Teaching Exposure Therapy: 'Exterminate! Exterminate!'

Abstract

Humour in education for counselling and psychotherapy is essential, particularly interventions that are pertinent to deep emotions and experiences such as trauma. Exposure Therapy has been actively employed for various symptoms and contexts including traumatic experiences, phobias and anxiety. Teaching this therapy often involves tragic events, therefore students may be distracted by the details of these events. Some students may feel that certain issues should not be talked in the classroom, which can hinder their learning experience. We have taught Exposure Therapy with humour, which enables students to focus on the intervention, and more importantly, without damaging their curiosity and spontaneous learning mindset. This book chapter reports two cases where we have utilised humour relating to a popular British TV series 'Doctor Who', and discusses the importance of humour in teaching this intervention.

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Teaching Exposure Therapy: ‘Exterminate! Exterminate!’
Michelle Brooks-Ucheaga1, Yasuhiro Kotera1
1University of Derby, Online Learning, Derby, United Kingdom
Citation
Brooks-Ucheaga, M. & Kotera, Y. (2021). Teaching exposure therapy: ‘Exterminate!
Exterminate!’ In K. Vaidya (Ed.), Teach counselling with a sense of humor: Why (and how
to) be a funnier and more effective counselling teacher and laugh all the way to your
classroom? Curious Academic Publishing.
Abstract
Humour in education for counselling and psychotherapy is essential, particularly
interventions that are pertinent to deep emotions and experiences such as trauma. Exposure
Therapy has been actively employed for various symptoms and contexts including traumatic
experiences, phobias and anxiety. Teaching this therapy often involves tragic events,
therefore students may be distracted by the details of these events. Some students may feel
that certain issues should not be talked in the classroom, which can hinder their learning
experience. We have taught Exposure Therapy with humour, which enables students to focus
on the intervention, and more importantly, without damaging their curiosity and spontaneous
learning mindset. This book chapter reports two cases where we have utilised humour
relating to a popular British TV series ‘Doctor Who’, and discusses the importance of
humour in teaching this intervention.
Keywords: Exposure therapy; Doctor Who; humour; curiosity; creativity; exterminate

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“Teachers, always remember that you are unique—just like the other teachers! - Unknown”
Exterminate! Exterminate!
‘Exterminate! Exterminate!’ is a common phrase shouted by characters called
‘Dalek’s’ in a popular long-running British science fiction TV series, entitled ‘Doctor Who’.
This series started on the British Broadcasting Corporation (BBC) in about the 1960s, and Dr
Who was able to travel in the time (BBC, 2021).
Dr Who during his famous travel would meet various aliens and would come in
contact with extra-terrestrial mutants called ‘Dalek’s, whose aim was to simply exterminate
anyone else that was not a cyborg alien like themselves (pretty deep hey!). When Daleks
witness an alien, they shout ‘Exterminate! Exterminate!’ to summon their colleague Daleks to
exterminate the aliens. This, we found, is highly relevant to teaching Exposure Therapy
(clearly!).
When you treat clients, who present with phobias or obsessive-compulsive disorder
(OCD), Exposure Therapy is a common approach, supported with robust evidence (Hezel and
Simpson, 2019). Phobias essentially involve the initial emotion and experience of fear or
anxiety to an object or experience and the response to this fear or anxiety creates an
avoidance, which creates a phobia. The main aim of treating phobias using Exposure Therapy
is to help this client to exterminate their irrational fear response to the phobia that they would
like to overcome (Eaton, Bienvenu and Miloyan, 2018).
As a trainee Psychotherapist
1
myself (MBU), I was always told by my psychotherapy
lecturers to demonstrate to the client how to overcome fear rather than simply telling them
what may be happening, which is in line with Exposure Therapy and associated behavioural
experiments (Bennett-Levy et al. 2004; Kube, 2017).
1
As with many other documents, the terms ‘counselling’ and ‘psychotherapy’ are used interchangeably,
however where we describe a specific registry/license, we used the noted term by our accreditation bodies.

