Exposure therapy is the most effective treatment for anxiety. As you can see below, exposure-based therapies show large effect sizes across the anxiety disorders:
But are you helping your clients as much as you could from your practice of exposure therapy? Sometimes helping your clients means going back to first principles. In the case of exposure therapy a 21st century approach means that you need to forget about habituation and understand inhibitory learning theory instead – don’t groan, this is important! This month we’ve gone all-out to help you get to grips with the principles and practice of conducting effective 21st century exposure therapy. Whether you’re new to exposure or have been using it forever you will find something to improve your practice here.
Figure adapted from: Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. (2011). Exposure therapy for anxiety: Principles and practice. Guilford Press.
New On Psychology Tools
Many clients have body sensations which they do not fully understand and experience as aversive. The Autonomic Nervous System handout is designed to help your clients understand their body reactions as a function of their nervous system. Therapeutic approaches such as compassion focused therapy (CFT) increasingly integrate ideas from neuroscience and clinicians will find it helpful to be able to offer explanations for client experience at biological levels.
We get it, you’re busy. That’s why we’ve distilled the key lessons into a single-page handout. It won’t tell you why, but it will tell you what to do to maximise the effectiveness of your practice of exposure therapy.
(Very) Recent Exposure Therapy Research
Directing your client’s attention to internal experiences during exposure leads to more behavioral improvement
Hot off the press is a new study from Benjamin Katz and colleagues in Behaviour Research and Therapy. They found that during exposure trials if they directed their clients to attend to their internal distress as well as a feared stimulus they got more behavioral improvement than attending to the feared stimulus alone. This looks to be a simple way to maximize responses to exposure therapy. Examples of the prompts they gave include:
“Focus on the cockroach. Pay attention, what thoughts are passing through your head? Don’t try to change these thoughts, or to “argue” with them. Just notice them.”
“Be aware of your body. Where do you feel the most tension? Where do you feel the least? Here too, notice that you can consider the tense feelings and accept the current reality, without trying to change anything.”
Katz, B. A., Breznitz, H., & Yovel, I. (2019). Gain through pain: Augmenting in vivo exposure with enhanced attention to internal experience leads to increased resilience to distress. Behaviour Research and Therapy, 113, 9-17.
Safety behaviors during exposure therapy – an RCT
Standard advice for exposure therapy is to encourage clients to drop safety behaviors as soon as possible. However there are some indications that judicious use of safety behaviors may enhance treatment acceptability and can facilitate approach to the feared stimulus. Now an RCT has been published comparing elimination of safety behaviors (ESB) during exposure with judicious use of safety behaviors during exposure. Some key findings from this more definitive exploration:
“Participants in both conditions evidenced large (and comparable) improvements in self-reported and behavioral symptoms from pre-to post-treatment, which were maintained over the follow-up period. Thus, our findings lend support to the claim that safety behaviors do not necessarily interfere with exposure.”
“…participants in the E/JU condition made more safety behavior-related attributions than would be expected by chance, which suggests individuals performing safety behaviors during exposure do not entirely conclude that their fear-based expectancies are mistaken.”
and the take-home message:
“…therapists may not need to be concerned if their patient is unwilling to immediately eliminate their safety behavior(s) as long as the patient explicitly tests their fear-based negative expectancies through direct and sustained confrontation with feared situations/stimuli and also understands they should eliminate their use of safety behaviors as soon as they are willing.”
Blakey, S. M., Abramowitz, J. S., Buchholz, J. L., Jessup, S. C., Jacoby, R. J., Reuman, L., & Pentel, K. Z. (2019). A randomized controlled trial of the judicious use of safety behaviors during exposure therapy. Behaviour Research and Therapy, 112, 28-35.