 The Role of Inhibitory Learning in the Development and Maintenance of Anxiety Disorders, OCD, and PTSDWritten by Hillary Gorin, PhD, LCP Exposure and response prevention (ERP) has historically encouraged using what is called habituation as a tool for and marker of symptom reduction in anxiety disorders (as cited in Abramowitz et al., 2019). Habituation generally entails repeated exposure to a feared situation or stimuli until the anxiety eventually subsides (i.e., getting habituated to the situation). In other words, overcoming a fear has generally been determined by how little anxiety someone feels at the end of treatment when engaging with the feared situation or stimuli.
For example, if someone is afraid of having panic attacks in the grocery store, successful treatment would look like having little anxiety (and elimination of panic attacks) in the grocery stores by the end of treatment. However, Craske and colleagues (2014) have suggested that habituation is not the most important factor in the extinction of fears in the long term. Specifically, Craske expresses concern regarding the goal of habituation, or anxiety reduction, claiming that it reinforces a problematic belief that anxiety is intolerable and that it must be eliminated. Instead, researchers like Abamowitz (n.d.), emphasize what is referred to as the inhibitory learning perspective, which suggests that the goal of exposure and response prevention should be to learn that, even if a trigger/stimuli makes us anxious or is slightly dangerous/distressing, we can also develop beliefs that the stimuli are not dangerous enough to be avoided or that the stimuli are generally safe. The inhibitory learning perspective suggests that the goal of ERP should be to learn to tune out or inhibit the idea that a stimuli is dangerous while allowing development of the the belief that the stimuli is generally safe, despite any anxiety and/or distress that arises (Abramowitz; n.d.). This perspective also emphasizes that learning new information/new safety associations that supersede or combat previous fear associations is critical to overcoming a fear. In other words, part of exposure therapy requires sitting with a feared stimuli long enough to develop new beliefs about it, mainly that it is not as dangerous as it seemed. This perspective also emphasizes that overcoming a fear requires new learning to take place that supersedes or combats previous fear associations (Abramowitz; n.d.). In other words, part of exposure therapy requires sitting with a feared stimuli long enough to develop new beliefs about it, mainly that it is not as dangerous as it originally seemed. For instance, in the example above, if someone fears going into a store due to fear of having a panic attack and being unable to escape, exposure therapy using habituation would entail repeatedly going into the store and seeing that the panic will subside if they stay in the store long enough and that they always could escape because no one is permanently trapped in a store. Per the inhibitory learning perspective, successful treatment would entail learning that the individual can in fact still function even when experiencing panic, as panic is not a harmful emotion. Conversely, panic is an emotion that naturally protects us. Although repeated exposure to a grocery store will teach the person referenced above that they can handle grocery stores and that they are safe, research suggests that fears/danger associations can’t be unlearned (as cited in Abramowitz et al., 2019). According to certain theories and researchers, the fear of grocery stores may remain and in the future may resurface even after exposure therapy. However, if we collect enough new safety information, which allows us to see that whatever we were afraid of is actually not as dangerous as we thought, then we will be able to overcome our fears in the future if or when they resurface. This is supported by the inhibitory learning perspective, in which the goal of treatment is to learn new and more accurate safety associations so that the old threat associations are no longer controlling thoughts and behavior. From this perspective, it is not as critical that one habituates to a feared situation or object (becomes less anxious or triggered). Instead, the exposure should be repeated until a new belief related to general safety of the situation is believable, and what the person expects to have happen (e.g., disastrous consequences) does not happen. For instance, if you are starting treatment with a fear that you will contract or spread a deadly disease if you do not wash your hands with bleach before cooking meals, the goal of exposure and response prevention therapy would be to refrain from hand washing with bleach and to cook a meal anyway until you start to learn that a deadly disease will likely not spread through cooking dinner. The updated model of exposure therapy using inhibitory learning suggests that, during this exposure work, additional learning takes place: that the originally feared stimuli, the possibility of spreading a deadly disease without washing with bleach, is actually unlikely, that the act of cooking using standard non-bleach handwashing methods is safe, and that the fear/thought/possibility itself is tolerable. If a new belief has not formed during exposure therapy, Craske and colleagues (2014) suggest that a future relapse is likely. Craske and colleagues (2014) therefore suggest that a new non-threatening cognition must be developed during therapy and the patient must be able to easily access the safety-based cognitions in a variety of contexts after gathering an abundance of evidence in opposition to the original fear. They believe that anxiety should not be controlled or resisted but instead exposure therapy should prioritize fear tolerance, because anxiety is universal, inevitable, and critical for our survival. Exposure therapy using the inhibitory learning model therefore does not encourage the use of a hierarchy, or slowly facing fears in a progressive way, from easiest to most difficult feared situation. Instead, it suggests that the patient commit to “desirable difficulties” (Bjork, 1994) in exposure therapy, or random choosing of exposure stimuli instead of utilizing a hierarchy. Craske and colleagues (2014) and Bjork (1994) believe that this approach assists with managing real life challenges because they will be able to retrieve newly learned information during surprise exposures in the future and learn that desirable difficulties aid in fear tolerance. They hope patients can start to see that when they feel fear, they can manage the distress. In other words, the end goal, according to the inhibitory learning perspective, is to learn that you did not increase the likelihood of developing or spreading a deadly disease because you refrained from bleach use. If your family survives the meal, you have gathered information that is inconsistent with your original belief and you may start to see that bleach is an unnecessary protection (even though it technically does kill germs). Every time you repeat this exposure, you will build up stronger and stronger new associations which suggest your old belief was inaccurate. Of note, we can never be 100% certain. The goal of therapy is also to be able to tolerate uncertainty and to let new information gathered during exposure work drive future behavior patterns, which thereby allows you to live life and welcome anxiety along the way. 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. Bjork, R. A. (1994). Memory and metamemory considerations in the training of human beings. In J. Metcalfe & A. P. Shimamura (Eds.), Metacognition: Knowing about knowing (pp. 185-205). Cambridge MA: MIT Press. Cras ke, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behavior Research and Therapy, 58, 10-23. Abramowitz, J. S. (n.d.). The Inhibitory Learning Approach to Exposure and Response Prevention (iocdf.org). Retrieved April 11, 2024 from https://iocdf.org/expert-opinions/the-inhibitory-learning-approach-to-exposure-and-response-prevention/  Alcohol Awareness MonthWritten by: Lee Ann Heathcoat, MSEd, LCPCApril kicks off alcohol awareness month for the Substance Abuse and Mental Health Services Administration (SAMHSA). I wanted to take some time to review information related to alcohol and bring awareness and understanding to alcohol use and misuse.
