An Underdeveloped Ingredient in Exposure Therapy
Every summer since 2008, myself, Dr. Travis Osborne, and Dr. Neil Kirkpatrick have facilitated a 3-day camp for teens or adults with Obsessive Compulsive Disorder (OCD). Eight campers and four staff spend the weekend participating in ropes course activities, hiking, and sitting around a campfire eating and talking, sleeping in tents and helping with camp-style cooking. After mealtime we do what we call “group exposures” where each camper gets a turn, if they want, to do an exposure for their specific OCD fear with the support of the group cheering them on. These “exposures on steroids” are an important part of the program, however, every summer a debate reignites amongst staff about what exactly “works” about our camp.
The data supporting that camp is useful for our campers is by now nearly irrefutable – our campers reassure us each year, both with spoken feedback and written data collection, that the camp is a powerful, insightful, and transformative experience. Our curiosity about what facets make the program work stirs up many questions: Is it that we do exposure therapy roughly seven times during the three days? Is it the outdoor environment and adventure-oriented activity base (ropes course, camping and hiking)? Or is it the relationships that are quickly formed between campers and staff and what we do with those relationships?
My curiosity about the curative elements of human connection led me to contemporary psychoanalytic theory, which ironically and unfortunately has been cast aside by much of the cognitive behavioral and exposure theory. As I took interest in psychoanalysis, I quickly recognized that where exposure therapy focused on learning theory and the human capacity to be behaviorally trained, psychoanalysis considered the many complex dynamics of human connection.
Somewhere in the middle of two poles between contemporary psychoanalytic and behavioral theory lies the heart of curative action for many struggling with anxiety.
There is no lack of literature focusing on behavioral and learning theory, and the critical impact these theories can have for informing effective treatment of various forms of anxiety, including OCD. However, it is in the crossroads, the intersection between psychoanalytic and behavioral theory that an underdeveloped idea exists. Human connection might for now be the most concise descriptor of the essence of what I mean by an unformulated curative action which needs to be more fully understood and valued in order for therapists to provide opportunity for lasting, useful change. Many therapists approach exposure in a caring way, meaning they have good intentions, want to be useful and helpful, and are empathic about their client’s struggle with anxiety. Although these attributes are part of a foundational stance therapists of all kinds commonly agree upon, it is the relationship itself, and more specifically the loving aspects of that relationship, which will go the distance in curative change. Behavioral theory is crucial, like the booster rocket propelling through and beyond gravity, but it is the therapeutic relationship and human connection that ultimately carries curative change forward unbounded.
Looking through exposure therapy clinical manuals, one has to squint hard to find mention of relationship between client and therapist. Tacitly understated, a brief note acknowledges a need to form an empathetic therapeutic alliance before exposure work can effectively begin. As therapists, empathetic therapeutic stance is a given so much so that not more than a passing mention needs to be taken up on the subject – better to get to the nuts and bolts of how to conduct good exposure therapy since behavioral change is what is most salient and useful, says the manual. The goal defined in the manuals, after all, is for sufferers to live a fuller more functional and satisfying life, by means of symptom reduction. Something more can be attained in therapy for individuals suffering from anxiety or OCD beyond crossing off a list of intolerable symptoms and contemporary psychoanalytic theory can provide a platform for filling in the blanks.
Contemporary psychoanalytic theory can help frame why it is that relationship can be the golden nugget, the under-recognized ingredient in anxiety management. We must first consider the connection between anxiety and human relationships.
Anxiety is an experience we all know and have known since birth. Lucky for us as newborns we are not alone, and the loving comfort of the mother not only keeps us alive physically and mentally but begins a dynamic life-long process of receiving soothing from another, while simultaneously teaching us to soothe ourselves. As we develop through life friends appear as surrogate soothers, and for some, life partners carry the torch of caring reassurance until death. Human relationship is a part of the antidote for anxiety, and the therapy relationship is an opportunity to capitalize on this curative element.
A lot has evolved in the past 120 years since Freud began developing psychoanalysis. Contemporary psychoanalytic theory is largely the study of dynamics of relationships of two different types; relations between people and relations between different parts of oneself, and the interplay of all of these different “selves”. The vibrant debate about salient factors within these relationships continues today, however, the two elements I believe are easily accessible without having to dive into a significant body of psychoanalytic theory are empathy and understanding.
In the 1950s a prominent psychoanalyst, Heinz Kohut, sparked a paradigm shift within the world of psychoanalysis as well as within all mental health theory; empathy is important. It is almost inconceivable today to imagine not holding this axiom as truth. Kohut was an outlier, departing from “traditional” psychoanalytic thinkers following in Freud’s footsteps who felt that inborn “drives” explained why humans think, feel and act the way they do. Kohut took great pains to elaborate that simply adopting an empathetic stance conjured therapeutic gains, but that empathy was a tool of understanding; a muscle that could be built which allowed the therapist access to getting closer to the client’s experience of living, and through this deeper knowing and uncovering, tolerance for human pain and suffering could be enhanced.
Again, many behavior therapists may pause here with the sentiment of these ideas as given, with no real need to elaborate a known truth. However “being nice” as a therapeutic stance drastically undercuts the potential of therapeutic gain.
This brief article is only an abstract of sorts, a starting point meant to provoke curiosity around the power and influence of human connection when managing anxiety.
At our OCD camp, we still facilitate exposure therapy, appreciating the exceptional impact behavioral change can have on an individual’s capacity to move more freely throughout life. What needs to develop is what happens at all of the other moments, that seem natural or inevitable, where campers experience a curiosity and caring from others that quietly heals.
Here I underscore the moments where a group of similarly-experienced people carefully listen to each other’s stories, and the catharsis the ensues by means of feeling heard and known in a profound and often life-changing way. We need to examine what happens in these moments of feeling known and apply our learning to exposure therapy, progressing a treatment strategy that already has achieved so much, but can stand to continue evolving.