Treatment for an anxiety disorder generally involves two components:

1. Taking small steps towards facing a fear, psychologically and/ or behaviorally.
2. Taking the same small steps over and over again until you can take another step.

​In theory, if you keep taking small steps, eventually, you get to the final step and overcome your fear. Why would you need to repeatedly take the same step over and over again to get used to it? Well, simply stated, that is the only way we learn that we can do something difficult as human beings. If we do not think we can do something difficult, we need to go do that thing over and over again until we feel like we are actually capable of doing it and have collected enough instances of success to be confident in our abilities. Treating an anxiety disorder, in this sense, is similar to training as an athlete. How many baskets does an NBA player have to make to feel confident? Many. 

Exposure therapy, a therapy that entails facing and overcoming fears that are interfering with your happiness and success in life, is therefore effective because it entails repeatedly taking small steps towards overcoming your fears. Your therapist will explain a part of this process as habituation, or getting used to or desensitized to unhelpful or unrealistic anxiety (as cited in Abramowitz et al., 2019, p. 17). Habituation involves anxiety reduction/ getting used to anxiety both within and between sessions. In other words, during sessions, you will work on sitting with anxiety but in between sessions you will repeat the exercises for successful habituation.  

Why can’t you just complete the work in one session per week? Because habituation or desensitizing is a process that takes several repetitions and a large amount of time (Abramowitz et al., 2019). You would never go to the gym and expect results after only one gym session. Similarly, modifying your brain will take repetition. As mentioned in the previous blog in this series (see The Role of Avoidance Learning in the Development of Anxiety-Based Disorders, OCD, and PTSD), fear is promoted through operant conditioning, or the encouraging or discouraging of behavior by using reinforcement or reward. Therefore, unconditioning a fear requires habituation or many repeated exposures to the conditioned stimulus (the now feared situation that you did not fear before) presented without the unconditioned stimulus (feared outcome taking place) until fear starts to diminish. For example, if someone is afraid of riding a bike because they fell off of it previously, successfully riding the bike many times will eventually lead to habituation, or getting used to riding the bike again and confident you can continue doing so. 

With respect to neurobiology, during habituation (and eventually elimination of a fear), an area of the brain called the medial prefrontal cortex or the mPFC blocks output in what is called the amygdala, the part of the brain that regulates fear (Kwapis & Wood, 2014). The mPFC is responsible for decision making (Euston et al., 2012). More specifically, during exposure work, neurons, or cells in a portion of the medial prefrontal cortex called the infralimbic cortex (as cited in Kwapis & Wood, 2014) undergo changes that reduce activation in the amygdala (as cited in Kwapis & Wood, 2014). In other words, cells in our brain help us get used to being exposed to a fear (that originally activates the amygdala) and eventually our rational brain realizes that we no longer need to be afraid because a situation is not inherently dangerous. 

Psychologically, one additional component of habituation is learning that our anxiety will not last forever, as we start to learn that the feared stimuli is not actually dangerous. It has been theorized that fear extinction, or complete elimination of a fear, first requires habituation. In other words, getting used to the fear and seeing that it is not as dangerous or intolerable as once believed, allows you to form new associations and to stop avoiding the originally feared situation, object, thoughts, etc. Due to habituation, exposure therapy remains a highly effective intervention for treating anxiety disorders. 
 
If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at [email protected]. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond.

References

Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press.
Euston, D. R., Gruber, A. J., & McNaughton, B. L. (2012). The role of medial prefrontal cortex in memory and decision making. Neuron, 76(6), 1057-1070. 
Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. https://doi.org/10.1016/S0005-7894(89)80067-X
Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.
Krypotos, A-M., Effting, M., Kindt, M., & Beckers, T. (2015). Avoidance learning: A review of theoretical models and recent developments. Frontiers of Behavioral Neuroscience, 9(189), 1-16. https://doi.org/10.3389/fnbeh.2015.00189   
Kwapis, J. L., & Wood, M. A. (2014). Epigenetic mechanisms of fear conditioning: Implications for treating post-traumatic stress disorder. Trends in Neuroscience, 37(12), 706-720. 
Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Department of Veterans Affairs.

​The development of anxiety-based disorders, OCD, and PTSD, as understood at this time, involves complex interactions between genetic and environmental, behavioral, and psychological factors. In this blog, I will discuss a leading theory on one major behavioral/ psychological contribution to the development of and maintenance of these disorders: Avoidance. Unfortunately, avoidance generally prevents overcoming a fear response. Why? Because you can’t see that a feared situation, thought, or memory is actually not harmful until you repeatedly encounter that thing and see that it is not harmful. 

