.org, ADAA.org, and IOCDF.org all provide a directory that enables you to search for CBT therapists in your area. Be sure to interview potential therapists and ask questions! Look for therapists who had formal training in exposure therapy in graduate school or during an externship, internship, or fellowship. Ask potential therapists what treatment typically looks like. The therapist should describe creating a hierarchy of feared stimuli, gradually facing these fears through exposure, and refraining from safety behaviors, avoidance, or compulsions. They should describe practicing the exposures in session and assigning exposures for you to practice at home. Finally, look for a therapist you feel comfortable with, as a good relationship is important to being successful in treatment!
Link to the primary paper
Gola, J. A., Beidas, R. S., Antinoro-Burke, D., Kratz, H. E., & Fingerhut, R. (2016). Ethical considerations in exposure therapy with children. Cognitive and Behavioral Practice, 23(3), 184-193. DOI: 10.1016/j.cbpra.2015.04.003
Additional related reading:
The Cruelest Cure? Ethical Issues in the Implementation of Exposure-Based Treatments
Finding the Right OCD Therapist
Addressing Myths and Mistaken Beliefs in the Treatment of Youth with OCD
Factors associated with Practitioners’ Use of Exposure Therapy for Childhood Anxiety Disorders
Jennifer Gola, Psy.D is a psychologist at the Center for Emotional Health of Greater Philadelphia, LLC in Cherry Hill and Princeton, NJ. She specializes in the treatment of OCD, anxiety disorders, and BFRB’s such as trichotillomania in children, adolescents, and adults. She earned her Psy.D from LaSalle University and was trained in the treatment of OCD, OCD-spectrum, and anxiety disorders at the University of Pennsylvania’s Center for Treatment and Study of Anxiety (CTSA) and the Child and Adolescent OCD, Tic, Trich, and Anxiety Disorders Group (COTTAGe).
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