Ethical Considerations of Exposure Therapy

Promoting Empirically-Supported Treatments and Dissemination of Research

Jill Davidson, Psy.D.

Empirically-supported treatments are underutilized in clinical practice despite clear and well established efficacy (whether treatment works) and effectiveness (whether it works in everyday practice). These empirically-supported treatments, such as exposure therapy for anxiety disorders in which patients are asked to deliberately face their fears, are the “gold standard” for various psychopathologies. Anxiety disorders comprise the most common mental categories in the United States and cost an estimated $42.3 billion annually, which represents one-third of the country’s total mental health bill of $148 billion per year (Greenberg et al., 1999). Without effective treatment, anxiety disorders have a chronic, often unremitting and worsening course. As such, effective, efficient, and efficacious treatment is of the highest importance, yet despite the abundance of evidence, empirical support and expert consensus guidelines identifying exposure as the gold standard care for individuals with anxiety, exposure remains underutilized leaving many patients undertreated according to the standards of care (Waller, 2009).

Why don’t more practitioners utilize this treatment modality when the benefits have been proven? If practitioners believe the delivery of exposure is harmful then ethical considerations are warranted, as practitioners must first “take care and do no harm” and “safeguard the welfare and rights” of their patients. (APA, 2010). According to the available evidence, exposure is not inherently harmful.

Practitioners may deem it uncomfortable or difficult for themselves to increase patient anxiety through exposure given their goal is generally to decrease patient discomfort. However, kind intentions in the short-term can lead to long-term immobility or exacerbation of the original condition (Waller, 2009). Practitioner perceptions that their patients will not tolerate exposure are unfounded (Deacon & Abramowitz, 2004). If exposure were intolerable, we would expect high drop-out rates, however, drop out rates for exposure therapies are no greater than other interventions, and drop-out rates are lowered for exposure when compared to psychotropic medications alone for anxiety disorders (Cahill & Foa, 2004).

Other barriers to the use of exposure include lack of training and supervision in exposure techniques, little confidence or trust in administering exposure and minimal knowledge in understanding the mechanisms of change involved in implementing exposure based therapies. Practitioners may worry about legal risk involved in exposure, but after all, we are asking our patients to feel anxiety, something they are already feeling everyday and the physiological response to fear is not inherently dangerous or harmful.

Exposure-based treatments are arguably the most efficacious and successful psychological treatments for anxiety disorders (Deacon & Abramowitz, 2004). Misinformation about exposure-based treatments and lack of dissemination are a clear barrier for this effective treatment.

Although exposure is safe, it may in fact place patients at more risk compared to traditional talk therapies. Patients are asked to do a variety of “uncomfortable” exercises such as touching toilets and animals, purposely inducing panic symptoms (hyperventilation, spinning, exercise, etc.) and eating without washing their hands. Olatunji, Deacon, and Abramowitz (2009) propose ways in which practitioners can avoid ethical conflicts and minimize risk in the use of exposure.

First, informed consent is used as an ongoing process, consistent with the APA ethical mandate (Section 10.01), and used to evaluate the risk and benefit of exposure as well as to decrease the likelihood of harm. Informed consent is frequently revisited during the treatment process. Olatunji et al. indicate, “exposure therapy is likely an exemplar among psychotherapies for satisfying the ethical principle of informed consent” (p.175).

Second, naturalistic comparisons can be used to determine whether the risk associated with exposure is acceptable by determining if the exposure is something at least some ordinary people do without adverse reaction such as eating after petting the dog without washing their hands first or exercising without checking their blood pressure. Specific exposures may not be appropriate for every patient, such as asking a patient who has heart problems to run up and down the stairs to induce panic symptoms.

Third, scheduling and session management are necessary to ensure the session is long enough to complete an exposure with anxiety reduction, which may take longer than the typical 50-minute session.

Fourth, it is important to manage and prepare for negative outcomes, because although rare, exposures may not go as planned (car accidents happen, people faint, animals bite). The costs and probability of outcomes are discussed before exposure work.

