A Review of the Research Supporting (and Not Supporting) Inhibitory Learning Strategies

In my posts about exposure therapy, I’ve written about inhibitory learning theory a bit. I’ve particularly focused on how inhibitory learning theory has supplanted emotional processing theory (EPT) as the best supported model for exposure.

I recently came across a thorough review article that walks through the major inhibitory learning principles and recommended procedures—as well as some not explicitly tied to inhibitory learning –and assess the degree to which these principles and strategies are supported by research to date

The authors conclude:

Collectively, research support for exposure augmentation techniques aimed at optimizing inhibitory learning has fallen short of theoretical expectation in several respects. Though the literature strongly suggests that this theory provides a better mechanistic explanation for the results of exposure therapy than alternatives such as EPT (at least as originally proposed), findings regarding particular enhancement strategies have been quite inconsistent; even among studies in support of specific techniques, the majority of effects are modest at best.

As a summary can’t do justice to this article, I recommend you check it out yourself. If you have any interest in exposure therapy, it is essential reading.

Weisman, J.S, & Rodebaugh, T.L. (2018). Exposure therapy augmentation: A review and extension of techniques informed by an inhibitory learning approach. Clinical Psychology Review, 59, 41-51.

Here’s a link to the author’s ResearchGate page, where you can request a copy of the article.

An Overview of Emotional Processing Theory

An Overview of Emotional Processing Theory

NOTE: This post is part of a larger series of on the theory, practice, and research on exposure therapy. If you are interested in other posts in this series, you can find them here.

Twenty-five years ago, in an attempt to create a unifying theory that would explain the processes of and guide the use of exposure in the treatment of anxiety disorders, Foa and Kozak (1986) developed the emotional processing theory (aka, information processing theory). The emotional processing theory has since guided an enormous amount of research, particularly for posttraumatic stress disorder (PTSD). Dr. Foa drew from the theory in developing prolonged exposure, a landmark PTSD treatment and the gold standard approach to PTSD treatment.

Much of my experience with the emotional processing theory comes from my training in prolonged exposure. When I was originally trained in prolonged exposure, I had the impression that it was more on the behavioral side of cognitive behavioral therapy. However, in reading about the emotional processing theory in greater depth, I realized that, although prolonged exposure looks procedurally like behavior therapy, the theory behind it is more of a product of the cognitive revolution with its emphasis on the computer as a metaphor for the human mind.

According to the emotional processing theory, fear is activated through associative networks that include information about the feared stimulus, escape or avoidance responses to the feared stimulus, and the meaning of the fear (e.g., threat or danger). Fear becomes problematic when it is intense to a degree that it gets in the way of functioning, or when it persists even when there are no clear indications of danger. In these instances, there may be maladaptive or pathological fear structures. The theory holds that chronic avoidance (e.g., escape behavior, avoidance, dissociation) often leaves these maladaptive schemas in place, as people do not remain in a situation long enough for new learning to occur.

Emotional processing theory proposes that exposure can alter the relationships between the fear stimulus and these networks. For this to happen, the network must first be activated, and then new information must be encoded that is incompatible with what is in the fear network. This is accomplished through habituation. Staying in contact with a fear stimulus until there’s a reduction in anxiety allows for the encoding of new information that is incompatible with the fear stimulus (e.g., it’s not dangerous). For example, in someone with OCD, repeated exposure to an obsession while refraining from engaging in a particular ritual serves to disconfirm maladaptive beliefs about the importance of the ritual in keeping harm away.

I break this process down with greater detail below.

Fear Structures

We’ll start with fear structures. Originally proposed by Lang (1977), fear structures are cognitive networks of maladaptive thinking that become activated through fear or anxiety. For people with anxiety-related problems, there are two common maladaptive beliefs about the fear stimulus: 1. That anxiety or distress will escalate to the degree it becomes unmanageable (e.g., “I can’t handle this”); 2. The feared stimulus or their experience of anxiety will cause harm (e.g., “I’ll lose control” or “I’ll go crazy”). For example, someone with panic disorder might think, “I’m going to die” when they start to notice panic cues like shortness of breath.

The major problem, according to emotional processing theory, is that people with anxiety disorders usually engage in some form of escape or avoidance behaviors when they feel anxious. As a result, they don’t remain in contact with their anxiety long enough to disconfirm the fear structure. Over time, people continue to engage in disruptive behaviors (e.g., escape) whenever they experience fear. An unfortunate side effect of continued avoidance behavior is that people’s lives begin to constrict in order to avoid things that trigger the fear structures. Their lives become narrower and more confined (e.g., they stop leaving the house).

Disconfirming Fear Structures Through Habituation

The solution then, according to the emotional processing theory, is for people to stay with their anxiety long enough for it to reduce on its own. Research suggests that so long as we don’t actively feed anxiety through worry, it tends to go down on its own after about 45 minutes –what is called habituation to the feared stimulus. Through repeated habituation, they begin to learn that what they’re afraid will happen (e.g., “I’ll go crazy”) doesn’t occur, and/or that the feared consequences are less likely to occur or are milder than expected (e.g., “If people notice I’m anxious, they’ll laugh at me”).

