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10 Ways to Maximize Exposure Therapy (ERP)

10 Ways to Maximize Exposure Therapy (ERP)

Today, I'm talking about how to maximize the effectiveness of exposure therapy for panic disorder, OCD, social phobia, agoraphobia, and PTSD. Hi, I'm Paige Pradko. Welcome to Therapy for a Better Life. I had a client, a male in his fifties, and he came in to see me with very severe contamination OCD. And he also had exactness and orderliness OCD as well. He experienced six-to-seven-hour showers and two-hour hand washes. And his life was very controlled by the OCD. For treatment, we started doing traditional ERP. We created hierarchies. We worked our way up the hierarchy. He had a lot of success and his hand washing and showering came down to very reasonable times. And at that point he decided to terminate therapy. Well, he called me a few months later and all his symptoms had returned including his showers, his hand washing, and everything had returned almost as if we never did exposure therapy. So what do you think happened? Why did the exposure therapy fail?

I wanted to know the same thing and began researching. I found out that exposure therapy fails about 40 to 50% of the time. People may not improve, and their fear comes back, and all their symptoms come back in 20 to 62% of the time. (M. Craske (2014) Exposure Strategies, Stockholm Psychiatry Lecture Series 2014).

But we can improve this. I have dug into the recent research and have discovered 10 ways to help make exposures stick. Now I'm going to review the research. A few of the key neuroscientists in this area are Joseph LeDoux and Michelle Craske. Joseph LeDoux wrote a book a few years ago called Anxious: Using the Brain to Understand and Treat Fear and Anxiety. It's a fairly technical book but has a lot of great information in it. So what happens during an exposure is that our brain is learning and it's putting down a brand new neuro pathway in our brain to teach us that whatever it was that we feared, we really don't have to fear that thing, whether it is, a thought, maybe we're afraid of spiders or panic attacks or whatever we fear. We can put ourselves in that feared environment. We can expose ourselves to that thought. And our brain learns that we are not in danger, but the old original fear that neural pathway of the old original fear never goes away. And it's very strong and there are certain things that can make our new neural pathway actually dissolve. For example, if we let a lot of time go by and we're not exposing ourselves to those situations or thoughts or objects. If we're not doing that, the new neuro pathway fades. If I have social phobia and I don't go to a party for another four months or socialize regularly, my original fear is going to come back. Now, another thing that can happen is that if we only practice in one certain context. For example, if I'm afraid of elevators and I only do my exposure on one elevator, my exposure therapy is specific to that one elevator. I can have a panic attack on another elevator. And so, we must make sure that our context is varied, that we're doing exposure therapy in every possible situation, as every elevator with people with, without people different times of the day to really make a solid new neural pathway and good exposure. And the third thing of reason why exposures can fail is if we have unexpected trauma, unexpected, negative events, and loss. This is exactly what happened to my client. He had many different unexpected losses and trauma after he had finished exposure therapy and the exposure, he was not doing them enough. They weren't strong enough at that time to make it last.

So I'm going to review with you today. 10 key points on making your exposures last. Not a lot of therapists know this information. It's very new information. So please take notes. It's critical that you don't waste your time with exposures that don't work and incorporate these ideas into your exposures to make sure that they last. So, let's get to those 10 ideas to design into your exposures when we're doing them. It's always helpful to work with a therapist, but if you do not have a therapist available to you, for whatever reason, you can do this on your own, just take these things into account when you're designing your exposures.

The first one that I'd like you to remember, number one, is called violate what you expect. For example, if you fear having a panic attack when you go to the grocery store, and then you do an exposure at the grocery store and you learn that you did not have a panic attack. And yet you expected to have a panic attack. You did the exposure. You did not have a panic attack. There's a mismatch. That's what we want in an exposure therapy. That's how your brain learns. Oh, she didn't have a panic attack and your brain learns. Grocery stores are not dangerous. And so, we want to have a mismatch. We want you to violate what you expect in every exposure.

Number two is we want to practice exposures in multiple contexts. I talked about that a moment ago. If you remember with the elevator, we want to mix it up as much as we can for every exposure. Our original fear, whether it is a thought or the situation or the object that you're afraid of generalizes easily across to everything. Our exposures, however, don't generalize. Our exposures only impact what we do the exposure on. And therefore, we must mix it up as much as we can. If we have contamination fear, we must put ourselves in all kinds of situations and exposures where we feel contaminated. If we have a fear of having a panic attack, when we're away from our house, we have to do all kinds of exposures away from our house in all kinds of situations, alone with other people, different times of the day, mix it up much as you possibly can. So important.

