Anxiety cycles are an undertreated symptom in medical care. Patients' fears can be as disabling as their medical conditions, creating invisible obstacles that prevent patients from exploring the widest range of their abilities.
Exposure Response Prevention (ERP) is an evidence-based counseling technique for patients who exhibit symptoms that go beyond anxiety-repetitive self-defeating mental or behavioral cycles that inhibit progress in rehabilitation or in life. Through exposure (E), patients are taught how to progressively face their fears through sequential steps. Through response prevention (RP), they learn how to cope with the feelings or thoughts associated with these fears and disengage from the avoidance behaviors that normally neutralize their anxiety.
The goal of ERP is to help the patient tolerate the anxiety necessary for progressing toward challenging goals. The technique is widely applied with patients who struggle with general anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder and phobias, but it can be useful for any patient who is stuck, either behaviorally or emotionally.
There are typically four steps to ERP interventions.
Step 1: Explain Exposure
"Patients need to hear from practitioners that fear and anxiety are completely normal human reactions and that there are tangible ways to work through it," notes Dr. Nick Sievert, a cognitive behavioral therapist specializing in exposure intervention with OCD patients.
Exposure can be a complex subject, so educating patients about the intervention is the foundation of a successful treatment. The following teaching points can be re-created in any type of handout, with visuals presented in a way that patients can understand.
Anxiety is normal. We are wired to have the flight-or-fight response when we experience stress or danger. Avoidance is a common coping technique; it temporarily relieves fear, which reinforces its use.
Exposure therapy, which is based on learning therapy, breaks this pattern by sequentially guiding patients to gain mastery over the feared circumstance. Most patients are not aware of the fear-avoidance connection.
Stress is different from distress. The aim of exposure techniques is not to push patients into distress (symptoms), but rather to help them build the appropriate levels of stress tolerance (frustration tolerance) required for achieving their goals.
Emphasize positive outcomes. When patients are afraid, they cannot see past the fear to anticipate gains. Coming up with a list of positive outcomes-such as greater independence, more confidence or a new skill such as learning to drive-can be a motivator.
Dr. Sievert recommends presenting exposure education in the affirmative. The heart of exposure therapy is to "help patients to choose behaviors that would enable them to build a better life," he notes.
Step 2: Define the Fear
The next step in exposure therapy is to define in detail what patients fear (see "Anxiety Management Training," June 3, 2008). When patients report anxiety, it is in general terms. It is critical to gain a clear picture of the nature of the anxiety (how it is expressed), but it is also important to understand the cycle in which the anxiety commonly manifests itself.
Some examples of issues to clarify include the following: How does the anxiety manifest itself: as an anxious thought (cognition), a feeling (emotion), a bodily sensation (physiological), or as a behavior? Has the patient stopped engaging in an activity that is important to her, e.g., not going to a social outing for fear of using public transportation? Even if each episode of anxiety may feel new to the patient, the patterns of how a patient exhibits anxiety are usually predictable and repetitive.
The following case study provides an example of a patient who was stuck in a cycle of anxiety.
Jane is a 17-year-old female with a severe form of muscular dystrophy, who is a wheelchair user and diabetic. She had the goal of going away to college, to live in a dorm away from home, but she would avoid the subject (cognitions) as well as appropriate planning or research (behaviors) regarding accommodations at the new campus.
Jane feared that in the event of an emergency she would be stuck in her room and unable to call for help. "I keep getting that image in my mind (cognitions); it happened to me at camp once," she stated. Even though this fear was based on a previous real experience, Jane realized that with planning and appropriate support and accommodations, she did not need to allow herself to be inhibited by this fear.
Step 3: Plan the Exposure
Establish a time frame. Depending on the patient's disability or medical condition, establishing a realistic time frame is important. Some goals may be best tackled in better weather (e.g., using public transportation), or by observation first (e.g., watching someone cook before taking on the task independently). Establish a time frame organically, based on the patient's energy level and actual level of ability. This could involve daily, bi-weekly or even 10-15 minute intervals, depending on the circumstances.
For example, Lisa is a patient who suffered neck and back injuries and wanted to return to cooking. She was instructed to start with one meal a day that she would prepare herself, while her husband would take over dinner, and she would order in for lunch (see "Integrating Behavioral Skills," April 3, 2008, and "Energy Conservation," Oct. 27, 2008).
