Therapeutic process during exposure: Habituation model

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Highlights

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    This model emphasizes natural decrease of anxiety in the absence of anxiety-reducing behaviors.

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    Fear activation, minimization of anxiety-reducing behavior, and habituation are important.

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    Prescribed behaviors during exposure are those that increase or maintain anxiety.

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    Proscribed behaviors during exposure are those that decrease anxiety.

Abstract

The current paper outlines the habituation model of an exposure process, which is a behavioral model emphasizing use of individually tailored functional analysis during exposures. This is a model of a therapeutic process rather than one meant to explain the mechanism of change underlying exposure-based treatments. Habitation, or a natural decrease in anxiety level in the absence of anxiety-reducing behavior, might be best understood as an intermediate treatment outcome that informs the therapeutic process, rather than as a mechanism of change. The habituation model purports that three conditions are necessary for optimal benefit from exposures: 1) fear activation, 2) minimization of anxiety-reducing behaviors, and 3) habituation. We describe prescribed therapist and client behaviors as those that increase or maintain anxiety level during an exposure (and therefore, facilitate habituation), and proscribed therapist and client behaviors as those that decrease anxiety during an exposure (and therefore, impede habituation). We illustrate model-consistent behaviors in the case of Monica, as well as outline the existing research support and call for additional research to further test the tenets of the habituation model as described in this paper.

Section snippets

Overview

According to the habituation model, exposure is effective because it provides structured contact with a feared stimulus while minimizing opportunity for avoidance, escape or ritualizing. The primary goal during exposures is anxiety reduction, which occurs through contact with a feared stimulus in the absence of avoidance, escape, and ritualizing. Thus, when fear elicited by a stimulus has decreased (and avoidance, escape, and ritualizing have not occurred), habituation is said to have taken

Selecting an exposure task

We will consider each of the following clinical issues in the context of the three tenets of habituation theory during exposure: fear activation, minimization of anxiety-reducing behavior, and habituation.

Exposure rationale

The rationale for the exposure should include a discussion of the exposure technique more broadly, as well as specific information about how we believe exposures work. Ideally, this should happen at the beginning of treatment as part of more general psychoeducation about OCD and treatment options. Many times it will be appropriate to repeat the rationale over the course of treatment and to use experiences during exposure to illustrate the theory underlying the rationale. The description of

Optimal therapist behaviors during exposure

Optimal therapist behaviors during exposure are presented in Table 1. Prescribed therapist behaviors are those that theoretically function to increase or maintain the client׳s contact with the exposure stimulus and would therefore facilitate the occurrence of habituation. These include discouraging client avoidance behavior (e.g., asking Monica to maintain eye contact with unlabeled food, asking her to avoid asking questions about the food, asking her to “re-expose” by touching the exposure

Ending exposure

When is the exposure “done?” It is appropriate to end an exposure when anxiety has reduced and was judged by the therapist to be mostly in the absence of anxiety reducing behaviors. There is no standard exposure length, and setting a time limit as a way to titrate exposure difficulty is not optimal (see “Proscribed techniques” above). However, savvy therapists with clients who habituate quickly may use this as an opportunity to increase the difficulty of the exposure in order to provide the

Conclusion

When considering the habituation model, it is important to distinguish conceptually between the mechanism underlying exposure, the therapeutic process that engages that mechanism, and intermediate outcomes that indicate the mechanism is being engaged. The therapeutic process variables outlined in this paper are based on functional analysis and are thought to engage the mechanism, but are not the mechanism itself. Likewise, habituation can be conceptualized as an intermediate treatment outcome

References (54)

  • J.S. Abramowitz et al.

    Strategies for improving long-term outcomes in cognitive behavioral therapy for obsessive–compulsive disorder: insights from learning theory

    Cognitive and Behavioral Practice

    (2014)
  • J.S. Abramowitz et al.

    The relevance of analogue studies for understanding obsessions and compulsions

    Clinical Psychology Review

    (2014)
  • K.C. Anderson et al.

