Exposure as a Path to New Learning
One of the most crucial insights in creating effective exposure therapy is the understanding that extinction learning is actually a form of new learning, not just the weakening of previous associations. This means that while the original fear-based learning remains intact, new associations of safety compete with those old fear connections. Treatment is successful when the new, safety-based learning becomes the dominant response to the previously feared cues, such as an anxious anticipation of an audience in social anxiety disorder (Otto 2010).
In simpler terms, after exposure therapy, the meaning of fear inducing cues becomes mixed, holding both anxiety and safety associations. The role of the cognitive behavioural psychologist is to guide this process, ensuring that the sense of safety outweighs the old fear response so that cues that once triggered anxiety and avoidance no longer do so. Ultimately, the therapist's challenge is to structure the exposure process in a way that helps the patient fully recognize that the feared cues are actually somewhat safe (notice I'm accepting that life is uncertain by saying 'somewhat').
To help patients make lasting progress, I focus on linking their feared cues with positive, successful exposure experiences. This is done by guiding patients through exposures to a range of relevant cues and situations while using as many recall and generalization cues as possible. Essentially, the more vivid and meaningful the exposure is to the patient, where they can directly connect their fear with the fact that a negative outcome didn’t happen, the more impactful the learning will be. Additionally, the more a patient can rehearse and recall these positive learning experiences, the more accessible and useful they become.
The approach I use is grounded in animal learning research and experimental studies. However, it's worth noting that this approach aligns closely with cognitive perspectives that use "behavioural experiments" to challenge and change the core beliefs behind anxiety disorders. When extinction is seen as a form of new learning, and when techniques for reinforcing retention and recall are employed, such as using empowering cognitive cues like “I can handle this” or “these situations no longer bother me,” the difference between behavioural experiments in cognitive therapy and exposure interventions becomes less significant (Otto 2010).
When structuring exposure therapy for anxiety, I focus on three key tasks: (1) helping the patient identify the core fears driving the anxiety disorder, (2) using exposures to directly challenge those fears by demonstrating the patient’s ability to safely confront and manage the feared cues, and (3) ensuring that this ability is experienced across enough different contexts so that it becomes strongly embedded for future use (Otto 2010).
In identifying core fears, we recommend careful evaluation based on patterns observed in psychopathology research. For example, panic disorder is often characterized by fears and catastrophic interpretations of anxiety and panic symptoms, while social anxiety disorder tends to involve fears of humiliation or embarrassment. Although these core fears are common across individuals with these disorders, there can be significant variation in how these fears manifest. For instance, in panic disorder, one person may fear symptoms like dizziness and interpret them as a sign they will faint, while another may worry about falling, being scrutinized, or feeling incapacitated. By targeting exposure to the specific fears that the patient is experiencing, I provide the most relevant learning experiences, breaking the connection between the feared cue and its negative outcome. Using techniques like "downward arrow" questioning can help clarify the exact concerns that need to be addressed in exposure therapy.
Otto, M. W., & Hofmann, S. G. (2010). Avoiding treatment failures in the anxiety disorders (1st ed.). Springer.