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In order to teach this, students need to learn to help their client face their own fears.
This requires practical skills, rather than theoretical understanding, which is an important part
of teaching counselling and psychotherapy (British Association for Counselling and
Psychotherapy, 2020).
This also means that when we educate students with these practical skills, we cannot
just describe the skills; we must demonstrate those skills to students so that they have a
deeper understanding of this intervention. Exposure Therapy needs to be taught with real
demonstration of the skills (Zoellner et al., 2011), and we found humour is helpful. Here are
two case studies.
Case Study 1 “Note to self: I am a fearless teacher!”
As an adventurous counselling/psychotherapist lecturer, we encourage our students to
practise facing their own fears so that students will have empathy, compassion and the skills
to work with their clients to implement Exposure Therapy.
On a bright and sunny afternoon, I (MBU) had asked students the week before to
share what some of their own fears were and consider what they would like to overcome if
they were a client. I shared that we would use one specific student’s phobia in this session to
demonstrate how exposure therapy works in practice, like any good
counselling/psychotherapist lecturer would show students and rather than just tell them.
A student very kindly decided to bring in a spider, a very large spider, I might add. A
spider that their roommate had collected and put in a jar for this experiment. The student
shared that they hate spiders but would like to experiment and see how Exposure Therapy
works for their phobia of spiders.
Having watched the film ‘Arachnophobia’ as a child, and having experienced as a
child my older brother perpetually taunt me with spiders, I must confess spiders are not my

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favourite thing in the world….okay I hate spiders! I avoid them at every chance and my heart
rate increases from a 1 on a scale of 1-10 to about 1 million at the mere sight of a huge spider
(just in case I did not make myself clear…yes I hate spiders and have a spider phobia). The
student proceeded to take the spider that was in a large jar out of their bag.
Unfortunately, having looked at the glass jar wrapped in a brown paper bag staring at
me on the table, I notice that my heart rate was gradually increasing and noticed my palms
were sweaty. Trying to not show my students my growing trepidation and my attempting to
remain calm at all costs in an attempt to help the student learn to exterminate their irrational
response to a mere spider, the student handed me the jar but due to my hands sweating, the jar
slid out of my hand, dropped to the floor and broke into pieces.
My main concern for approximately 0.01 second was the glass on the floor then it
dawned on me, there is a huge spider probably the size of a Tyrannosaurus Rex, just like in
the film ‘Jurassic Park’ (not quite but in my head that’s what image I had mustered up that
was crawling on the floor). The spider had escaped!
I looked around and noticed that almost half of the class were either on the table or
backed into all four corners of the classroom. Then for a split second, I realised I was on top
of my own teaching table. Me the counselling/psychotherapy lecturer was on top of my own
teaching table, speechless. I asked myself a question ‘Am I the lecturer who is supposed to be
teaching the students how to overcome their own phobias?’.
I, then noticed that my students were looking at me and I was not sure if they were
asking themselves ‘Is she OK?’ ‘Does she need therapy herself?’ Having come to myself and
realised that I am the person that is supposed to be leading the class, I composed myself,
straightened my shirt and burst out laughing-kind of a nervous laugh which teetered on the
edge of hysteria. I laughed not because it was funny because, believe me, at the time it was
not! But I quickly realised that my laughing was a nervous, adrenaline reaction coupled with

