When Logic is not Enough - Exposure and Response Prevention for Anxiety

Cognitive-behavioral therapies generally comprise four strategies for helping people change:

1. Learning new coping skills and desired, healthy behaviors

2. Challenging problematic thoughts and beliefs about the self, others, and the world

3. Changing environmental rewards and punishments to support behavior change

4. Using exposure to lessen the interference of unjustified, negative emotions

Using assertiveness as an example, some people may simply not know how to be assertive, and benefit from learning the skill. Others may know how to assert, but have thoughts/beliefs which interfere - beliefs such as, "I don't deserve to get what I need." Challenging such a belief can be fundamental to change. What if someone knows how to be assertive, believes it to be an option, but can't because emotions like anxiety or guilt present a barrier? Harping on how to be assertive or trying to change the person's intellectual understanding of what it means to be assertive may be of little benefit. In order to break the link between assertive behavior and anxiety/guilt, exposure may be a more useful strategy.

Exposure and Response Prevention is a specific exposure therapy used for anxiety disorders and is a principal treatment for Obsessive Compulsive Disorder. ERP involves facing anxiety-provoking situations, thoughts, or other stimuli (the exposure), while refraining from escape or avoidance behaviors normally used to manage anxiety (the response prevention). While such behaviors neutralize anxiety in the short-term, they reinforce its presence. Avoidance behaviors send the subversive message of, “This situation is truly dangerous. I need to continue to fear and avoid it” to the fear-response centers of the brain.

Anxiety has a way of overriding rational thinking, even when the person understands the fear to be unfounded. The inability to control fear with logic is often a source of frustration and even shame. In eating disorders, for example, “I know I’m not really fat, logically, but deep down I still feel like I am” is a common refrain. The disconnect between rationality and anxiety may also bewilder loved ones, who may offer simplistic suggestions such as, “Why don’t you just eat?!” Facing fears head-on via exposure (as opposed to simply discussing them in therapy) can bridge the gap between what someone knows to be true and the anxiety he or she nevertheless experiences.

ERP works via neuroscience, not magic. Successful exposures promote a process called “habituation” or "desensitization". After habituation has occurred, what once produced fear and anxiety instead become neutral, boring, or distressing to a more normative degree. Facing a fear long enough for it to dissipate sends a powerful message to a part of the brain that is less accessible to logic. The brain’s fear centers slowly learn that because a fear was faced and not avoided AND nothing catastrophic happened, perhaps the situation is not actually so dangerous. Over time, the fear diminishes, as the body has a vested interest in not activating the fear-response system (and wasting energy) when no actual danger is present.

Habituation occurs when three criteria are met:

1. The fear is faced frequently enough.

2. The exposure is hard enough to activate the fear response system, raising anxiety levels to at least a 7 out of 10.

3. The patient sits with the anxiety long enough for it to reduce by a noticeable degree (generally 50%) merely by the passage of time, rather than by avoidance/escape behaviors/compulsions.

People with eating disorders, anxiety disorders, and related conditions often remain stuck, without professional help, because of the difficulty of satisfying the third criterion. They experience significant anxiety on a frequent basis, but often need to develop the ability to sit with the fear and anxiety until it passes on its own. People typically need help to overcome the natural tendency to avoid discomfort. However, the benefits of doing so can be profound. I have witnessed mirror exposures allow patients struggling with body image to meaningfully say, “I guess I’m not thrilled with my body, but I think I can tolerate or even accept it.” Patients once tormented by obsessive thoughts have remarked, “Now that I hear the thoughts out loud they seem kind of silly. And I think it’s sad that I’ve had to suffer from them for so long.”

If you struggle with obsessive thoughts, irrational fears, anxiety, intrusive memories, compulsive behaviors, or avoidance, it is likely that a treatment with an emphasis on exposure may assist you in freeing yourself from these troubling symptoms, perhaps in ways that purely talk-based therapies have not.