Specifically, the avoidance learning theory on the development of fear suggests that fear responses develop through two processes. First, fear development is based on forming an association between two stimuli: A neutral thing and a scary or unpleasant thing (as cited in Krypotos et al., 2015). This is often referred to as classical conditioning. For instance, at an early age, we learn to associate a stove (neutral thing) with being hot (an aversive and scary stimuli), after we accidentally touch the stove or are warned by our parents that it will burn us. Therefore, we learn to avoid touching hot stoves and we develop a healthy fear of putting our hands on the burners when the stove is on. Similarly, unrealistic or anxiety-disordered fear associations develop when a previously neutral stimulus gets paired with an aversive or anxiety-provoking stimulus. For instance, if a dog is startled by the loud sound of a garbage truck every time the garbage gets picked up, the dog might start to fear garbage trucks, trucks/ cars in general, or even the garbage can. Although we know the garbage truck is not actually a dangerous stimuli, the repeated pairing of a previously neutral/ safe stimulus (garbage truck/ can) and aversive stimulus (loud noise) will generate a conditioned stimulus (truck/ can) and a conditioned response (fear). In the event that the garbage truck was actually dangerous, it would be adaptive for the dog to avoid seeing or being near the garbage truck or garbage can. However, because the garbage truck is not actually dangerous, the dog has now developed a maladaptive anxiety response and false narrative about garbage trucks being dangerous. 

After this maladaptive anxiety response is formed, disordered anxiety will be further maintained by avoidance, often termed operant conditioning. For instance, if the dog starts to run and hide every time the garbage truck arrives, he will not only maintain the fear but also strengthen the fear. Every time he hides, he is confirming that something about the garbage truck is dangerous and he feels a sense of relief while hiding under the bed. This process is often termed operant conditioning, or the encouraging or discouraging of behavior by using reinforcement or reward. In this way, operant conditioning plays a role in the maintenance of anxiety disorders. When something is pleasant, it is reinforcing/ feels good, and therefore the behavior continues. Conversely, when something is unpleasant/ feels bad, that thing will be avoided so the behavior discontinues. When the dog runs and hides, he feels a reduction in negative emotion (which is pleasant) and therefore the behavior is reinforced and the fear is maintained. 

Thus, the avoidance learning theory suggests that anxiety disorders are developed through classical conditioning and are maintained through operant conditioning. After one fear-provoking situation, our brains can trick us into believing something is dangerous, when it actually is not, and then avoidance fuels and strengthens unhelpful and unrealistic anxiety responses and beliefs over time. 

Understanding this theory is important for your treatment. Why? Because the most effective interventions we have to date for the treatment of anxiety-based disorders, OCD, and PTSD involve breaking these associations using exposure-based interventions and thought challenging strategies. Thus, there is good news! If avoidance maintains these disorders, then challenging it and reducing avoidance will serve as effective treatment for overcoming your fears. 

If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at [email protected]. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond.

References
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press.
Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. https://doi.org/10.1016/S0005-7894(89)80067-X
Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.
Krypotos, A-M., Effting, M., Kindt, M., & Beckers, T. (2015). Avoidance learning: A review of theoretical models and recent developments. Frontiers of Behavioral Neuroscience, 9(189), 1-16. https://doi.org/10.3389/fnbeh.2015.00189   
Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Department of Veterans Affairs.

You may have seen the viral TikTok trends about oranges and birds only to wonder what that has to do with the strength of your relationship. “Orange peel theory” and “bird theory” are both real life examples of the famous research study by relationship expert,
John Gottman. After observing thousands of couples in his lab, he found that the couples with the greatest long-term success had one major thing in common: how they responded to bids for connection. A bid for connection can be something as simple as asking your partner to peel an orange or look at the interesting bird outside but often they are an indicator of much deeper aspects of the relationship like shared values, dreams, and desires.

What Gottman noticed is that couples who were happiest (and stayed together) responded consistently to bids for connection from their partner and responded with genuine interest and curiosity. This showed each partner’s willingness to learn and understand more about their partner during regular day-to-day interactions. He called this “turning towards” the bid for connection. Couples who were less satisfied with their relationship often ignored bids (“turning away”) or responded with disinterest or even hostility (“turning against”).

