Response Prevention Exposure Therapy: What is it?

It is possible that on some occasion it has happened to you that you have done something on impulse, without even reflecting and without having good reasons to do it. For example, overeating when facing a state of anxiety, or arguing with someone without a justifying cause or buying things even if you do not need them.

In all these cases there is some kind of motivation or impulse behind that we have not been able or known to manage. This also occurs in different types of psychological problems that can lead to compulsive behaviors over which there is little control and which 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.

• Related article: "Types of psychological therapies"

Response Prevention Exposure Therapy: What is it?

It receives the name of exposure technique with prevention of response to a type of therapeutic procedure used from 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 utility and that has shown to be beneficial for the treatment of various pathologies, usually linked to anxiety. Its objective is to modify the behavior patterns derived from the existence of cognitions, aversive emotions or impulses as well as coping with negative cognitions and expectations on the part of the subject affected.

Its basic functioning is based on the idea of ​​exposing or making the individual face, deliberately, the situation or situations that generate discomfort or anxiety while preventing or preventing the problem behavior that such situations usually trigger.

In this sense, what is sought is that the subject experiences the corresponding anxiety or feeling of discomfort and is able to experience it without performing the behavior until anxiety naturally subsides to a point that is manageable (It is important to note that the goal is not necessarily to make the anxiety disappear, but to be able to coping adaptively), at which point the urge or need to carry out the behavior is reduces.

This prevention can be total or partial, although the first is much more effective. It is essential that it is due to the actions of the person suffering from the problem and not to external imposition or involuntary physical restraint.

At a deep level we could consider that it is working 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 carry it out. Likewise, through this habituation the link between emotion and behavior is extinguished, in such a way that there is a de-habit of 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 the expectations of self-efficacy in patients, making them feel that they have a greater capacity to achieve their objectives and face the 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 starting the procedure properly it is necessary to know as much as possible about the problem behavior. Among these aspects, what is the problem behavior itself, the degree of affectation that it generates in the life of the patient, antecedents, modulating variables and consequences of the behavior stand out.

We must know how, when and to what this behavior is attributed, and the different elements that cause a greater or lesser level 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 is intended to be done and why.

It is relevant to mention that what is intended is not to eliminate anxiety itself but to allow it to reduce to make it manageable (something that on the other hand and over time can generate its disappearance). After the explanation and if the patient accepts its application, the technique is performed..

3. Exposure hierarchy construction

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 between a dozen and a score of highly concrete situations (including all the details that can shape anxiety), which will later be ordered according to the level of anxiety generated 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 per session should be carried out, since the subject must remain in the situation until the anxiety is reduced by at least half.

Each of the situations should be repeated until anxiety remains stable low in at least two exposures, when the next item or situation in the hierarchy will be moved (in ascending order depending on the level anxiety).

While exposing, the therapist must analyze and help the patient to orally express his emotional and cognitive reactions. Powerful reactions can appear, but exposure should not stop unless absolutely necessary.

Substitute or anxiety avoidance behaviors should also be worked on, since they can appear and prevent the subject from really getting used to it. If necessary, some alternative activity can be provided as long as it is incompatible with the problem behavior.

It may be recommended 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 does the same. In regards to preventing responses, providing clear and rigid instructions has been more effective rather than providing generic prompts.

Response prevention can be for the entire duration of the entire treatment, only toward behaviors that have been previously worked on exhibitions or for a specified time after exposure (although it depends on the type of problematic)

5. Discussion and subsequent evaluation of the exhibition

After completing the presentation, the therapist and patient can enter to 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. Process assessment and analysis

The results of the intervention should be monitored and analyzed so that they can be discussed and altering the expositions if it is necessary to include something new, or to show the achievements and improvements made by the patient.

The possibility that the problem behavior may occur at some point, both when exposure occurs and in daily life, should also be taken into account: Working with this type of behavior is not easy and can cause great anguish for patients, which may break to neglect 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 can allow us to get an idea of ​​elements and variables that previously had not been taken into bill.