Establish a hierarchy for fear-inducing steps. Exposure treatment is generally done in a series of steps, not in the stereotypical "plunge into the water" approach. Write out a hierarchy of situations ranked on a 0 to 10 scale, with 0 representing the least anxiety-producing step and 10 representing the step of highest anxiety. This is a helpful way to plan the frequency, intensity and duration of exposure (see Dr. Mathew's Exposure Intervention Worksheet available at http://occupational-therapy.advanceweb.com/SharedResources/Downloads/2009/090709/OT_worksheet.pdf).
Prepare for exposure. Including medical safety is an essential part of exposure interventions for rehabilitation patients. If patients are prone to injury, dependent on assistive devices, in need of an aide, etc., a good plan should consider the relevant medical factors. The point of ERP is to work through anxiety constructively and safely.
For example, a patient with cerebral palsy wanted to set a goal of going on accessible hikes. She explored participating in group tours. She chose not to participate in hikes on trails that were hilly, because these hikes would be too physically taxing for her and could cause injury. Instead she chose to take part in flat land hikes. Once she took the medical risks out of the exposure equation, she was able to focus on the true source of her anxiety, going on a trip independently with a group of strangers.
For patients with medical risk factors, I have often found it helpful to use imaginal exposure as a pre-step to actual behavioral exposure. A patient imagines the feared situation, and the clinician guides him to visualize working through his fears step by step. In this strategy, the patient can write scripts, use imagery, or imagine himself in a movie until the fear image becomes boring or no longer evokes its original intensity.
There are two main types of ERP. Systematic desensitization is a variation of the exposure technique in which the patient moves toward the feared situation, starting with the least anxiety-provoking step. In vivo exposure is a real-time exposure technique in which the patient encounters the actual feared circumstance (see "Disabling Fear," Aug. 20, 2009).
The following example demonstrates both types; it shows a set of exposure steps appropriate for Jane, the college student described earlier, who was concerned about living in a dorm away from home.
• Creating a hierarchy of tasks: reaching out to connect with another student with a disability, looking at pictures on the university's web site, imagining a day on campus and a night routine (imaginal exposure).
• Visiting campus (desensitization).
• Planning to stay over one weekend at college pre-orientation (in vivo exposure).
• Coping skills training: behavioral planning, coping statements, mindfulness, establishing a crisis plan (coping strategy).
• Getting information on a potential roommate to establish a connection (coping strategy).
• Using relaxation training to foster healthy sleep patterns during first week of staying at dorm (in vivo exposure).
Step 4: Repeat the Process
Repeating is the final step of exposure. The designed exposure plan requires repetition in as many intervals as possible until the patient's anxiety has dissipated and he or she has achieved mastery. Individual patients may vary greatly in learning ability and capacity to tolerate the emotional and physiological stress that exposure interventions may require, so I assess for coping-skills deficits between exposure sessions.
Depending on how the patient manifests anxiety, coping techniques can be applied to the specific symptom areas.
• Cognitive distress: mindfulness techniques. Teach patients how to observe anxious thoughts and not drown in them. Use anxiety coping statements to counteract anticipatory anxiety.
• Physiological stress: stress management techniques. Teach patients to self soothe or reduce stress levels during exposure.
• Behavioral stress: behavioral skills. Teach patients how to pace or break down tasks as they go through the exposure steps.
• Overstimulation: mind-body techniques. Teach patients to "tune in" to what is going on in their minds and bodies and maintain a sense of balance.
Self-Directed ERP
All types of progress patients may seek in life will elicit anxiety. Often, patients have no mental image of how to work through inhibiting patterns. They may need to refer to role models or education on relevant research, or the trust generated from the therapeutic relationship may convince them that working through anxiety is worth it.
Exposure interventions are hard work; they require effort and commitment by the patient and the practitioner. Patients who are experienced with exposure techniques can learn to engage in self-directed ERP with the help of family and friends or independently.
ERP is time efficient and cost effective, and is an invaluable skill for patients when insurance restrictions limit visits. In my clinical work, patients who learn exposure techniques gain confidence that they have mastered a skill they can use widely in their personal and professional lives. It helps them face their fears and actively maintain their wellness. n
Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. She is a disability advocate and freelance writer. The main focus of her work is to promote coping skills education for persons with chronic illness and disability. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via e-mail at her website: rejimathewwriter.com.