Exposure and Response Prevention

A different version of his article was published In the New Jersey Psychologist.

Randomized controlled trials have found that exposure and response prevention (ERP) is a powerful, probably the most powerful CBT intervention for panic, OCD, phobias, and PTSD. But I believe that ERP can also be a valuable therapeutic intervention for virtually all emotional disorders.

Part I of this article describes general principles of exposure and response prevention.

Part II explains how ERP is typically utilized in the treatment of panic, OCD, PTSD, and phobias.

Part III describes how ERP can be a powerful therapeutic technique for treating most emotional disorders.

Part IV shows how many common therapeutic techniques are at base exposure and response prevention.

Exposure means asking patients to expose themselves to their anxiety symptoms and to the situations that evoke their anxiety symptoms. Exposure sometimes occurs naturally, when patients experience anxiety as a reaction to their normal life events. Exposure can also be planned, when patients intentionally confront situations that evoke their anxiety symptoms. There are two main types of exposure:

2. Imaginal exposure is exposure in the imagination -- patients visualize themselves in anxiety-provoking situations.

To be effective, exposures should be frequent and prolonged. If too much time elapses between exposures, patients will regress and the benefits will be lost. Exposures should continue as patients’ anxiety increases, reaches a peak, and diminishes from that peak. For an exposure to be effective, patients’ anxiety should at least 50% from its peak.

During exposures, patients should try to get their anxiety as high as possible, and keep it there as long as possible. The more anxiety a patient experiences during an exposure, and the more the anxiety diminishes during the exposure, the more effective the exposure. If a patient does not experience any anxiety, the exposure will probably not be therapeutic.

In some treatment programs patients expose themselves to an anxiety provoking situation for three hours. This is usually not feasible in private practice, but telling this to patients conveys the importance of prolonged exposure. If a patient suffers from panic attacks, exposure will be most effective if, during panic attacks, the patient imagines having a heart attack, going crazy, dying, or whatever that patient fears most.

Asking patients to imagine their worst case scenario not only encourages them to do the most powerful exposure, but also sends the message that anxiety is good, that anxiety is therapeutic, and that anxiety is not to be feared or avoided. This helps to counteract the tendency of most patients to fear and avoid anxiety, and therefore avoid doing what is most therapeutic.

Although maximizing anxiety during exposures is the most effective technique, many patients are unable or unwilling to endure such intense anxiety. Most patients have to do graduated exposure, initially exposing themselves to mildly anxiety-provoking situations, and, as they learn to tolerate that level of anxiety, gradually exposing themselves to situations that elicit more and more anxiety.

When patients do imaginal or in vivo exposure, ask them to rate the anxiety level at the height of the exposure and at the end of the exposure. This enables both the therapist and the patient to determine the effectiveness of the exposure, and also helps determine when the patient is ready to move on to a more anxiety-provoking exposure.

Do what you can. If patients do not do their exposure homework, find less anxiety-producing exposures for them, and ask them to keep trying until they are able to do some ERP. Remind patients not to berate themselves for not doing their between-session exposures. Berating themselves lowers their self-esteem, makes it harder to do future exposure, and may cause them to drop out of treatment.

Bruce had the obsession that he would sexually molest his son. I asked him to do an imaginal exposure of molesting his son, being discovered, going to jail, and his family and friends reading about it in the newspaper. But he found this too anxiety-provoking. We tried various imaginal exposures, and learned that Bruce experienced less anxiety when:

1. The child in the imaginal exposure was an unknown child rather than his son.

2. When he talked about being arrested, going to jail and his friends and family reading all about it in the newspaper, rather than when he talked about molesting his son.

3. When he talked in general about “molesting” his son or another child, rather than when he specifically imagined touching his son’s penis.

So we began with exposure to the less anxiety-provoking situations, and over time Bruce was able to do exposures which provoked more and more anxiety, eventually including touching his son’s penis. These exposures dramatically reduced his anxiety over being with his son, and enabled Bruce to comfortably spend more and more time with his son.

