Exposure Therapy With Response Prevention: What It Is And How It Is Used
It is possible that on some occasion it has happened to you that you have done something on impulse, without even thinking about it and without having compelling reasons to do it. For example, overeating when facing a state of anxiety, or arguing with someone without a justified reason, or buying things even if you don’t need them.
In all these cases there is some type of motivation or impulse behind it that we have not been able to or knew how to manage. This also occurs in different types of psychological problems that can lead to compulsive behaviors 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 behavioral exposure therapy with response prevention And it is about this therapeutic technique that we will talk about in this article.
Exposure therapy with response prevention: what is it?
It is called the exposure technique with response prevention to a type of therapeutic procedure used in the field of psychology. for the treatment of conditions and disorders based on maladaptive responses over which control is lost and that generate discomfort or loss of functionality.
It is a procedure based on the cognitive-behavioral current, of great clinical use and which has been shown to be beneficial. for the treatment of various pathologies, generally linked to anxiety Its objective is to modify behavioral patterns derived from the existence of aversive cognitions, emotions or impulses while facing negative cognitions and expectations on the part of the affected subject.
Its basic operation is based on the idea of ​​deliberately exposing or making the individual confront the situation or situations that generate discomfort or anxiety while preventing or preventing the problem behavior that these situations usually trigger.
In this sense, what is sought is for the subject to experience the corresponding anxiety or feeling of discomfort and be able to experience it without performing the behavior. until the anxiety naturally decreases to a point that is manageable (it is important to keep in mind that the goal is not necessarily for the anxiety to disappear, but rather to be able to cope with it adaptively), at which point the impulse or need to carry out the behavior is reduced.
This prevention can be total or partial, although the first is much more effective. It is essential that it is due to the person’s own actions and not to external imposition or involuntary physical restriction.
At a deep level we could consider that work is being done through habituation and extinction processes: we are trying to ensure that the subject manages not to carry out the response to be eliminated through the acquisition of tolerance to the sensations and emotions that usually lead to carrying it out. Likewise, through this habituation the link between emotion and behavior is extinguished, in such a way that there is a dishabituation of the behavior.
The advantages of applying this technique are multiple, starting with the reduction of the symptoms of various psychopathologies and the learning of coping techniques. It has also been observed that it contributes to increasing 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 series of basic steps Let’s see what each of them are.
1. Functional analysis of behavior
Before actually starting to carry out the procedure it is necessary to know everything possible about the problem behavior These aspects include what the problem behavior itself is, the degree of impact it generates on the patient’s life, antecedents, modulating variables and consequences of the behavior.
We must know how, when and to what this behavior is attributed, and the different elements that cause greater or lesser levels 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 they intend to do and why.
It is relevant to mention that what is intended is not to eliminate anxiety itself but rather to let it reduce until it is manageable (something that, on the other hand, and over time, can lead to its disappearance). After the explanation and if the patient accepts its application, we move on to performing the technique
3. Construction of 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 develop an exposure hierarchy.
In this sense, it must be carried out and negotiated between patient and therapist. a list of around ten to twenty highly specific situations (including all the details that can shape anxiety), which will subsequently 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 should be carried out per session, since the subject must remain in the situation until anxiety is reduced by at least half.
Each of the situations must be repeated until anxiety remains stably low in at least two exposures, at which point the next item or situation in the hierarchy will be moved on (in ascending order depending on the level of anxiety).
While exposing, The therapist must analyze and help the patient to verbally express his emotional and cognitive reactions Powerful reactions may occur, but exposure should not be stopped unless absolutely necessary.
Substitution or anxiety-avoidance behaviors must also be worked on, since they can appear and prevent the subject from really getting used to it. 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 is going to undergo before he or she does the same. Regarding response prevention, Providing clear and rigid instructions has been found to be more effective rather than providing generic instructions.
Response prevention can be for the entire duration of the complete treatment, only towards the behaviors that have been previously worked on in the exposures or for a certain time after the exposure (although it depends on the type of problem).
5. Discussion and subsequent assessment of the exhibition
After carrying out the presentation itself, the 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.
6. Assessment and analysis of the process
The results of the intervention should be monitored and analyzed, so that the presentations can be discussed and altered if it is necessary to include something new, or to show the achievements and improvements achieved by the patient.
The possibility that the problem behavior may occur at some point both when exposure occurs and in daily life must also be taken into account: Working on this type of behavior is not easy and can cause great distress for patients, which can lead to them breaking away from response prevention.
In this sense, it is necessary to show that these possible falls are a natural part of the recovery process and that in fact they can 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 very useful technique in multiple mental conditions, 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 anxiety-producing obsessive thoughts for the patient and which usually leads to rumination or the performance of compulsive rituals to reduce anxiety (something that ultimately ends up causing a reinforcement of the problem), it is probably one of the disorders in which ERP is most applied.
In Obsessive-Compulsive Disorder, EPR 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 can eliminate said ritual, at the same time that it could even reduce the importance given to the obsessive thought (something that would also reduce the obsession and the discomfort it generates). A typical example in which it is applied is in obsessions linked to pollution and cleaning rituals, or in those linked to the fear of attacking or harming loved ones and rituals of overprotection.
Another type of disorder in which ERP is used is impulse control disorders. In this sense, problems such as kleptomania or intermittent explosive disorder They may benefit from this therapy by learning not to engage in problem behaviors when the urge arises, or by reducing the strength of the urge to engage in 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 abstinent and relapse prevention is intended.
For example, in the case of people with alcoholism or gambling addiction, they can be exposed to situations that they associate with their habit (for example, being in a restaurant or bar) while preventing the response, as a way to help them cope with the desire to consume. or game since if they find themselves in said situation in real life they do not resort to addictive behavior.
4. Eating disorders
Another case in which it may be relevant is in eating disorders, especially in the case of bulimia nervosa. In these cases, exposure to feared stimuli can be worked on (such as the vision of one’s own body, influenced by cognitive distortions) or the experience of anxiety preventing the binge or later purge response. In the same way, it can also be useful in binge eating disorder.
Limitations
From what is known about the results obtained through exposure therapy with response prevention, This psychological intervention resource is effective against various types of mental disorders if applied consistently during several sessions carried out periodically. This makes it commonly applied in psychotherapy.
Of course, despite being highly effective in modifying behavior, it is necessary to keep in mind that the exposure technique with response prevention also has some limitations.
And although it is highly effective in treating problematic behavior and modifying it, by itself it does not work directly with the causes that led to the appearance of anxiety that led to motivating maladaptive behavior.
For example, you can treat the obsession-compulsion cycle for a specific behavior (the clearest example would be washing your hands), but even if you work on this fear, it is not impossible for a different type of obsession to appear.
In the case of alcoholism it can help treat cravings and help prevent relapses, but it does not help work on the causes that led to the acquisition of dependency. In other words: it is very effective in treating the symptom but it does not directly work on its causes.
Likewise, it does not deal with aspects linked to personality such as perfectionism or neuroticism, or hyper-responsibility, although it makes it easier to work on it at a cognitive level if said exposure is used as a behavioral experiment through which to carry out cognitive restructuring. This is why it is necessary that exposure with response prevention is not carried out as the only element of therapy, but rather there must be work at a cognitive and emotional level both before, during and after its application.
