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Obsessive Compuls Relat Disord. Author manuscript; available in PMC 2016 Jul 1. Published in final edited form as: PMCID: PMC4525711 NIHMSID: NIHMS662091 The current paper outlines the habituation model of exposure process, which is a behavioral model emphasizing use of individually tailored functional
analysis during exposures. This is a model of therapeutic process rather than one meant to explain the mechanism of change underlying exposure-based treatments. Habitation, or a natural decrease in anxiety level in the absence of anxiety-reducing behavior, might be best understood as an intermediate treatment outcome that informs therapeutic process, rather than as a mechanism of change. The habituation model purports that three conditions are necessary for optimal benefit from exposures: 1)
fear activation, 2) minimization of anxiety-reducing behaviors, and 3) habituation. We describe prescribed therapist and client behaviors as those that increase or maintain anxiety level during an exposure (and therefore, facilitate habituation), and proscribed therapist and client behaviors as those that decrease anxiety during an exposure (and therefore, impede habituation). We illustrate model-consistent behaviors in the case of Monica, as well as outline the existing research support and
call for additional research to further test the tenets of the habituation model as described in this paper. According to the habituation model, exposure is effective because it provides structured contact with a feared stimulus while minimizing opportunity for avoidance, escape or ritualizing. The primary goal during exposures is anxiety reduction, which occurs
through contact with a feared stimulus in the absence of avoidance, escape, and ritualizing. Thus, when fear elicited by a stimulus has decreased (and avoidance, escape, and ritualizing have not occurred), habituation is said to have taken place. Importantly, this model purports that the process of habituation is both passive and internal, such that any active and/or external attempt to reduce anxiety will interfere with the process of habituation by way of
providing negative reinforcement. Said another way, behaviors like compulsions provide short-term escape or relief from anxiety and therefore do not allow anxiety to decrease naturally. Both therapists and researchers should be careful to define the term habituation according to this theoretically consistent definition: reduction in anxiety in the presence of a feared stimulus, while minimizing anxiety-reducing behaviors. Habituation should occur both within an exposure task such that the task
becomes easier before ending the exposure, and it should occur across tasks, such that repetition of the same exposure over time elicits lower anxiety. The term “mechanism” refers to the underlying psychological, social, and neurophysiological processes through which therapeutic change occurs during treatment
(Kazdin, 2009). In exposure therapy, data support various mechanisms, including neural mechanisms (Hauner, Mineka, Voss, & Paller, 2012), cognitive changes
(Solem, Haland, Vogel, Hansen, & Wells, 2009), and learning mechanisms (Anderson & Insel, 2006).The mechanism of a treatment is conceptually distinct from the therapeutic processes that engage that mechanism. Therapeutic process is broadly defined as
“everything that can be observed to occur between and within the client and therapist during their work together” (Orlinsky & Howard, 1986). Mechanism is also distinct from intermediate treatment outcomes, which may serve as an indicator that the mechanism is being engaged but are not the mechanism per se. The term “habituation” can also be thought of as an intermediate outcome (i.e. as an
indicator that another process, such fear extinction learning or cognitive change, is taking place). For example, patient ability to resist ritualizing (a therapeutic process variable) may increase the likelihood of experiencing habituation (an intermediate outcome), while the occurrence of habituation could indicate that cognitive change (mechanism of change) is taking place. Given that habituation can be qualitatively observed and measured during exposure (e.g., through subjective ratings), it
is therefore a useful guide for tailoring the therapeutic process that is theorized to engage the mechanism. Rather than focusing on the mechanism itself, which could be neural, cognitive, learning, or some combination thereof, the primary goal of this paper is to elucidate theory-specific therapeutic processes that are presumed to engage the mechanism in exposure-based treatments. According to the habituation model, the process of exposure and response prevention is guided by
behavioral theory and an understanding of functional relationships that are specific to a given individual and/or situation. Therefore, the habituation model is more accurately described as a behavioral model of exposure process. There are several potential misconceptions about habituation, which are likely due to its historical measurement
