Let truth be thy aim, not victory: Comment on theory-based exposure process
Introduction
Cognitive behavioral therapy (CBT), usually involving some form of exposure to fear- and anxiety-eliciting stimuli, is widely recommended as the go-to intervention for a range of anxiety-based problems and there is ample evidence to support its efficacy for treating OCD (Abramowitz et al., 2006, Houghton et al., 2010, Rosa-Alcazar et al., 2008). As Conelea and Freeman (2015) note, however, even when therapists are delivering treatment from the same protocol within a carefully controlled and supervised setting (e.g., an RCT), studies have shown variability in patient outcomes between therapists (Pediatric OCD Treatment Study Team, 2004). While some of this variation is likely due to client characteristics, this series makes a compelling proposition that exposure processes, defined as the specific and nuanced therapist and client behaviors and interactions that occur when implementing exposure therapy, also warrant consideration. Such exposure processes include, among other things, how to select, construct, and order exposure tasks, the rationale and instructions for how, when, and where to engage in exposure tasks, the pace and timing of exposure implementation, and what ancillary procedures (e.g., cognitive and instructional techniques) to use, or refrain from using, when conducting an exposure. These nuanced aspects of treatment have thus far received little empirical investigation, vary across CBT models, and are less explicitly outlined in existing “how to” procedural manuals. The overarching theme of this set of manuscripts is that a better understanding why and how to implement exposure tasks across CBT approaches might provide valuable insights into how to enhance treatment outcomes.
Section snippets
Understanding exposure processes by connecting the “how” with the “why”
In this series, the application of exposure-based treatment for OCD is described from within four different models, all of which fall under the umbrella of CBT: the habituation model (Benito & Walther, 2015), the cognitive model (CT; Berman, Fang, Hansen, & Wilhelm, 2015), the acceptance and commitment model (ACT; Twohig et al., 2015), and the inhibitory learning model (Arch & Abramowitz, 2015). In contrast to other series on this topic, this set of manuscripts goes beyond simply comparing and
The rationale for exposure therapy: starting with the “why?”
Any discussion of how to best conduct exposure therapy for OCD necessarily begins with consideration of the rationale for conducting exposures in the first place. One common theme that emerged across all of the CBT approaches in this series is that the purpose of utilizing exposure tasks during therapy is to teach an individual with OCD to confront feared situations, experience fear and anxiety, and behave differently in their presence. In doing so, corrective learning of one form or another is
Designing and implementing exposure tasks: the “what, when, and where?”
One procedural element that is common to each of the models described in this series is that treatment begins with the careful identification of relevant internal and external stimuli that elicit fear, anxiety, and distress and thus motivate the performance of compulsions or other avoidance behavior. Across all models, identifying relevant stimuli is an idiosyncratic process that is based on a careful individualized assessment, taking account the functional relationships between fear-eliciting
What the therapist and client do during and after an exposure: the “how?”
Across each of the models, obsessional thoughts and anxiety are thought to serve a discriminative function that signals the need to avoid and/or encourages escape. In other words, Monica׳s obsessions and anxiety are deemed bad, dangerous, and/or intolerable and necessitating a response, such as a compulsion. By engaging in avoidance or escape behavior, this pattern is strengthened. Although they differ procedurally, each of the approaches aim to change the way in which Monica responds to
How to know if exposure is activating the underlying mechanism
All four approaches emphasize the importance of collecting information regarding what the client actually experiences (anxiety, thoughts, feelings, urges) and how she responds when confronted with feared stimuli in order to assess whether learning is taking place. Both the habituation and inhibitory learning approaches ask the patient to rate the degree of overall distress or discomfort that she is experiencing during the exposure. In both approaches, the purpose of ascertaining these ratings
Summary
The focus of this commentary was to briefly highlight conceptual and procedural similarities and differences in why and how exposure therapy is conducted across various CBT approaches. In doing so, one unifying theme emerged. Regardless of the approach, exposure involves teaching the individual to confront feared stimuli, experience obsessional thoughts and distress, and behave differently in their presence. Across all of the approaches, overt or subtle therapist behaviors that signal that
Where do we go from here?
In their introductory statements, Conelea and Freeman state that the primary goal of this series of papers was to generate an empirically informed discussion about exposure process as a first step in linking theory with in-session therapist and client behaviors presumed to reflect “optimal exposure.” They have more than accomplished that goal. The masterful and accessible way in which each of the authors have tied exposure techniques to their presumed underlying processes provides substantial
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Comparison of patient-reported distress during harm avoidance and incompleteness exposure tasks for youth with OCD
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2021, Behavior TherapyCitation Excerpt :Exposure also elicits other forms of acute distress (e.g., disgust, incompleteness), which we include under the term “fear” for parsimony. Variants of mechanistic theory differ with respect to the neurocognitive underpinnings of exposure learning (e.g., inhibitory learning, emotional processing; Craske et al., 2018), yet there are many more similarities than differences across them with respect to recommended delivery (Himle, 2015). Most theories also implicate some form of fear change as a signal or facilitator of learning.
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2020, Exposure Therapy for Children with Anxiety and OCD: Clinician's Guide to Integrated TreatmentExposure Tasks in Anxiety Treatment: A Black Box That Still Needs Unpacking
2017, Journal of the American Academy of Child and Adolescent PsychiatryPlayful CBT with Children Diagnosed with OCD
2022, Creative CBT with Youth: Clinical Applications Using Humor, Play, Superheroes, and Improvisation