Response prevention means that during exposure, patients do nothing to avoid, escape, or reduce their anxiety. For example, if a patient with acrophobia is at the top of a tall building, that patient should not look away from the window to reduce his anxiety. Here is a hierarchy of what patients can do during exposure, with the items listed in descending order of therapeutic value:

1. Focus on the situation provoking the anxiety, and imagine the worst possible outcome.

2. Pay attention to the anxiety, and do whatever they would do if they weren’t anxious.

3. Stop what they are doing and wait passively for their anxiety to diminish, then continue doing whatever they were doing before they became anxious.

During exposure patients should not leave the anxiety-provoking situation, call anyone, do anything that will calm them down, or go home or to a “safe” place. These actions will reduce their anxiety at the moment, but increase their anxiety the next time they experience the anxiety-provoking situation. Leaving the anxiety-provoking situation while still anxious impedes habituation and prevents patients from learning that the situation is neither dangerous nor intolerable.

Most compulsive handwashers are unable to completely refrain from washing their hands. Before beginning exposure with these patients, ask them to keep a record of how often and for how long they wash. Then ask them to gradually reduce the duration or the number of times they wash. For example, if they wash their hands 10 - 15 times a day, you can first ask them to commit to washing only 10 times every day. Once they become fairly comfortable with 10 washes a day, ask them to commit to wash eight times a day.

Some OCD patients compulsively check that their front door is locked before leaving their house because they fear being robbed. Ask these patients to leave home and wait 30 seconds before going back to check that they locked the door. When they successfully accomplish this partial response prevention, ask them to wait 60 seconds. After waiting a short time, OCD patients’ anxiety often diminishes enough for them to not perform the compulsion at all.

When patients finally completely refrain from performing their compulsions, they often report that they experienced little or no anxiety.

It is usually very helpful if patients learn to rate their anxiety during exposure on a scale of “0” - “10,” where “0” is no anxiety and “10” is the most anxiety the patient has ever experienced. There are at least three benefits of self-monitoring:

1. It enables patients to be more aware of their anxiety and the situations and cognitions that trigger it.

2. It enables patients to more accurately describe the intensity of their anxiety to their therapist.

3. It helps both patients and therapists track progress. As therapy continues, patients may not notice gradual reductions in their anxiety symptoms, but their self-monitoring may reveal that their average level of anxiety in a particular situation has diminished from 7 to 5.

1. Habituation. Habituation refers to the observation that if a person experiences a situation over and over, the person’s emotional reaction to that situation usually diminishes. When people eat a food they love over and over, their enjoyment of the food usually diminishes. Similarly, when patients experience an anxiety-provoking situation over and over, their anxiety reaction to that situation will usually diminish.

2. Cognitive change. When patients erroneously believe that a situation is dangerous or intolerable, and they experience that situation over and over, they usually learn that the situation is neither dangerous nor intolerable.

These two psychological processes can also work synergistically. When anxiety diminishes through habituation, patients can appraise anxiety-provoking situations more realistically and recognize that these situations are neither dangerous nor intolerable.

to their anxiety symptoms and to situationsthat provoke their anxiety symptoms,

Several studies have found that for most anxiety disorders, medication plus exposure and response prevention is no more effective than exposure and response prevention without medication (Abramowitz, et al., 2011). Two studies have found that medication plus exposure and response prevention for panic is less effective than exposure and response prevention without medication (Barlow et al., 2000; Otto, et al., 1996).

This is not surprising, since patients on either anti-depressant or anti-anxiety medication are exposed to less anxiety than patients who are not taking medication. By reducing the intensity of the anxiety, medication reduces the effectiveness of the exposure.

In addition, taking medication may strengthen patients’ beliefs that they cannot tolerate the situations that provoke their anxiety, or that these situations are dangerous. Medication may prevent patients from learning that these situations are neither dangerous nor intolerable.

