Oppressive Practice and the Risks of Exposure Therapy

by Jessica Goodnight, PhD

This week, a colleague came to me expressing concern about something she’d been taught in a training. “You can’t do exposure therapy wrong. It just works,” she was told. I’d like to start by saying, if you ever encounter someone telling you that some form of psychotherapy CAN’T be done wrong, you’re looking at a giant red flag.

Yes, no matter how powerful the person is who said it. In fact, an especially high level of power itself might add another red flag to the mix.

I’ve got to talk about why this statement is dead wrong and dangerous - but is also common, reflecting a broad issue in structures of power and how they impact the healing professions.

For those unfamiliar with exposure therapy, allow me to offer a primer. When people develop a fear response that gets in the way of something important to them, they would often like to change this. Luckily, our field knows a thing or two about fears and how to treat them. Exposure therapy, in particular, works well for most.

Say a person has a lifelong fear of driving they would finally like to tackle after moving to a car-dependent neighborhood. They hear that exposure therapy helps, so they find themselves an exposure therapist and bravely start this process.

A competent therapist would first work to understand the client and their fear well enough to be able to answer the question, “What does this client need to learn, experientially, to feel safe driving a car?”

Then, the therapist’s job is to help the client 1) encounter experiences that teach this lesson and 2) learn from them. Rather than the typical therapy experience of sitting together in a room discussing the fear, exposures are active, experiential exercises that might involve leaving the office together in order to encounter a feared situation.

A typical early exposure might be the therapist and client sitting together in a car with the engine off, working through the feelings that show up when the client even imagines turning it on. When this exercise becomes easy, a future session might involve simply turning the car off, then off again until it evokes little fear. Exposure therapy continues like this, involving increasingly challenging exercises, until the client feels safe and capable driving anywhere they’d like to go.

I have to say, it is so very cool to do this work with people. Exposure can be tremendously liberating in a very short span of time, and it’s an honor to walk people through it to the other side.

Exposure therapy can also be disastrous, both in the practicalities of its application, and in the relational dynamic that must be navigated, particularly when the fears are complex.

A driving fear, for example, is not always just a driving fear. If I make an error in assessing a client’s level of driving skill, they could do great harm on the road. If driving fears are “about” some other, more complicated fear, like a fear of independence, driving exercises might completely miss the mark. If someone is working to overcome a fear primarily because they see themselves as fundamentally broken and unworthy because of it, the therapy might inadvertently perpetuate the very patterns that keep a client stuck more generally in life. These are mistakes even a competent, well-meaning exposure therapist might make.

Any therapy can do harm, but exposure uniquely breaks the boundaries of the typical protective therapeutic frame. To help clients truly encounter their fears with my assistance, it is often necessary. I have made home visits, coached clients with OCD through exposures while they were showering, and asked clients to bring knives to a session to work on fears of being near sharp objects. Impeccable training in maintaining a professional relationship is even more essential when we are doing exposure therapy.

Imagine this tool in the wrong hands.

Because as much as I so deeply wish it was not true, there are people operating in the helping professions who have no business doing this work. Yes, most of us are operating with deep care and ethically grounded practice. But stories of therapy harm are unfortunately common in our work, from mundane instances of malpractice to horrific stories of abuse.

If the "wrong hands" have been taught that they can't get this treatment wrong, who might they blame if and when it does go wrong? Where is a client to go if the therapy that was supposed to help them with a deeply painful struggle only deepens the wound?

How is it that any psychotherapy trainer can get away with saying such an alarming, easily falsified claim as "you can't get (treatment X) wrong"?

Because many of the most powerful figures inside the healing professions, as is typical of those who seek power, are not operating from a place of curiosity and altruism.

They want you to submit to their dominance. They want you to agree that their perspective is infallible.

What horrifies me is that these are folks who have turned the noble principles of the scientific method, which is meant to be inherently humble and curious, and turned them into a method of control. Science is meant to be a candle in the dark. It is meant to offer a method of careful exploration of our world that seeks to clear biases from our quest for truth. Science never makes permanent conclusions. Scientists always assume that tomorrow, someone might find a better answer.

Scientific dogma is the place where the truth of "exposure probably works for most" turns into "exposure works for all and cannot go wrong." This dogma is the opposite of science. It is heresy against the scientific method.

Exposure is not a miracle, nor is it inherently toxic. It is simply a powerful tool. And like any effective tool, it can be used to liberate, or it can be used to oppress. As philosopher Gilles Deleuze said in A Thousand Plateaus, “A concept is a brick. It can be used to build a courthouse of reason. Or it can be thrown through the window.”

When a trainer teaches that a tool "cannot be done wrong," they aren't just selling a technique. They are spreading a narrative that strips the clinician of critical thought, strips the client of their agency, and hands the practitioner an instrument of compliance while granting them immunity from the consequences.

I believe that every therapist who works with any form of anxiety in their practice, regardless of their theoretical orientation, would benefit from solid training in exposure-based therapies. The frame is exactly what many clients need to be able to gain freedom and mastery in their daily lives.

I also believe every healing professional carries a lifelong responsibility to be on the lookout for the insidious nature of oppressive practice. No model is immune. Not even yours.