In this blog, we will learn more about Exposure and Response Prevention (ERP), the critical core of CBT treatment for OCD. In short, ERP is an evidence-based therapeutic approach for people with OCD. Initially, it was thought to work by a principle of HABITUATION (reduced response to the stimulus on repeated exposure). Still, it is known that it works on a principle known as INHIBITORY LEARNING. During the treatment of ERP, one does not “UNLEARN” the obsessive fear or anxiety. However, “NEW LEARNING” takes place. This new learning is powerful enough to inhibit or block out the original fear caused by the obsessive thought.
The new learning overrides the old learning and teaches the brain that it is safe and not fearful. For example., One might have thought, “One’s hands are not clean enough after using a public toilet and will get infected and die”. The obsessive fear behind this is “Public toilets are unsafe”. During ERP treatment, a person is gradually exposed to public toilets. As they start a step-wise exposure to public restrooms, they are testing out their fears and learning that public toilets are generally safe and that washing hands once is enough. The new learning over a period of time is powerful enough to inhibit the old learning.
Inhibitory learning teaches a person that the Obsessional fears are safe. Secondly, it teaches that worries and anxieties are tolerable. Compulsive rituals are not required to ensure safety. The probability of an over-anxious outcome is very low or does not happen. The five elements of inhibitory learning are focusing on tolerating anxiety instead of Habituating oneself to it. The second element is to disconfirm expectations. The third is to surprise. Fourth is to combine cues of fear, and fifth is variety. This blog will consider the first and second elements of inhibitory learning. During ERP, the focus tends to be more on providing new knowledge instead of extinguishing the old knowledge about the fear. One learns that the probability of the feared outcome is less. The anxiety and discomfort experienced are tolerable.
They also learn that compulsive rituals are unnecessary to keep them safe or reduce stress. It teaches them that not only the thought is safe, but the emotional distress is safe to experience. The second element of Inhibitory learning is to disconfirm expectations. For example., say a mother has an obsessive thought and ensuing fear of harming her baby. She is highly distressed and is scared to handle her baby alone by herself. By exposing her to being with the baby for 2 hours by herself, she learns not only that it is safe to have obsessive thoughts and discomfort but also that her expectations are not realised, and this is a source of relief to her that she is safe with the baby. The following blog will examine the other three aspects of Inhibitory learning.
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