I am not suggesting that patients with these anxiety disorders should never take medication. There are some cases in which medication works immediately and can prevent a serious loss, such as the loss of a job. Exposure and response prevention usually takes longer to achieve results.

Note that medication is helpful only so long as patients take the medication. After a course of medication patients will be just as anxious as they were before taking the medication. But the benefits of frequent and prolonged ERP endure, and often increase after termination.

Cloitre et al. (2002) point out that many PTSD patients reject exposure and response prevention or drop out of treatment because they are not willing to endure the discomfort of exposure. Cloitre has developed the STAIR program to prepare PTSD patients for exposure therapy. Although developed for PTSD, this program can also prepare patients for ERP for panic, OCD, and phobias.

I would add that any improvement in patients’ general psychological functioning will reduce their general distress and make them more willing to tolerate the discomfort of exposure and response prevention. So improving low self-esteem, resolving marital conflicts, and overcoming any psychological problem could be added to Cloitre’s program to prepare patients for ERP.

Cognitive interventions to reduce patients’ fears about exposure and response prevention can also be used to prepare patients to do ERP. For example, patients may fear that they will have heart attack if they do ERP for panic, or they may fear that if they imagine molesting a child, they will actually molest a child. Reducing these dysfunctional cognitions can reduce resistance to doing ERP.

Research has found that exposure is more effective when therapists accompany and guide patients during exposure exercises (Gloster et al., 2011). This is probably because patients are more likely to do ERP when accompanied by their therapists.

1. Inadequate psychoeducation. Patients will not do exposure unless they understand that exposure will cause distress in the short run, but resolve their psychological problem in the long run.

2. Inability to create or endure the anxiety provoked by exposure. Patients must be able to create and endure the emotional discomfort of exposure. ERP will not be effective for patients who are unable to create anxiety during exposure. If patients are not initially willing to tolerate the anxiety created by exposure, psychotherapy should focus on distress tolerance and on their other psychological problems to increase their willingness to undertake exposure and response prevention.

3. Brief or infrequent exposure. If patients leave the anxiety-provoking situation before their anxiety diminishes significantly, exposure may worsen the psychological problem. If too much time elapses between exposures, the psychological problem may worsen between exposures.

4. When the dysfunctional behavior is obtaining reinforcement. For example: When patients are receiving social security disability, getting attention, or getting out of unwanted or difficult responsibilities, like working or going to school.

5. Safety Behaviors are anything that diminishes anxiety during exposure. Carrying Xanax reduces anxiety for most patients, therefore carrying Xanax is a safety behavior that reduces the effectiveness of exposure, even if the patient never takes the Xanax. Powers et al. (2001) found that if a claustrophobic patient is in a locked room, treatment is less effective if the patient knows he or she can open a window and let some fresh air into the room. The possibility of opening a window to let in fresh air diminishes the effectiveness of this exposure, even if the patient never opens the window.

Sometimes patients will not endure exposure without their safety behaviors. In these cases, allowing the safety behavior might be considered a successive approximation until that patient is able to do ERP without safety behaviors.

6. Social phobias. Patients with social phobia make the following cognitive errors:

B. They believe that others view their social behavior as more inadequate than others do;

C. They overestimate the negative consequences of the social behavior they perceive as inadequate. So even if they practice exposure, social phobics never correct their faulty cognitions because they never learn that they are misperceiving their social behavior and its consequences. For social phobics, cognitive interventions to correct these misperceptions must be part of the treatment.

The vast majority of CBT theorists and researchers believe that panic, OCD, PTSD and phobias are caused by dysfunctional cognitions. Most leading CBT theorists and researchers, including David Barlow and Edna Foa, add some cognitive techniques to exposure and response prevention, but assert that ERP is the most powerful technique for changing dysfunctional cognitions to functional cognitions in patients who suffer from panic, OCD, PTSD, and phobias.

