Student Notebook: Learning Through Exposure

Over the last several months, have you continually feared that you might contract a serious physical disease or illness?” The patient stared at me incredulously and I stared back, confused. Then it hit me. “Other than COVID,” I added. I was on Zoom administering my first-ever diagnostic interview, kicking myself for making such a silly error. Of course this standard screening question for illness anxiety disorder sounded absurd during a pandemic. My frustration with myself quickly morphed into frustration with the situation—I was completing this difficult work over Zoom, feeling isolated and underprepared while crammed in a corner of my apartment that was masquerading as an office.  

From that corner, I’ve trained virtually with two clinics that specialize in treating obsessive-compulsive and anxiety-related disorders with cognitive-behavioral therapy (CBT). A core tenet of CBT is exposure: asking patients to confront the precise thing they would most like to avoid. In short, exposure is doing something very difficult in the short term in order to improve our lives in the long term. The basic principles of exposure extend beyond the psychotherapy room, and I frequently like to apply what I’ve learned about exposure to challenges in my daily life. It’s never been more relevant, however, than during clinical training this past year.  

By considering how reality contrasts with our original fears, we can process the meaningful progress we have made.

I’ve come to see training to be a psychotherapist during COVID-19 as an excellent opportunity to practice exposure: doing something hard now that leads to solid, meaningful learning for the future. We can borrow from the field’s knowledge of exposures to approach the deeply challenging experience of remote training in a way that maximizes our learning. 

Embrace pushing beyond the norm. A good exposure often means pushing past what would be considered normal in daily life (Gillihan et al., 2012). We ask patients to learn that they can handle something extreme so that quotidian events don’t phase them. For example, we may ask a patient with contamination OCD to touch a public toilet and then not wash their hands. We do so not because we want them to move through life caressing toilets, but because after that exposure touching a doorknob seems easy. Training during the pandemic follows this same pattern—it is doing something harder than the norm, which in turn provides us with an opportunity to learn that we can handle challenging clinical circumstances (and perhaps even enjoy them). If I can connect with a patient hundreds of miles away over a screen, surely I can connect with them when we’re sitting in the same room. If you can help a patient with contamination-based OCD when the entire world is obsessively washing their hands, certainly you can treat OCD in a world that is no longer saturated with pandemic precautions. Because what we are pushing ourselves to do now is beyond the norm, it provides us with the opportunity to broaden our clinical skill set beyond its typical boundaries.   

Track expectancy violations. One of the most powerful cognitive tools during exposures is expectancy violation–highlighting the difference between what the patient expected would happen and what actually happened (Craske et al., 2014). What was the worst-case scenario you feared? Did it come true? If it did, was it as bad as you thought it would be? Noticing discrepancies in these domains solidifies new learning and highlights how anxiety may lead us astray. Although these contrasts can be straightforward in a 50-minute exposure, they are easy to miss when the object of our anxiety is our own slow-moving development. Consider thinking back to the fears that populated your mind when training first went remote and challenge yourself to notice how your expectations may have been violated. For example, did you worry that you would not be able to build a strong alliance over Zoom, and instead found that you’ve had multiple successful therapeutic relationships? Alternatively, have you watched a patient progress clinically despite your therapeutic alliance being mediated by a computer screen? By considering how reality contrasts with our original fears, we can process the meaningful progress we have made. 

Resist excessive reassurance. Particularly when things do not go as planned, it is extremely tempting to gain short term relief by cheerleading ourselves into certainty. You will be just as effective of a clinician over Zoom as you would be in person! This pandemic won’t interfere in your training at all—you’ve got this! As we know from the exposure literature (and intuition), removing all doubt and fear only sets us up for failure (Gillian et al., 2012). Unabashed positive thinking denies reality and reinforces the false idea that errors are intolerable, whereas uncertainty leads to growth. We wouldn’t reassure our socially anxious patient that other people like them, so let’s not reassure ourselves that training during COVID will be perfect. Rather, we can accept that this period of our clinical training will likely be replete with disappointments and errors, and then lean into this uncertainty and grow more because of it.  

Celebrate successes. To my knowledge, celebrating the successful completion of an exposure is not a formal component of any treatment manual. However, it is far and away my favorite part of this work. There is something wonderfully earnest about the pride one generates after pushing through a challenging exposure, and this pride undoubtedly fortifies a person’s ability to move forward with an exposure plan. As a clinician, it is immensely satisfying and moving to see my patients experience that feeling, and I cannot imagine a successful exposure occurring without it.  To this end, let’s afford ourselves room for that same pride by acknowledging that training to be a psychotherapist is difficult, and that doing this training remotely is even more so. Though we cannot and should not deny the frustration and isolation we have all felt in our respective apartment corners, challenging ourselves in the short-term will undoubtedly help us, and the patients we aim to serve, in the long-term. This is worth celebrating.

References 

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006 

Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common pitfalls in exposure and response prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 251–257. https://doi.org/10.1016/j.jocrd.2012.05.002 

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