Foa and Kozak (1986) suggested that exposure weakens associations and replaces maladaptive fear associations with more adaptive ones. However, this view was revised in Foa and McNally (1996), where the authors incorporated animal behavior models of exposure from the lab of Bouton. Bouton’s work suggests that exposure does not actually alter associations so much as creates new, competing associations. What this means is that following exposure, there may now be two associations: a pathological one and a non-pathological one. Ideally, the person begins engaging in behaviors that are more in accordance with the non-pathological association, strengthening it over time.

Here’s an example: A motor vehicle accident survivor develops a fear structure involving thoughts that all automobiles are extremely dangerous. As a consequence, he stops driving. The therapist might arrange a series of exposure exercises involving automobiles. The person might start by sitting in a parked car each day until his anxiety decreases. He may then drive very slowly on low traffic streets, working his way up to driving again. The man may retain the association that all automobiles are dangerous, but through exposure a competing association that harm is unlikely accompanies it. The man may then make choices in accordance with this second association (e.g., the choice to drive a car).

A Glimpse Into the Future of the Emotional Processing Theory

This is a brief sketch of the emotional processing theory. It has been hugely influential in guiding research on anxiety treatment, particular for posttraumatic stress disorder and obsessive-compulsive disorder. The application of the emotional processing theory to PTSD has led to a very successful treatment—prolonged exposure. However, treatments may be effective even if the theories guiding them are not entirely accurate.

As I’ve written in a previous post, the main area in which newer research has brought the emotional processing theory into question is its emphasis on habituation. There’s no reason to offer a complete retread of the post, but newer research suggests that it’s not necessary for someone’s anxiety to go down during exposure in order for him or her to benefit. Additionally, McNally (2007) argued that the concept of “fear structures” is vague, circular, and not supported by research. Dr. Craske at UCLA, in particular, has criticized the principles underlying the emotional processing theory (See Craske et al, 2008 for a summary of exposure research; Baker et al, 2010, for study from Craske’s lab questioning the usefulness of habituation in predicting treatment outcome).

In upcoming posts, I’ll be discussing newer research that challenges the emotional processing theory, and that offers glimpses into where our understanding of exposure may go.

For more information about Emotional Processing Theory

If you want to read more about emotional processing theory, here’s a good book:

 Pathological Anxiety, Emotional Processing in Etiology and Treatment (2005), by Barbara Rothbaum.

Or for the most widely used guide for Prolonged Exposure, the main therapy approach guided by emotional processing theory, see:

Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (2007) by Edna Foa, et al.

UPCOMING TRAINING EVENTS

An Introduction to Exposure Therapy for Anxiety Disorders: Traditional and Inhibitory Learning Approaches

Dr. Brian Pilecki
January 29, 2021 from 12:00pm-1:30pm PST
Exposure therapy is the gold-standard treatment for anxiety and obsessive compulsive and related disorders. The aim of this workshop is to provide a solid foundation in theory and knowledge for those newer to exposure therapy. This workshop will include a brief history of exposure therapy, including a description of its roots in classical and operant conditioning. Read More.


Using Acceptance and Commitment Therapy to Guide Flexible Exposure

Dr. Brian Thompson
February 26, 2021 from 1-2:30pm

Drawing from the ACT model, participants will learn to conceptualize and create exposure exercises to maximize flexibility. We will explore common pitfalls in using ACT as a context for exposure and how to create ACT-consistent exposure exercises for clients who are skeptical of “acceptance” and appear disinterested when you try to engage them about values. The presenter will use practice-based data to support these principles (Thompson, Twohig, & Luoma, in press). Read More.


An Introduction to Psychedelic-Assisted Psychotherapy for Clinicians

Dr. Brian Pilecki and Jason Luoma, Ph.D.
March 26, 2021 from 9am-12:10pm

Psychedelic assisted therapy is emerging as a highly effective form of mental health treatment. This workshop will provide health care professionals an overview of this new clinical area. The workshop will highlight the importance of preparation and integration in therapy using a harm reduction approach. The current legal status of psychedelics will be reviewed, including Oregon’s recent passing of an initiative to legalize psilocybin-assisted therapy. Finally, diversity issues around lack of access for underserved and non-majority populations will be explored. Read More.


How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Dr. Brian Pilecki
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

December 11th, 2020 – Ethical and Legal Considerations in Providing Psychedelic Integration Therapy with Brian Pilecki, Ph.D. & Jason Luoma, Ph.D.
January 8th, 2021 – What’s it Like to Trip? The Patient Experience in Psychedelic-Assisted Therapy with Brian Pilecki, Ph.D.
February 12th, 2021 – 5-MEO-DMT with Rafael Lancelotta, M.S.
March 12th, 2021 – What does Psilocybin-Assisted Therapy for Depression Look Like? A Clinical Case Presentation based on a Recent Clinical Trial from Johns Hopkins with Alan K. Davis, Ph.D.
April 9th, 2021 – Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.