Exposure therapy with response prevention: what it is and how it is used

There may have been times when you did something on impulse, without at least thinking about it, and without having a compelling reason to do it. For example, overeating when you are anxious, arguing with someone for no reason, or buying things even if you don’t need them.

In all of these cases, there is some kind of motivation or impulse behind it that we haven’t been able or able to handle. This also occurs in different types of psychological problems that can lead you to compulsive behaviors over which there is little control and which for some reason can be damaging or severely limiting.

Fortunately, there are different ways by 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 this therapeutic technique that we will talk about in this article.

    Exposure therapy with response prevention: what is it?

    This is called an exposure technique with prevention of response 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 which generate discomfort or loss of functionality.

    It is a procedure based on the cognitive-behavioral stream, of great clinical utility and which has been shown to be beneficial. for the treatment of various pathologies, generally related to anxiety. It aims to modify behavioral patterns derived from the existence of aversive cognitions, emotions or impulses at the same time as dealing with negative cognitions and expectations on the part of the affected subject.

    Its basic functioning is based on the idea of ​​exposing or dealing with the individual, deliberately, the situation (s) generating discomfort or anxiety at the same time as the problematic behavior that these situations usually trigger is prevented or prevented. .

    In this sense, what is desired is that the subject experiences the corresponding anxiety or feeling of discomfort and is able to experience it without performing the behavior. until the anxiety naturally decreases to a manageable point (It is important to keep in mind that the goal is not necessarily to get rid of anxiety, but to be able to cope with it adaptively), how much the motivation or the need to achieve the behavior is reduced.

    This prevention can be total or partial, although the former is much more effective. It is essential that this is due to the actions of the person suffering from the problem and not to external imposition or unintentional physical duress.

    At a deep level, we might consider the work to be in progress through addiction and extinction processes: We try to ensure that the subject manages not to realize the response to be eliminated by acquiring tolerance to the sensations and emotions which usually lead to it. Likewise, through this habituation, the link between emotion and behavior is extinguished, so that there is a cessation of behavior.

    The benefits of applying this technique are many, starting with reducing symptoms of various psychopathologies and learning coping techniques. It has also been observed to help increase expectations of self-efficacy in patients, making them feel that they have a greater ability to achieve their goals and cope with difficulties.

    Some basic steps

    The implementation of the exposure technique with prevention of responses involves following a number of basic steps. Let’s see what each is.

    1. Functional analysis of behavior

    Before starting the procedure correctly you need to know as much as possible about the problematic behavior. These aspects include the problematic behavior itself, the degree of affect it generates in the patient’s life, the context, the modulating variables and the consequences of the behavior.

    You have to know how, when and to what this behavior is attributed, and the different elements that show a more or less level of discomfort.

    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 because it allows the subject to express doubts and understand what to do and why.

    It is relevant to mention that it is not a question of eliminating the anxiety itself but of letting it reduce in order to become manageable (which on the other hand and over time can lead to its disappearance). After the explanation and if the patient accepts its application, the technique is performed.

    3. Construction of the exhibition hierarchy

    Once the problem has been explored and the behavior to be treated analyzed, and if the patient agrees to perform the intervention, the next step is to establish a hierarchy of exposures.

    In this sense, it must be carried out and negotiated between the patient and the therapist a list of ten to twenty very concrete situations (Including all the details that can shape the anxiety), which will then be sorted according to the level of anxiety they generate in the patient.

    4. Exposure with prevention interventions

    The technique itself involves exposure to the situations mentioned above, always starting with those that generate moderate levels of anxiety, while the subject endures and resists the need to perform the behavior.

    Only one exposure to one of the elements per session should be done, as the subject will need to remain in the situation until the anxiety is reduced by at least half.

    Each of the situations should be repeated until the anxiety remains stable for at least two exposures, at which point it will move to the next item or situation in the hierarchy (in ascending order based on anxiety level) .

    By exhibiting, the therapist must analyze and help the patient to orally externalize his emotional and cognitive reactions. Powerful reactions may appear, but the exposure should not stop unless absolutely necessary.

    The substitution or avoidance behaviors of anxiety must also be worked on, because they can appear and prevent the subject from getting used to them. If necessary, you can offer an alternative activity as long as it is incompatible with the problematic behavior.

    It may be desirable that at least in the first few sessions, the therapist acts as a role model, representing the exposure to which the subject has been subjected before doing the same. In terms of response prevention, it has been found to be more effective to provide clear and rigid instructions instead of providing generic indications.

    Prevention of response may be for the duration of the entire treatment, only for behaviors that have been worked on before exposures or for some time after exposure (although this depends on the type of problem)

    5. Discussion and subsequent evaluation of the exhibition

    After the presentation itself, the therapist and the patient can come in to discuss the details, aspects, emotions and thoughts felt during the process. The beliefs and interpretations of the patient will be worked on at the cognitive level, If necessary by applying other techniques such as cognitive restructuring.