(Craske, Kircanski, et al., 2008), emphasis on anxiety reduction (Abramowitz & Arch, 2014), and a failure to embed understanding of habituation within the framework of behavioral theory. Common potential misconceptions may include: Habituation must occur
during the session. The ideal exposure outcome is not conceived of as simply a reduction in anxiety, but rather as a reduction in anxiety during an exposure task that is not explained by anxiety-reducing behaviors such as compulsions. The key here is not that anxiety drops, but why it drops. Habituation that occurs during a “session” (within session habituation) is ideal primarily because the chances of post-session ritualizing are lower. Continued resistance of rituals after the
session is important and may lead to habituation at a time point more distal than the session end. Furthermore, the absence of within session habituation does not discount the possibility of between session habituation. Habituation must be evident at the end of the exposure. Habituation has historically been measured in several ways (Craske, Kircanski, et
al., 2008). One such way is by comparing end-state anxiety ratings to other anxiety ratings in the exposure (peak SUDS, beginning SUDS, etc.). One potential issue with this method of measurement is that if end-state SUDS is not lower than peak or beginning SUDS, it is not necessarily the case that habituation has not occurred. This is due to the fluid nature of exposure therapy. For example, a client may have habituated to a feared stimulus in the middle of the exposure, but the therapist
may have inadvertently or purposefully caused an escalation in the patient’s anxiety by making the exposure more difficult (e.g., moving the feared stimulus closer to the child). Given the limitations of habituation measurement, as outlined in potential misconceptions one and two, conceptual understanding of habituation may likewise have been limited. Habituation is an active process. Habituation is an outcome that occurs in the absence of anxiety-reducing behaviors.
Purposeful attempts to “bring down” anxiety are therefore not encouraged. Such techniques are best defined according to their function for a given individual and/or situation (i.e. that they reduce anxiety during an exposure), rather than their topography (i.e. the name or structure of the technique), and could include cognitive restructuring, relaxation techniques, and distraction. These techniques are discouraged because it is thought that they directly interfere with habituation. Thus,
habituation is thought to be a passive, not active process. This potential misconception may have occurred due to overemphasis on anxiety reduction as the goal in a habituation model, which limits our conceptual understanding of the circumstances under which habituation is optimally facilitated (Abramowitz & Arch, 2014). Habituation is an “all or none” construct. In an
attempt to measure and characterize habituation, others have referred to habituation as an “all or none” construct, which is likely overly simplistic (i.e., either the client habituated to the point of no anxiety or did not). It is probably more accurate to conceptualize habituation continuously, as opposed to categorically. However, there are limited data with which to inform an understanding of the amount of habituation needed for optimal treatment outcome and whether this varies by
individual. Finally, understanding of anxiety-reducing behaviors is necessary to accurately measure habituation, as the anxiety rating will need to account for the degree of “undoing” such behaviors provide. This is because the reason why anxiety changes is critical. For example, a client who reports a pre-to-post reduction in SUDS would not be considered to have experienced habituation if SUDS ratings decreased as a function of ritualizing or avoidance of the target stimulus over the
course of the exposure task. This potential misconception of habituation may occur because of the need to clinically discriminate between a successful and an unsuccessful exposure, resulting in a dichotomous conceptualization. Instead, we argue that conceptualization of habituation should be embedded within the behavioral theory that underpins ERP (i.e. that avoidance and rituals maintain symptoms). Summary of Empirical EvidenceAccording to the habituation model, exposures should be optimal when 1) fear is activated, 2) behaviors providing negative reinforcement via anxiety reduction are minimized (e.g., rituals, avoidance), and 3) anxiety reduces within and across exposure tasks (habituation; Craske, Kircanski, et al., 2008; Craske, Waters, et al., 2008; Foa & Kozak, 1986). Note that this model differs from the Emotional Processing Theory (EPT; Foa & Kozak, 1986). The primary difference is that EPT is a model of mechanism purporting that activation of a “fear structure” and corrective learning through exposure results in replacement of that fear structure with a “non-fear structure” (Foa & Kozak, 1986), while the habituation theory outlined in this paper is a model of therapeutic process built on functional analysis and is somewhat agnostic to the precise underlying mechanism.
