Trusting Clients to Build Resilience as an Exposure Therapist

by Mark Burton, PhD

Clinicians learning prolonged exposure therapy often ask about the risk of secondary traumatization. In response to this concern—that listening to details of trauma could lead to distress for the therapist—I encourage clinicians to seek consultation and work within a supportive team. I also encourage clinicians to think hard about whether this work is right for them, as it can be difficult. But most of all, I remind clinicians that as your clients learn to handle it, so will you. This is the basic premise of prolonged exposure, that repeatedly confronting the feared experience in a supportive environment, will take the power of that fear away as the person learns they are safe and capable.

Despite decades of clinical research showing that prolonged exposure is very helpful for a broad range of people and clinical presentations, many clinicians are hesitant to discuss trauma due to fears that clients will “destabilize.” The term “trauma” itself has become synonymous with pathology and “treating trauma” often involves avoiding the topic altogether. This is the wrong approach to PTSD, a disorder of avoidance that will take advantage of any messaging from clinicians, whether explicit or implicit, that discussing trauma could be harmful.

Effective delivery of exposure may also be impacted in more subtle ways. For example, it is a common belief that exposure can be helpful but only when clients are provided emotional regulation strategies to better tolerate the exposure. A therapist may, for example, suggest to a client that they do their exposure while slowing their breathing to relax or holding an ice cube to distract.

While these suggestions are well intentioned, they actually run counter to the core principle of exposure, which is that trying to avoid your own distress makes it worse. In the exposure world, we term this “colluding with avoidance” and we acknowledge that as therapists, it’s very easy to fall into this trap. Its difficult to watch our clients in distress, but we also know that avoidance is a trick. It feels good in the short term but actually prolongs distress in the long term. Whether you are a spouse accommodating unhelpful isolation habits by running all the errands for your hypervigilant partner, or a therapist offering a self-soothing strategy to get your client through an exposure exercise, the effect is the same. You are preventing an opportunity for someone to learn they can handle their own mind.

Exposure therapy works well and is safe. We have decades of clinical trial research demonstrating this fact. But only by practicing exposure therapy fully and without avoidance, will you be able to see the profound impact it can have for your clients and build your confidence and skills as a therapist. To bear witness to suffering and help our clients to the other side is the duty and privilege of every therapist. This can be grueling work but we can look to our clients and their resilience as inspiration. Hearing a client tell their trauma narrative without fear at the end of a course of PE, fills me with profound gratitude and hope to refuel my tank as a therapist. But to get there, I have to stay the course and engage without fear myself. The trainers at MBBI are extremely passionate about helping clinicians learn and gain confidence in evidence-based, effective therapies like exposure. Join one of our CE course offerings or reach out for consultation to energize your clinical practice by helping your clients make lasting change.