Clinician's Corner - Exposure & Response Prevention

I was fortunate to acquire an academic job directly out of my pre-doctoral internship. However, the downside of this was that opportunities to apply my clinical skills were largely nonexistent, and acquiring the required 1500 hours of postdoctoral licensure hours was a daunting task while embarking on the tenure track. While I had always found academia fulfilling, after two years focusing solely on teaching and research, a level of monotony began to appear, and the lack of opportunities to work with clients began to frustrate me. Not to mention, I dreaded the prospect of having to repeat the same stories from my past clinical work to my students for the next 50 years if something did not change. Accordingly, despite the challenge and risk of adding a new responsibility to an already full workload, I decided to take on a part-time clinical position to complete my licensure hours. Looking back, this was one of the best decisions I have ever made, and the following case exemplifies why I will always have one foot in the clinic.

One of the aspects of clinical practice that I always admired is the variety of challenges, twists, and turns it brings. Even the most seemingly “simple” cases always seem to offer a wealth of complexity, opportunities for creativity and problem solving, as well as the ability to put science to practice. Needless to say, “monotonous” is never a descriptor I would use for clinical practice. This brings me to the case of “Jerry.”

Due to my behavior therapy training and experience, I received a referral to treat Jerry, a college student who was seeking treatment for an unspecified phobia. The referring psychologist contacted me and informed me that Jerry would benefit from exposure and response prevention (ERP) therapy, but cautioned me that his phobia was “unique” and that he was very reluctant and embarrassed to discuss it. Given my experience, I had my initial assumptions of what this phobia could possibly be. Never in a million years would I have guessed that his phobia involved an intense fear of makeup and cosmetics. More specifically, Jerry had an intense fear response to the sight of makeup. Even the discussion of makeup, or seeing someone casually apply makeup, caused him to feel uncomfortable, nauseous, and panicked. Worse yet, “unnatural,” unexpected, or heavy applications of makeup made him faint—often in social situations. Jerry did not know how or why he had these fears, but his difficulties existed as he could remember.

Thankfully, there is an intervention that can be applied to an infinite number of situations—behavior therapy. I love behavior therapy for its simplicity. Clinical “wisdom” or “insight” is not necessary. In my experience, the most simple and straightforward approaches are often the most successful. We can address the problem as well as make immediate progress without necessarily knowing its origins. Further, behavior therapy is a treatment that is idiographic, and can be uniquely applied to the client’s specific concerns. Moreover, behavior therapy, particularly ERP, is an active treatment that allows one to step outside the walls of the clinic and engage in creative interventions in nearly any environment. I particularly appreciate ERP’s logical and straightforward rationale: exposing one to feared stimuli and situations allows one to habituate to them and unlearn the threatening associations. Best of all, behavior therapy allows a client to take their life back, and ERP is one of the few treatments I feel confident informing the client that, if they complete it, they will get better.

While initially nervous about the intervention, Jerry recognized the opportunity to overcome his phobia and bought in. Our work began in a straightforward manner (e.g., thoroughly discussing his phobia, tracking behavior, creating a fear hierarchy). I was excited to have an opportunity to identify creative exposure exercises to target each level of the hierarchy. However, just as treatment was about to commence, the COVID-19 pandemic escalated, forcing us to move to telehealth. It was back to the drawing board. While I had my initial doubts regarding how we would successfully continue treatment via telehealth, I was motivated by the challenge and it was another opportunity to creatively address my client’s concerns.

Thankfully, Zoom actually happened to be an incredible asset for our work together. Having been previously forced on to Zoom to teach my classes, I was familiar with its capabilities and saw its potential as a stimulus delivery mechanism. Borrowing again from my teaching experience, I put together PowerPoint slide shows of images involving makeup, each photo increasing in intensity. It was successful. At the start, even the most seemingly benign images of makeup elicited a strong fear response from Jerry. However, he was determined, and pushed on. Our work expanded into slideshows targeting specific aspects of his phobia (e.g., makeup application around eyes, extreme unnatural-looking makeup, mortuary makeup). This then advanced to using Zoom to show YouTube makeup application videos, and then eventually, live demonstrations of me applying makeup to my face (which led to many humorous, frantic attempts to remove it before the start of my next class).

Jerry continued to make progress, habituating to more and more intense stimuli. Before long, he had reached the point where he had the courage to go to the store and purchase makeup items himself. Over several sessions, Jerry slowly gained comfort applying makeup to himself—first a dot of eyeliner on his hand, slowly working up to him applying makeup to his face, and eventually, around his eyes. Perhaps the most significant moment was when we began exposures involving nail polish. Mirroring our previous work, we worked up to where he was able to apply the polish to his fingernails, and sit with the anxiety. Beaming with pride and confidence that he overcame an obstacle that he once thought was insurmountable, Jerry went from being incapable of having and seeing the polish on his fingernails, to tolerating it, to eventually embracing it.

To Jerry, being able to wear the nail polish became a symbol of overcoming, a recognition that, if he could triumph over this lifelong fear that negatively affected nearly every domain of his life, he could take on anything. Jerry now confidently wears nail polish on at least one of his fingernails every day. When people ask him about it, Jerry proudly shares his success story of overcoming his fears. He is no longer ashamed and embarrassed about his struggles. Rather, he more confident in social settings and now shares his story to inspire others.  

When our clinic reopened, we continued our exposure work together in-person. Jerry has continued to make strides. While there is much more work to go, the impairment Jerry experiences from his phobia has decreased significantly. He no longer avoids social situations where makeup might be present, nor does he fear having panic attacks or fainting.

Cases like Jerry’s highlight what I admire about clinical practice, and what I missed most when I was away from it. It is a privilege to work with Jerry and several other incredible clients, and I am grateful to have a career where I have opportunities to teach, research, and now, practice.


The Clinician Corner is a new monthly feature of the Iowa Psychological Association Blog where we highlight a therapeutic tool, intervention, or style of therapy that has been useful in the therapy room. Please consider contributing so that we all might continue to learn from one another. If you are interested in contributing, contact the blog editor here

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Comments on "Clinician's Corner - Exposure & Response Prevention"

Comments 0-5 of 2

Scott Young - Tuesday, May 25, 2021

I feel very fortunate to have learned so much through this client, and you're expertise in ERP. Thank you for the learning opportunity Dr. Lengel. - Scott.

Valerie Keffala - Monday, April 19, 2021

What a powerful story, Dr. Lengel! It sounds like you really made a difference for Jerry. Thank you for sharing! Valerie

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