Conditions and disorders in which it is used

Response prevention exposure is an effective and highly useful technique in multiple mental conditions, the following being some of the disorders in which it has been successful.

1. Obsessive-Compulsive Disorder

This problem, which is characterized by the intrusive and recurrent appearance of highly anxious obsessive thoughts for the patient and that usually leads to brooding or the performance of compulsive rituals to reduce anxiety (something that in last term ends up causing a reinforcement of the problem), it is probably one of the disorders in which the EPR.

In Obsessive-Compulsive Disorder, ERP is used to achieve the elimination of compulsive rituals, whether they are 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 this ritual, at the same time that it could even reduce the importance given to obsessive thinking (something that would also reduce the obsession and the discomfort that it generates). A typical example in which it is applied is in obsessions related to pollution and cleaning rituals, or in those linked to the fear of attacking or hurting loved ones and rituals of overprotection.

• Related article: "Obsessive-Compulsive Disorder (OCD): what is it and how does it manifest?"

2. Disorders of impulse control

Another type of disorder in which RPE is used is in 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 prompted, or by reducing the strength of the urge to do them.

• You may be interested: "Kleptomania (impulsive theft): 6 myths about this disorder"

3. Addictions

It has been seen that the field of addictions, both those linked to substances 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 compulsive gambling, they can be exposed to situations that are associated with their habit (for example, being in a restaurant or a bar) while prevents the response, as a way to help them cope with the desire for consumption or gambling and so that if they find themselves in this situation in real life they do not resort to the behavior addictive.

4. Eating disorder

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 your own body, influenced by cognitive distortions) or the experimentation of anxiety preventing the binge response or later purging. In the same way, it can also be useful in binge eating disorder.

Limitations

From what is known about the results obtained through response prevention exposure therapy, This psychological intervention resource is effective against various types of mental disorders if it is applied consistently over several sessions conducted on a regular basis. This causes it to be applied regularly in psychotherapy.

Of course, despite being highly effective in modifying behavior, it is necessary to bear in mind that the exposure technique with response prevention also has some limitations.

And it is that although it is highly effective in treating a problem behavior and modifying it, by itself does not work directly with the causes that led to the appearance of anxiety which led to motivate maladaptive behavior.

For example, you can treat the obsession-compulsion cycle for a certain behavior (the clearest example would be washing hands), but even if this fear is worked on, it is not impossible for another type of obsession to appear different.

In the case of alcoholism it can help treat craving and help prevent relapses, but it does not help to address the causes that led to the acquisition of dependence. In other words: it is very effective in treating the symptom but it does not work directly on the causes of it.

Likewise, it does not address aspects related to personality such as perfectionism or neuroticism, or hyperresponsibility, although It makes it easier to work on a cognitive level if said exposure is used as a behavioral experiment through which to carry out a restructuring cognitive. For all these reasons, it is necessary that exposure with response prevention is not carried out as the only element of therapy, but rather there must be a job at a cognitive and emotional level both before, during and after its application.

Bibliographic references:

• Abramowitz, J.S., Foa, E.B. and Franklin, M.E. (2003). Exposure and ritual prevention for obsessive-compulsive disorder: Effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71, 394-398.
• Bados-López, A. & García-Grau, E. (2011). Exposure techniques. University of Barcelona. Faculty of Psychology. Department of Personality, Evaluation and Psychological Treatment.
• Nestadt, G.; Samuels, J.; Riddle, M.A.; Liang, K.I. et.al. (2001). The relationship between obsessive – compulsive disorder and anxiety and affective disorders: results from the Johns Hopkins OCD Family Study. Psychological Medicine 31.
• Rosen, J.C. and Leitenberg, H. (1985). Exposure plus response prevention treatment for bulimia. In D.M. Garner and P.E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford.
• Saval, J.J. (2015). Exposure and response prevention in the case of a young woman with obsessive-compulsive disorder. Journal of Clinical Psychology with Children and Adolescents, 2 (1): 75-81.
• Stephan WG, Stephan CW (1985). Intergroup Anxiety. Journal of Social Issues.