EP 226 – How Does Exposure Work? Habituation vs Inhibitory Learning

How Does Exposure Work For Anxiety? Habituation vs Inhibitory Learning

We know about exposure.  Going toward the thing we fear rather than trying to avoid it, escape from it, or engineer life so that it is never “triggered”.  We know that exposure is en effective tool when it comes to anxiety disorders. But how does it actually work?  Why does it sometimes only work halfway?  Why does it sometimes not last?  What is habituation?  What is inhibitory learning?  Let’s get geeky with it this week!

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The Highlights

Old school exposure is based on habituating to anxiety is about learning that you are OK as long as anxiety decreases or disappears. This works, but leads to fragile recovery and frequent relapses and setbacks.  Current models of exposure are in many cases harsher and more difficult, but are based on learning that you are OK and can handle it even when or if you get anxious or even panic. This leads to more durable and wider states of recovery. 

Habituation:  “I’m OK as long as I don’t get anxious.”

Inhibitory learning, when we allow it to happen:  “I’m no longer worried about being anxious.”

Which do you think is better? 

When you encounter a fully recovered person that does not experience relapse or setback, you are talking to someone that wound up with the second result, not the first.

This can get super technical and super geeky. I’m not going to get technical and geeky on you here.  Honestly, I could link a bunch of research papers, but that is likely a bad idea. I know many of my listeners wind up almost obsessively researching recovery techniques and “methods” trying to find the best way, to ensure that they are doing it right, to guarantee that they will recover, or to get immediate relief.  You can Google on your own if you must, but if you are prone to this kind of habit, please think twice about that.

Also, please remember that inhibitory learning is not a type of therapy or a technique.  You don’t have to look for an inhibitory learning therapist. You do not “do inhibitory learning” to recover.  Keep listening/reading for more on this.

A few important points.  

Exposure is not the thing you are doing.  Driving, walking, staying home alone, and holding a knife in your hand are not the exposures.  The exposures are the sensations, thoughts, and emotions you experience while doing those things. Nobody is learning to drive, walk to the park, stay home alone, or hold a knife.  We’re learning how to relate in a different way to we feel when we do those things.  This is important. Keep it in mind.

Exposure not just doing things and pushing through.  If you are forcing yourself to do things because you don’t want to avoid, great.  But if you are just pushing through, hanging on, or trying to find ways to minimize the feelings so you can just get through what you’re doing and exit that distressing situation, that’s going to be problematic.

Exposure is about coming into contact with the things we fear while also resisting the desire to perform safety rituals or compulsions that you hope will take away the bad feelings and the fear you hate so much.  For example:

• Going home when you start to panic at work
• Turning the car around if you feel anxious while driving
• Only doing certain things with a “safety” person
• Using safety devices like oils, mints, snacks, water, or ice packs
• Calling someone to have them “talk you through” anxiety
• Instantly turning on a podcast episode when you are anxious

Do you do any of these things?

Habituation is a natural process. Humans and animals habituate.  So when we looked at exposure as being based on habituation – getting used to something so that your reaction to is decreases – we were kinda accidentally right, but missing some important parts of the puzzle.

People often expect that if they do exposure work, then anxiety will lessen because they will “get used to it”. To be sure, this can happen. In the earlier days of CBT, exposure was done in an incremental way with lots of repetition, but in a more simplistic way simply to get someone acclimated or habituated to anxiety. If you are hoping that you can just keep pushing through your exposures or engineering them so that they are easy as you can make them (see the above list), you are banking on habituation to get you to a recovered state.  

This often leads to partial recovery, or “good enough” recovery where you can do most of what you need to do and manage life on a daily basis but you are doing that with a set of conditions and restrictions. 

“I can do the school pickup now but if I’m having a bad day my partner does it.”

“I can stay home alone now as long as I know that there’s someone I can call if I get anxious.”

“I’m pretty good at handling my intrusive thoughts now but I can’t watch any movies with babies in them or I spiral.”

“Good enough recovery” has a limit. When you cross that limit, you often experience anxiety and fear again because you still see anxiety and fear as things you can’t really handle.  A partially recovered person does some things with conditions, but refuses to do other things because of how they may feel if they do them.  A partially recovered person that just “got used to it” and learned how to make it stop will tell you that they are OK in the supermarket, but can’t go to the movies.  Fear extinction based on habituation tends to be very specific.

Habituation is useful, but it essentially teaches us that we are only OK as long as we can be sure that anxiety won’t be there or won’t last very long. 

We see this when a partially recovered person may experience one or two episodes of intense anxiety and then winds up in a relapse or setback. If we are aiming at fear extinction, or making your anxiety go away, relying solely on habituation makes for a fragile state full of conditions and prerequisites for being OK.

See the problem there?

(Side note, now we know that we never unlearn a fear response.  That response is coded permanently once we learn it and have experiences associated with that fear response. This helps explain the whole setback and relapse thing to some extent.  We’re not just unlearning our fear.  We’re learning new ways to relate to it and those new pathways get coded alongside the old pathways.)

Enter inhibitory learning. 

Inhibitory learning isn’t so much concerned with making anxiety go away as it is concerned with teaching us that we can tolerate and navigate through anxiety when it happens. How many times have you heard me say the words “tolerate” and “navigate”?  Lots of times, right?

When you hear me talk about changing your reaction to anxiety and fear, giving up the fight, and surrendering, we are in inhibitory learning territory. When you hear me tell someone to mix up exposures and have varied experiences because that is most effective, we’re banking on the mechanism of inhibitory learning. When I tell you to be incremental and keep adding difficulty to your exposures, we’re leveraging the power of inhibitory learning.  And when I plead with you to take the lessons that reality gives you after an exposure – that nothing happened besides being afraid – I am pointing you in the direction of inhibitory learning.

Inhibitory learning is not so much a technique as it is a model that describes how brains achieve more wider and more durable states of recovery. This is not so much about guaranteeing that your fear is made extinct, but that knowing that even if you do wind up afraid, you are still OK and can move through and past that.

What are the hallmarks of exposure work that tap into the power of inhibitory learning?

• Exposures focused on tolerating anxiety, not making it decrease.
• An openness to experience all anxiety during exposures rather than trying to minimize it.
• Varied experiences that trigger anxiety
• Resisting escape, avoidance, and safety rituals and behaviors
• Difficulty. We need exposures to be difficult. Difficulty now leads to better outcomes later. Tiptoeing through life trying to not be anxious is not exposure..
• An openness to accept the outcome of the exposure based on the feared disaster not happening rather than how you felt during. This is where you hear me, and people that sound like me, telling you that how you felt and what you thought does not matter.  Only what happened matters.

I love this stuff.  I love staying on top of the latest research in the field.  I love talking about it and trying to teach these concepts in a relatable way. I hope that in this episode I’ve helped make some of the nuts and bolts of exposure more understandable, but above all more relatable and useful in your own recovery.