If you’ve found this page, there is a good chance you or a loved may be suffering with Obsessive Compulsive Disorder and are looking for cognitive treatment options. So, what is OCD? OCD involves, according to the DSM-5, “recurrent, persistent thoughts urges, or images that are intrusive and unwanted…attempts to ignore or suppress such thoughts, urges, or images with some other thought or action.” This is summative and brief, but essentially it consists of an unwanted and bothersome pattern of obsessions (thoughts, fears, worries) and compulsions (actions or attempts to control or suppress the obsessions). An example of contamination may be the obsessive thoughts that I or my family will become sick, and the compulsion is to avoid germs or certain items.
The current treatment of preference is Exposure Therapy (ERP). This essentially consists of confronting those very things one obsesses, be they fears, thoughts, images, and create new learning in the deep parts of the brain that are currently highly skilled at saying ‘No, avoid that at all costs!’
So HOW DOES Exposure Work? The following article by Jonathan Abramowitz, PHD, helps explain Emotional Processing, Exposure, Inhibitory Learning and ACT:
______________________Full Article Below__________________________________
Blog available online: http://www.jabramowitz.com/blog/do-you-know-how-exposure-therapy-works-what-i-have-to-say-here-might-surprise-you
I thought I'd blog about one of my favorite topics-- exposure therapy. Research shows that exposure is the most effective intervention for anxiety problems—particularly those that involve some sort of fear, such as phobias, panic and agoraphobia, OCD, and PTSD. But how does exposure work? And how can we tell if it’s working? There are a lot of misconceptions about this; and I will try to clear some of them up in this post. Some of what you read might surprise you!
Emotional Processing Theory
The first science-based theory of how exposure reduces anxiety and fear was called emotional processing theory (or “EPT”). It was first proposed by Stanley (Jack) Rachman in 1980), but then elaborated by Edna Foa and Michael Kozak in a famous 1986 article. Foa and Rich McNally further elaborated on the model in a paper written in 1996. The basic idea of EPT is that when a phobic person confronts a feared stimulus, this sort of exposure activates a fear structure—a set of ideas about the feared stimulus (for example, a spider) one’s response to the stimulus (such as the urge to run away) and their meaning (such as, "It’s dangerous and I could be hurt or killed"). This information is thought to be stored in memory. When the fear structure is activated, according to EPT, and information that is incompatible with it is observed (that is, by doing exposure and learning that things turn out OK), it is thought to result in the development of a new non-fear structure that replaces (or competes with) the original fear structure.
In 1986, Foa and Kozak pointed out that, according to EPT, the basis for this “corrective learning” (that is, the incorporation of incompatible information into the fear structure) is the habituation (reduction) of fear during and between exposure trials, and in the absence of any avoidance behavior. So, according to EPT, initial fear activation, within-session habituation, and between-session habituation are indicators of successful learning (and therefore successful exposure therapy).
To put it another way, EPT assumes that performance during exposure is equal to learning: fear reduction at the end of an exposure session represents improvement in the anxiety problem, while continued fear throughout the session does not.
Research (perhaps surprisingly to some of you) does not really provide much support for the main tenants of EPT. That is, in studies, neither the initial activation of fear, nor the habituation of anxiety (during or between exposure sessions) is a terribly reliable predictor of the outcome of treatment. In fact, lots of research shows that performance in general is not necessarily a strong indicator of how much a person learns. So, experts have looked for more scientifically consistent ways to understand what’s going on during exposure.
The Inhibitory Learning Model of Exposure
A more recently developed way of thinking about the mechanism of exposure therapy focuses on inhibitory learning processes (which I will define in a second). This model was recently described by Michelle Craske, who conducts research in this area. One benefit of the inhibitory learning approach is that it explains discrepancies between performance during extinction training (exposure) and post-extinction (post-treatment) levels of fear.
In the context of exposure therapy, inhibitory learning refers to the idea that fear associations (or “fear structures”) are not actually removed during extinction, but instead new learning about the feared stimulus occurs and competes with the old fear learning.
To put it another way, after successful exposure therapy, the feared stimulus actually possesses two meanings: (1) the original “excitatory” (fear-based) meaning, and (2) an “inhibitory” (safety-based) meaning.
So, even if habituation occurs and fear subsides during and after exposure therapy, the original excitatory meaning is still there—and it may even rear its ugly head under certain circumstances. This explains why relapse is possible after exposure. Mark Bouton has eloquently explained some of the conditions under which relapse might be possible following even successful exposure therapy. Some of these include (1) confronting the feared stimulus in a new or different context than was practiced during exposure, (2) the simple passing of time (as in “spontaneous recovery” of the fear), and (3) experiences where the person re-learns the original fear.
So, one important implication of the inhibitory learning perspective on exposure is that during this treatment a person learns new non-threat associations; but exposure must be conducted in a way that enhances the accessibility of these newly learned associations (relative to the older threat-associations) in different contexts and over time.
Another important implication of the inhibitory learning model is that the best indicators of the effects of exposure therapy are post-treatment and follow-up assessments, when the inhibitory learning acquired during exposure will shape how fear is expressed. This is more important than whether habituation occurs during exposure.
So, contrary to popular belief, it is not crucial that anxiety goes down during exposure. That is, it’s OK if habituation doesn’t occur. In fact, many would argue (me being one of them) that anxiety tolerance is just as important (if not more so) than anxiety reduction.
Exposure and ACT
If you know about Acceptance and Commitment Therapy (“ACT”), my last point above will sound very familiar. I have always thought that ACT and exposure therapy are more alike than different. I think of them as simply two different techniques for getting to the same place and achieving the same outcome. Both would say that that it is better to learn to tolerate anxiety than to fight it or make it go away.
And there’s lots of research showing that learning to accept negative emotional states (like anxiety, fear, uncertainty, etc.) reduces distress; whereas attempts to control, suppress, avoid, or escape from negative emotions (like demanding that until habituation occurs) is associated with more severe symptoms of anxiety disorders. Fostering anxiety tolerance during exposure also compliments the goal of enhancing inhibitory learning: to the degree fear is tolerated, inhibitory associations (such as, “Fear is not dangerous”) can be maximized. So, demonstrating through exposure that fear and anxiety are tolerable, and that one can “act with anxiety,” might actually be more important in the long-run than trying to ensure habituation.” -Jonathan Abramowitz, PHD
Books, Links and Resources
International OCD Foundation: www.iocdf.org
OCD Georgia: www.ocdgeorgia.org
Peace of Mind: www.peaceofmind.com
Shala Nicely: www.shalanicely.com , also Jon and Shala’s tips: https://www.shalanicely.com/wp-content/uploads/2016/08/Jon-and-Shala%E2%80%99s-Top-10-Tips.pdf
OCD Challenge: www.ocdchallenge.com
Freedom from Obsessive Compulsive Disorder, Jonathan Grayson, PhD
Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life, Shala Nicely, LPC
Everyday Mindfulness for OCD: Tips, Tricks, and Skills for Living Joyfully, Shala Nicely, LPC
Stopping the Noise in Your Head, Reid Wilson, PhD