Once a patient develops panic attacks, the most important cause of panic attacks is the fear of panic attacks. Patients will generally accept the concept that the best way to overcome a fear is to do the thing you are afraid of. So the best way to overcome the fear of panic attacks is to have panic attacks. Of course agreeing to this abstract principle is far easier for most patients than intentionally provoking panic attacks and doing nothing to avoid, reduce, or escape their symptoms.

Exposure for panic attacks means experiencing panic attacks, or, more aggressively, seeking out situations that are likely to provoke panic attacks. Response prevention for panic attacks means doing nothing to avoid, escape, or diminish the panic symptoms. To increase the benefits of exposure for panic attacks, patients can focus their attention on their symptoms and imagine their worst case scenario – losing control, having a heart attack, going crazy, or embarrassing themselves.

Interoceptive exposure means asking patients to provoke panic symptoms during therapy sessions or at home. For example, patients can spin around to provoke dizziness, or they can breathe though a straw to provoke the feelings of suffocation. Interoceptive exposure often demonstrates to patients that their panic symptoms are neither dangerous nor intolerable. Interoceptive exposure is often helpful for patients who avoid situations that may provoke their panic symptoms, or make catastrophic appraisals of their symptoms.

Agoraphobia. Most patients who suffer from panic disorder have also developed agoraphobia -- fear and avoidance of places or situations that are likely to provoke their panic attacks. Agoraphobic patients often have certain “safe” areas -- places they are comfortable going, places where they never have had panic attacks. These places are usually close to home. Because panic patients have never had panic attacks in these “safe” places, patients believe they will not have panic attacks in these places, and therefore they do not fear these places. Because they are not fearful, they do not have panic attacks in these “safe” places.

Kevin’s mother was my patient. She told me that Kevin, her 10 year old son, was having panic attacks during the night and had become afraid to go to sleep. She agreed to my suggestion that she bring Kevin in for a consultation. Kevin told me that wakes up in the middle of the night, feels like he can’t breathe, starts sweating, his heart starts pounding, and he feels like he is suffocating.

I asked Kevin what he thought was happening to him. He said he feared that he was suffocating and would die. I began treatment with a cognitive intervention -- I told him he would faint and begin breathing involuntarily before he died. But how might he really suffocate and die? He thought for a moment and replied “If I was buried alive.” So I asked him to imagine that he was buried alive, couldn’t breathe, and he gradually suffocated to death. I asked him to keep visualizing this kind of death until his anxiety peaked and diminished by at least 50%.

After he performed the exercise, I asked Kevin to rate his maximum anxiety during the exposure on a scale of “1” to “10.” He immediately replied “14.”

Subsequently his mother told me that after this one exposure, Kevin had not had another panic attack, and was going to bed without a problem. Kevin has not had another panic attack in the twelve months since we did the imaginal exposure. However, I warned his mother that Kevin will probably develop other anxiety problems in the future, and would probably need more extensive treatment at that time.

Obsessions are repetitive, distressing, unwanted thoughts that come into the patient’s mind. The thoughts usually concern some kind of danger and often begin with the words “What if …. ?”

These obsessive thoughts create anxiety, and OCD patients usually develop compulsions -- repetitive, ritualistic behaviors that are attempts to reduce the anxiety created by obsessions.

“I better wash my hands very carefully to make sure I have killed any germs.”

In vivo exposure for OCD patients means putting themselves into situations that provoke their obsessions. In vivo response prevention for OCD means tolerating the ensuing anxiety, and not performing the compulsive behavior which is intended to reduce the anxiety. For example—

· Intentionally dirtying their hands (exposure), but not washing them (response prevention).

· Spending time with children in spite of the obsession of being a child molester.

Imaginal exposure and response prevention. OCD patients can perform imaginal ERP by visualizing themselves in situations that provoke their obsessions and their anxiety, and visualizing themselves not performing their compulsions. For example, they can visualize themselves having a fatal disease (exposure), but not going to a doctor (response prevention).

