In a special issue of Behavior Therapy on “The Theory-Practice Gap in Cognitive Behavior Therapy,” Jonathan Abramowitz, PhD, authored an interesting paper on the importance of understanding theory when doing exposure therapy. Dr. Abramowitz is a well-respected OCD researcher, and I was attracted to this article as part of my ongoing interest in exposure therapy.
The article is lucid, well-written, and I think would be of value to anyone beginning to work with exposure therapy. He offers anecdotes about where therapists go wrong and makes a good argument for why understanding theory enhances exposure therapy. Dr. Abramowitz writes from a strictly cognitive behavior perspective, so this work does not cover exposure in Acceptance and Commitment Therapy, something I’ve been writing about; however, he does cover the controversy with the emotional processing theory and why habituation is not a good marker of learning.
The point that struck me most in this piece is the importance of being able to convey to the client why exposure is important. This is something that has been increasingly apparent to me—in particular, in working with people with OCD—but which I had not quite put the words to. When you’re asking someone to do scary things, it’s vital for people to understand the reasons. More importantly, understanding the theory behind exposure helps clients to become exceptional collaborators, in my experience.
Recently, I was working with a client with OCD in coming up with a particular exposure for her harm-related obsessions. Without any prompting from me, she anticipated a likely safety behavior (e.g., looking behind her to see if she had inadvertently hurt someone) that she predicted she would need to deliberately block. I was so focused on designing the exposure that I hadn’t even thought to ask about safety behaviors until she brought it up. She could not have done so if she hadn’t understood the theory behind what we were doing. I had another client create and implement his own exposure exercise that was right on when something unexpected came up between sessions! Understanding theory is especially helpful for clients engaging in spontaneous exposure when appropriate situations come up.
Because the article is straightforward and engagingly written, there’s no point in offering a summary here. If you’re interested in reading it for yourself, I found a free pdf available here.