Is Exposure Therapy Ethical?
A young man sits across from me in my office. He is so nervous he can hardly breathe. I can tell that he is strongly considering standing up and walking out of my office, determined to never tell anyone about the thoughts in his head, but he also knows that he’s tried that for too long and has to try something new to make the suffering stop.
“I would never hurt anyone, especially a child” he starts, discussing how just a few months ago he enjoyed playing with his niece and nephew more than anything else in the world. “But then I started thinking, what if I could hurt them. What if I wanted to hurt them? What kind of person would put their family at risk like that?” The man had done research on exposure and response prevention (ERP) therapy but had serious reservations, “How could you do exposures to this? I would never put myself in the position of hurting anyone!”
This man is worried about ethically being able to do ERP for OCD. When faced with this dilemma I remind myself of one of the traps that OCD uses to get people hooked: It is unlikely that something bad would happen, but the bad thing is so important that it cannot be risked. This question leads people to take unnecessary precaution; for this man it meant not seeing his family in months. And these precautions only reinforce the OCD.
If we believe that OCD has set this trap, the typical ERP approach of tolerating the uncertainty that something bad will happen may not be maximally helpful. Instead, ERP should focus on living a valued life complete with risks that terrible things may occur. That is not unethical, that is the same risk we all take every day. We risk it when we are in cars, in public, and using any restroom. And we should not treat an OCD concern differently than we treat “normal” daily risk taking. If we look at ERP from this perspective it is not unethical to allow normal daily risk, instead it is more unethical to allow someone with OCD to continue to suffer!
As a therapist specializing in ERP for OCD and other anxiety disorders, I believe that our brains lie to us sometimes. This young man knows that he does not want to harm anyone but has been tricked into thinking that he has to protect himself and others anyway! If we believe that OCD is a trick, we should not wait out the uncertainty, we should call its’ bluff. Exposure therapy should focus on enjoying time with family and allowing the ever-present risk of harm to be present. Can we allow unwanted thoughts and have fun with family? Can we treat thoughts as thoughts instead of truths? If we can, people can find relief from OCD in a meaningful way without pushing perceived ethical boundaries!
If you would like more information about ERP for OCD, please reach out to me or another mental health provider!