In his research, Gottman discovered that “master couples” (those who stayed together and were satisfied in their relationship) responded by turning towards their partner 86% of the time while “disaster couples” (those who experienced high conflict and eventually ended their relationship) turned towards the bid only 33% of the time. This research was groundbreaking because it highlighted that the majority of the work in the relationship happens in small, everyday moments. Not extravagant date nights, vacations or gifts but asking your partner whether they had a good day at work and actually listening to their response.

It may seem simple and straightforward to respond when your partner asks a question or tries to engage you in a conversation. However, bids for connection require emotional attunement and vulnerability on both sides. Let’s look at some examples of turning against, turning away and turning towards. 

Turning Against

Becca: Hey, I’m thinking about looking for a new job. You know how unhappy I’ve been at this one.

Alex: Oh jeez, not again! I swear you can’t stay at a job for more than six months. Do you know how stressful it is for me when you’re constantly switching jobs?

In this example, Becca is receiving the message that her partner is not a safe person to discuss her dreams and concerns with. She will likely internalize the concept that showing vulnerability is stressful to her partner and she should keep these thoughts to herself which prevents Alex from understanding his partner. Not only will Becca refrain from making bids for connection in the future but it’s likely she will make decisions without informing her partner which can lead to even more conflict.

While Alex is able to clearly assert his needs in the situation (a desire for stability), the hostility he used to communicate will likely keep Becca from fully understanding his fears and create defensiveness instead. Because Becca will probably respond to Alex with a focus on defending herself, the original issue (looking for a new job) will remain unaddressed and both parties will leave the interaction feeling misunderstood.

Turning Away

Becca: Hey, I’m thinking about looking for a new job. You know how unhappy I’ve been at this one.

Alex: Uh-huh… did you remember to get mustard at the store this week?

In this example, Becca is not receiving hostility but the concerns about her current job are being ignored. While this might not create a conflict in the moment the way that “turning against” can, this type of response will lead to a build-up in resentment. Over time, Becca will internalize that her needs are irrelevant and her attempts at building intimacy are not worthwhile.

Alex may not realize that he is ignoring an important interaction because he is distracted. We all experience moments where our partner is trying to connect with us and we have our attention elsewhere. This is where Gottman suggests utilizing a “repair bid” or a follow-up question from the partner who initially ignored the bid. Repair bids are an attempt to turn towards our partner when we missed the first request for connection and go a long way in reducing resentment over time.

Turning Towards

Becca: Hey, I’m thinking about looking for a new job. You know how unhappy I’ve been at this one.

Alex: I know this job hasn’t turned out the way you’ve hoped. What kind of new jobs are you considering? 

It’s important to highlight a few aspects of what makes Alex’s response a good one:

• Validation: Alex starts out by validating his partner’s feelings about her current job. Not only is he providing reassurance that it’s okay she doesn't enjoy her current job but that she is safe to share negative emotions with him
• Emotional Attunement: Learning that Becca is unhappy at work is not a surprise to Alex. He implies that the couple has had conversations about this topic previously and Alex is fully attuned to his partner’s feelings about her workplace.
• Positive Regard: Alex’s response is illustrating that things Becca has shared in the past are important to him. When we show our partners that their fears, anxieties and concerns are valuable to us, it furthers that sense of safety and encourages them to share more frequently. 
• Curiosity: Rather than problem solving or trying to make suggestions for how Becca could be happier at her current job, Alex asks her an open-ended question. This shows a genuine curiosity for learning more about what Becca wants and also allows Alex to gather more information about where his partner is at in their own process. 
• Openness: It is very likely that Alex has his own feelings about his partner switching jobs but he utilizes an open and non-judgmental response to give the couple a chance to have a constructive conversation. Often couples worry that if they don’t voice all of their concerns right away, they won’t get the chance. In practice, the opposite is true. As we can see here, Alex is holding off on passing judgment and allowing Becca to share which in turn will make her more open to hearing his concerns further into the conversation.

Once we start to notice how we are responding to our partner’s bids for connection, we can begin turning towards them with more intention. Your partner might say, “Hey, did you see that bright red cardinal?” when they actually mean “Hey, are you paying attention to things that are interesting to me? Do my experiences matter to you? Do you see me and enjoy who I really am?” Learning to respond to these questions at the heart of the bid will strengthen the foundation of the relationship and ultimately lead to a happier, longer-lasting bond for both partners.

If you are interested in couples counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at [email protected]. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond.