Kind to be cruel: The ethics of exposure therapies

by Joye C. Anestis

We have written rather extensively by now about the benefits of exposure therapies for a variety of psychological disorders.  These treatments, which ask clients to deliberately face the very things which scare them, are among the most-researched and most empirically-supported interventions.  We know that therapies involving exposure are efficacious (show clear gains in randomized controlled trials) and effective (show clears gains in real-world clinical situations) for obsessive-compulsive disorder, specific phobias, social anxiety disorder, panic disorder, post-traumatic stress disorder, and bulimia nervosa, to name just a few.  But despite such clear and unequivocal findings, exposure therapies are not used by clinicians in actual practice as much as would be expected.  I'm sure there are a number of reasons for this, ranging from theoretical disagreements on the nature of the psychological illness being treated, to a lack of training in the EST for the specific disorder, to actual lack of knowledge about the existence of such treatments (ESTs have a notorious public relations problems - one of the reasons we decided to create PBB in the first place).  One day, I will write about my thoughts on the ethics of not providing treatments which have such clear empirical support in favor of a treatment for which we have no data on its utility.  But today I am interested in discussing another reason why clinicians are reluctant to provide exposure therapies, beliefs that such treatments are unethical. 

I find discussions about the ethics of exposure to be fascinating - on the one hand, it is argued that not providing the best treatment for a mental illness is unethical (we wouldn't accept our medical doctors providing us with Vitamin C for the flu when Tamiflu is the most effective)...and the opposing argument includes concerns over the ethics of providing a treatment that initially increases distress, beliefs that exposure therapies are harmful, and concerns over the acceptability of such a treatment by clients (& I'm sure there are many more!).  A new paper by Olatunji, Deacon, & Abramowitz published in Cognitive & Behavioral Practice tackles these concerns about exposure therapies, examining the logic and the research evidence behind these concerns.  They also offer strategies for ensuring exposure is conducted in the safest manner possible.

Is exposure harmful?  Obviously, this is a concern that must be taken seriously.  If exposure therapy actual causes harm to clients (i.e., is exposure therapy an iatrogenic treatment?), then ethical concerns are warranted - after all, just like medical doctors, therapists must first "do no harm" (APA, 2002).  Here's what we know:

• Attrition rates: If exposure therapy is so intolerable, surely almost all clients drop out of the therapy, right?  This argument is not supported by research data, meaning clients in exposure treatments do not drop out of therapy at greater rates than clients drop out of other therapies.  This has even been found in studies on prolonged exposure for post-traumatic stress disorder (Hembree et al., 2003), which many consider to be the most aversive type of exposure therapy.
• Symptom intensification: If exposure therapy is indeed harmful, then clients' symptoms should get worse after receiving the treatment, right?  Some clients (i.e., a small minority of them) may temporarily experience a heightening of symptoms; however, these clients are not at increased risk for dropout or treatment nonresponse (Foa et al., 2002).  The conclusion: the vast majority of clients will not experience a worsening of symptoms.  For the few who do, this worsening is temporary and has no relationship with overall treatment outcome.
• Patients don't like it: A wealth of studies actually show that exposure therapies are rated as acceptable and more likely to be effective by anxiety patients, parents of anxious children, and undergraduate students (e.g., Brown et al., 2007; Deacon & Abramowitz, 2005; Norton et al., 1983).  Thus, therapist perceptions that their clients won't like exposure therapy are unfounded.
• Legal concerns: This concern is two-fold: worries about the legal risk of implementing the treatment and actual risk posed by inadequate or incompetent treatment.  Olatunji et al. note that, concerning the legality of the treatment, exposure therapists are only asking their clients to feel anxiety, something the clients are doing essentially every day.  Furthermore, anxiety is a natural bodily response and, thus, not inherently dangerous.  Several searches for actual litigation involving exposure therapy have found none (Richard & Gloster, 2007).  The secondary legal concern about the actual risk of providing exposure incorrectly is more relevant.  Exposure therapy is complicated and difficult to conduct (contrary to some beliefs) and should not be attempted without proper training (doing so might be harmful and would certainly be unethical; APA, 2000).  There is a possibility for client harm and poorer treatment outcome if care to the complexities of the clients and the treatment are not considered (e.g, Sloan & Tech, 2002).

So, we know that exposure therapy is not iatrogenic...instead, it is remarkably efficacious and effective for a variety of conditions.  Still, perhaps exposure inherently involves (slightly) more risks than other strictly verbal therapies.  Olatunji et al. offer tips for minimizing risk when asking clients to interact with snakes, refrain from hand washing after touching "contaminated" objects, and purposely hyperventilating, for example.

