Clinicians and graded exposure

Some people do, and some people don’t, some of us will, and some of us won’t!
Graded exposure can be an uncomfortable experience for both the person who is learning to approach activities that don’t feel very good – and for the clinician! It goes against the grain for some of us to elicit anxiety and see distress as we work with people, after all, our job is to help people feel better isn’t it?

There are some consistent findings about clinician anxiety vs patient anxiety when it comes to pain. It seems that clinicians can often be more conservative with regard to what is OK for a person to do than the person can be. This conservatism can be related to clinician’s beliefs about hurt vs harm, clinician’s orientation to a biopsychosocial model – and possibly, although I haven’t seen any specific studies, it could be associated with clinician ability to self-regulate emotional content. This last one is a hypothesis that I’ve been considering as I watch my own responses to people who are distressed. Learning to regulate my own responses as I ‘make room for’ a person’s emotions has been an important part of learning ACT, and it has allowed me the privilege of being present with people who are processing some incredibly emotional material.

So, how do I work with my own responses while working with people to do activities that they’ve been avoiding?

It probably doesn’t surprise anyone reading these blogs to know that I tend to want to understand and apply reason to most situations. So one way I have often managed my own responses has been to know why I’m following this path – and to explain why to the people I’m seeing in therapy. This can be one way to down-regulate anxiety, simply by putting it into a bigger picture and removing that ‘unknown and scary’ aspect of the treatment.
On its own, however, this isn’t the be-all and end-all, but it is an important component of pain management (have a chat to Lorimer Moseley and David Butler if you don’t believe me!).

Another way for me has been to recognise that the short-term distress is in the aid of longer-term function, and remembering that distress doesn’t last forever. No emotion does carry on, they start low and build to a peak – then taper off. Just think of a two-year-old tantrum to remember this! And it can be worth saying this to the person you’re working with too, to remind them that emotions don’t remain forever – although it can feel like a long, long time in the middle of it!

But we need to remember these mirror neurons that start to fire up when we observe another’s behavior. Remember we can’t feel someone else’s emotion or pain – what we’re doing is observing behavior and our brains are firing up to remind us of situations where we’ve carried out those behaviors too. So what happens in empathic people, especially newbies, is that our mirror neurons fire and we start to experience some of the emotional impact these behaviors might generate in ourselves. Studies have shown that over time the amount of ‘mirror’ activity reduces as clinicians observe or carry out procedures that are known to increase pain. This is a form of down-regulation that we’re not typically aware of, and it probably works in a similar way to what occurs during graded exposure – rather than ‘turning off’ the empathy, we learn to inhibit the expression of this empathy and at least some of the power of the emotion is reduced in our consciousness.

Studies of mindfulness show that we are able to learn to be open to experiences as they are rather than judging them as either positive or negative, and by developing this skill we can be more flexible and able to cope with situations we would otherwise avoid. Maybe this is a skill clinicians should learn as part of training, to help us manage the many situations we encounter as we practise.

Shapiro, Shauna L; Carlson, Linda E. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. (pp. 107-117). xvii, 194 pp. Washington, DC, US: American Psychological Association; US.



  1. Thanks for this post Bronnie. As I read about your experience and how that changes over time with more “graded exposure” I have at least a couple of concrete take away points that I will be able to anchor and reflect back-on:
    the ‘normal curve’ of a particular emotional experience and the less attention/notice of the mirror neuron feedback that I will experience over time. I agree that the pitfalls as well as the positives of therapeutic empathy would be a very useful addition to basic training for therapists. And yes the focus on the longer term picture is another important frame for me to remember.

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