Selecting an exposure taskWe will consider each of the following clinical issues in the context of the three tenets of habituation theory during exposure: fear activation, minimization of anxiety-reducing behavior, and habituation. Hierarchy Development
Prescribed Techniques (“Dos”)
Proscribed Techniques (“Don’ts”)
Exposure SelectionGiven the emphasis of this theory on minimizing anxiety-reducing behaviors, the ideal exposure is one that is judged to be maximally difficult while still able to be completed without anxiety-reducing behaviors. For this reason, exposures of moderate overall difficulty are likely to be preferable to those that are very easy or very difficult. It is important to note that the actual difficulty level of an exposure may or may not be closely tied to the SUDS rating itself. Objectively, some clients reporting SUDS of 8/10 may appear extremely anxious to the therapist and the exposure cannot be conducted as planned, while others reporting an 8/10 may look moderately anxious to the therapist and can complete the task. Thus, exposure difficulty level should be informed by therapist judgment and stage of treatment (i.e. beginning vs. end) as well as SUDS. The optimal titration of exposure difficulty will be highly idiosyncratic to a given individual and may be influenced by a variety of factors, such as insight, developmental level, and baseline level of anxiety (i.e. existing level of anxiety outside of the exposure task). The exposure hierarchy should be used to guide choice of a moderately difficult exposure and should be continually revised throughout treatment and prior to each exposure. This revision process is critical to ensure 1) activation of the most relevant core fear by adding or revising exposure tasks as new information about fears is obtained over the course of treatment, and 2) appropriate titration of exposure difficulty, as the difficulty level of a given task is likely to change across treatment. Additionally, it is important to note that the hierarchy does not need to be completed in order and it is not proscribed to choose items of varying difficulty levels from the hierarchy so long as no item is so easy that it does not produce fear or so difficult that it cannot be completed without significant anxiety-reducing behavior. In the case of Monica, items she has rated as moderately difficult would be most appropriate to begin with (e.g., eating packaged food or fresh food without a label, smelling unnatural products, using unnatural soap or body wash). However, Monica’s therapist should ensure that the moderate ratings for these items hold up after clarifying the expectation to avoid all anxiety-reducing behaviors and to focus completely on the task and any relevant thoughts during the exposure. Exposure “set up”Exposure RationaleThe rationale for the exposure should include a discussion of the exposure technique more broadly, as well as specific information about how we believe exposures work. Ideally, this should happen at the beginning of treatment as part of more general psychoeducation about OCD and treatment options. Many times it will be appropriate to repeat the rationale over the course of treatment and to use experiences during exposure to illustrate the theory underlying the rationale. The description of habituation should include emphasis on both within-exposure and across-exposure habituation and should be careful to illustrate that habituation only takes place when clients are fully approaching the exposure stimulus. In the case of Monica, the therapist may use the following rationale:
Exposure InstructionsBoth at the beginning of treatment and prior to each exposure, therapists should give careful instructions about desired client and/or parent behaviors, as well as some information about the therapist’s own behaviors. Although the therapist should have given the rationale for exposure including an explanation of habituation as described above, it will be important that the therapist does not give specific guidelines about when the exposure would end (e.g., that it would end when anxiety goes down by half). This is to avoid the client anticipating the end of the exposure, and thus provide negative reinforcement via escape (i.e. “whiteknuckling”). In the case of Monica, the therapist may use the following instructions:
The therapist should end the exposure following some meaningful amount of anxiety reduction in the absence of anxiety-reducing behaviors. A clinical guideline that is often used is a 50% reduction from starting anxiety, in which anxiety-reducing behaviors, if present, were not judged to be mostly responsible for the anxiety decrease. Similarly, Monica could be instructed to complete home exposures until she experiences a 50% reduction from starting anxiety, with heavy emphasis on being accurate with SUDS ratings so as not to result in premature escape from the exposure (i.e. making lower ratings in order to be “done”). If the therapist feels that Monica will struggle with this task, he or she may wish to enlist the help of a parent to support her during home exposures. However, at this time the 50% reduction guideline is entirely based on clinical lore and there are no empirical data to guide the decision to end exposures. This is an area that warrants significant research attention in order to provide therapists with more accurate guidelines.
