Is ERP Traumatizing? (with Dr. Amy Mariaskin) | Ep. 365

Kimberley: Is ERP traumatizing? This is a question I have been seeing on social media or coming up in different groups in the OCD and OCD-related disorders field. Today, I have Amy Mariaskin, PhD, here to talk with us about this idea of “Is ERP traumatizing” and how we might work with this very delicate but yet so important topic.

Thank you, Amy, for being here.

WHY MIGHT PEOPLE THINK ERP IS TRAUMATIC? 

Kimberley: Let’s just go straight to it. Why might people be saying that ERP is traumatic or traumatizing? In any of those kinds of terms, why do you think people might be saying this?

Amy: I think there’s a number of reasons. One of which is that a therapy like ERP, which necessitates that people work through discomfort by moving through it and not moving around it or sidestepping it, is different than a lot of other therapies which are based more on support, validation, et cetera, as the sole method. It’s not to say that ERP doesn’t have that. I think all good therapy has support and validation. However, I think that’s part of it. The fact that’s baked into the treatment, you’re looking at facing discomfort and really changing your relationship with discomfort. I think when people hear about that, that’s one reason that it comes up.

And then another reason, I think, is that there are people who have had really negative experiences with ERP. I think that while that could be true in a number of different therapeutic modalities and with a number of different clinicians and so forth, it is something that has gained traction because it dovetails with this idea of, well, if people are being asked to do difficult things, then isn’t that actually going to deepen their pain or worsen their condition rather than alleviate it? That’s my take.

Kimberley: When I first heard this idea or this experience, my first response was actual shock because, as an ERP therapist and someone who treats OCD, I have seen it be the biggest gift to so many people. I’ve heard even Chris Trondsen, who often will say that this gave him his life back, or—he’s been on the show—Ethan Smith, or anyone really who’s been on the show talk about how it’s the most, in their opinion, like the most effective way to get your life back and get back to life and live your life and face fear and all of those things. 

DO PEOPLE FEEL ERP IS A DIFFICULT TREATMENT?

I had that first feeling of surprise and shock, but also then asked more questions and asked about their experience of ERP being very pressured or feeling too scared or too soon, too much too soon, and so forth. Do you have any other ideas as to why people might be experiencing this difficult treatment?

Amy: I do. I think that sometimes, like any other therapy, if you’re approaching therapy as a technician and not as a clinician, and you’re not as a therapist really being aware of the cues that you’re getting from the very brave people sitting in front of you, entrusting their care to you—if we’re not being clinicians rather than technicians, we can sometimes just follow a protocol indiscriminately and without respect to really important interpersonal dynamics like consent and context, personal history, if there’s not an awareness of the power dynamic in the room that a therapist has a lot of power. 

We work with a lot of people as well who might have people pleasing that if you’re going to be quite prescriptive about a certain treatment, you do this, and then you do this, and then you do this without taking care to either lay the foundation to really help somebody understand the science of how ERP works or get buy-in from the front end. I know we’ll talk a little bit more about that, as well as there’s a difference between exposure and flooding. There’s a difference between exposure that serves to reconnect people with the parts of their lives that they’ve been missing, or, as I always call it, reclaims. We want to have exposures that are reclaims, as opposed to just having exposures that generate negative emotion in and of itself. 

Now, sometimes there are exposures that just generate negative emotions, because sometimes that’s the thing to practice. There are some people who feel quite empowered by these over-the-top exposures that are above and beyond what you would do to really have a reclaim. I’m going to go above and beyond for an exposure, and I’m going to do something that is off the wall. I am eating the thing off of the toilet, or I have intrusive thoughts about harming myself, and I’m going to go to the top of the parking garage, and I’m really going to lean all the way over. Would I do that in my everyday life? No. There are some clients for whom that is not something that they’re willing to do or it’s not something that’s important for them to do to reconnect with the life that they want to live, and there are others who are quite empowered. 

If you’re a therapist and you don’t take care to listen to the feedback from clients and let their voice be a part of that conversation, then you may end up, again, as a technician, prescribing things that aren’t going to land right, and that could result in some harm. My heart goes out to anyone who’s had that experience, because I think that’s valid.