OCD patients can also write down or record their obsessions, then do exposure by frequently reading or listening to their written or recorded obsessions. To create maximum anxiety and obtain the maximum therapeutic benefit, the obsession should include with the outcome feared most by the patient.

Reassurance-seeking is a common compulsion of many OCD patients, especially those with medical OCD. Reassurance-seeking means asking friends or family members to assure them that they are o.k., or checking their symptoms on the internet to make sure they don’t have the disease they fear, or making constant visits to doctors, or taking frequent medical tests to make sure they don’t have that fatal disease. After obtaining reassurance, OCD patients usually feel better. But soon they begin to wonder, “What if a friend is saying I look o.k. to make me feel better?” ”What if the doctor missed something?” “What if the lab made a mistake?” OCD patients then seek out another friend or another doctor or another test “just to be sure.” For compulsive reassurance-seeking, response prevention means not asking friends if they look o.k., not going to doctors, and not requesting medical tests. Often, part of treatment is asking friends, family members, and doctors not to provide reassurance to OCD patients.

Differentiating exposure from compulsions. Certain behaviors can constitute either exposure, which is therapeutic, or a compulsion, which is countertherapeutic. For example, medical OCD patients who avoid any reminder of the disease they fear can do exposure by visiting internet sites that discuss that disease. But medical OCD patients who visit internet sites to seek reassurance that they don’t have a fatal disease can do response prevention by not visiting those medical websites. So the patient’s motive in visiting a medical website determines whether the visit is exposure, and therefore therapeutic, or reassurance-seeking, and therefore countertherapeutic.

Visiting doctors can similarly be therapeutic or countertherapeutic, depending on the patient’s motive. For OCD patients who constantly visit doctors to seek reassurance that they do not have a fatal illness, not visiting the doctor and not having medical tests constitutes response prevention and is therefore therapeutic. But other patients with medical OCD refuse to see doctors for fear that they will be told they have a fatal disease. For these patients, visiting doctors constitutes exposure and is therefore therapeutic.

Similarly, for patients who have the obsession that they are gay, and avoid anything related to being gay, visiting gay websites can constitute exposure and therefore be therapeutic. But for patients who compulsively visit gay websites to seek reassurance that they are not gay, refraining from visiting these websites constitutes response prevention and is therefore therapeutic.

Compulsions without obsessions. Sometimes compulsions occur without any identifiable obsession. Patients will explain that these compulsions are to make something “right,’ or “just so,” or “even.” For example, if they do something with their right hand, these OCD patients will feel a compulsion to do the same thing with their left hand.

Some OCD patients feel a compulsion to do something a certain number of times, and over time, these compulsions can become more and more elaborate. For example, not just checking that the front door is locked, but checking five times, or doing five sets of five checks that the door is locked.

Compulsions can gradually become more and more elaborated until they take up hours every day. One patient felt compelled to perform a 45-minute ritual before he could walk through any doorway. Once compulsions become elaborated, they are much harder to treat. So it is important to eliminate compulsions as soon as they begin, before they become elaborated and treatment-resistant.

To illustrate exposure for specific phobias, let’s consider a common phobia -- the fear of flying.

Clinical Vignette: Ruth Couldn’t Fly to California

Ruth wanted to see California but she had a flying phobia. It was of course not feasible for her to do frequent and prolonged exposure to flying, so we did successive approximations. First she drove to the airport and parked where she could see planes taking off and landing. Next she went into the terminal, walked around and sat down near the gate of a flight to California. With each of these steps she was initially very anxious, but after several exposures her anxiety diminished.

She terminated treatment before flying to California, but ten days later I received a card from her that was postmarked California.

Ost et al. (1997) used some cognitive techniques in addition to exposure for patients who were so fearful of flying that they were unable to take a one--hour flight. The first two sessions took place in the therapist’s office. These sessions were devoted to eliciting the patient’s catastrophic thoughts about flying, and correcting misinformation about the dangers of flying. The third session was spent at the airport watching planes take off and land, and observing safety procedures. The fourth session was spent taking a simulated flight in a simulator that airlines use to train personnel.

