Anger and Aversion

 

Exposure therapy, like so much of behavior therapy, is based upon work with animals, especially rats and mice. Critics have pointed out, especially as neuroimaging of brains and brain study in general have become more sophisticated, that what’s true for a rat brain may not have much to do with what’s true for a human brain. But don’t try telling that to Northwestern University psychologists Richard Zinbarg, co-director of the university’s anxiety and panic treatment program, and Susan Mineka. In the March, 2006 Monitor on Psychology, reporter Sadie Dingfelder describes Mineka’s research into how and why exposure therapy works to alleviate anxiety, panic and PTSD symptoms.

 

Exposure therapy, in which people confront their fears in a controlled, dose-measured environment, has not only amassed considerable empirical support, but it makes a kind of metaphorical sense. If we can build up our physical immune system by exposing ourselves to measured doses of toxins, allergens or viruses, then, the reasoning goes, we may be able to build up our psychological immune systems as well.

Of course, metaphors can sound logical and true, but they’re a poor substitute for empirical evidence. Fortunately, much concrete evidence supporting exposure therapy exists. Studies have clearly demonstrated that conditioned fear can be reversed through exposure therapy. Condition a rat to fear a tone by immediately following a tone with a shock, and the rat learns to fear the tone. Then, if you subsequently expose the rat to the tone without the shock, eventually it loses its fear of the tone. But Mineka has added an intriguing twist to this classic experiment. She finds that by giving an animal the ability to turn off the shock, it significantly reduces the intensity of the fear the animal exhibits when it hears the tone.

Mineka has also worked with monkeys and found that when they’re raised in environments in which they can control their access to food, they exhibit much less anxiety in stressful situations than monkeys who have not learned that they can control their own food supplies.

These findings probably induce an empathic aha! in you. They make sense, not just for monkeys and rats but for humans, suggesting that people who have a sense of control may be able to also control their previously uncontrollable anxiety. Mineka’s findings suggest that the reason why exposure therapy works is not so much because of an immune response, but because it helps people develop a sense of control. “Over the years,” says Metin Basoglu, MD, PhD, head of trauma studies at the Institute of Psychiatry of King’s College London, quoted in the Monitor article, “we have demonstrated that this therapy works with torture survivors, war survivors and earthquake survivors.” Basoglu has developed a short-term therapy partly based on Mineka’s findings. Others have suggested that what’s really effective about Eye Movement Desensitization and Reprocessing (EMDR) is not so much the eye movements themselves, but the sense of control people have over their eye movements and feelings while they’re recalling their trauma in a controlled, safe environment. In other words, the effective ingredient of EMDR, some people say, may be exposure therapy. (EMDR advocates and some researchers insist that EMDR is much more than exposure therapy).

Mineka has found that in addition to a sense of control, when people feel that they can predict something terrible or painful, they also feel less panic. This of course also resonates with the idea of control. (Psychoanalysts might speculate that people who claim to be clairvoyant are actually dealing with their unconscious fear of not having control over future events.) Indeed, many PTSD researchers and clinicians have noted that one of the worst aspects that people often report about a precipitating trauma is that it came out of nowhere.

Dingfelder reports that Basoglu has taken Mineka’s ideas about control and prediction and constructed his own brief therapy for people suffering from PTSD. In a single one-hour session, he has treated survivors of Turkey’s 1999 horrendous earthquake. Clinicians talk with people about their fears, ask them to identify situations they find frightening, and then ask them to go into those situations and allow themselves to feel their anxiety. So far, as Dingfelder reports, that’s traditional exposure therapy. The difference: clients are told the purpose isn’t to extinguish fear but to realize that they can control it. Basoglu also encourages clients to visualize their fear as an opponent, with predictable patterns and actions. That takes fear out of the amorphous, overwhelming, unknowable realm and brings it into a concrete shape where it can be anticipated, confronted and controlled.

Did it work? Six weeks following treatment, 55 percent of the participants showed fewer post-traumatic stress symptoms, compared with 14 percent of the control group. And the treatment group continued to improve and consolidate their gains on their own. By continuing to practice the skills they learned. Six months after the single session, about 85 percent of participants still showed abated symptoms.

Research finds that exposure therapy, considered in the domain of CBT therapy, is also effective when working with children in a psychodynamic play therapy setting. Weisman (2017) finds that incorporating exposure therapy into play therapy helps shift children from an avoidant position to an explorative one, heling them change their approach to the world to one of adaptive mastery rather than a anxious attempt to achieve total control.

“If we can succeed in helping people to get the sense they can do something about their anxiety, at that point 99 percent of the battle is won,” says Zinbarg. That statement by Zinbarg actually hits at a deeper fact about treating anxiety disorders than endorsing exposure therapy. Transtheoretical studies indicate that the therapist’s belief in the treatment—whatever treatment—and client hopefulness about outcome are the most important predictor of any empirically supported treatment success. Like depression, anxiety makes a person feel powerless, and the decision to begin treatment, couples with the hope that treatment will work, are an important factor in successful outcome. Boswell (2016) in a case study of two anxious clients successfully treated with a transtheoretical treatment, concluded, “Even when different clients appear to similarly benefit from the same treatment, specific intervention effects on putative change factors may be more prevalent for some clients and less prevalent for others. Regular assessment is needed to determine if a client requires an alternative set of specific intervention strategies (p 710).”

 

References:

Boswell, James F.; Bugatti, Matteo (2016). An exploratory analysis of the impact of specific interventions: Some clients reveal more than others. Journal of Counseling Psychology, Vol 63(6), Nov 2016, 710-720doi: https://dx.doi.org/10.1037/cou0000174

Dingfelder, Sadie, F. (2006). “Fear itself,” in Monitor on Psychology, 37 (3), p 22. Retrieved from https://www.apa.org/monitor/mar06/fear.html.

Weisman Kra-Oz, Ora; Shorer, Maayan (2017). Playful exposure: an integrative view on the contributions of exposure therapy to children with anxiety, Journal of Psychotherapy Integration, Apr 20, 2017doi: https://dx.doi.org/10.1037/int0000088

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