    The promise of extinction research for the prevention and treatment of anxiety disorders

    Biological Psychiatry

    (2006)
  • J.C. Beckham et al.

    Emotional processing and fear measurement synchrony as indicators of treatment outcome in fear of flying

    Journal of Behavior Therapy and Experimental Psychiatry

    (1990)
  • Benito, K. (2014). Effective therapist behaviors during EX/RP for pediatric OCD. In: Proceedings of the Paper Presented...
  • K. Benito et al.

    CBT specific process in exposure-based treatments: initial examination in a pediatric OCD sample

    Journal of Obsessive Compulsive and Related Disorders

    (2012)
  • T.D. Borkovec et al.

    The contribution of relaxation and expectancy to fear reduction via graded, imaginal exposure to feared stimuli

    Behaviour Research and Therapy

    (1979)
  • C.A. Conelea et al.

    Integrating behavioral theory with OCD assessment using the Y-BOCS/CY-BOCS symptom checklist

    Journal of Obsessive–Compulsive and Related Disorders

    (2012)
  • M.G. Craske et al.

    Optimizing inhibitory learning during exposure therapy

    Behaviour Research and Therapy

    (2008)
  • M.G. Craske et al.

    Is aversive learning a marker of risk for anxiety disorders in children?

    Behaviour Research and Therapy

    (2008)
  • B. Deacon et al.

    Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learning: a randomized controlled trial

    Behaviour Research and Therapy

    (2013)
  • B.J. Deacon et al.

    Does the judicious use of safety behaviors improve the efficacy and acceptability of exposure therapy for claustrophobic fear?

    Journal of Behavior Therapy and Experimental Psychiatry

    (2010)
  • P.M. Emmelkamp et al.

    Cognition and exposure in vivo in the treatment of agoraphobia: short-term and delayed effects

    Cognitive Therapy and Research

    (1982)
  • Farchione, T. J. (2002). Effects of overlearning on return of fear. (62), ProQuest Information & Learning, US....
  • E.B. Foa et al.

    Success and failure in the behavioral treatment of obsessive–compulsives

    Journal of Consulting and Clinical Psychology

    (1983)
  • E.B. Foa et al.

    Emotional processing of fear: exposure to corrective information

    Psychological Bulletin

    (1986)
  • E.B. Foa et al.

    DSM-IV field trial: obsessive–compulsive disorder

    American Journal of Psychiatry

    (1995)
  • E.B. Foa et al.

    Differential effects of exposure and response prevention in obsessive–compulsive washers

    Journal of Consulting and Clinical Psychology

    (1980)
  • Frank, H., Benito, K., Walther, M., Edmunds, J., Freeman, J., & Garcia, A. (2014). Therapist effects in CBT...
  • J.B. Grayson et al.

    Habituation during exposure treatment: distraction vs attention-focusing

    Behaviour Research and Therapy

    (1982)
  • S. Grey et al.

    Synchronous and desynchronous changes during fear reduction

    Behaviour Research and Therapy

    (1979)
  • S.J. Grey et al.

    Return of fear: the role of inhibition

    Behaviour Research and Therapy

    (1981)
  • K. Hauner et al.

    Exposure therapy triggers lasting reorganization of neural fear processing

    Proceedings of the National Academy of Sciences of the United States of America

    (2012)
  • K.A. Johnstone et al.

    Attention to phobic stimuli during exposure: the effect of distraction on anxiety reduction, self-efficacy and perceived control

    Behaviour Research and Therapy

    (2004)
  • J.H. Kamphuis et al.

    Effects of distraction and guided threat reappraisal on fear reduction during exposure-based treatments for specific fears

    Behaviour Research and Therapy

    (2000)
  • J.H. Kamphuis et al.

    Effects of distraction and guided threat reappraisal on fear reduction during exposure-based treatments for specific fears

    Behaviour Research and Therapy

    (2000)
  • A.E. Kazdin

    Understanding how and why psychotherapy leads to change

    Psychotherapy Research

    (2009)

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