Exposure “dos and don’ts”Optimal Therapist Behaviors during ExposureOptimal therapist behaviors during exposure are presented in Table 1. Prescribed therapist behaviors are those that theoretically function to increase or maintain the client’s contact with the exposure stimulus and would therefore facilitate the occurrence of habituation. These include discouraging client avoidance behavior (e.g., asking Monica to maintain eye contact with unlabeled food, asking her to avoid asking questions about the food, asking her to “re-expose” by touching the exposure stimulus again if she wipes her hands), discouraging client avoidance of thoughts (e.g., asking Monica to verbalize fears of developing cancer), making statements that function to increase or “ramp up” anxiety (e.g., therapist agrees that Monica is looking a little sick and might have cancer, asking Monica to eat a second unlabeled food item), and taking actions to reduce parent/family accommodation (e.g., asking Monica’s parents to resist answering any questions she has related to the safety of the unlabeled food). Asking for frequent anxiety ratings is also a prescribed therapist behavior, as it functions to inform therapist understanding of anxiety level, but it also encourages clients to stay in mental contact with the exposure task. It is important to note that prescribed therapist behaviors could be most important when applied contingently (e.g., Monica’s therapist discourages avoidance after observing her attempt to spit some food out), OR could be important regardless of the events that precede it. Table 1Habituation Model: Prescribed and proscribed therapist behaviors during exposure Proscribed therapist behaviors are those that theoretically function to decrease a client’s level of anxiety during the exposure and therefore impede the likelihood of a client experiencing habituation. These include prompting clients to use relaxation (e.g., cueing Monica to use anxiety-reducing imagery or deep breathing), prompting clients to employ cognitive techniques that function to reduce anxiety (e.g., emphasizing low dose of pesticides on the unlabeled food), therapists providing accommodation (e.g., telling Monica that the food is safe because it is washed before being sold), therapists engaging in distraction techniques (e.g., playing a card game), therapists talking about unrelated topics (e.g., building an unrelated hierarchy during the exposure; talking to Monica about her weekend), or teaching skills that are counter to the principles of CBT (e.g., teaching Monica to use thought-stopping). One behavior that is neither prescribed nor proscribed, but may be important to consider, is the use of “externalizing” language to distance the client from his/her symptoms. This involves using language that refers to OCD in the 3rd person and serves to provide clients with some distance from OCD thoughts or impulses while still remaining in contact with the exposure and with fear cognitions. For example, Monica’s therapist might say “What is OCD saying to you right now?” rather than “What thoughts are you having right now?” This technique is often used with children, who are encouraged to name their OCD in order to better externalize their symptoms and to assist families in adopting a “non-blaming” attitude toward the child. This particular technique is more consistent with the concept of cognitive defusion (vs. cognitive restructuring), and does not have a hypothesized theoretical function on anxiety level in the moment, but may serve to enhance participation and motivation. However, given the emphasis of this model on function rather than topography of in-session behavior, therapists should not use this technique with clients for whom it serves to decrease anxiety level (e.g., for a client having scrupulosity concerns, externalizing language may serve to “undo” a belief that something is his/her fault). Optimal Client/Family Behaviors During ExposureOptimal client/family behaviors are presented in Table 2. Prescribed family and client behaviors are those that theoretically function to increase or maintain anxiety during an exposure. Prescribed family behaviors include those described above as prescribed therapist behaviors. Prescribed client behaviors include engaging in approach behavior (e.g., Monica swallowing the unlabeled food, maintaining eye contact with the unlabeled food), approaching fear cognitions (e.g., staying focused on the thought that she might get cancer), and approaching feared sensations (e.g., noticing increased heart rate). Table 2Habituation Model: Prescribed and proscribed client behaviors during exposure Proscribed family and client behaviors are those that theoretically function to decrease anxiety during an exposure. Proscribed family behaviors include those described above as proscribed therapist behaviors. Proscribed client behaviors include use of rituals (e.g., spitting out food, asking questions), avoidance of the exposure stimulus (e.g., averting gaze), escape behavior (e.g., leaving the room, requests to use the bathroom), using cognitive techniques to reduce anxiety (e.g., Monica telling herself that this is unlikely to happen; attempts to push thoughts of cancer out), using relaxation to reduce anxiety (e.g., using deep breathing), or using distraction (e.g., attempts to talk about other topics, thinking about other things). Ending exposureWhen is the Exposure “done?”It is appropriate to end an exposure when anxiety has reduced and was judged by the therapist to be mostly in the absence of anxiety reducing behaviors. There is no standard exposure length, and setting a time limit as a way to titrate exposure difficulty is not optimal (see “Proscribed Techniques” above). However, savvy therapists with clients who habituate quickly may use this as an opportunity to increase the difficulty of the exposure in order