Optimizing fear extinction through exposure based on inhibitory learning

Background

Research has shown that if current treatments (pharmacotherapy and psychotherapy) cannot act on the initial causes of anxiety disorders, they are nevertheless effective in modifying the conditions which maintain these disabling disorders and in allowing patients who suffer from them to recover the natural healing processes necessary for the remission of pathological anxiety and the return of their life balance.

In the anxious individuals we see in our clinic, the combination of genetic and psychological vulnerability factors (neurotic personality traits coupled with a personal history often marked by neglect, psychological and physical abuse, or even trauma) contributes to:

1. Low threshold fear conditioning.

2. Persistence of recall of the conditioned fear response.

3. Greater resistance to learning extinction (safety).

4. Deficiencies in processing safety signals, with an attentional bias toward "threat" signals.

In summary, these people more easily develop pathological fears and they have more difficulty "unlearning" these fears once they have taken hold.

Principles and practice

Research indicates that three elements are necessary for effective psychotherapy for pathological anxiety (see specific article on Exposure therapy):

1. During exposure to their pathological fear, the patient must receive information that contradicts their beliefs about the danger of the phobic stimuli and the intolerability of the accompanying anxiety.

2. Avoidance behaviors that interfere with the acquisition, reinforcement, or consolidation of this new information must be modified or reduced as much as possible (see the specific article "Safety Behaviors").

3. The new information learned during exposure therapy must be reinforced in memory and generalized through further exposure in different contexts with a variety of phobic stimuli.

Effective clinical exposure encompasses these three conditions and enables the learning of fear response extinction through the repeated presentation of an object or situation that triggers fear in the absence of an aversive consequence with which it was previously associated.

This is what "extinguishes" the conditioned fear response.

Basic research in learning theory (see specific article on functional analysis) has allowed us to propose clinical hypotheses to better explain the psychophysiological mechanisms underlying the effectiveness of exposure.

Today, the theoretical model of exposure with the highest level of scientific validity is that of inhibitory learning. Unlike the traditional habituation model, the inhibitory learning model maintains that acquiring new knowledge during exposure is necessary to reduce anxiety symptoms. This model further posits that fear extinction is a form of learning, rather than simple habituation without associative learning.

The therapeutic objective during exposures is no longer to erase the "initial fear memory," which we now know to be permanent, but to inhibit it with a new "safety memory", more fragile certainly, but likely to be strengthened by repeated exposures to varied stimuli and in different contexts to "promote dialogue between the cortex and the amygdala" and regulate the fear reaction.

This implies that the first learning is not erased – we do not forget a fear, that is why it returns – and that we rather do new learning, in particular through exposures which must contain the three necessary elements seen previously, to reinforce the new safety memory and reduce as much as possible the probability of reappearance of the fear reaction.

Thus, therapist and patient will collaboratively design varied and gradually increasing exposures, tailored to the patient's abilities and motivation, focusing on what the patient needs to learn in the feared situation in order to:

1. Modify the heightened/exaggerated perception of the nature and severity of this "threat."

2. More realistically assess the likelihood of this "threat" occurring.

3. Develop a more accurate perception of their personal effectiveness in coping with this "threat."

4. Improve the perception of available resources in the environment to help them cope with this "threat."

5. Learn that they can accept and tolerate, at least for the duration of the exposure session, a high, and if necessary, very high level of fear without endangering themselves. This is where the therapeutic effectiveness lies: accepting rather than trying to control this normal and often useful emotion (fear) by engaging in desperate avoidance attempts to feel quickly relieved. Because what is effective in the short term for controlling fear is definitely the best way to allow it to persist in the long term, since: The best way to overcome fear is to confront it.

Exposure therapy for an anxiety disorder, where exposures are conducted according to the principles of inhibitory learning, typically unfolds in the same way as any other exposure therapy (see specific article):

• Initial assessment of the individual and their difficulties.

• Clinical conceptualization.

• Treatment plan and verbal therapeutic "contract."

• Psychoeducation.

• Exposures selected and planned with the patient.

• Regular evaluation of progress and the therapeutic alliance.

• Relapse prevention.

Therapists introduce the exposure exercise by asking patients:

• What exactly are you most afraid of? (specificity)

• What is the worst possible outcome that could happen to you? What do you fear most?

• Under what conditions and circumstances is this feared outcome most likely to occur?

• What do you need to learn during your confrontation with this fear to prove to yourself that you can overcome it?

• How will you plan and carry out this "experience" (exposure)?

Pre-exposure form

Using a pre-exposure sheet like the one shown here (see clinical tool), the patient prepares their targeted and specific exposure for their pathological fear.

Post-exposure form

After the exercise, the patient returns to his exposure by completing a post-exposure form (see clinical tool)

Acceptance

It is by accepting the fear and distress it evokes, rather than demanding that it diminish during exposure therapy, and by choosing exposures that foster a sense of efficacy in coping with this fear, that the patient regains hope and the inner resources to face other life challenges.

Supervision and the therapeutic relationship

We hope that this brief article and others on this site will evoke your interest in finding psychotherapists, supervisors, readings, and clinical training to deepen your mastery of exposure therapy according to the principles of inhibitory learning. If you are a psychotherapist, we hope you will prioritize the use of exposure therapy in your clinical practice, as it remains the psychotherapeutic technique whose clinical efficacy has been most empirically validated for treating or alleviating individuals suffering from pathological anxiety.

One last point before we part: remember, as Barkham et al. (2021) remind us, that “psychotherapeutic treatments do not treat people; psychotherapists treat people by talking with them.” Using “good” techniques in psychotherapy is good, and using them with a good therapeutic alliance is even better!