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the image of myself on top of a desk in the middle of the day in front of my students because
a spider was free and liberated from a jar.
Teachable moments are necessary, even for the ‘fearless’ teacher
It was funny, I have to confess. I decided to turn this into a ‘teachable moment’ for
my students that irrational responses to objects or experiences do exist. As a counselling and
psychotherapy lecturer, I learned the following top-tips:
1. It is OK to be human first and a teacher; in fact, in some instances, it can help students to
feel more comfortable being vulnerable.
2. Overcome your own fear.
3. If you don’t have enough time to do that… then be open to learn to face your fears and
help your students to be able to face their fears in a safe space with you.
4. Start small, grade your exposure. I don't think a spider of that huge size was helpful at that
time, maybe a mini spider (maybe even an almost invisible spider) would have been helpful
first.
Ultimately allowing your students to see you not just as their teacher but also as a
human being allows them to know that you are not invincible like Dr Who. Even though
irrational anxious responses to phobias still need to be exterminated as a lecturer in
counselling and psychotherapy, we have learned the importance of using humour
(intentionally or unintentionally) to convey key learning points.
Students in this module have learned a lot, per module feedback and gradebook. This
may mean that this humorous event did not detract them from the subject; rather humour
enhanced their engagement, making learning of Exposure Therapy more relatable, which is
often associated with better learning outcomes.

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Case Study 2 “Sometimes teaching experiments make you want to vomit!”
Live supervision is a good tool to equip students learning counselling and
psychotherapy, to practice skills in a one-to-one context to apply their theory to one or more
specific client(s) or a real-life case study (Andres and Harris, 2017). We have learnt from our
years of teaching that when it comes to trainee counselling students, there generally seems to
be three types of students.
Type 1, you have the ‘I have no desire to engage in practice, thank you very much. I
will just let my client practice.’ Type 2, you have a student who believes ‘I will practice a
skill in the classroom if someone else does it first! (I’m the one to start? Never!)’.
The last but not least is Type 3 who is the first one to answer every question or has a
very detailed and theoretically loaded question two minutes before the end of a lecture, and
they are always raring to go, raring to expose themself and to jump into any opportunity to
practise skills on the name of ‘taking one for the team’.
Here is an example involved a teaching session on Emetophobia. According to the
Diagnostic and Statistical Manual of Mental Disorders (as known as DSM–5) (American
Psychiatric Association, 2013), Emetophobia is defined as a specific phobia of vomiting and
the presentation includes an extreme and persistent fear in relation to vomit. According to
Anxiety UK (2021) Emetophobia is the fear of vomiting or seeing others vomit.
The treatment for Emetophobia can include graded exposure to the phobia (Veale et
al. 2012) which includes an exposure approach. This process often involves exposure to
vomit or vomiting cues, exposure to imagining vomiting and role plays concerning the
exposure of vomit with the client (Riddle-Walker et al. 2016). To help students to work with
clients experiencing Emetophobia, a useful experiment involves the exposure of vomit with
the client. This can be real vomit or a concoction of ingredients that make it look like it is

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vomit, let us call this ‘pretend’ vomit. ‘Real’ vomit or ‘pretend’ vomit works for exposure
therapy but for health and safety purposes a potent concoction of appropriate ingredients
called ‘pretend vomit’ works just fine for exposure therapy.
Remember the three types of students mentioned previously? Well for these types of
tasks we find student Type 3 ‘I am ready and willing taking one for the team’. Such students
are never at the precontemplation or preparation stage; they comfortably sit within ‘action’
(to learn more about motivational interviewing, we recommend Rollnick and Miller, 1995;
Miller and Rollnick, 2009).
A classic exercise, I (MBU) frequently work with students in teaching sessions to
create the best (or you could call it the worst) vomit concoction that students can use to
stimulate Exposure Therapy for Emetophobia. A favourite assignment of mine includes
bringing the ‘vomit’ into lesson on a set day with the requirement that it must smell and look
like vomit. The best vomit gets the best-in-class grade!
A recipe not one that famous chefs like Gordon Ramsey or Michel Roux might create
but certainly one that creative chef Heston Blumenthal might experiment with. So here it
goes, feel free to try it but no need to write us back regarding positive feedback!
5x rotten raw egg
2 boiled eggs preferably at least 1 week old
Stale milk…just a dash or two
Lashings of tinned diced carrots
A smidgen of chopped beetroot.
Half a slice of half-eaten crackers
Last but not least a generous dollop of out-of-date sour cream and one or two large spoons of
dog or cat food. Let’s eat five of them after your meal, as a dessert! Delicious!

