Exposure therapy with response prevention: what is it and how is it used?

This psychotherapy tool is mostly used for anxiety and impulse control disorders.

It may have happened to you that you have done something on impulse, without even reflecting and without having a good reason to do it. For example, overeating when facing a state of anxiety, or arguing with someone without a justifying cause, or buying things even if you don't need them.

In all these cases there is some kind of motivation or impulse behind it that we have not been able to manage. This also occurs in different types of psychological psychological problems that can lead to compulsive behaviors over which there is little control over which we have little control and that for some reason can be harmful or highly limiting.

Fortunately, there are different means with which we can try to reduce or even eliminate these behaviors, among which we can find exposure behavioral therapy with response prevention.. And it is about this therapeutic technique that we will talk in this article.

Exposure therapy with response prevention: what is it?

It receives the name of technique of exposure with prevention of response to a type of therapeutic procedure used from the field of the psychology for the treatment of conditions and disorders based on maladaptive responses over which control is lost and which generate discomfort or distress. and that generate discomfort or loss of functionality.

It is a procedure based on the cognitive-behavioral current, of great clinical utility and which has proven to be beneficial. for the treatment of various pathologies, usually related to anxiety.. Its objective is to modify behavioral patterns derived from the existence of aversive cognitions, emotions or impulses, as well as to deal with negative cognitions and expectations on the part of the affected subject.

Its basic operation is based on the idea of exposing or making the individual face, in a deliberate way, the situation or situations that generate discomfort or anxiety while preventing or impeding the problem behavior that these situations usually trigger.

In this sense what is sought is that the subject experiences the corresponding anxiety or feeling of discomfort and is able to experience it without performing the conduct until the anxiety decreases naturally to a point where it is manageable. (it is important to bear in mind that the objective is not necessarily that the anxiety disappears, but to be able to face it in an adaptive way), moment in which the impulse or necessity to carry out the behavior is reduced.

This prevention can be total or partial, although the former is much more effective. It is essential that it is due to the actions of the person suffering from the problem and not to external imposition or involuntary physical restraint.

At a deep level we could consider that we are working through habituation and habituation processes. through habituation and extinction processesWe are trying to achieve that the subject manages not to perform the response to be eliminated through the acquisition of tolerance to the sensations and emotions that usually lead to perform it. Likewise, through this habituation the link between the emotion and the behavior is extinguished, so that there is a dishabituation of the behavior.

The advantages of the application of this technique are multiple, starting with the reduction of the symptomatology of various psychopathologies and the learning of coping techniques. It has also been observed that it contributes to increase self-efficacy expectations in patients, making them feel that they have a greater capacity to achieve their goals and cope with difficulties.

Some basic steps

The implementation of the exposure technique with response prevention involves following a number of basic steps. involves following a series of basic steps. Let us see what each of them are.

Functional analysis of the behavior

Before starting the actual procedure, it is necessary to know as much as possible about the problem behavior. it is necessary to know as much as possible about the problem behavior.. These aspects include what the problem behavior itself is, the degree of affectation it generates in the patient's life, antecedents, modulating variables and consequences of the behavior.

We must know how, when and to what the behavior is attributed, and the different elements that cause a greater or lesser level of discomfort to appear.

2. Explanation and justification of the technique

Another step prior to the application itself is the presentation to the patient of the technique itself and the justification of its importance. This step is essential since it allows the subject to express doubts and understand what is intended to be done and why.

It is important to mention that the aim is not to eliminate the anxiety itself, but to allow it to be reduced until it becomes manageable (something which, on the other hand, can eventually lead to its disappearance). After the explanation and if the patient accepts its application, the technique is performed..

3. Construction of the exposure hierarchy

Once the problem has been explored and the behavior to be treated has been analyzed, and if the patient agrees to carry out the procedure, the next step is to elaborate an exposure hierarchy.

In this sense, the patient and therapist must draw up and negotiate between patient and therapist a list of about ten to twenty highly specific situations (including all the details that may be involved). (including all the details that can model anxiety), which will later be ordered according to the level of anxiety they generate in the patient.

4. Exposure with response prevention

The technique itself involves exposure to the situations listed above, always starting with those that generate moderate levels of anxiety, while the subject endures and resists the need to carry out the behavior..

Only one exposure to one of the items per session should be carried out, since the subject should remain in the situation until anxiety is reduced by at least half.

Each of the situations should be repeated until the anxiety remains stably low for at least two exposures, at which point the next item or situation in the hierarchy (in ascending order of anxiety level) is moved on to the next item or situation in the hierarchy.

While exposing, the therapist should analyze and help the patient to externalize orally his emotional and cognitive reactions.. Powerful reactions may appear, but the exposure should not be stopped unless absolutely necessary.

Substitute or anxiety-avoidance behaviors should also be worked on, since they may appear and prevent the subject from actually becoming habituated. If necessary, an alternative activity can be provided as long as it is incompatible with the problem behavior.

It may be advisable that in at least the first sessions the therapist acts as a behavioral model, representing the exposure to which the subject will be subjected before he/she does the same. As far as response prevention is concerned, providing clear and rigid instructions rather than providing generic cues has been found to be more effective. rather than providing generic directions.

Response prevention can be for the duration of the entire treatment, only for the behaviors that have been previously worked with in the exposures or for a certain time after the exposure (although it depends on the type of problem).

