Today’s blog is by Sam Kramer, PhD, a clinician at Anxiety Specialists of St. Louis who specializes in working with adults who struggle with anxiety, OCD, phobias, and related disorders.
Exposure and response prevention (ERP) is typically our method of choice for treating anxiety. ERP is challenging and requires consistent effort, but it has life changing benefits and has strong research support. An important element of treatment involves purposely confronting fears, so it is very important you understand why doing so (in a therapeutic context) is in your best interest.
When a patient first hears about ERP they might think, “Wait…I wanted to see a therapist to decrease my anxiety, not purposely seek it out!” If you engage in exposures and don’t understand why you’re doing it, you will more likely feel as though you are putting yourself through unnecessary hardship and will receive less benefit. The intended purpose of this blog post is to help you understand why you will be asked to do things in therapy that temporarily increase your anxiety or discomfort.
How Anxiety Disorders Begin
There are two primary mistaken assumptions at play when anxiety becomes a problem in someone’s life:
- Overestimation of the severity and likelihood of a fear* (i.e., overly invested in the doubt or fear)
- Underestimation of one’s ability to cope with a feared outcome OR cope with the mere possibility/uncertainty of a feared outcome.
*The fear could be a literal situation or more abstractly an emotional state of being that is perceived to be intolerable.
When this occurs, people often go to great lengths to avoid or reduce the likelihood of the feared outcome (which is completely understandable). This is called “avoidant coping” or “safety behaviors” (or “rituals” in the OCD world). Avoidant coping may be overt behaviors (e.g., avoiding highway driving) or covert mental behaviors (e.g., worry, figuring out, over-analysis). Very quickly, the brain makes a very convincing (but mistaken) argument that:
- The avoidant coping is absolutely necessary in order to ensure that the feared outcome doesn’t take place.
- You must be literally certain the feared outcome won’t happen/isn’t possible before you can move forward with your life. Any doubt must be resolved before proceeding.
The relief that comes from avoidant coping is incredibly rewarding in the short term, so it is repeated. And just like that, an anxiety disorder is born.
Though anxiety might seem like the enemy, it is not. It is our response to anxiety (usually some form of resistance or avoidance) that causes most of the interference in our life and becomes what we classify as a “disorder.” If you have panic disorder, right now your brain may associate tingling hands with danger/threat (specifically: “My shaky hands mean I’m getting anxious and about to have a panic attack and lose control”). There may or may not be identifiable reasons why this association started, but it is the avoidant coping in the present that is maintaining the association and making the threat seem justified and real. The amygdala is the threat detection center of your brain, and each time it is triggered by an anxiety cue (e.g., doubt) and you respond with avoidant coping, it further reinforces the association between the trigger and the associated feared consequence. We can call this “Danger Learning.”
Reinforced danger learning: “Whew, that was close! If I didn’t do (safety behavior) then (the feared outcome) might have happened!”
A key point here is that even if there wasn’t actually any real danger, the avoidance itself gives convincing support to the perception that there was indeed real danger that was narrowly avoided.
ERP has two main objectives:
- Create an opportunity for your brain to learn realistic, healthier associations instead of the fear-driven associations.
- Increase your ability to retrieve this new knowledge across settings and apply it when triggered on your own.
Remember, the anxiety disorder is maintained by avoidance behaviors, which is why eliminating your mental and behavioral avoidance is the key ingredient that leads to recovery. Eliminate avoidance = eliminate the disorder. The act of refraining from avoidant coping is referred to as “response/ritual prevention.” So what role does exposure play? The primary purpose of intentionally seeking out anxiety cues (i.e., exposure) is to give your brain opportunities to practice the response prevention. It’s all about new learning. When pairing the anxiety cue (exposure) with response prevention, the brain has the opportunity to learn for itself that:
- The feared outcome was less severe or likely than predicted. (Your doubts are mistaken)
- You can indeed thrive while acknowledging the mere remote possibility of the feared outcome happening.
- Being “certain enough” is indeed good enough for moving on with life.
- The avoidant coping wasn’t actually keeping you safe. You no longer need it.
- You can live a meaningful, functional life even while experiencing anxiety and uncertainty.
We call this “Safety Learning.” A great bonus of this method is that you don’t have to take your therapist’s word for it. The learning happens through your own lived experience and is self-evident.
Just because you learn new healthy associations does not mean the old anxiety associations are gone. We cannot erase or undo memories. Both associations exist when the triggers are present. Think of it as a competition in your brain. Who will win…? The one that is practiced the most. Neurons that fire together wire together, and you want the neural pathway connecting the trigger with the desired response to be like a well-traveled interstate highway, leaving the fear pathway to be more like an overgrown path through the jungle. Both are still there, but we want to train the brain so the safety learning pathway wins the retrieval competition. The fancy word for this is “inhibitory learning” because the new safety learning takes over as the default response, thus inhibiting the previous danger learning.
Changing Your Brain for the Better
In summary, anxiety disorders are maintained when the brain mistakenly assumes that mental or behavioral avoidance is necessary to keep safe in feared contexts. Seeking out feared contexts makes therapeutic sense because doing so creates opportunities for the brain to learn and self-correct these unhelpful associations (as long as this was paired with response prevention). This is how you get your life back. You are literally changing your brain for the better! How cool is that!
Another key point is that it is important to have an attitude of curiosity and desire to learn when doing exposures. ERP is the how, and your recovery-oriented learning is the why. Afterall, you are not just seeking out anxiety provoking situations just for the sake of being anxious, you are doing it to learn. Values and fear are different sides of the same coin. When we pursue what is important to us, we inevitably come in contact with doubt, anxiety, and fear along the journey. Instead of seeing an anxiety inducing situation as suffering to be reluctantly endured, think of it as an opportunity to strengthen the pathway in your brain that supports resilience in the face of discomfort. There is profound purpose and meaning in exposures because by leaning into the anxiety you are also leaning into the things in life that you value most.
If it sounds like this approach to overcoming your anxiety is a good fit, you can call our care coordinator at 314-462-2965.