Kimberley: I will be completely honest. I think that my early training as an ERP therapy clinician, because I was new, meant that I was showing up as a technician. When I heard this, again, I said my first thought was a little bit of shock, but then went, “Oh, no, that does make sense.” When I was an intern, I was following protocols and I was learning. We all, as humans, make mistakes. Not mistakes so much as if I feel like I did anything wrong, but maybe went too fast with a patient or pushed too hard with a patient or gave an exposure because another person in supervision was saying that that worked for their client, but I was learning this skill of being attuned to my client, and that was a learning process. I can understand that some people may have had that experience, even me. I’m happy to admit to that early in my training, many years ago.

Amy: That’s a great point. I think if we’re all being honest with ourselves, whether it be within the context of ERP or otherwise, there is a learning curve for therapists as well. I think going back to the basic skills and tenets of what it means to have a positive therapeutic relationship is that so much of that has to do with the repair as well. If there are times, because there will be times when you misjudge something or a client says, “I really think that I’m ready to try this,” then we say things like when exposures go awry, when the worst-case scenario happens, or what have you. 

That’s another philosophical question because I think in doing exposures, we’re not necessarily, at least my style, saying the bad thing’s not going to happen. It’s about accepting the risk and uncertainty, which is a reasonable amount. However, I think when those things happen where it does feel like, “Hey, this felt like too much too soon,” or this felt like, “Wow, I wasn’t ready for this,” or “I don’t feel like that’s exactly what I consented to. You said we were going to do this, and then you took an extra step”—I think being able to create an environment where you can have those conversations with clients and they feel comfortable bringing it up with you and you can do repair work is also important. That it’s not just black or white like, “This happened and I feel traumatized.” Again, I don’t want to sound like I’m blaming anybody who’s had that experience, but I’m just saying that I think that happens on a micro level, probably to all of us at some point. 

I think it’s also important to acknowledge, and later we’re going to talk about it, but the notion of the word ‘traumatizing’ is a little bit difficult for me to hear as well because I think from the perspective of an evidence-based practitioner, the treatments that we have, even for so-called big T trauma, many of them integrate in exposure. All of my first-line treatments, including ones that maybe come at it a little bit more obliquely like EMDR or something like that, which is not something that I personally use, are certainly out there as like a second-line trauma treatment. But things like prolonged exposure and cognitive processing therapy, they all have this exposure component to them. Even the notion that if there’s trauma, you can’t go there or that talking about hard things is traumatizing. I don’t know. Can we talk a little bit about that? Because I don’t know if that’s something you’ve thought about too, that it’s hard to reconcile.

Kimberley: Yeah. Let me give a personal experience as somebody who had a pretty severe eating disorder. I was doing exposure therapy, but I didn’t get called that, and I didn’t know what to be that at the time. But I had to go and eat the thing that I was terrified to eat. While some people might think, “Well, that’s not a hard exposure,” for me, it was a 10 out of 10. I wanted to punch my therapist in the face at the idea that she would suggest that I eat these things. I’m not saying this is true for other people; I’m just giving a personal experience. I’m actually really glad that she held me to these things because now I can have full freedom over the things that used to run my life. I know that there is nothing on any menu I can’t eat. If I had to eat on any plane, whatever they served me, I knew I was able to nourish my body with what was served to me, which I didn’t have before I did that. 

The other piece is somebody who has also been through trauma therapy. A lot of it required me to go back and relive that event over and over. Even though I again wanted to run away and it felt like my brain was on fire, that too was very helpful. But what was really helpful was how I reframed that event. If I was doing it and, as I was doing it, I was saying, “This is re-traumatizing me,” it was a very bad experience. But if I was saying, “This is an opportunity for me to learn how to have our full range of emotions, even the darker stuff,” that ended up being a very important therapeutic experience for me. That’s just my personal experience. Do you want to speak to that?

Amy: Yeah. I wasn’t planning on speaking to this part of it, but I will say as well that having had a traumatic event—a single event, big T trauma—that happened at my place of employment years ago. This is over 10 years ago now, which involved being held at gunpoint, which involved a hostage-type situation. It’s interesting when you talk about trauma, that you want to tell the whole story, but I’m like, “Oh, we don’t have enough time,” which is interesting because our brains first don’t want to tell the stories or we want to bury them. But suffice to say that after this very painful, very terrifying experience, after which all the hallmark symptoms of hypervigilance and quick to startle and images in my head and avoidance of individuals who looked like this particular individual and what have you. The most powerful thing for me in knowing this as somebody who works in exposure protocols, going back to work and being so kind to myself as I was, again, I come back to this word reclaim. It doesn’t happen overnight. It’s not something I wish there were. I do wish there’s, “Oh yeah, we just push this button in our brains, and then that’s just where we feel resilient again.” 