Number three relates to scheduling exposures. We have learned that it is important to do an exposure, take a 10 minute break and then do another exposure. It's a process in the brain that's happening, and it works best if you do an exposure, take a 10-minute break, do another exposure. It's also better to do a series of several different exposures instead of one big long one. We've learned that too in research. And we've learned something interesting that to help our brain learn, do an exposure, and then as soon as you can afterwards, the take a nap. Or do an exposure at the very end of the day and go to bed. Our brain learns new information and consolidates it into long-term memory during a protein synthesis that happens when we're sleeping. And so this is even important when you're studying for an exam study and then go to bed because that's how the memory gets consolidated in the brain. Very important.

Number four, we have learned that cognitive therapy like cognitive reconstruction hurts exposure therapy. This is still controversial, but I no longer recommend cognitive reconstructing when someone is also doing exposure therapy. We don't want to change our thoughts and talk about why we shouldn't be afraid of such and such. It makes the exposure less effective. We don't want to risk disrupting the process until after exposure therapy is 100% complete. And any of those little phrases that you say to yourself to get yourself through the exposure may not be helpful. They actually make the exposure less effective. Try your best to not say anything or do any kind of relaxing or do anything to bring your fear down. During an exposure, our fear must be activated. Our amygdala must be activated in the fear center to form new safety learning neuropathways.

Number five, we want to vary the stimulus or the feared object. Whatever the feared object is, if it's public speaking, you want to vary it and have as many different ways of public speaking, different audiences and different situations. If you're afraid of spiders, you want to do exposure therapy on as many of different kinds of spiders. If it's a fearful thought, you want to expose yourself to that trigger and core fear in as many ways that you can. We want to vary it. And we also want to vary the intensity of our fear versus the old way of working up the hierarchy. In fact, I even talked about using a hierarchy in a video and now inhibitory learning research suggests that we know longer want to do that in exposure therapy. Instead, we want to switch it all up. It makes the exposure more effective. We want to start, maybe we start with an easy exposure, but then we might go high and then we might go medium. And we're going to mix up the hierarchy of fears all over the place so that our emotion is not just the same, going into every exposure, skip it around.

Number six, we want to label our emotion before, during and after the exposure. So before I'm afraid, I'm really scared to do this. I'm feeling terrified, you know, during the exposure, this is really uncomfortable for me. I don't, I don't like this. I'm feeling afraid. Maybe after the exposure, I'm feeling relieved. I'm glad I'm done. I thought it was going to be a little bit worse than it was.

Number seven is we want to have an occasional bad experience in an exposure. So, occasionally, let's say that I am afraid I'm going to have a panic attack. Again, I always use the grocery store…picking on grocery stores. I'm afraid I'm going to have a panic attack in a grocery store. And let's say I do several different exposures, different times of the day, different grocery stores. Sometimes I'm with people and sometimes I'm not. And all of a sudden I have a panic attack and I hadn't had one in a long time. That's good for exposure therapy, because it teaches your brain to tolerate anxiety, tolerate fear, and it makes it stronger. If occasionally, we have a bad exposure, don't let it discourage you. It's good for lasting exposure therapy.

The next one, number eight is we want to wean off the safety behaviors. I've talked about this in other videos as well. Sometimes we need safety behaviors at the very beginning of exposures for someone with agoraphobia. At first, they might want somebody with them going to different locations. Over time, we want to wean off any safety behaviors. They might be people, they might be carrying medicine with us. It might be always having our phone with us. We may also want to wean off benzodiazepines with medical management as there is evidence that they make exposure therapy ineffective. Sometimes however, low doses are used to help people begin exposures and then they are slowly discontinued under medical management.

We also want to introduce a phobic stimulus very briefly 30 minutes before our exposure. So, if we are going to do a contamination exposure, we very briefly introduce ourselves to a contamination just briefly before the exposure therapy, 30 minutes before. If we're doing an exposure on a thought, briefly introduce the thought to yourself 30 minutes before. The science behind that may be that we're activating our amygdala. Remember that it must be very active for an exposure to work.

The final number 10 is that we want to verbalize and review or consolidate our learning after every exposure therapy experience. Again, this research comes out of Inhibitory Learning Theory. During every exposure we want to review and verbalize what happened? What did we learn? It helps to consolidate it in our brain. So, you can ask yourself, what did I fear? Well, I feared doing public speaking. And you know, as I did the exposure, I went into my office, and I did a presentation in front of a couple of people. What happened when you were there? I was anxious, but as I got going, I became a little bit more comfortable. What did you learn from it? I learned that it wasn't quite as hard as I thought it was. I was scared going into it, but I realized that once I got going, my fear dropped, and I learned that it wasn't quite as bad as I thought. This is great because it is consolidating the learning into your brain. I would love to hear about anything that you found interesting in the video, and I look forward to seeing you next time. So an until then I will see you in session, take care. Bye-Bye.

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