Institute 2 - Desirable Difficulties: Optimizing Exposure Therapy for Anxiety Through Inhibitory Learning

A large proportion of therapists’ caseloads includes individuals with clinical anxiety. Although exposure therapy is highly effective for these conditions, many clients fail to benefit and/or experience a return of fear (“relapse”) at some point after treatment. Cutting-edge models of exposure therapy focus on an inhibitory learning theory of fear extinction, derived from basic research on learning and memory, which points to specific implementation techniques to optimize short- and long-term gains and guard against relapse. Collectively, inhibitory learning strategies emphasize distress tolerance, as opposed to habituation of distress, and introduce “desirable difficulties” into exposure sessions by challenging clients to consolidate and generalize learning via novel therapeutic strategies. This institute aims to help clinicians understand and apply this model to optimize exposure therapy. The inhibitory learning model will first be described and distinguished from traditional approaches to exposure. Numerous strategies to optimize inhibitory learning will then be introduced and illustrated in detail. These strategies include framing exposure to disconfirm threat-based expectations (and thus selectively using cognitive therapy), introducing variability into exposure to decontextualize safety learning, deepening and augmenting safety learning (by combining fear cues, labeling affect, and targeting attentional focus), and eliminating (or judiciously using) safety behaviors. Applying the inhibitory learning model of exposure to complex, diverse, and comorbid symptom presentations, and in an inclusive and justice-based way, will also be discussed. The institute will be interactive and include (a) numerous case examples highlighting implementation with individuals from diverse backgrounds, (b) video demonstrations, and (c) experiential exercises.

Recommended Reading 1: Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour research and therapy, 58, 10-23.

Recommended Reading 2: Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical psychology review, 49, 28-40.

Recommended Reading 3: Knowles, K. A., & Olatunji, B. O. (2019). Enhancing inhibitory learning: The utility of variability in exposure. Cognitive and Behavioral Practice, 26(1), 186-200.

Recommended Reading 4: 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.

Recommended Reading 5: Pittig, A., Heinig, I., Goerigk, S., Richter, J., Hollandt, M., Lueken, U., ... & Wittchen, H. U. (2023). Change of threat expectancy as mechanism of exposure-based psychotherapy for anxiety disorders: Evidence from 8,484 exposure exercises of 605 patients. Clinical Psychological Science, 11(2), 199-217.

Outline:
I. Overview
A. Importance of the Topic
B. Challenges in fear extinction and exposure therapy outcomes

II. Theoretical Background
A. Learned Fear and Extinction
1. Clinical and nonclinical fear and anxiety
B. Fear Conditioning and Context
1. Pavlovian threat conditioning and safety-seeking behaviors.
C. Emotional Processing Theory
1. Key concepts and relevance to exposure therapy.
D. Inhibitory Learning Theory (ILT)
1. Differences from emotional processing theory.
2. Emphasis on fear tolerance.

III. Optimizing Inhibitory Learning in Exposure Therapy
A. Key Strategies
1. Expectancy Tracking
a. Framework for testing threat-based predictions.
b. Consolidation of learning through feedback.
2. Variability in Exposure
a. Context, interval, and intensity variability.
b. Benefits of introducing "desirable difficulties."
3. Combining Fear Cues
a. Deepened extinction through multiple fear cues.
4. Affect Labeling
a. Augmenting learning by verbalizing emotions.
5. Attentional Focus
a. Deliberate attention to fear stimuli.
b. Avoiding distraction.
6. Reinstating Safety Learning
a. Use of retrieval cues.
b. Strategic application to prevent return of fear.
7. Occasional Reinforced Exposure
a. Occasional feared outcomes during exposure therapy to enhance extinction learning

IV. Practical Applications
A. Case Examples
B. Addressing Common Challenges
C. Tailoring Strategies for Specific Populations
D. Justice-based and inclusive exposure therapy

V. Empirical Support
A. Research Evidence Supporting Inhibitory Learning Strategies
B. Comparisons Between Techniques
1. Cognitive Restructuring
2. Affect Labeling

VI. Advanced Topics
A. Safety Behaviors
1. Judicious Use vs. Elimination
B. Troubleshooting
1. Handling Panic Attacks During Exposure
2. Addressing Unique Challenges in Therapy Settings

VII. Group Activities
A. Breakout Sessions
B. Group Discussions

VIII. Summary and Future Directions
A. Key Takeaways
B. Research Gaps