But the process of building resilience for me was confronting this environment, reclaiming this environment. I think any exposure protocol has the ability to have that same effect if the framing is there and if it resonates with the person. Being somebody who’s such a believer in exposure therapy for my clients, I was able to step into a role where I came out of that situation feeling so empowered and the ability to hold all of my experience gently and with compassion, as opposed to sweeping it under the rug and then having it come out sideways.

Kimberley: I really appreciate you bringing that up because, similarly, I stowed mine down for many years because I refused to look at it until I was forced by another event to have to look at it. I think that’s a piece of this work too. You have to want to face it as part of treatment. In my case, I either avoid the things that are so important to me or I am going to have to face this; I am going to have to. I showed up and made that choice. I think that’s also a piece of it, knowing that that’s an opportunity for you to go and be kind and to train your brain in different ways. 

HOW TO MAKE ERP ETHICAL AND RESPECTFUL

We’re speaking directly now about some ideas and solutions to making ERP ethical and respectful. Are there other ways that someone who’s undergoing ERP, considering ERP, or has been through it—other things we might want to encourage them to do moving forward that might make this a more empowering and validating experience for them?

Amy: That’s a great question because I think we can talk about it both from the perspective of clients who are looking for a new therapist as well as what therapists can do. But if we start first with clients and maybe you’re out there, and it’s been something you’ve either been hesitant to engage with because of some of these ideas about it being harmful or you’ve had a negative experience in the past, I do think that there is a mindset shift into feeling really empowered and really willing. 

The empowerment part is coming in and bringing in-- your fears about ERP are also fears that can be worked on. If you’re white-knuckling from the first moment of like, “Okay, I’m in here, I know I’m supposed to do this. I already hate it and it hasn’t started,” sharing that with a clinician. I know I’m used to hearing that. I’m very used to hearing that. I’ve had folks come in who have been in supportive therapy, talk therapy, or other modalities that haven’t been effective for many, many years. There is a part of me-- I’m sorry, this is a tangent, but it’s a little soapboxy tangent. I feel like when I think about my clients who’ve had therapy for sometimes 10, 20 years and it hasn’t been effective, I don’t think we talk enough about how harmful that is for people, like putting your life on hold for 10 or 20 years. I don’t hear the word necessarily ‘traumatizing,’ but that can be harmful as well. People will go through that. 

BE OPEN WITH YOUR ERP THERAPIST

After these contortions to maybe even avoid ERP because it’s scary, they’ll come in, and I welcome them, saying, “I’m really nervous about this,” because guess what? Saying that aloud is a step in the direction of exposure. You’re owning it. And then having a therapist who can say, “I’m so proud of you for being here.” This is exposure number one. Sitting down on this couch, here we are. Well done, check and check. Because I think that a therapist who’s looking at exposure, not just as what’s on a strict hierarchy, or even from an inhibitory learning perspective, like a menu—exposure is what you’re doing day to day to help yourself get closer to the life that you want and the values you have. When you said, “I can eat anything because I want to nourish my body,” that’s a value.

When I say ‘empowerment,’ like empowerment to discuss that with your therapist. And then that shift into willingness versus motivation or comfort or like, “Oh, I want to wait till the right moment,” or “Things are tough now. I don’t want to add an extra tough thing.” I know you’re not here to tell anybody, “Well, this is the way you should think.” But if there’s any room to cultivate even a nugget of willingness to say, “I can do something difficult, and I am willing to do difficult things on the path toward the life that I want,” those would be two things that come to mind right away.

Kimberley: Yeah, I agree. It takes me to the second piece for a client. I think a huge piece of it is transparency with your therapist or clinician. There have been several times where we’ve discussed an exposure—again, this was more in my earlier days—agreed that that would be helpful for them, gone to do it, and then midway through it, them saying, “I felt like I had to please you, but I’m so not ready for this,” or “I was too embarrassed because this is such a simple daily task and I should be able to do it.” I think it’s okay to really speak to your therapist and share like, “I don’t know how I feel about this. Can we first just talk about if I’m ready?” We don’t want to do that to the degree of it becoming compulsive, but I want to really encourage people who are undergoing treatment of any kind to be as completely honest as you can.