    6. Process evaluation and analysis

    Monitoring and analysis of the results of the intervention should be done, so that they can discuss and modify the presentations if something new needs to be included, or to show the successes and improvements made by the patient.

    He It is also worth considering the possibility that at some point the problematic behavior can occur both during exposure and in everyday life: working on these types of behaviors is not an easy task and can be very painful for patients, who may break down for neglecting response prevention.

    In this sense, it is necessary to show that these are possible Falls are a natural part of the recovery process and can in fact allow us to get an idea of ​​elements and variables that had not been taken into account before.

    Conditions and disorders in which it is used

    Response prevention exposure is an effective and very useful technique in multiple mental conditions, the following being some of the disorders in which its success has been observed.

    1. Obsessive-compulsive disorder

    This problem, which is characterized by the intrusive and recurring appearance of very anxious obsessive thoughts for the patient and which usually leads to contemplation or to performing compulsive rituals to reduce anxiety (which ends up causing a reinforcement of the problem), is probably one of the disorders in which it is applied the most.

    In obsessive-compulsive disorder, the RPE is used to eliminate compulsive rituals, both physical and mental, seeking to expose the subject to the thought or situation that typically triggers the compulsive behavior without performing the ritual.

    Over time, the subject he can even eliminate this ritualWhile at the same time, it might even reduce the emphasis placed on obsessive thinking (which would also reduce the obsession and discomfort it generates). A typical example in which it is applied is in obsessions related to pollution and cleaning rituals, or in those related to fear of assaulting or hurting loved ones and overprotective rituals.

      2. Impulse control disorders

      Another type of disorder in which RPE is used is in impulse control disorders. In this way, problems such as kleptomania or intermittent explosive disorder they could benefit from this therapy by learning not to perform problem behaviors when the impulse arises, or by reducing the strength of the impulse to perform them.

        3. Outbuildings

        It has been shown that the area of ​​addictions, both substance and behavior related, can also be treated with this type of therapy. however, its application is typical of advanced stages of treatment, When the subject is abstinent and relapse prevention is considered.

        For example, in the case of people suffering from alcoholism or gambling addiction, you may be exposed to situations associated with their habit (for example, being in a restaurant or bar) while the response is anticipated, in order to help them manage the desire. for consumption or gambling because if they are in this situation in real life, do not resort to addictive behavior.

        4. Eating disorders

        Another case where this may be relevant is with eating disorders, especially bulimia nervosa. In these cases, exposure to feared stimuli can be worked out (Like seeing your own body, influenced by cognitive distortions) or feeling anxiety preventing overreacting or purging afterward. Likewise, it can also be helpful in binge eating disorders.

        limits

        Based on what is known about the results of exposure therapy with response prevention, this psychological intervention remedy is effective against various types of mental disorders if it is applied consistently over several sessions conducted regularly. This makes it commonly applied in psychotherapy.

        However, although it is very effective in modifying behavior, it should be borne in mind that the exposure technique with response prevention also has certain limitations.

        And it is that although it is very effective in treating problematic behavior and modifying it, by itself, it does not work directly with the causes that led to the onset of anxiety which led to motivating maladaptive behaviors.

        For example, you can deal with the obsession-compulsion cycle for a certain behavior (the clearest example would be washing your hands), but even if you work on that fear, it is not impossible that another type of obsession appears.

        In the case of alcoholism, it can help treat the craving and helps prevent relapses, but does not determine the causes that led to the acquisition of addiction. In other words, it is very effective in treating the symptom but does not directly act on its causes.

        It also does not address aspects related to personality like perfectionism or neuroticism, or hyper-responsibility, although it does facilitate work at the cognitive level if this exposure is used as a behavioral experience to do cognitive restructuring. . Therefore, exposure with response prevention should not be performed as the only part of therapy, but there must be work at the cognitive and emotional level both before and during and after its application.

        Bibliographical references:

        • Abramowitz, JS, Foa, EB and Franklin, ME (2003). Exposure and ritual prevention of obsessive-compulsive disorder: effects of intensive sessions versus twice a week. Journal of Consulting and Clinical Psychology, 71, 394-398.
        • Bados-López, A. and García-Grau, E. (2011). Exposure techniques. University of Barcelona. Faculty of Psychology. Department of Personality, Psychological Assessment and Treatment.
        • Nestadt, G .; Samuel, J .; Riddle, MA; Liang, KI et al. (2001). The Relationship Between Obsessive-Compulsive Disorder and Anxiety and Affective Disorders: Findings from the Johns Hopkins OCD Family Study. Psychological medicine 31.
        • Rosen, JC and Leitenberg, H. (1985). Treatment of exposure and response to bulimia. In DM Garner and PE Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford.
        • Saval, JJ (2015). Exposure and response prevention in a young woman with obsessive-compulsive disorder. Journal of Clinical Psychology with Children and Adolescents, 2 (1): 75-81.
        • Stephan WG, Stephan CW (1985). Anxiety between groups. Journal of Social Affairs.

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