Straight Up Guide to Exposure Therapy
These guides were born out of Noah and Christine’s frustration with overly complicated and jargon-filled articles, newsletters, books, and therapy websites. Our mission is to create clear and practical guides in order to learn, grow from challenges, and lead more meaningful and impactful lives.
Exposure and Response Prevention, or ERP, is a highly specialized form of behavioral therapy in the CBT school that was originally developed to treat phobias and OCD, but is now used across a variety of anxiety disorders.
Exposure means gradually moving closer to what you fear or are avoiding – this could be dirt, germs, spiders or heights, but also more abstract things such as mistakes, unevenness, or even “bad” thoughts. Response Prevention means that you modify or “prevent” your usual response to these fears. The usual, maladaptive responses tend to be either compulsions such as hand-washing, rituals such as counting, mental compulsions such as thought-stopping, or by avoiding them altogether. The new more adaptive response tends to be tolerating the discomfort that the exposure brings.
How does changing your response to a fear make it decrease? This has been traditionally explained through what is called the habituation model, which means that after repeated exposure to a given stimulus, or fear, the response will decrease or cease altogether. Imagine watching a scary movie for the first time, and then for the fortieth time. It’s safe to assume that the fortieth time would be much less scary, if scary at all. You eventually become habituated to the fear that the movie produces, and it does not feel as threatening as it was before. In other words, you get used to it. Recently, the habituation model has been overtaken by Inhibitory learning theory, or ILT, which states that new learning about a given fear inhibits old learning about it. For instance, one may develop a fear of elevators and learn that they will become trapped in them if they ride one. If one does a series of exposures in which you ride in elevators and don’t get trapped, you will then have new learning that can compete and hopefully override the old learning about being trapped. It’s important to note that the old learning never disappears or goes away, but rather that the new learning provides new evidence that allows the old fear to no longer loom so large. New good experiences can now compete with the old bad ones.
Exposures can be broken down into three different categories: 1) Interoceptive, 2) Imaginal, and 3) In vivo. The first kind, interoceptive, refers to stimuli or sensations that occur within the body. These could include breathing, dizziness, or the feeling of being hot. In panic disorder and panic attacks, it’s often an internal cue or sensation that sets them off. Therefore interoceptive exposures target these by intentionally inducing these states in session. Examples of interoceptive exposures include breathing through a straw, spinning in a chair, or drinking a glass of water in one fast gulp. Through practicing these types of exposures, people can become more comfortable and able to tolerate uncomfortable internal sensations.
The second type of exposures, imaginal, are what they sound like – the person imagines various scenarios and writes them down in narrative form. These are then recorded and listened to over and over again on a loop through on a tape recorder or the voice memos app on your phone. After repeated listens, the fear response that the narrative originally produced becomes more tolerable. For instance, someone with a fear of driving could write a narrative about being caught in traffic with horns blasting, etc. These could be done as “training” of sorts before progressing to real actual driving. Imaginal exposures are especially useful with PTSD, or others scenarios when it is impossible to recreate the fear in real life.
In vivo exposures are the most difficult and most intense – they are when you actually confront your fear in real life. For someone with contamination OCD, this would mean touching dirt or a toilet seat, and not washing their hands. Someone with social anxiety, it could be introducing yourself to strangers on the street. For someone with a fear of elevators, it could be riding an elevator for an hour without stopping. In general, exposures are administered in a gradual way. For instance, if one has a phobia of spiders, the first exposure might be to write a story about spiders, followed by looking at photos of spiders. The next level of exposures could be videos of spider, then looking at a real spider in a cage. The last exposure might be going to a pet store and having an actual spider crawl on one’s hand or arm.
Exposures are not easy, and most people will not choose to overcome their greatest fears unless they have a compelling reason to do so. Therefore motivation plays an integral role in ERP. The art of ERP is developing exposures that are challenging and scary for the patient, but not so much that they are incapable of doing them. This is understandably difficult, and there is a some trial and error involved in the process. That being said, ERP is highly effective and really is the gold standard for the treatment of anxiety.
Christine Izquierdo and Noah Laracy are the co-founders of Straight Up Treatment, an anxiety disorder specialty treatment center. Straight Up Treatment utilizes a variety of cognitive-behavioral approaches to treat anxiety-based conditions such as Obsessive-Compulsive Disorder, Social and Performance Anxiety, Panic Disorder, Depression, and Generalized Anxiety.
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