Amy: Right. I think that, again, it’s an interesting dynamic because people are coming to specialists because we do have the knowledge and awareness of protocols and so forth. But again, I think mental health is-- well, I wish all medical health folks were a little bit more open to these kinds of conversations too. But that being said, I think having that honesty and knowing that-- if you go in and you say, “Oh, I’m a little bit nervous,” and you’re getting pushback of, “Well, I’m the doc, this is what you do. Here’s step one, here’s step two,” frankly, there are going to be therapists who are like that regardless of modality. 

It was interesting because I was talking to somebody about this and about—I think if we frame it as a question—"Is ERP inherently harmful” is a really different question than “Can ERP be harmful?” I think any modality implemented without that clinical touch can be potentially harmful. 

I know your motto is, “You can do hard things.” That kind of shift as well is so powerful at the beginning of ERP. You’ve been transparent. You’ve said, “Look, here are my fears about this.” 

And then often, what I will do as a clinician if people don’t get to that place of like, I” can do things through the discomfort, there’s no going around it,” is ask them about things. If they’re adults, it could even be like, “When you were a little kid, did you have any fears, and how did you get over those? What was that like?” Not always, of course, but 9 nine times out of 10, it is some kind of like, “Well, I did the thing.” Or sometimes it’s more complicated, “Well, I did the thing and then I got support from others, and then I learned more.”

But I think people have this innate capacity to learn by changing behavior and to do things that are outside of their comfort zone, and that doesn’t have to mean way outside of their comfort zone. Often, that notion of these hard experiences or these difficult thoughts that you need to-- people will come in and feel like, “Well, I need not to be thinking about them.” That’s not really an option. Being a human with a full life, there are going to be things that are provocative. But I think I’ve heard you talk about this notion of shifting from wanting protection from negative thoughts or discomfort to almost willingness and acceptance. I love that as well.

Kimberley: I agree. I want to also maybe back up a little bit and speak to that just a little bit. I do hear the majority of people saying this, coming from those who are seeking treatment from unspecialized people. Even this morning, people are emailing me saying, “I’m following this OCD coach online, and they’re saying, ‘Follow my six-month program and you will be OCD-free.’” That sounds good. I’ll do whatever you say if that’s what I can give you. There is a power dynamic. 

But then you’re in the program and being told that you have literally two months to go and you better double down or you will fail my program. I think that urgency to get better can cause you to sometimes agree to things or seek out treatment from people who aren’t super trained and who aren’t taking an approach of, “Let’s practice being uncomfortable, let’s practice having every single emotion kindly and compassionately so that there is no emotion you can’t ever have in your lifetime through the darkest ages.” They’re more coming from a, “I’m on a timeline here and I have to get this done, so I’m going to do these things that are absolutely terrifying.” I think a lot of people are speaking to this.

Amy: I think that’s right. A lot of times, people have been-- I think we, as a field, like mental health professionals, there’s this delicate balance of wanting to instill hope and really talk about like this works and to not overpromise or not simplify the circuitous way that we get there together as a therapist and client, because there are a lot of sound bites out there. I know you and I have talked about this. It’s like these “better in 12 weeks” or “better in with these five tips” or what have you.

I think even looking at research, and I have a strong research background, I was training to be a researcher when I was in grad school. I think it’s important as well to remember that even with research, we are looking at-- if we say like, “Hey, this is a 12-week protocol that’s been effective.” Okay, what does effective mean? Does effective mean that you get to pick up your baby again? Or does it mean, oh no, it probably means an X amount reduction in the Y box? Does effective mean it was that amount of reduction for everyone? Well, no, it’s averages and things like that. 

I can wear both hats and say, this is an incredibly empirically validated treatment that works for many people. It’s not going to work the same way for every person, so why would we as clinicians go in and be like, “Here’s a timeline?” You can’t do that.

Kimberley: Yeah. Let’s speak to the therapist now. What can therapists be doing to make this a more effective, compassionate, and respectful practice? Do you have anything that you want to speak to first?

Amy: Yes. I think that if we start at the beginning of therapy itself and the steps that you go through, the very first step is assessment because exposure is something that we know is very effective for anxiety, to a lesser degree, disgust, and not quite right feelings as well, and some sensory issues, to a lesser extent. But exposure is effective for certain things. We want to make sure that those are the things that are occurring. So, making sure because somebody can have OCD, or can have anxiety, or something like that and also have other things going on.

I think sometimes when exposure is treated-- exposure and response prevention. I know we talk a lot about exposure, but even response prevention, that side of things, it’s just this one size fits all. Okay, something you don’t like doing, we’re going to expose you to it, and something that alleviates your distress, we’re going to eliminate those. If you’re doing that outside of the context of where it’s clinically indicated for OCD, i.e., areas that provoke obsessions and compulsive behaviors, then you’re really missing the target. 

I know there’s been a lot of discussion about neurodiversity and for autistic people who may have routines and things like that or may have stereotypies or stimming behaviors, things that are pleasant for them or self-regulatory to really get a good assessment in there. Again, you’re not having people do exposures or engage in response prevention in places where it’s not clinically indicated.

I think even if somebody has a trauma history, for something like PTSD, exposure is often, as I mentioned, a part of treatment protocols. The way in which we are doing those kinds of exposures and really centering the sense of agency in the client who’s had that sense of agency taken away by prior experiences is really important. I think assessment is the first thing that comes to mind, followed--

Kimberley: I would add-- sorry, I didn’t mean to cut you off, but I would add even assessment for depression. A lot of what we teach in ERP school for therapists and what I teach my staff is, if a client has depression, I might do more exposures around uncertainty and not around their worst-case scenario happening because sometimes that can make the depression come in so strong that they can’t get out of bed the next day. We can tailor exposure even to make depression, and so forth. 

I think it is so important that we do get that assessment and really understand the big picture before we proceed. Even understanding other anxiety disorders, health anxiety, the history of trauma with health, and so forth, or even the things you were taught as a child, can be really important to understand before we proceed with exposure.

Amy: I love that you added that in—the things that we were taught as a child—because I love this story. I mean, I love it and hate it, and you’ll understand why in a moment. But when I was on my internship—this was back in 2008, 2009—there was a fellow intern. He and I were co-presenting on a case, and we had the other interns. They were asking questions, and this was a makeshift IOP case. We were both doing a little bit of individual therapy, and people in the audience were asking questions, and somebody asked about childhood. This was an adult. The other intern said, “We don’t care about that stuff.” I said, “Time out, I care about it,” and we all laughed. 

I get where he was coming from in the sense that he was like, “Hey, here are the symptoms, here’s the protocol for the symptoms, and it is important.” Like you said, I mean, even from a CBT, this is very consistent with CBT and how we form core beliefs and schemas and our ideas about the world and fairness and justice, and all of that is a part of it. We don’t want to lose the C part, the cognitive part as well in ERP. But I love that you said that about depression as well, because even something co-occurring can just nudge. It just nudges the way that we do exposure and so forth.

Kimberley: Yeah. I think culturally too. Think about the different traditions that come with different cultures or religions. Sometimes some of their rituals can seem compulsive. If I didn’t know that that’s why they’re doing these, I could easily, as an untrained or ineffective therapist, be like, “Just expose yourself.” We’ve got to break this ritual, without actually understanding, like, is this actually a value-based ritual that you’re doing because of a religion or a culture or tradition that is in line with your values? I think that’s very, very important. After assessment, what would you say the next steps are?

Amy: I think that-- and this is the part where I’m really going to own that. I get really excited, and I just want to jump into treatment. This is me, I’m calling myself out. But I think psychoeducation, that not only very clearly lays out the evidence and the why, like here’s the process, here’s why we’re asking you to do these things that are really difficult, here are the underlying patterns, and here’s what we’re looking out for, and so forth. 

I think not only that, but also laying out very clearly what the expectations are. “This is how this is going to look,” and maybe at that point as well, clinicians saying—this is very collaborative—"I am here to provide this information, and then together we are going to formulate a treatment plan and formulate these exposures.” I have heard so many people who do a lot of ERPs say how proud they are by the end of therapy when clients come in and they say, “I was thinking I need to do this as my exposure.” They’re really taking that ownership. 

I think not only again talking about the science and all the charts and things like that, but really talking about this as a collaborative, consensual process, that it’s like, “I’m handing this off to you, and this is going to be something you have for the rest of your life.”

Kimberley: Yeah. I’ll tell a similar story. I had a patient who-- I’ll even be honest, I don’t think this was in my internship. This was in my career as an OCD therapist. But my client was just doing the exposures that he and I had agreed to. He would come back and be very frustrated with this process until he came to me and said, “I need you to actually stop and explain to me why I’m doing this.” I thought I had done a thorough job of that. I truly, really, honestly did. But he needed me to slow down and explain. We got out the PET scans of the brain, and I had a model of the brain. I showed him what part of the brain was being triggered and where the different parts of why-- from that moment, he was like, “I got you. I know what we’re doing. I’m on board now. I got this.” 

I think that I was so grateful that he was like, “Hold up, you need to actually slow down and help me to understand because this still doesn’t make sense to me.” This was a very important conversation. In my case, I think it’s checking in and saying, “Do you understand why we’re doing this? Do you understand the science of this?” I think it’s so important. What else might a therapist do?

Amy: I love that. I was just going to say, I love that you create that culture because that’s what I was talking about earlier. Sometimes we don’t quite get it right. And then it’s like, “What can I do better?” It’s such a powerful question. 

Knowing the why of ERP and then also the why, like, why is it worth it for you? Why is this? ACT has these wonderful metaphors about it. We’ve heard the monsters on the bus analogy. You’re driving the bus, and all your symptoms are the passengers yelling out or different fears you might have. But so often we don’t talk about, where are you driving the bus toward? Where are you going? 

I get misty when I think about this. I get almost a little teary because I think that people with OCD have such incredible imaginations, and yet, having OCD can make it so hard to dream and dream about what you truly want. Especially if it’s quite entrenched, it can just feel like, “Well, that’s a life that other people have. I don’t get to have that.” On the one hand, there’s this expansive imagination about illnesses, danger, harming others, or what have you. These things that are just dystonic—you don’t want to be thinking about them. 

I love to see people exercise that other part of their imagination and really encourage them to dream because if you have that roadmap, or rather that end destination of what you want your life to be, those very concrete moments that you want-- for some people, it’s like, “I want to have a family,” or “I want to travel,” or “I want to have the freedom to be around whomever I want to be around, regardless of the thoughts that come up,” whatever it is. Sometimes it can feel scary to even dream and envision that, either through values work or if it’s somebody who had a later onset thinking about where were you heading before. How did this derail you? What were you heading toward? I think that’s really important as well. If we don’t do that-- I mean, frankly, I wouldn’t want to do anything if I didn’t know my why.

Kimberley: No, agreed. I think that another thing—I often talk about this with my therapists in supervision—is one thing that I personally do-- and this is just me personally. Every therapist has their own way of doing it, but I often will ask my patients, “What kind of Kimberley do you need today?” I have the question as an opening where they can be like, “No, we’re good. Let’s just get to work.” We knew what we were going to do and so forth. My patients now know to say, “I need you to actually push me a little today.” They’re coming to me saying, “I want you to push you.” Or they’ll say, “I’m feeling very vulnerable today. I’m on my period,” or “It’s been a hard week,” or “I haven’t slept.” I don’t consider that me accommodating them. I consider that me being attuned to them. It might be that I might go, “Okay, but there’s been several weeks in a row that you’ve said that. Can we have a conversation?” It’s not that I’m going to absolutely let them off with avoidant compulsions, but I love offering them the opportunity to ask, what kind of Kimberley do you need? Sometimes they’ll say, “I need you to push me today, but I also need you to really encourage me because I have run out of motivation and I don’t have a lot.” 

I think that as clinicians, the more we can offer an opening of, what is it that you’re ready for? What do you want to expose yourself today? Is there something coming up that you really need to be working on? I think those conversations create this collaborative experience instead of like, “I’m the master of treatment, and you’re my follower” kind of model.

Amy: Right. I love that, and I love the idea that we can be motivational, encouraging, and celebratory in the face of exposure. Like exposures, I do feel like there has been a shift, and perhaps with the shift away from the strict habituation paradigm in the field, where it’s not like you have to just do the thing and be scared, be scared, be scared, be scared, be scared, and then it goes down. You can explore, “Hey, are you feeling stronger now? Are you feeling like I’m nervous, but I’m also curious?” 

Again, some of this is just personal style, but I use a lot of humor. There are often a lot of inside jokes with clients and things like that. I don’t see that as incompatible with really good exposure work because you’re learning that you can be scared and laughing. You’re learning that you can feel discomfort and empowerment. These kinds of things are huge. But again, I think when I was newer to ERP, there was a little bit of like, “Nope, we’re not cracking a joke, because that would be avoiding negative emotion.”

