Exposure therapy is a type of behavioural therapy, designed to treat many psychological disorders associated with anxiety. It helps patients engage in repeated and prolonged contact with feared stimuli to overcome the anxiety associated with it (Abramowitz, Deacon & Whiteside, 2012). The therapy dates to the 1900’s, where Ivan Pavlov (1959) discovered that behaviour could be changed via classical conditioning. Mary Cover Jones (1924) then used this conditioning method to successfully help a client overcome his fear of rabbits. From this, Joseph Wolpe (1958) developed systematic desensitisation, a type of exposure therapy in which people use relaxation methods to cope with anxiety. Exposure-based therapies have since expanded to treat various psychological disorders such as Obessive-Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD), social anxiety, phobias and even problems with strong anxiety components such as hypochondriasis (Taylor ; Asmundson, 2004). The method has proven to be very effective (Deacon ; Abramowitz, 2004), as some patients with acrophobia had tolerated decades of anxiety and were successfully treated in less than three hours using exposure-based therapy (Williams, Turner ; Peer, 1985).
Despite empirical support for its effectiveness, exposure-based therapies are not a popular method of choice in the field of psychotherapy (Richard ; Gloster, 2007). There are many negative beliefs about the treatment, and these beliefs are held primarily by practitioners (Prochaska ; Norcross, 1999). They feel that the therapy is rigid and insensitive to the individual needs of the patient, as it is unsuccessful for complex cases (Olatunji, Deacon ; Abramowitz, 2009). Practitioners treating individuals with PTSD confirm such beliefs, and feel the techniques are done to the individual rather than with them (Becker, Zayfert ; Anderson, 2004). Furthermore, the effects found in research settings do not generalise to the real-world clinical settings (Feeney, Hembree ; Zoellner, 2003). These negative perceptions seem to influence public opinion, whereby exposure treatments are deemed unhelpful, unacceptable and unethical (Richard ; Gloster, 2007). The media has also claimed that exposure is torture, as patients cannot tolerate the adrenaline-based approach (Slater, 2003). These views appear to stem from the fact that exposure techniques intentionally evoke anxiety rather than soothe it (Olatunji, Deacon ; Abramowitz, 2009). However, the views of practitioners do not seem to mirror those of patients who have undergone treatment. Anxiety patients perceive exposure-based therapies as a more acceptable and effective therapy in the long-term (Deacon ; Abramowitz, 2005; Norton, Allen ; Hilton, 1983). Even if exposure is less likeable, it is still perceived as highly useful, particularly when treating panic disorders (Cox, Fergus ; Swinson, 1994). The central objection to exposure-based treatments is comprised of the ethical concerns regarding how safe, tolerable and humane exposure therapies truly are (Olatunji, Deacon ; Abramowitz, 2009). The ethical challenges which have been, and continue to be, facing the utilisation of exposure-based therapies refer primarily to the ethical principles of potential harm, informed consent, confidentiality and crossing boundaries. As mandatory ethical principles of the American Psychological Association (2002), these issues must be addressed for exposure-based therapy to be accepted as a morally correct and effective treatment.
Psychologists must do no harm and safeguard the welfare and rights of their patients, as well as take reasonable steps to avoid harming patients/clients, and minimise harm where it is foreseeable and unavoidable (American Psychological Association, 2002). Exposure therapy violates these guidelines to an extent, as therapists evoke anxiety as a means of overcoming it, which is psychologically harming. The safety of exposure therapy can be determined by evaluating risks beforehand and examining outcomes such as attrition rates and symptom exacerbation.
Many would assume that if the treatment is intolerable, attrition rates would be high (Leahy, 2007). Prolonged exposure for PTSD patients is often considered the most aversive application of exposure as patients deliberately recall traumatic events (Olatunji, Deacon ; Abramowitz, 2009), yet there are no differences in dropout rates for this therapy in comparison to exposure with cognitive therapy, anxiety management or eye movement desensitisation and reprocessing (Hembree, Foa, Dorfan, Street, Kowalski ; Tu, 2003). Motivation to begin treatment can also be a problem for therapists, which is understandable given the anxiety-provoking nature of exposure therapy (Abramowitz, 2006). Therefore, therapists should use readiness programmes for patients to discuss treatment with former patients, helping to increase compliance with treatment. They should also provide a clear rationale with detailed explanations of participation requirements to increase adherence during therapy (Olatunji, Deacon ; Abramowitz, 2009).
Even though exposure therapy holds the potential to exacerbate symptoms, studies demonstrate that many do not experience worsening of symptoms, and some only experience temporary exacerbation (Foa, Zoellner, Feeny, Hembree ; Alvarez-Conrad, 2002). Patients may be less intimidated by the idea of heightened anxiety as it is a temporary exacerbation of emotions which are already familiar and long-standing (Richard ; Gloster, 2007). Exposure also provokes a natural defence mechanism of a fight or flight response. Therefore, exposure therapy seems to hold little risk of harming patients further, and appears more safe and tolerable than opinions suggest.