The fifth session was longer and consisted of the patient and therapist riding the bus to the airport; waiting to board the plane; taking the flight; buying return tickets; and finally taking the return flight home. The therapist accompanied the patient and asked the patient to rate how strongly he or she believed the catastrophic thoughts about flying.

At post-treatment, 24 of the 28 patients were able to take the flight. At the one-year follow-up, 18 of the patients were able to take a one hour flight. Note that six patients in this study relapsed between the end of treatment and the one year follow-up. The authors speculate that this deterioration was due to the lack of continued exposure to flying after treatment ended. In fact, all six patients who relapsed had occupations which did not require flying. This finding supports the assertion that exposure and response prevention may not be effective unless it is frequent as well as prolonged. If too much time passes between exposures, the benefits of exposure may be lost.

Edna Foa’s theory (Foa & Kozak, 1986) asserts that PTSD is maintained by dysfunctional cognitions, mainly about danger. Her theory also asserts that PTSD patients must emotionally process the traumatic event, and come to clearly understand their thoughts and feelings, in order to change their dysfunctional cognitions and overcome their PTSD. Rumination about the traumatic event impedes the emotional processing of traumatic or difficult events, but in vivo or imaginal exposure enables patients to process these events, clarify their emotions and cognitions, and eventually change their dysfunctional cognitions and dissipate their dysfunctional emotions.

Clinical Vignette: Bruce Saved the Lives of Two Children

Bruce was driving in a residential neighborhood when he noticed a crowd of people clustering around a house. When he got closer he realized that the house was on fire and two children were visible in a second storey window. Bruce was shocked that no one was doing anything. He yelled for someone to bring a ladder, and he climbed up and carried the children down the ladder to safety. Later the house exploded in flames.

Bruce felt good about his rescuing the children until he learned that a third child had perished in a back room.

Bruce became distraught that he had rushed to save the two visible children without thinking to ask if anyone else was in the house. He blamed himself for the death of the third child. He developed nightmares about the incident, flashbacks of the incident, plus insomnia, anxiety and depression.

Bruce’s treatment consisted of imaginal exposure to the incident, plus work on his more general tendency to blame himself for any weakness, mistake, or failure. In our sessions he described the incident over and over, including the events, his thoughts during and after the event, the sensations he experienced during the event, and his complex emotional reactions. As he described the events and his reactions, I asked him to visualize the incident, describe it in the first person, and imagine it was actually happening in the present.

After doing multiple exposures his emotional reactions began to diminish, his self-criticisms began to subside, and his PTSD symptoms remitted. Eventually his cognition “My carelessness caused the death of the third child” diminished and was replaced by “I saved two children and I did a lot more than the others who were just standing around doing nothing. Someone should have told me that there was a third child.”

Note that in the above vignette, I never challenged Bruce’s self-blame, and I never suggested the new cognition to him. In accordance with Foa’s theory, as he emotionally processed the traumatic event, his dysfunctional emotion diminished, he stopped blaming himself, and he adopted a more realistic cognition. Exposure, a purely behavioral intervention, had led to spontaneous cognitive change.

Part III – Reformulating ERP to Treat A Wide Variety of Emotional Disorders

We originally defined exposure and response prevention as “Asking patients to expose themselves to their anxiety symptoms and to the situations that provoke their anxiety symptoms while doing nothing to avoid, escape, or reduce their anxiety.”

But suppose we reformulate ERP more generally as “Asking patients to expose themselves to their psychological distress, and to situations that provoke their distress, but do whatever they would do if they weren’t experiencing that distress.” Using this more general definition, we will find that ERP can be helpful or is actually the treatment of choice for a wide variety of emotional problems. Let’s consider a few emotional problems other than panic attacks, OCD, phobias and PTSD.