• Informed consent: As is required for all psychotherapy, clients in exposure therapy must provide their consent prior to the initiation of treatment.  More unique to exposure therapy, client consent should be obtained before each and every exposure.  It is imperative to stress that no client in exposure therapy is forced to face any feared stimuli without agreeing to it (I've mentioned the disturbing Maury Povich clip before in which a woman with a pickle phobia is bombarded with pickles...I repeat, this is not how exposure works!).  Often clients negotiate and even design the exposure themselves, and clients can and certainly do refuse to do certain exposure tasks and are not penalized in therapy for doing so.  Exposure therapists also provide copious amounts of rationale for the treatment itself and for each exposure in general.  Thus, as Olatunji et al. point out, "exposure therapy is likely an exemplar among psychotherapies for satisfying the ethical principle of informed consent" (p. 175).
• Naturalistic comparisons: In evaluating whether or not a specific exposure task represents acceptable and minimal risk to the client, Olatunji et al. recommend considering: "Do at least some people ordinarily confront the situation/stimulus in the course of everyday life without adverse consequences?" (p. 176) I think this a very useful question...when confronting the idea of asking a client to engage in aversive situations, think about how many people don't wash their hands after using the bathroom without consequence (possible task for an OCD client), how often people ask a grocery store employee where the spice aisle is without incident (social anxiety disorder), how rigorously people exercise without having a heart attack (an exposure task for panic disorder might involve activity to increase heart rate), or how often people fly across the country without dying (specific phobia).  Of course there are times when a specific exposure task might be inappropriate for a certain client (e.g., it is not recommended to expose a client with a compromised immune system to germs) but for the vast majority of clients, exposure represents no greater risk than anything else. 
• Session management: Exposure sessions can require more time than the typical 50-minute session, so therapists should plan for this.  Exposure therapy should not be ended until the client's anxiety is reduced, and for some clients and some stimuli, this can take many hours (I have spent 2 hours with a client on one exposure task before). 
• Managing "negative" outcomes:  Although it is rare, there are times when the exposure does not go the way you plan.  Dogs bite, people have fender benders, and intentional hyperventilation causes a client to faint.  The best way to handle these outcomes is to be prepared for them.  Discuss with the client not only the probability of such outcomes but also the cost of the outcome before the exposure.  If a socially anxious client is scared to walk across the campus quad because they might trip on the sidewalk and fall on their face, prepare them for exposure by not only talking about the probability of that outcome but also the consequence of doing so.  Will tripping and falling result in complete humiliation and denigration?  Unlikely.  Of course, not all "negative" outcomes can be prepared for.  There is a small chance that a flying phobic could be in a fatal plane crash, but this risk is no greater in exposure therapy than in real life.  The remote chance of a plane crash should not prevent a client from engaging in flying exposure any more than it should prevent their therapist from flying to their son's college graduation.
• Taking therapy outside the office: Unlike other forms of therapy, it can be necessary to conduct exposure sessions outside of the therapist's office.  Some believe that this represents a clear violation of the boundary between therapist and client and can ultimately lead to the development of harmful dual relationships (a clear ethical violation in which the therapist-client relationship develops into something different, often sexual).  In reality, Olatunji et al. argue that the temporary boundary "crossings" done in a systematic and ethical manner in exposure therapy represent no great risk of developing harmful client relationships.  Furthermore, doing so is necessary in implementing some treatments in an effective manner. In order to treat a client with a driving phobia, it is necessary for both client and therapist to get into a car and drive.  Some OCD clients may modify their beliefs so that "it is ok to not wash my hands after touching things at the clinic, but not in other places."  In this instance, exposure must be conducted outside of the office.  In order to treat a home-bound agoraphobic client, it is accepted practice for the therapist to travel to the client's home.  Again, none of this is done without client consent and any boundary "crossing" should only be done when it is necessary for treatment.
  • One legitimate concern, however, in taking therapy outside the office is how to maintain client confidentiality.  First and foremost, before embarking on exposure outside of the office, confidentiality should be discussed with the client as part of the informed consent process.  If the decision is made to take the therapy out into the world, Olatunji et al. offer several suggestions on how to limit or deal with possible interactions with others.  The therapist should de-identify themselves as a healthcare worker (e.g., remove name badges) and refrain from doing any conspicuous activity that might suggest the nature of the therapist-client relationship (e.g., taking notes on a clipboard).  Running into acquaintances can sometimes be unavoidable, and the therapist & client can agree on a "cover story" to prepare for this.  Patients should be aware that they are not compelled to introduce the therapist to anyone or make any explanations.  Sessions can be done in neighborhoods where the client doesn't live or in low-traffic times.  It should be noted that many clients are not as concerned with confidentiality as the therapist is.  As long as therapists take caution to discuss these issues beforehand, the likelihood of a problem arising is low.

Thus, exposure therapies appear to be ethical and pose no great risk of harm to clients.  They are effective and efficacious and well-tolerated by clients.  Therapists with the proper training are encouraged to implement exposure therapies whenever appropriate (i.e., whenever it is an EST for a specific illness).  If you have not been trained in exposure therapies, look for training opportunities around you.  As the literature indicates, exposure therapies are not inherently cruel...and implementing them is one of the kindest thing you can do for your clients!!

Joye Anestis is doctoral candidate in clinical psychology at Florida State University.