to provide the client with another opportunity for habituation. Though this may increase the pace of client improvement and is standard practice among specialists, it likely contributes to difficulty drawing conclusions about habituation using standard measures at standard times during a session (i.e. WSH and BSH). Importantly, this relies heavily on therapist judgment about 1) what constitutes enough anxiety reduction and 2) what anxiety reducing behaviors have occurred and the extent to which those behaviors have “undone” the anxiety elicited by the exposure task. It will be critical for future studies to develop guidelines about the right amount of these things, as well as measures to support therapists in making those decisions. It is also critical for therapists to use time-management skills appropriately, to facilitate optimal ending of the exposure with time remaining for debriefing and instructions for continuing response prevention after session’s end. What happens after the exposure?After the exposure, it is important to discuss any relevant considerations for minimizing anxiety-reducing behaviors even after the exposure is over. For example, Monica may be instructed to avoid brushing her teeth for the remainder of the evening, to the extent that brushing her teeth would neutralize worries about having eaten unlabeled food. If there are events during the evening during which minimizing anxiety-reducing behaviors would be too difficult, the therapist may provide instructions about “re-exposing” following those events. For example, if eating dinner after having touched unlabeled food is too difficult for Monica, she may be instructed to wash her hands before dinner but to re-touch unlabeled food immediately after dinner. For many clients, it is appropriate to involve a parent or spouse in this discussion so that the client has support to implement this plan at home. Given Monica’s age, it would be beneficial to include her parents in this plan. The present model is most specific to the behaviors and events that happen during exposure; however, it is worth mentioning that events and behaviors during other parts of the session are also important (i.e. preparing for the exposure, debriefing after the exposure). For example, it may be that the window of time following exposure is useful for consolidating learning that occurred during the exposure. Techniques that may be proscribed during an exposure because they reduce anxiety could be beneficial at this time. Use of cognitive tools, such as asking the client to reflect about the occurrence of feared consequences, may aid learning. For example, Monica might say that she has not noticed any preliminary symptoms of Parkinson’s disease as expected. Alternatively, Monica might also notice that, although she cannot disprove the feared consequence by virtue of its time course (i.e. illness would have developed in her 20’s or 30’s), she no longer believes the consequence will occur. However, according to this model, it is not specifically prescribed to engage the client in an analysis of whether feared consequences have occurred, nor are exposures necessarily designed for the purpose of doing so. In contrast to some other models (i.e. Inhibitory Learning Model), therapist questions post-exposure would be less directive and not specific to the question of expectancy. Finally, the time after exposures could also be a useful time to reflect about the process of habituation. For example, Monica might also notice that her anxiety decreased even in the absence of anxiety-reducing behaviors. In the case of Monica, an example of post-exposure discussion illustrates this point: Therapist: How do you think that went? Monica: Pretty well—I really didn’t think this would work, but it did. Therapist: What do you mean when you say it “worked?” Monica: I feel much better now. Therapist: So, it sounds like you’re saying that your anxiety went down. Why do you think that happened? Monica: I don’t know, it just happened. Therapist: Did you do anything to make that happen? Monica: No—that’s the thing. Usually I would ask a bunch of questions, but I didn’t do anything like that this time. Therapist: Are you still worried about getting Parkinson’s? Monica: Well, I guess it’s still possible. I’m not sure. Therapist: That’s true—anything is possible. Why would you feel better if you could still get Parkinson’s? Monica: It just doesn’t worry me as much as it did before. Therapist: So, what do you think you learned from this exposure? Monica: I guess I learned that I can do something that feels scary, even if something bad might happen to me. Therapist: Anything else? Monica: Well, now I believe you that my anxiety can go away on its own. ConclusionWhen considering the habituation model, it is important to distinguish conceptually between the mechanism underlying exposure, the therapeutic process that engages that mechanism, and intermediate outcomes that indicate the mechanism is being engaged. The therapeutic process variables outlined in this paper are based on functional analysis and are thought to engage the mechanism, but are not the mechanism itself. Likewise, habituation can be conceptualized as an intermediate treatment outcome or initial marker of treatment success, but may or may not be the mechanism per se. None of these relationships have been adequately tested in the research literature, and future studies should employ innovative methods to tease them apart. The basic tenets of the habituation model suggest that fear activation, minimizing anxiety-reducing behaviors, and habituation are necessary conditions for engaging the theorized treatment mechanism and maximizing the benefits of exposure. This has implications for therapeutic process during exposures, and the role of the therapist is to facilitate these conditions. Therapists should consider this in all phases of exposure-based treatment: providing a rationale for exposures, development of the hierarchy, selection of the exposure task, monitoring their own behaviors during exposure tasks, and debriefing following an exposure. The case of Monica presented in this series of papers helps to illustrate which behaviors during treatment are consistent or inconsistent with the habituation model. We want to note that this paper presents optimal conditions for exposures, and real-world exposures are rarely optimal in all of the ways outlined above. From a research standpoint, it will be important to determine the degree to which an exposure can be suboptimal and still be effective. For example, what “dose” of these therapeutic process variables and/or habituation is needed before clinical improvement is seen? What amount of anxiety-reducing behavior can take place before it precludes habituation? Do different therapeutic process variables have different potency for producing habituation/treatment response? Do these factors affect individuals differentially, and what client or therapist variables predict the strength of those relationships? Clinically, it is important to use information from these suboptimal exposures to inform the design and implementation of subsequent exposures. One indication that an exposure has been “too hard” is if it results in substantial anxiety reducing behavior. When an exposure has been “too hard,” the best short-term (i.e. within the exposure task) option is to encourage the client to re-expose by coming back into contact with the exposure stimulus. Strategies that make the exposure easier by reducing anxiety in the moment (e.g., distraction) are discouraged. The best long-term strategy (i.e. across exposure tasks) is to choose an easier exposure from the hierarchy. An exposure may be “too easy” if it elicits minimal or no anxiety. When an exposure has been “too easy,” the first step should be to ascertain whether subtle or internal avoidance behavior has taken place (e.g., mental rituals). In the absence of such anxiety-reducing behaviors, the best short-term solution is to immediately choose a more difficult exposure from the hierarchy, or to employ greater use of therapist techniques to increase anxiety (e.g., statements that imply risk). In the long-term, it may be helpful to reassess the core fear that the exposure was trying to elicit and revise the hierarchy if necessary. It is also important to consider the impact of symptom severity on the development of hierarchy items and conduct of exposures. Although it is preferable to eliminate anxiety-reducing behaviors during an exposure, for some clients, particularly those with very severe symptoms, it may be necessary to dismantle rituals before expecting completion of exposure without any rituals (e.g. reduce duration of ritual, eliminate one element of a multi-part ritual). In this case, dismantling rituals should be done such that there is some degree of residual discomfort following the ritual OR that the ritual is completed but the exposure stimulus is re-contacted (e.g., touching a dirty object again after washing hands). However, completion of exposures without anxiety-reducing behavior should be the eventual goal. Finally, we want to note that this paper focuses primarily on theoretically derived behaviors during the exposure task itself. It is likely that these behaviors have other functions after the (i.e. preparing for exposure, debriefing the exposure). Future studies of therapeutic process in exposure-based treatments should be careful to tease apart function of therapeutic process variables based on the timing within the session. Review of evidence for the habituation model and optimal exposure behaviorsAlthough evidence for the relationship of fear activation and habituation to outcome has been mixed, the bulk of these studies have failed to consider the role of anxiety reducing behaviors during exposures. As this is a critical part of the model, future studies should be careful to measure and account for these behaviors when investigating fear activation and habituation in treatment. Additionally, the conceptualization and measurement of fear activation and habituation has been too limited and warrants careful consideration in future studies. Data regarding optimal behaviors during exposures has also been quite limited, and this represents a relatively new area of research that needs exploration. Nearly all treatment trials that include exposure-based treatment for OCD have used a treatment manual. However, available treatment manuals specify that exposure should happen, but do not provide guidelines about specific therapist or client behaviors during exposure. As reviewed above (“Evidence for Minimizing Anxiety Reducing Behaviors”), ritual prevention is considered to be a critical client behavior, though the actual occurrence of rituals during exposure has not been examined for its relationship with treatment outcome. Very few studies have provided data linking any observed therapist or client behaviors during exposure to habituation or to treatment outcome. One method for beginning to collect such data is to conduct secondary data analysis using video- or audiotapes from sessions in treatment trials. Traditionally, these session-level data are coded to determine global therapist adherence to the treatment manual. However, microanalytic coding methods are likely to be more appropriate for identifying the client and therapist behaviors as outlined in this paper. This method may also be especially useful for measuring habituation, as the need to identify and account for anxiety-reducing behaviors could be critical for accurate measurement of this construct. A microanalytic coding system (Exposure Process Coding System; EPCS) has been designed to measure the therapist and client behaviors outlined in