Relaxation and worry control are the most common CBT interventions for generalized anxiety disorder. Since GAD is not situation-specific, it is sometimes difficult for GAD patients to expose themselves to anxiety-provoking situations. But exposure and response prevention can be utilized when GAD patients do experience more intense anxiety.

Clinical Vignette: Gladys Cleaned When She Was Anxious

Gladys experienced intense GAD which had prevented her from working at certain points in her life. She had been hospitalized for this condition once. After about a year of treatment her GAD was 50% better. At this point her husband came in with her to discuss their marriage. He mentioned that whenever Gladys was anxious, she started cleaning furiously. Applying ERP for Gladys, I suggested that the next time she felt the impulse to clean, she just sit down and pay attention to her feelings.

At the start of her next session she said “It worked.” She explained that she had experienced the impulse to clean, but instead of cleaning she had sat down and paid attention to her feelings. Recognized what she was anxious about and her anxiety slowly dissipated. This technique continued to effectively dissipate her anxiety whenever she experienced the impulse to clean.

For Gladys the exposure was sitting down and paying attention to her feelings, and the response prevention was not cleaning.

What I called ERP for Gladys has also been called “mindfulness of the emotions,” one form of the currently popular mindfulness movement. I had asked Gladys to be mindful of what she was feeling at the moment, and to do nothing to avoid, escape, or reduce her distressing feelings. Looked at from this point of view, mindfulness of the emotions could be considered exposure and response prevention.

ERP can be reformulated as “Asking patients to expose themselves to their psychological distress

and to situations that provoke their distress, but to do whatever they would do

2. Negative feelings about themselves -- feeling worthless, inadequate, like a failures.

Now let’s think of exposure as patients exposing themselves to their psychological distress and to the situations that provoke their distress. And let’s think of response prevention as doing whatever they would do if they didn’t experience that distress. From this viewpoint, ERP for depression would address the two most important characteristics of depression as follows:

1. Inactivity. Patients experiencing low energy, but not acting in accordance with their low energy would mean getting out of bed in the morning and going to work or school, even when they feel that this would be an intolerable burden. This is behavioral activation, one important component of all CBT protocols for treating depression.

2. Negative feelings about themselves. Exposure would mean asking patients to experience their negative feelings about themselves and the situations that provoke these feelings. Response prevention would mean doing whatever they would do if they didn’t feel so negative about themselves. For example, patients would undertake tasks which are appropriate to their skill level, but which their depression tells them they are inadequate to deal with. And achieving success in these tasks would demonstrate to depressed patients that their negative feelings about themselves are unrealistic. Undertaking appropriate tasks and achieving some successes will increase self-esteem and constitutes another important component of most CBT protocols for treating depression.

Experiencing negative feelings about yourself also means just experiencing them, not analyzing them, not judging them, not trying to understand the meaning or the causes of these feelings. In humanistic psychotherapy, and also in CBT, trying to understand or analyze emotions is viewed as a way of avoiding fully experiencing those emotions.

Treating depression with imaginal exposure. Kandris and Moulds (2008) describe the case of a 55-year-old man who was experiencing major depression precipitated by the loss of a relationship due to a prolonged argument four months earlier. The patient also experienced anxiety-producing memories of the argument several times a day, and these memories produced a subjective level of distress of 100 on a scale of 0 - 100. Treatment consisted of five weekly 90-minute therapy sessions in which the patient described the argument in a first-person narrative for 50 minutes, imagined the argument, and re-experienced the argument emotionally and physiologically.

At post-treatment he no longer met the criteria for major depression, he had not experienced any intrusive memories the preceding week, and his level of distress over the memory was 0.

Clinical Vignette: George Felt Controlled and Martha Felt Abandoned

Martha had a tendency to feel abandoned, and her husband George had a tendency to feel controlled. From time to time George went out in the evening and didn’t tell Martha where he was going. Martha’s tendency to feel abandoned caused her to fear he was seeing another woman. In fact, George was playing cards with friends. He didn’t want to tell Martha because that would make him feel as if he had to “report his every movement” to her. George’s tendency to feel controlled caused him to feel Martha was trying to control him when she was simply curious about where he was going.

