Focus on Exposure-based Therapies

Edna FoaAt one time it seemed like exposure protocols were to be consigned for the few cases that therapists see each year of specific phobias – fear of spiders, or flying where the logic of a graded exposure program is self-evident. Curiously though, even in the treatment of OCD where exposure and response prevention (ERP) is the NICE recommended treatment, therapists (anecdotally) seem reluctant to go down that route. There is something that perhaps feels unkind or scary in taking people directly towards the thing they fear – particularly if you are a person driven to do a job by your desire to alleviate suffering, why ramp it up if there is another way to go? My friend and colleague Jennifer Sayrs co-director of the Evidence Based Treatment Centers of Seattle told me that sometimes clients who come from all over the USA to the clinic for treatment for OCD will never have been offered ERP despite seeing numerous therapists in the past.

Perhaps the one area in which an exposure protocol has continued to hold the foreground has been in the treatment of PTSD, with Employee assistance programs keen to ensure clients have access to suitably qualified practitioners to deliver this therapy. When I worked in Primary care counselling I was frequently asked to help people suffering from trauma associated with road-traffic accidents. And then of course with those who have suffered the trauma of rape and sexual abuse, which led me personally down a circuitous training route to eventually become a Dialectical Behaviour Therapist.

Marsha Linehan, the treatment developer of DBT has remarked that she believes exposure (talking through the details of the traumatic event) is the common ingredient in all therapies, and certainly avoidance of traumatic material was noted in the seminal work by Judith Lewis Herman, Trauma and Recovery, as the most common therapeutic error.

More recently there has been a resurgence of research and development in the trauma field. Martin Bohus of Germany is making great strides in in-patient exposure work with clients with Borderline Personality Disorder suffering from sexual abuse trauma, with some unusual techniques – having patients recall the trauma whilst standing on a balance board to prevent dissociation for example.  Melanie Harned has developed a simultaneous DBT/exposure-based protocol, again for clients with borderline personality disorder that has had some life-changing results for patients unable to emotionally access the DBT therapy because the trauma symptoms were too intrusive. Melanie’s protocol was devised in consultation with Marsha Linehan and maybe the most prolific name in developing exposure treatments, Edna Foa who will be visiting the UK later this year to deliver her 4 day training to mental health professionals wishing to use her Exposure protocol*. I did this training a couple of years ago and despite being quite a fan of exposure therapies already, picked up nuances from Edna’s vast experience and training videos that took my own practice to a higher level. I think it is easy to overlook some of the subtle therapist interventions, but seeing actual tapes of sessions with patients and having Edna point out the pertinent strategies was definitely the best part of the course. Having delivered mostly long-term therapies myself I was amazed at how speedily Foa’s protocol gets results, in very severe trauma cases.  A sobering thought.

Taken altogether the current interest in revisiting exposure can only be good for patients who have suffered for so long with trauma symptoms. Although it is difficult for both therapists and clients to hold to a protocol, the life-changing benefits can clearly be seen. I am looking forward to continued research in the field.

*Attendees at Edna’s 4-day training receive a certificate endorsed by the University of Pennsylvania. for details go to 




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