It is possible that at some time it has happened to you that you have done something on an impulse, without even thinking about it and without having a good reason to do so. For example, overeating when faced with a state of anxiety, or arguing with someone without cause, or buying things even if you don’t need them.

In all these cases there is some kind of motivation or impulse behind it that we have not been able or able to manage. This also occurs in different types of psychological problems that can lead to compulsive behaviours over which we have little control and that for some reason can be harmful or highly limiting.

Fortunately, there are different means by which we can try to reduce or even eliminate these behaviors, among which we can find exposure behavior therapy with response prevention . And it is about this therapeutic technique that we will talk in this article.

Exposure therapy with response prevention: what is it?

It is called an 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 which generate discomfort or loss of functionality.

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

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

In this sense, the aim is for the subject to experience the corresponding anxiety or feeling of discomfort and to be able to experience it without carrying out the behaviour until the anxiety diminishes naturally to a point that is manageable (it is important to bear in mind that the aim is not necessarily for the anxiety to disappear, but to be able to cope with it in an adaptive way), at which point the impulse or need to carry out the behaviour is reduced.

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

At a deep level we could consider that we are working through processes of habituation and extinction : we are trying to achieve that the subject does not realize the answer to be eliminated through the acquisition of tolerance to the sensations and emotions that usually lead to its realization. Likewise, through this habituation the link between the emotion and the behaviour is extinguished, in such a way that there is an unhabitability of the behaviour.

The advantages of the application of 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 increase the expectations of self-efficacy in patients, making them feel that they have a greater capacity to achieve their goals and face difficulties.

Some basic steps

The implementation of the exposure technique with response prevention implies the following of a series of basic steps . Let us see what each of these steps is.

1. Functional analysis of behavior

Before starting the procedure properly it is necessary to know as much as possible about the problem behaviour . Among these aspects, the problem behaviour itself, the degree to which it affects the patient’s life, the history, modulating variables and consequences of the behaviour stand out.

We must know how, when and to what such behaviour is attributed, and the different elements that make it appear more or less unpleasant.

2. Explanation and justification of the technique

Another step prior to the actual application 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 important to mention that the aim is not to eliminate anxiety per se, but to reduce it until it becomes manageable (something that, on the other hand, can eventually lead to its disappearance). After the explanation and if the patient accepts its application, the technique is performed .

3. Construction of exhibition hierarchy

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 a hierarchy of exposure.

In this sense, a list of around ten to twenty highly specific situations must be made and negotiated between patient and therapist (including all the details that may model 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 behaviour .

Only one exposure to one of the items should be carried out per session, as the subject should remain in the situation until the anxiety is at least halved.

Each of the situations should be repeated until the anxiety remains low in a stable manner in at least two exposures, at which time the next item or situation in the hierarchy will be moved (in ascending order according to the level of anxiety).

While exposing himself, the therapist should analyze and help the patient to orally externalize his emotional and cognitive reactions . Powerful reactions can occur, but the exposure should not be stopped unless absolutely necessary.

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

It may be advisable that in at least the first sessions the therapist acts as a behavioural model, representing the exposure to which the subject will be subjected before he or she does the same. In terms of response prevention, it has been found to be more effective to provide clear and rigid instructions rather than generic indications.

Prevention of response can be for the duration of the entire treatment, only to the behaviors that have been worked on previously in the exposures or for a certain time after the exposure (although it depends on the type of problem)

5. Discussion and further assessment of the exposure

After the presentation, therapist and patient can 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. Evaluation and analysis of the process

The results of the intervention should be monitored and analysed so that exposures can be discussed and altered if necessary to include something new, or to show the achievements and improvements made by the patient.

The possibility that at some point the problem behaviour is carried out both when exposure occurs and in daily life must also be taken into account: working with this type of behaviour is not simple and can cause great distress for patients, who may even break away from response prevention.

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

Conditions and disorders in which it is used

Exposure with response prevention is an effective and very useful technique in multiple mental conditions, the following being some of the disorders in which its success has been seen.

1. Obsessive-Compulsive Disorder

This problem, which is characterized by the intrusive and recurrent appearance of highly anxious obsessive thoughts for the patient and which usually leads to cavilation or compulsive rituals to reduce anxiety (something that ultimately ends up reinforcing the problem), is probably one of the disorders in which RPE is most applied.

In the Obsessive-Compulsive Disorder the EPR is used to achieve the elimination of the compulsive rituals, as much if they are physical as mental, looking for to expose the subject to the thought or situation that usually triggers the compulsive conduct without it gets to make the ritual.

Over time, the subject may eliminate this ritual , and may even reduce the importance given to obsessive thinking (something that would also reduce the obsession and discomfort it generates). A typical example where it is applied is in the obsessions linked to pollution and cleansing rituals, or in those linked to the fear of attacking or hurting loved ones and overprotection rituals.

2. Impulse control disorders

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

  • You may be interested in: “Kleptomania (Impulse Theft): 6 Myths about the Disorder”

3. Addictions

It has been seen that the field of addictions, both substance-related and behavioural, 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 sought.

For example, people with alcoholism or pathological gambling may be exposed to situations that they associate with their habit (e.g. being in a restaurant or bar) while preventing the response, as a way of helping them to cope with the desire to consume or gamble and not resort to addictive behaviour if they find themselves in such a situation in real life.

4. Eating disorders

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 (such as the view of one’s own body, influenced by cognitive distortions) or the experience of anxiety can be worked on by preventing the binge eating or subsequent purging response. Similarly, in binge eating disorder, it can be helpful.

Limitations

Despite being highly effective in modifying behaviour, it is necessary to take into account that the technique of exposure with response prevention also has some limitations.

Although it is very effective in treating and modifying problematic behaviour , it does not work directly with the causes that led to the appearance of anxiety , which led to the development of maladaptive behaviour.

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

E n the case of alcoholism may help to treat craving and help prevent relapses, but it does not help to work out the causes that led to the acquisition of dependency. In other words, it is very effective in treating the symptom but does not directly work on the causes of the symptom.

Likewise, it does not deal with aspects linked to personality such as perfectionism or neuroticism, or hyperresponsibility, although it does facilitate working at a cognitive level if this exposure is used as a behavioural experiment through which to carry out cognitive restructuring. For all these reasons, it is necessary that exposure with response prevention is not carried out as the only element of the therapy, but that there must be work 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). Exhibition techniques. University of Barcelona. Faculty of Psychology. Department of Personality, Evaluation and Psychological Treatment.
  • 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 prevention of response in the case of a young woman with obsessive-compulsive disorder. Journal of Clinical Psychology with Children and Adolescents, 2 (1): 75-81.