This article is part of the After series, which explores life after trauma and all that entails. This week is Part 1 of Exposure Therapy. Although this was originally meant to be one post, it quickly became clear during researching and writing that this would make for one very long read! Instead, this has been split into two.
Below is an outline of Part 1:
1. What is exposure therapy?
2. Why do people undergo exposure therapy?
3. What is classical conditioning / Pavlovian conditioning / associative learning?
4. What is fear conditioning / aversive learning?
5. Okay, so what is fear extinction?
6. Why does it matter?
7. Where do we go from here?
What is exposure therapy?
Exposure therapy is (for once!) actually as it sounds. It’s a form of therapy, often seen as a ‘gold standard’ for conditions such as PTSD, which involves gradual exposure to a ‘trigger’ over time, until encountering the trigger no longer produces the inappropriate response.
Why do people undergo exposure therapy?
Disorders such as PTSD and anxiety are often characterised by an ‘inappropriate’ response to a ‘neutral’ stimulus. This is easiest to understand with an example.
Picture a spoon. Yes, I do mean just a generic spoon – you probably have many in your kitchen. Its nothing special, right? No, not particularly frightening at all.
And for most people, a spoon is just a utensil – something you use to eat soup or make your morning tea. You don’t particularly have any response at all to seeing or using a spoon. But for someone else, a spoon may be what’s known as a trigger – something which ‘triggers’ a (trauma/panic) response.
For someone with PTSD, it may not be just a spoon.
Rather, it’s something which triggers memories of their abuse. Just looking at a spoon is enough to stop this person being able to breathe. They completely freeze, eyes glazed over. Ask them to touch it? Now they’re transported back to that spoon being used as a weapon against them.
They associate the spoon with the trauma they experienced.
This is what exposure therapy aims to address. In this case, the person would continually be exposed to the spoon, in a safe environment and at their own pace. Over time, as they are exposed to this more and more without any negative outcomes, they begin to learn that the spoon doesn’t necessarily mean all those bad things after all.
Is the response really ‘inappropriate’?
Whether having a trauma/panic response to e.g., an object which formed a part of a persons trauma is truly ‘inappropriate’ is a good question. It’s very possible to go back and forth on this, and I’m not sure there is a singular ‘true’ answer. Rather, I think what’s important is the impact this has on the person’s life. If it’s something which is incredibly rare and obscure, so is very unlikely to be encountered often, then I’d probably argue there are more important things to expend time and energy on. But if its something ubiquitous, then having such a strong response likely has an impact on the person’s quality of life. In this case, it’s likely worth addressing with a trained professional, in a safe environment.
That said, it’s up to the individual to decide this for themselves – and there’s no right or wrong answer.
What is classical conditioning / Pavlovian conditioning / associative learning?
Like most things in science, associative learning is unfortunately known by many names, just to add an extra layer of confusion. Here, we will use the term associative learning simply because its the most descriptive: associative learning involves learning to associate one thing with another. To understand this better, we’ll need to go back in time to see a man called Pavlov about some dogs.
In the early 1900’s, a physiologist called Ivan Pavlov discovered that dogs would salivate in response to food. This is a normal physiological response which gets them ready to eat (we do it too – just picture your favourite dessert!)
Pavlov also noted the dogs would salivate before the food was present – rather, they were salivating in response to the person who feeds them. He theorised it was possible for dogs to learn to associate a person with an outcome: person = being given food = salivating. To test this, he designed an experiment where a cue (or trigger) was paired with an outcome.
In this experiment, food was paired with the ringing of a bell (Figure 1) until the dogs would salivate at the sound of the bell alone – even with no food present.
The dogs had learned to associate the sound of the bell with food, and so they responded by drooling.
What is fear conditioning / aversive learning?
Although Pavlov’s initial experiment involved using a neutral stimulus (the bell), it’s possible to pair an aversive stimulus with an outcome.
One infamous example of this, before ethics became a fundamental part of research, is the ‘Little Albert’ study. In this study, much like Pavlov paired food with a bell, the experimenters paired benign objects e.g., a white Santa’s beard with an aversive stimulus – in this case, a loud noise. They used a 9 month old boy, dubbed Little Albert, as their participant. Over time, simply being presented with the cue (Santa’s beard) was enough to cause the panic response.
This is often dubbed ‘fear conditioning’ but we will use the alternative term ‘aversive learning’.
A note on terminology:
In the field of aversive learning and memory, we often use the terms ‘fear memory’, ‘fear learning’ and ‘fear extinction’. A lot of the time, these vernacularised terms aren’t as helpful as we’d hope, as the lack of specificity confuses people as to what, exactly, we’re investigating. More on this will follow in a post on the difference between anxiety and fear, and why the distinction matters at all.
Okay, so what is fear extinction?
Fear extinction is associative learning in reverse. Here, the cue/trigger e.g., Santa’s beards is presented without the aversive outcome (the loud noise). The person slowly begins to learn that the cue/trigger no longer = aversive outcome. This is done multiple times, until presentation of the cue no longer results in the conditioned response.
Sound familiar? That’s because fear extinction is the theoretical basis for exposure therapy.
Why does it matter?
Knowing that fear extinction is the theoretical basis for exposure therapy allows us to examine things in more detail. Clinically, exposure therapy doesn’t work for all traumatised individuals and isn’t as ‘permanent’ as we may hope. The same is true of fear extinction, but this isn’t as well known. By investigating fear extinction, we can learn more about exposure therapy, how it works and why it sometimes doesn’t go exactly as planned.
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As always, if you have an aspect of post-trauma life you’d like to see covered in this series, please comment below or e-mail contact@traumatranslated.co.uk
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