Jonathan Abramowitz Addresses NJ-ACT on New Concepts in Exposure for Anxiety Disorders
By Lynn Mollick
On Sunday, April 10, Jonathan Abramowitz delivered NJ-ACT’s 21st Master Lecture to 88 mental health professionals. Below is a summary of Dr. Abramowitz’s afternoon lecture, “New Concepts in Exposure for Anxiety Disorders.”
According to Dr. Abramowitz, Exposure is the most powerful technique for treating anxiety. There are 3 kinds of Exposure for fear and anxiety:
1) In vivo Exposure means confronting fears in real life, touching objects that might be contaminated, crowds, handling snakes, etc.
2) Imaginal Exposure means confronting fears in the imagination.
3) Interoceptive Exposure means intentionally provoking feared physical sensations such as a pounding heart or dizziness.
Therapists have used Exposure since the beginning of CBT, but over the years understanding of this technique has evolved. Foa & Kozak’s 1986 Emotional Processing Theory was the accepted explanation for Exposure’s success for many years. According to Emotional Processing Theory, Exposure works by habituation and cognitive change. When stimuli that provoke anxiety are experienced over and over, eventually the anxiety response diminishes through habituation and cognitive change results — patients learn that they do not need to fear stimuli that previously evoked anxiety.
According to Emotional Processing Theory, anxiety must be elicited during Exposure, and it must diminish within and between Exposure sessions. However, research has found that sometimes anxiety does not diminish during Exposure, but patients improve anyway. And sometimes anxiety does diminish during Exposure, but patients do not improve. Dr. Abramowitz stated that therapists may be relying too heavily on the habituation model. Other models – Inhibitory Learning (IL) and Acceptance & Commitment Therapy (ACT) – suggest that slightly different Exposure interventions may be more helpful.
Inhibitory Learning (IL)
Animal research on extinction indicates that fears are never truly extinguished or “unlearned.” According to the IL model, a new, non-fear response develops during Exposure. This new non-fear response inhibits, but does not eliminate, the original fear response. The old fear response may return with the passage of time, in new contexts, or when the individual is surprised.
According to the IL model, fear does not need to habituate during EXP. According to IL theory, during Exposure patients learn fear tolerance, they learn to accept fear instead of fearing it. Anxiety is not something “bad” that must be gotten rid of. Anxiety is a normal human response that patients can accept and tolerate. Note that these concepts have not been demonstrated with human subjects.
The IL model leads to the following procedural modifications of Exposure:
1) Frame Exposure as an opportunity to develop new expectations. Set up Exposure as an experiment, a way to violate patients’ expectation that they will experience intolerable fear. Instead of tracking Subjective Units of Discomfort (SUDS), track expectations. Did what you expected happen? Was it as bad as you expected? If you became upset, was it as difficult and embarrassing as you expected? When the feared outcome is in the future, ask “How hard is it to live with the uncertainty that you will experience intense fear?
2) Make the effects of Exposure as surprising as possible for maximum change in expectations of fear. Avoid cognitive interventions before Exposure because they reduce the element of surprise.
3) After an Exposure exercise, ask patients to summarize what they learned. This will facilitate change in expectations of fear.
4) Expose patients to a variety of feared situations. Inhibitory learning is stronger when patients are exposed to multiple situations that evoke the fear response.
5) Linguistic Processing means asking patients to put labels on their feelings during Exposure. This facilitates development of a non-fear response.
6) Vary Exposure intensity. Instead of using a hierarchy, simply give patients an Exposure “to do list”, or to pick Exposures out of a hat. You don’t want to suggest that items high on the hierarchy are “hard,” because this idea strengthens fear of anxiety.
7) Gradually fade exposure sessions. Begin with twice a week, and then move to once a week, followed by every other week. This allows patients to forget and then re-learn the inhibitory non-fear response.
Acceptance & Commitment Therapy (ACT) to Encourage Exposure
According to ACT, anxiety, in and of itself, is not a problem. Problems occur when people try to avoid anxiety, because avoiding anxiety prevents patients from achieving their valued goals. ACT encourages patients to do Exposure not to overcome anxiety, but rather to reach their valued goals.
To assess valued goals, Dr. Abramowitz favors a bull’s eye target divided into quadrants labeled “relationships,” “work & education,” “personal growth & health,” and “leisure.” Patients mark the target in each of these four quadrants to indicate how closely they approach the bull’s eye in each aspect of their life.
Pursuing valued goals inevitably leads patients to confront feared and avoided thoughts, feelings and situations, i.e. to do Exposure.
ACT uses metaphors to motivate patients to confront experiences they fear and avoid. Dr. Abramowitz described the “Man in the Hole” metaphor and how to use it to motivate patients to do Exposure. Ask your patient:
“Can you imagine a man in a deep hole who is trying to get out, but his only tool is a shovel? What happens if he keeps digging? He only digs himself in deeper and he can’t get out. If the hole is your anxiety, what is the shovel? The shovel is trying to avoid anxiety. So, what do you conclude? You need a new tool, something other than avoiding anxiety.”
The new tool is willingness to accept anxiety. Treatment is about pursuing valued goals and learning to experience and accept anxiety. Dr. Abramowitz showed several video clips where patients did Exposure using these metaphors for guidance. Before and after each Exposure, the therapist asked how willing the patient was to accept unpleasant experiences. With each Exposure, patients experienced more willingness to pursue valued goals in spite of their anxiety.