5. Discussion and post-exposure assessment

After the exposition, therapist and patient can discuss the details, aspects, emotions and thoughts experienced during the process. The patient's beliefs and interpretations will be worked on at a cognitive level, if necessary applying other techniques such as cognitive restructuring.If necessary, other techniques such as cognitive restructuring can be applied.

6. Evaluation and analysis of the process

A follow-up and analysis of the results of the intervention should be carried out, so that the expositions can be discussed and altered if it is necessary to include something new, or to show the achievements and improvements made by the patient.

It should also be taken into account the possibility that at some point the problem behavior is carried out both when exposure occurs and in daily life: working with this type of behavior is not easy and can be very distressing. for patients, who may even break away from response prevention.

In this sense it is necessary to make it clear that these possible falls are a natural part of the recovery process and may in fact allow us to get an idea of elements and variables that had not previously been taken into account.

Conditions and disorders in which it is used

Exposure with response prevention is an effective and useful technique in multiple mental conditions, with the following being some of the disorders in which its success has been seen.

1. Obsessive-Compulsive Disorder

This problem, which is characterized by the intrusive and recurrent appearance of highly anxiogenic obsessive thoughts, is characterized by The fact that it often leads the patient to brooding or to performing compulsive rituals to reduce anxiety (something that ultimately ends up reinforcing the problem), is probably one of the disorders in which ERP is most commonly applied.

In Obsessive-Compulsive Disorder, ERP is used to achieve the elimination of compulsive rituals, whether physical or mental, seeking to expose the subject to the thought or situation that usually triggers the compulsive behavior without actually performing the ritual.

Over time the subject may eventually eliminate the ritualIn time, the subject may even reduce the importance given to the obsessive thought (which would also reduce the obsession and the discomfort it generates). A typical example in which it is applied is in the obsessions linked to the contamination and the rituals of cleanliness, or in those linked to the fear to attack or to do damage to the loved ones and rituals of overprotection.

2. Impulse control disorders.

Another type of disorder in which ERP is used is impulse control disorders. In this regard, problems such as kleptomania or such problems as kleptomania or intermittent explosive disorder could benefit from this therapy by learning not to perform the problematic behaviors when the impulse appears, or to reduce the strength of the impulse to perform them.

3. Addictions

It has been seen that the field of addictions, both substance-related and behavioral, can also be treated with this type of therapy. However, its application is typical of advanced phases of treatment, when the subject is abstinentwhen the subject is abstinent and relapse prevention is sought.

For example, in the case of people with alcoholism or gambling addiction, they can be exposed to situations associated with their habit (for example, being in a restaurant or a bar) while the response is prevented, as a way of helping them to cope with the desire to consume or gamble and that if they find themselves in that situation in real life they will not resort to the addictive behavior.

4. Eating disorders

Another case where it can be relevant is in eating disorders, especially in the case of bulimia nervosa. In these cases the exposure to feared stimuli can be worked on. (such as the view of one's own body, influenced by cognitive distortions) or the experience of anxiety preventing the binge response or subsequent purging. Similarly also in binge eating disorder it can be helpful.

Limitations

From what is known about the results obtained through exposure therapy with response prevention, this psychological intervention resource is effective against several types of mental disorders if applied consistently over several years. if it is applied consistently during several sessions carried out periodically. This is why it is commonly applied in psychotherapy.

However, despite being highly effective in behavior modification, it is necessary to take into account that the exposure technique with response prevention also has some limitations.

Although it is highly effective in treating problematic behavior and modifying it, by itself does not work directly with the causes that led to the appearance of the anxiety that motivated the maladaptive behavior. that led to motivating the maladaptive behavior.

For example, it can treat the obsession-compulsion cycle for a given behavior (the clearest example would be hand washing), but even if this fear is treated, it is not impossible that a different type of obsession may appear.

In the case of alcoholism, it can help to treat craving and help prevent relapse. and help to prevent relapses, but it does not help to work on the causes that led to the acquisition of dependence. In other words: it is very effective in treating the symptom but it does not work directly on the causes of the symptom.

Likewise, it does not deal with personality-related aspects such as perfectionism or neuroticism, or hyperresponsibility, although it makes it easier to work on them at a cognitive level if such exposure is used as a behavioral experiment through which to carry out cognitive restructuring. It is therefore necessary that exposure with response prevention should not be carried out as the only element of the therapy, but rather that there must be cognitive and emotional work both before, during and after both before, during and after its application.

Bibliographical references:

• Abramowitz, J.S., Foa, E.B. and Franklin, M.E. (2003). Exposure and ritual prevention for obsessive-compulsive disorder: Effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71, 394-398.
• Bados-López, A. & García-Grau, E. (2011). Exposure techniques. University of Barcelona. Faculty of Psychology. Departamento de Personalidad, Evaluación y Tratamiento Psicológicos.
• Nestadt, G.; Samuels, J.; Riddle, M.A.; Liang, K.I. et.al. (2001). The relationship between obsessive–compulsive disorder and anxiety and affective disorders: results from the Johns Hopkins OCD Family Study. Psychological Medicine 31.
• Rosen, J.C. y Leitenberg, H. (1985). Exposure plus response prevention treatment for bulimia. En D.M. Garner y P.E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia. Nueva York: Guilford.
• Saval, J.J. (2015). Exposición y prevención de respuesta en el caso de una joven con trastorno obsesivo-compulsivo. Revista de Psicología Clínica con Niños y Adolescentes, 2 (1): 75-81.
• Stephan WG, Stephan CW (1985). Intergroup Anxiety. Journal of Social Issues.