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In general, students ‘enjoy’ this exercise, reporting that they have gained the ‘real
clinical experience’. What is great about this is that this exercise tends to exterminate the 3
categories of students, noted above. They are all emotionally engaged!
Moreover, they continue to be engaged after this exercise: the overall module
engagement increases. Of course, we teach this while making sure the cohort would be safe
to conduct this (and so far, all students were okay). Using humour in this context can bring
humour, experimentation and learning in a way in the absence of humour does not have quite
the same effect.
Discussion
Here, we would like to reflect on our teaching practices reported in the case studies
and discuss helpful knowledge for future education for counselling and psychotherapy.
Needless to say (and we imagine this will be repeated over and over in this book), humour is
essential in counselling and psychotherapy education.
Indeed, this discipline deals with people’s raw, deep, sensitive emotions more often
than any other disciplines (Kotera, Green and Sheffield, 2019) but this doesn’t mean that
counselling education needs to be serious and anyone in the discipline should not laugh
(Kotera et al., 2021). Contrarily, humour has been reported positively in education research
(e.g., Liu et al., 2017; Unsal, Aggam and Aydemir, 2018). This chapter, as well as the other
chapters in this book can offer insights regarding how humour can be helpful in education for
counselling and psychotherapy.
The two case studies we described above, you may have several ideas about what you
may want to implement in your own modules (if you are an educator) or what you may want
to request to your lecturers (if you are a student). Those new practices would offer new
learning for both students and educators, and leading to innovative practices. But we must

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emphasise that those practices would work better when there is a strong trust between
educators and students.
It is the same as humour; we need a background to make things funny. Many sitcoms
are funny, because they establish relationships and patterns of characters, which then later
can be used for humour. This relationship, background making in sitcoms is equivalent to
trustful relationship between educators and students. So, when using humour in counselling
classrooms, you may want to consider relationships with your students. Often, when you
think about each of your student, humour emerges, if you think about bringing humour in
your classroom.
Another point we would like to highlight is the importance of relatable contents, to
which humour is a great contributor. If you think about your best learning, it often involves
the real case learning, where you or your emotions are highly involved (i.e., relatability is
high). For example, when I (YK) was in a graduate school in San Francisco, I was also
working at a psychiatric unit, working with people with various symptoms.
When I only learned about mental disorders at school, my learning was rather
cognitive, not involving somatic, experiential learning. But when I worked with a client with
that disorder, I was able to have more holistic view of that disorder, deepening my
understanding. I had a client with PTSD, and one night, he went on panic at 3 am at our
residential hall. A smell of gasoline, brought by a track that ran by the facility, triggered his
tragic memory from a war field (he was a veteran). I focused on managing his anxiety with
my colleagues, and the client calmed down eventually.
As having learned counselling in my second language, I can emphasise that
counselling, in a humorous way, is an occupation, where we sell air (unlike, for example,
architecture where you deal with more tangible items such as ‘roof’, ‘window’ etc.)! It is easy

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that learning stays in the conceptual, intangible world, therefore, how to make those learnings
tangible is crucial, namely relatability.
Humour is definitely one good, healthy way to make the learning relatable, leading to
deeper understanding for students. We will continue to use humour in our programmes to
support quality student learning, with a view of conducting empirical studies.
Conclusion
This chapter introduced two case studies with humour, relating to the famous phrase
in ‘Doctor Who’, ‘Exterminate! Exterminate!’ in the context of teaching Exposure Therapy.
As the discipline of counselling and psychotherapy has been gaining its importance,
responding to the mental health challenges in many countries, the advancement of teaching in
this discipline is essential. We hope that insights in this chapter will contribute to better
counselling education worldwide.

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