Guides
Setting up exposures that work
A practical guide to the inhibitory learning principles
Exposure was once explained as staying in the situation until the anxiety comes down. Anxiety often does come down, and it is a reasonable description of what a session looks like, but the drop within a session turns out to be a poor predictor of who gets better.
The better account, which researchers call inhibitory learning, is that the original fear is not erased. What treatment builds is a second, competing piece of learning. Part of it can come from the gap between what you expected and what actually happened, and with OCD a large part is learning that you can handle the anxiety and the uncertainty without the compulsion. Everything below follows from that.
This is my own summary, written for the people I work with. The framework comes from Craske and colleagues, and the two papers worth reading are cited at the end.
One. Know what you are expecting, and what the learning is
Write down what you expect before you start, including how long you think you could stay with it without the compulsion. Expectations about coping count as much as expectations about the feared outcome, and with OCD they are often the main ones. “I will not cope” is too vague to look back at. “I will have to check within ten minutes, and I will still be going over it at bedtime” is specific enough.
Many OCD fears cannot be checked, such as whether you might act on a thought. Do not design the exposure to prove those wrong, because looking for proof is a compulsion. Design it so that you stay with the doubt without settling it. Where the feared outcome can be checked, as with fainting in panic, design the exposure around that expectation rather than around the anxiety rating.
Two. Drop the safety behaviours (the things you do to feel safer)
While a safety behaviour is in place, your brain has somewhere else to put the outcome: it was fine, but only because I checked, or because someone was with me. The test does not count. If dropping one everywhere is too much at first, drop it completely in one situation rather than partially in all of them. Prescribed medication, inhalers, adrenaline pens and other medical equipment are not safety behaviours to drop. Keep taking and carrying them as prescribed, and speak to your doctor before changing anything.
Three. Vary it
Steady progress up a ladder produces learning that stays attached to the ladder. Varying the difficulty, the place, the time of day and the company produces learning that transfers. Occasionally doing something harder than the last one, then something easier, is deliberate rather than disorganised.
Four. Combine things you have worked on separately
Once two triggers have been worked on alone, doing them together produces a stronger test than either alone. Research suggests this can help gains last.
Five. Practise in more than one context
Fear that has only been tested in one room tends to return in other rooms. Different places, different people, and different states, including tired and stressed, all count as new contexts.
Six. Say what you are feeling, out loud
Putting the feeling into plain words during an exposure, rather than trying to argue it away or calm it down, may help. The research on this is still limited. Describing is not the same as reassuring yourself.
Seven. Do not measure success by how you felt
The question at the end is not “did the anxiety come down”, it is “what do I know now that I did not know before”, and with OCD the answer is often that you could stay with the doubt. A session where the anxiety stayed high and you did not do the compulsion is a good session.
Eight. Expect it to come back sometimes
Because the old association is still there, fear can return after a gap, in a new place, or under stress. That is the old learning coming back for a while, not a sign that treatment has failed. Occasional refresher practice, and knowing in advance what you would do, is what keeps the new learning available.
References
- Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., and Vervliet, B. (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.
- Craske, M. G., Treanor, M., Zbozinek, T. D., and Vervliet, B. (2022). Optimizing exposure therapy with an inhibitory retrieval approach and the OptEx Nexus. Behaviour Research and Therapy, 152, 104069.