In 2013 I graduated as a Master of Arts in Professional Counseling. I was as unprepared as any intern would be, thrown into a world I hadn’t encountered until high school. I quickly realized that being a traditional “talk therapist” was not appealing to me. I couldn’t find my specialty or ideal client. I felt inadequate.
I worked with individuals in traditional settings and dealt with traditional things that people seek therapy for: depression, work problems, parenting and relationship problems, and life dissatisfaction. It’s not to say that these issues aren’t serious or worth seeking help for, but dealing with those issues just didn’t suit me.
I’ve tried working in other settings, such as a residential treatment center for traumatized children, where I loved the job, but the physical demands, secondary trauma, and burnout weren’t sustainable for me.
So when I saw an offer 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 applied for the position and was offered the job. So I moved halfway across the country to try something new: working exclusively with clients with anxiety and obsessive-compulsive disorder (OCD) using an approach under the cognitive behavioral therapy (CBT) umbrella called Exposure and Response Prevention (ERP).
ERP is used to break the negative reinforcement cycle by encouraging the individual to confront stimuli that cause distress. I use ERP to treat specific phobias such as agoraphobia (fear of leaving one’s own home), emetophobia (fear of vomiting or vomiting), aerophobia (fear of flying), nosophobia (fear of catching chronic diseases), fear of driving, fear of natural disasters, and even fear of monsters under the bed.
When working with clients who have OCD, I use it to treat variable subtypes such as contagion (obsessions about contracting disease or spreading germs), sexual obsessions, harm obsessions (intrusive thoughts or images about harming oneself or others inflict), perfectionism, relationship obsessions, controlling behaviors, cleaning/washing rituals, mental compulsions, “just right” obsessions (thoughts or feelings that something isn’t quite right), feelings of disgust, and more.
ERP may also be indicated in school avoidance, social phobia, panic disorder and eating disorders.
Once I started successfully helping people face their fears, I knew I had finally found my specialty. ERP took me out of the office, increased creativity and trust in the therapeutic relationship, and delivered measurable results.
My working days look very different than during my internship days. Now my day depends on my client’s fears. If they’re afraid to drive, we’ll drive. If they’re afraid of social judgment, I can ask them to order me coffee, ask someone stupid questions over the phone, or go around the block.
If my day includes clients with OCD, we may try to conjure up images of perceived threats, such as knives or bridges. We can challenge fears like, “What if I steal something?” by entering a store or throwing away a receipt.
These behavioral changes allow the brain to distinguish between real and perceived danger. As the client builds anxiety tolerance, the intensity and duration of their anxiety decreases over time.
I often give my clients homework that I call “experiments.” These experiments allow the client to build confidence in themselves and their ability to tolerate uncertainty and feelings of anxiety. Experiments can be anything from leaving the front door open while walking around the block to resisting a compulsion to make sure the stove is turned off.
Some exposures require more creativity. One of my favorite parts of being an exposure therapist is helping clients create their own experiments for their OCD/anxiety. For example, a client with a fear of flying asked to be locked in a closet to mimic the feeling of being trapped. Another client ventured into a creepy basement with me to face the fear of contracting leptospirosis. (The fear was based on the uncertainty of whether or not there were rats in the basement that could carry the disease.)
To build stress tolerance, we sat in space weekly while increasing the length of time. As a result, the customer’s fear decreased and they can now enter other areas that they previously feared, such as tunnels and parking garages.
If a client challenges their magical thinking, we might watch the traffic go by and think about the cars crashing into each other, or I might ask them to hope that I get hurt driving home from work. When these things don’t happen, it challenges their belief that their thoughts have power and can create or change results.
Some of these experiments are also challenging for me. For example, while I don’t experience emetophobia (fear of vomiting) myself, making a concoction of pea soup, white vinegar, and crackers to put in my mouth and spit into a toilet was definitely an inconvenience I could have lived without. But I think what makes me a successful exposure therapist is a willingness to experience discomfort with my clients.
One of the first things I tell them before we start exposure is, “I won’t ask you anything that I wouldn’t do myself.” This helps the client build trust in me and rebuild trust in themselves. 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 willingness, patients have been able to increase their tolerance and live fulfilling lives that are in line with their values.
Seeing someone go from “I don’t think I can do this” to “Meh, it’s not such a big deal anymore” still amazes me, and I get a little bit of excitement every time it happens. The process of overcoming fear teaches the patient that their values are much more important than their fears. When a person is able to live according to what is important to them instead of letting fear 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 one of the most difficult to diagnose and treat. I usually see clients after years of experiencing intrusive thoughts, compulsions, and avoidance behaviors.
When a patient first comes into my practice and is told about exposure therapy, they are often quite frightened and hesitant. Sometimes they have had bad experiences with therapy, been told exposure therapy doesn’t work, or confused it with “flooding” (also called implosive therapy).
Flooding is when a person is exposed to their fear at maximum intensity for an extended period of time. This type of treatment is not recommended because it can be traumatizing for the individual, especially if their fear stems from a site of trauma and is not just an overactive fear response.
Exposure and response prevention involves gradual exposure to the fear using a fear hierarchy created during the session. It’s the difference between being thrown into a pool and being forced to swim and gradually entering the pool and learning how to swim.
Part of what I love about this job is being able to provide psychoeducation to clients and their families or partners. When a person understands what is happening 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 a treatment.
So often I see the world of clients start out small and closed, unable to go where they please, spend time with their children or engage in leisure activities. When exposure therapy is successful, they can regain what fear has taken away from them. The strength and resilience of people make me go back to work every day.
Do you have a compelling personal story you’d like to see on The Singapore Time? Find out what we’re looking for here and send us a pitch.