Regardless of whether the therapy causes or has the potential to cause harm, patients should still be informed that exposure is likely to provoke temporary distress (Foa et al., 2002). Therapists need to evaluate the risks involved before beginning the intervention. In comparison to other forms of psychotherapy, exposure therapy seems to place patients at a greater risk of harm during situations where patients handle phobic objects. However, these exercises usually involve low level risks, when conducted properly. The therapists need to ask at which point is the risk unacceptable and how the possibility of harm can be minimised. For instance, an inadvisable treatment would be exposing germs to a patient with a compromised immune system. To evaluate whether the risk is acceptable, therapists should consider if, by doing the exercise, patients are at a significantly higher risk of harm than others who face the same stimuli in everyday life without consequence.
Exposure-based therapies have the potential to cause harm if the session is terminated before habituation of the anxiety has occurred. If this happens, patients can suffer from worsening anxiety and a sense of demoralisation, which ultimately leads to doubts about the effectiveness of therapy (Lilienfeld, 2007). By using session management, therapists can account for such individual variations in habituation times. Firstly, longer sessions could be scheduled, but the therapists could also frame exposures, treating behaviour as hypotheses to test (Gola, Beidas, Antinoro-Burke, Kratz ; Fingerhut, 2016). In this format, patients can view the event as a valuable learning experience even if they fail to habituate. There is always the possibility that exposure-based treatment sessions do not proceed as planned by the therapist, and not all possible outcomes can be anticipated. Therefore, there is no absolute guarantee of safety during exposure tasks. Patients must be made aware of this before consenting to treatment.
Informed consent is likewise a mandatory requirement. It is critical for the evaluation of perceived harmfulness and decreasing the probability of harm. Treatment should be described in advance by the therapist, and agreed to by the patient before beginning the process (Abramowitz, 2006). Patients should also be aware that they are free to negotiate or revoke consent during the session. With regards to potential harm, patients should be told that even if the treatment is successful, there may still be negative feelings of experiences. Informed consent provides patients with the opportunity to distinguish exposure as a form of therapy rather than “torture” (Slater, 2003), as they will be aware of the procedure and emotional side effects. Providing that the therapist conducts the intervention properly, exposure-based therapies satisfy the ethical principle of informed consent.
When exposure therapy sessions extend to situations outside of the clinical setting, the intervention defies many ethical principles. Practitioners face an ethical dilemma when maintaining the boundary for therapist-patient relationships, particularly during in-vivo, flooding and imaginal exposures (Richard ; Gloster, 2007). Some cases require the practitioners to explore situations which match the patient’s fear. For instance, home-based exposure therapy may need to be used for patients with social anxiety, but the boundaries for therapist-patient relationships become uncertain in doing so. Temporarily crossing boundaries does not necessarily lead to violations (Zur, 2001; Zur, 2007), but it does increase the chance of violations occurring (Lazarus, 1998). Practitioners should therefore envision the best and worst outcomes by crossing the boundary or not crossing the boundary (Pope & Keith-Spiegel, 2008). By using this cost-benefit analysis, the overall value of boundary crossing could be established before beginning treatment. Ultimately, for exposure to be optimally effective, it should be conducted under the supervision of a therapist and in various contexts (Power, Smits, Leyro & Otto, 2007). Therapists are however required to attend training sessions where they are taught how to cross boundaries temporarily and ethically, for helping a patient through an exposure task (Olatunji, Deacon & Abramowitz, 2009).
A major issue which arises after crossing boundaries is the maintenance of confidentiality (Gottlieb, 1993). This is a core ethical principle for clinicians. By limiting therapy to the office, it helps to maintain confidentiality rights of patients, but this may not always be the best environment for exposure to be optimally effective. Interventions outside of the office may result in others becoming aware of the relationship between patients and therapists, without patients consenting to this occurrence. Therapists should discuss this concern with patients during the informed consent phase, as consent would then be consistent for the entire intervention not just the preparation for exposure therapy. There are many strategies therapists can use to deal with confidentiality risks outside of the clinical setting. The therapist could firstly de-identify themselves as a health professional, removing their staff badge, coat, tie, etc. They could further refrain from actions which could demonstrate the nature of the relationship between themselves and the patient, such as note taking. Alternatively, the therapist could construct a cover story with the patient, and use this during situations with acquaintances of the patients. The exposure intervention could also take place in a different town or during times where less people are present. Despite the various precautions, there is no guarantee that confidentiality can be completely maintained, and so patients need to be aware of this from the onset. By strictly obeying the boundaries, negative consequences could arise if the intervention bypasses the patient’s best interests (Lazarus, 1994; 2007). Having relaxed boundaries could essentially help the patient to progress, as a collaborative working relationship is essential for helping patients face fears during exposure. Therapists do not always have to be remote or inflexible, but must remain professional whether in the clinical or real-world environment.