this paper (Benito, Conelea, Garcia, and Freeman, 2012). Pilot data from the EPCS in a small sample of young children with OCD indicate initial feasibility, reliability, and validity (Benito, Conelea, Garcia, & Freeman, 2012). Furthermore, some observed therapist behaviors during exposure using the EPCS (i.e. discouraging avoidance, making statements that increase anxiety) were linked to improved treatment outcome in that pilot sample. Our laboratory is currently conducting a larger investigation using the EPCS, the revised version of which includes several novel measures of habituation. We are applying the EPCS to videotaped exposures from three large RCTs for pediatric OCD, and plan to investigate the relationships of these observed therapeutic process variables, as well as habituation, with treatment outcome (Benito, 2014; Frank et al., 2014). Our experience with this study so far suggests a high degree of therapist variability in employing the behaviors described in this paper, even among this group of highly trained therapists who were adherent to the treatment manual. Notably, we have not devoted space within the present paper to discuss specific differences between the habituation model and other theoretical models of exposure. We believe that the tenets of these models are not necessarily mutually exclusive and have more similarities than differences. Although the models themselves hypothesize different mechanisms (e.g., cognitive change, psychological flexibility), there are fewer differences in the therapeutic processes hypothesized to trigger those mechanisms. The use of terminology across models that implies a given underlying mechanism likely compounds this problem and results in some difficulty comparing behaviors or concepts that would otherwise be similar at the level of therapeutic process. For example, teaching the concept of willingly and fully experiencing anxiety is important to both ACT and Inhibitory Learning models. This is quite consistent with the principles of the habituation model as outlined in this paper, in that feeling anxiety with minimal anxiety reducing behavior will ultimately facilitate habituation and improvement in treatment. Additionally, it is likely that any given model may unintentionally include active components from another model, or might intentionally include aspects of those active components with a different “brand name.” The habituation model is a function-based approach, with every activity happening during exposures being in the service of letting habituation occur naturally. This model purports that treatment ingredients should be tailored to the individual and flexible within the bounds of strong functional analysis, and that treatment ingredients should not be delivered in a “cookbook” fashion. However, these function-informed activities are likely to encounter and include active ingredients from other models, such as violation of fear expectancy (Inhibitory Learning) or increased contact with valued activities (ACT). For this reason, attempts to compare models by artificially disentangling these ingredients using a group-based research design is likely to significantly impact external validity of findings and have little bearing on actual clinical practice. Furthermore, it is unlikely that such a group-based approach could measure and report therapeutic process with enough detail to conclude definitively that the manipulation ensured no active ingredients from other approaches. Rather, novel methods for capturing these activities as they unfold in real treatment, while complicated to use and interpret, are more likely to help us understand therapeutic process during exposure. While there is a growing body of literature in support of various mechanisms underpinning exposure efficacy, particularly in the field of Inhibitory Learning, there is almost no literature describing theory-consistent behaviors during real exposures (i.e. what therapists and clients say or do that makes treatment work). Ultimately, it will be critical to objectively define and measure those behaviors that lead to optimal treatment outcome and then consider their link to the underlying mechanism. It may be that behaviors without a logical link to a purported mechanism (e.g., focusing on fear cognitions as if they are “true”) can still lead to mechanism engagement (e.g., cognitive change). It may also be that more than one mechanism is responsible for change in exposure-based treatment and that incorporating techniques from multiple models will facilitate tailoring to individual needs and ultimately produce the most robust change during treatment. Highlights
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What is known as the process of pairing positive stimulus with a negative one to counteract fear?Counterconditioning. a pleasant stimulus is paired repeatedly with a fearful one, counteracting the fear. Operant Conditioning. a type of learning in which people and animals learn to behave in certain ways because of the results of what they do. Reinforcement.
Is a conditioning method in which people with fears are exposed to harmless stimuli until fear responses are extinguished?Chapter 6 Psych. What is the process of conditioning?conditioning, in physiology, a behavioral process whereby a response becomes more frequent or more predictable in a given environment as a result of reinforcement, with reinforcement typically being a stimulus or reward for a desired response.
What is the act of responding differently to stimuli that are not similar to each other?Discrimination is the act of responding differently to stimuli that are not similar.
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What is known as the process of exposing people to harmless stimuli in which they are fearful of until their fear is gone?
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