Lastly, it is often necessary and clinically appropriate to provide exposure sessions outside of an office setting (riding elevators, driving over bridges, touching dumpsters, travel to the patient’s home), which can lead some practitioners to believe there is grater risk of boundary violations or multiple relationships. Olatunji et al. propose that boundary “crossings” done judiciously and ethically in exposure treatments do not create a risk of these violations. Precautions can also be taken in protecting confidentiality while working in a community setting such as planning with the patient ahead of time. Olatunji et al, propose several suggestions of how to protect patient confidentially in the real world such as the practitioner de-identifying themselves (removing name badges), doing exposures in an area outside of where the patient lives, and planning ahead of what to do if they run into acquaintances.

Practitioner beliefs as aforementioned combined with lack of training contribute to the underutilization of exposure with anxiety sufferers.  Many practitioners simply do not think scientifically. There is a large divide between research and practice. There is not even consensus in our field that “good practice” should even be guided by science (Kettlewell, 2004). The divide between lab and couch is a disconcerting problem. Psychotherapeutic treatment should be sufficiently tested before reaching the consuming public and to do anything differently could fault practitioners for not doing what ethical and scientific considerations require. There is not adequate dissemination of information of empirically-supported treatments to practitioners, regulatory bodies, the general public and prospective patients. These obstacles are not unique to anxiety disorders and the lack of dissemination is not specific to a particular form of treatment.

These are such exciting and promising times in the field of psychology. There have been so many advances in the comprehension of psychopathology and methods of assessing an ever broadening range of people and problems and an abundance of scientifically and empirically principled treatments. There are also numerous countervailing practical concerns facing clinical practitioners (reimbursement, employment, continuing education, licensing, expanding scopes of practice) that make successfully navigating clinical practice challenging.

It is challenging to feel assured that one is practicing with prudence and due diligence when choosing treatments with the broadening array of increasingly complex patients. The APA Ethical Principals of Psychologists and code of conduct 2.01 refer to boundaries of competence, “Psychologists provide services, teach and conduct research with populations and in areas only within their boundaries of competence, based on their education, training, supervised experience, consultation, study, or professional relationship.” The integrity of the professional service of psychology depends upon its scientific foundation, and continued strengthening of that foundation is essential (Peterson, 2004).

Adequate training is the determining factor as to whether practitioners will use empirically-supported treatments. It is our ethical responsibility to critically evaluate innovative ways to provide effective training and delivery of such treatments and to increase the overall utilization of empirically-supported treatments such as exposure. The majority of practitioners have simply not received specific enough training in these evidence-based treatments. The answer is simple: train increasing numbers of clinical practitioners to be scientific thinkers.

Practitioners may, while perhaps unknowingly in many cases, not be taking reasonable steps to avoid harming their patients if they are not aware of the expert guidelines for treating anxiety disorders and the use of exposure in clinical practice. If you are an expert in providing an evidence based treatment modality, seek opportunities to train your peers and if you have not been trained in exposure therapies and treat anxiety and related disorders, seek out training opportunities.


American Psychological Association. (2010). Ethical principles of psychologists and code of

conduct. Available at

Cahil, S.P. & Foa, E.B. (2004). A glass half empty or half full? Where we are and directions for

future research in the treatment of PTSD. In S. Taylor, (Ed.). Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (pp 267-313). New York: Springer.

Deacon, B.J. & Abramowitz, J.S. (2004). Cognitive and behavioral treatments for anxiety

disorders: a review of meta-analytic findings. Journal of Clinical Psychology, 60, 429-

Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R. T.,

Ballenger, J. C., & Fyer, A. J. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 44 (6), 427-435.

Kettlewell, P.W. (2004). Development, dissemination, and implementation of evidence-based

treatments: Commentary, Clinical Psychology: Science and Practice,11(6), 190-195.

Olatunji, B.O., Deacon, B.J., Abramowitz J.S. (2009). The Cruelest Cure? Ethical Issues in the

Implementation of Exposure-Based Treatments. Journal of Cognitive and Behavioral Practice 16 (2), 172-180.

Peterson, D.R. (2004). Science, scientism, and professional responsibility, Clinical Psychology:

Science and Practice, 11 (2), 196-210.

Waller, G. (2009). Evidence-based treatment and therapist drift. Behaviour Research and

Therapy, 47, 119-127.