Kimberley: Yes. I remember that. Or being like, “I hope I don’t trigger them. I’m not going to [unintelligible].” The joke is what created an attunement and a collaboration between the two of us, which I think can be so beautiful. Another question I ask during exposure is, would you like to keep going? Would you like to make it a little harder? How could we? Even if we don’t, how might we? No pressure, but how might we make it so that they’re practicing this idea of being curious about making decisions on their own? Because the truth is, I’m only seeing you for 50 minutes a week. You have to then go and do this on your own. We want the clients, us as therapists, to model to them a curiosity of like, “Oh, it’s here.” Am I going to tell myself this is terrible and I can’t handle it? Or am I going to be curious about what else I could introduce? Would I like to send them a text to a loved one while I do this exposure? How would I like to show up? What values do I want to show up with? Those questions can take the terror out of it.

Amy: Yes. I think that all of this is hitting on something. I’ve noticed that oftentimes this notion of ERP is traumatizing. Again, not to discount anybody’s personal experiences with it if that has been negative, but it’s often based on this caricature of ERP that all those things that we’re saying don’t need to have that element of consent. It needs to have that collaborative nature, really good assessment, really good psycho-ed. I think that’s something I just realized because I don’t like feeling defensive about things. If I feel defensive, I’m like, “Uh-oh, this is a me thing.” I think in this case, it’s because I’m seeing a lot of misinformation about ERP, or perhaps just poorly applied ERP.

Kimberley: Yeah, for sure. I want to be respectful of time. We could make this into a whole training easily, but let’s end here on the healing because we’ve talked about everything today—ideas, concepts, mindsets, conceptualizations. But I also want to really make sure we are slowing down and creating a safe place where some people may actually, like you said, have had not great experiences. What might we do, and what might patients do in terms of healing moving forward?

Amy: It’s a good question. There’s a couple of things. I think if it’s something that we were talking about with the transparency and the talking, number one, finding support and finding support from, ideally, somebody who’s going to understand ERP enough that they can speak to. That doesn’t have to be the type of therapy that you’re getting with them, but understands it well enough to have a conversation like this. Just knowing it should never feel disrespectful, it should never feel non-consensual, and if that was your experience, then—I mean, I hate to say this, but I do think it’s true—I know I would want to know if somebody felt that way. If somebody was working with me and they felt that way, I know that can be quite a burden for people to reach out to someone with whom they’ve had a negative experience. 

But I think if you’re able to do that, that can be really helpful and really restorative, even if you’re not looking for a response, even if it’s just something that you’re letting them know. If you still have a relationship with that therapist, or let’s say it’s a clinic where you saw a therapist and you ended up moving to a different therapist, consider sharing it with them directly. I think we live in a very contentious culture of, “Well, I’ve made my mind up. That’s bad, and I’m moving on.” 

But truly, I think validation also starts with self-validation. My hope is that even though we’re both clearly ERP therapists who believe very strongly in its positive application for many people, we want to validate that if you’ve felt any harm, that’s valid. I think that also starts with self-validation as a first means of healing and then seeking support.

Kimberley: Yeah. What I think too, if you’re not wanting to do that, which I totally understand, sharing with your new clinician. One of the questions we have about our intake is what therapy was helpful and why, and what therapy wasn’t helpful and why. As you go with a new therapist, share with them, “This was my experience. This is what I found to be very effective. This is what I am very good at, but these are the things that I struggled with, and here’s why.” And then giving them the education of your process so they can help you with that, I think, is really important. 

I think you hit the nail on the head—also being very, very gentle. The administering of therapy is not a perfect science; it’s a relationship. It’s not always going to go well. I wish it could. I truly wish there was a way we could, but that doesn’t mean that you’re bad, that therapy won’t work for you in the future, or that all therapists are similar to what your experience was. I think it’s important to know that there are many therapists who want to create a safe place for you.

Amy: That’s so well said.

Kimberley: Anything else you want to add before we finish up?

Amy: No, no, I think this has been great. Again, anybody out there, I don’t know. I feel like, as therapists, sometimes we’re the holders of hope. If this could give you any hope, and again, ERP may not be the route that you choose, but just anyone who’s felt like therapy hasn’t been what you wanted, you deserve to find what’s going to feel like the best, most helpful fit.

Kimberley: Amy, I have wanted to do this episode for months now, and there is no one with whom I would feel as comfortable doing it as much as you. Thank you for creating a place for me to have this very hard conversation and a conversation I think we need to have. I’m again so grateful for you, your expertise, your kind heart, and your wisdom.

Amy: Thank you.