George telling Martha where he was going would of course be the appropriate thing to do. But it wouldn’t help Martha overcome her tendency to feel abandoned. Exposure for Martha’s tendency to feel abandoned would consist of George going out without telling her where he was going, provoking Martha’s distressing feelings of abandonment. Response prevention for Martha would mean not acting on her distressing feelings, not insisting that George tell her where he was going.

But for George, exposure would be telling Martha where he was going, provoking his distressing feeling of being controlled. And response prevention for George would mean not acting on those distressing feelings, not complaining about Martha wanting to know where he was going.

George not telling Martha where he was going would be an excellent opportunity for her to overcome her tendency to feel abandoned. And George telling Martha where he was going would be an excellent opportunity for him to overcome his tendency to feel controlled. But the first step in treatment would be for Martha and George to accept that their distressing feelings were caused not by the other’s behavior, but by their own tendencies to feel controlled and abandoned.

ERP, systematic desensitization, and EMDR. Controlled research has found that exposure and response prevention is the active ingredient in both systematic desensitization and EMDR. Remove the hierarchy construction and progressive muscle relaxation from systematic desensitization, and the treatment will be just as effective. Remove the eye movements from EMDR, and that treatment will be just as effective (Davidson & Parker, 2001). But when you remove the eye movements from EMDR and you remove the hierarchy construction and relaxation from systematic desensitization, what do you have? Exposure and response prevention.

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When you remove the eye movements from EMDR, and when you remove the relaxation and hierarchies

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ERP and Acceptance and Commitment Therapy. This currently very popular form of CBT has three important components:

But “accept rather than avoid your internal experiences” really means “expose yourself to your distressing emotions and cognitions.” Those are the emotions and cognitions that patients tend to avoid. And “pursue your valued goals in spite of your negative emotions and cognitions” is another way of saying“ do whatever you would do if you weren’t experiencing distressing emotions.”

ERP and psychodynamic therapy. The most important component of contemporary psychodynamic therapy is providing an empathic therapeutic relationship where patients feel safe to face and explore their deepest thoughts and feelings. Patients do this repeatedly, and eventually their dysfunctional emotions dissipate and their dysfunctional cognitions change to functional cognitions. In psychodynamic therapy, this occurs without the therapist challenging the patient’s dysfunctional cognitions or suggesting functional cognitions. In other words, psychodynamic therapy is an example of imaginal exposure.

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I once did a workshop where a psychodynamic therapist and I discussed how each of us would treat a patient who was unassertive with her husband. The essential difference between us was that I would tell the patient, “I think you should go home and say XYZ to your husband.” The psychodynamic therapist would say to the patient, “I wonder why you don’t go home and say XYZ to your husband?” But substituting a questioning attitude for my homework suggestion does not change the fact that we were both suggesting that the patient to expose herself to a situation that would provoke distressing feelings.

So whenever you aren’t sure how to proceed with certain patients, consider utilizing this reformulation of ERP:

Ask these patients to expose themselves to their psychological distress and to the situations that provoke their distress, but do whatever they would do if they weren’t experiencing that distress.

Abramowitz, J.S., Deacon, B.J., & Whiteside, S.P.H. (2011). Exposure therapy for anxiety. New York: Guilford Press.

Barlow, D.H. Gorman, J.M., Shear, M.K., & Woods, S.W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. J. of the American Medical Association, 283, 2529-2536;

Cloitre, M., Koenen, K.C., Cohen, L.R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure. Journal of Consulting and Clinical Psychology, 70, 5, 1067-1074.

Davidson, P. R. & Parker, K. C. H. (2001). Eye movement desensitization and reprocessing (EMDR): A met-analysis. Journal of Consulting and Clinical Psychology. 69, 305-316.

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