According to data from the 2022 National Survey on Drug Use and Health, among the 137.4 million respondents aged 12 and older self-reporting current use of alcohol, 44.5% reported binge drinking, with the most prevalent age category being 18-25 years old (29.5%). Among people 12-20 years old, 15.1% used alcohol in the past month. Estimates of binge alcohol use and heavy alcohol use in the past month among underage people were 8.2% and 1.7%, respectively. The Centers for Disease Control and Prevention estimate about 178,000 people die from excessive alcohol use in the U.S. each year (SAMHSA, 2024). Let's review how SAMHSA classifies a standard drink of alcohol:
Signs of Using Too Much Alcohol:
If reading the information provided above resonated with you and you may be struggling with alcohol use, reach out. I’d like to connect and find out more about how I can support you on your journey. References Alcohol Awareness Month. (n.d.). Alcohol Awareness Month. SAMHSA. Retrieved April 17, 2024, https://www.samhsa.gov/newsroom/observances/alcohol-awareness-month 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.  The Benefits of BoundariesWritten by Anna Perkowski, MSW, LCSWThe concept of boundaries has seemed to take off in the social media realm and in therapy offices alike. The Merriam-Webster Dictionary defines a boundary as “something that indicates or fixes a limit or extent.” Boundaries apply to things like property lines and city limits, and they also apply to both intrapersonal and interpersonal relationships. Boundaries are an opportunity to determine how and when we will utilize our innate and external resources such as emotional capacity, verbal and non verbal communication, time, and money, to name a few things, when we relate to ourselves and other people in our lives, for the purpose of creating and maintaining safe and satisfying relationships.
As a recovering people pleaser, I can attest that setting healthy boundaries is hard, but it’s not selfish. The furthest thing could be from the truth - boundaries are actually kind. Merriam-Webster defines kind as being “of a sympathetic or helpful nature.” Boundaries are also helpful. Here’s an exercise: Consider someone you personally know who you would describe as having healthy boundaries, and as being kind and helpful - ask them if they believe it is selfish to have and maintain boundaries. In regard to continuing to unlearn some misconceptions about boundaries, I like to envision them as a “gate” instead of a “fence.” This means that there is a pathway, an opportunity for the boundary to be responsive, to allow others in and out when appropriate, but it does not mean shutting the world out forever. A barrier I’ve also noticed for so many individuals in setting healthy boundaries is the fear of coming across as “mean” or “selfish.” This fear of negative perception maintains the boundaryless behavioral pattern until it’s no longer sustainable. What usually happens over time is that resentment will set in and all of a sudden, it’s “boundaries for everyone!” as an attempt to regain some peace. The only problem with this is that when boundaries are coming from a place of burnout and resentment, and it becomes tempting to isolate, they’re usually less effective. However, regardless if someone is setting a boundary proactively or somewhat reactively, they are still so important to have. Without them, we risk enabling poor behavior in ourselves and in others. Here are some signs and questions to ask to determine if boundaries are needed with self or others:
I hope you’re now wondering how to get ahead of burnout and resentment, and how to learn to set boundaries from a place of health and peace. One of my favorite ideas to think on is that instead of being responsible for other grown people, we are instead responsible to them; to do no harm. This distinction can help shift away from the tendency to engage in people-pleasing tendencies at the expense of one’s own needs and desires. How to set and communicate boundaries:
Lastly, I want to expand a bit more on this idea of having healthy boundaries with ourselves. The relationship we have with ourselves is one of the most, if not the most, important relationship we have, and yet I find this to be an area that often gets overlooked. Some examples of this could be forgetting to eat or sleep well, not advocating for what we need in our homes or relationships or workplaces, not doing what we say we will do, etc. Here are some examples of boundaries that someone can have with themselves:
 Positive DefianceWritten by Adam Ginsburg, MA, LCPCWhen we think of what it is to be defiant or to display a level of defiance in our everyday lives, more times than not, this isn’t exactly viewed from the lens of being a desirable trait that one would possess in their arsenal. After all, when’s the last time a friend got back from a social engagement, perhaps a first date of sorts, and when pressed for details on what their counterpart was like, jubilantly exclaimed, “Oh, it was magical! They were so defiant!” Yeah, not so much *shrug emoji*
To take this a step further, according to the upstanding, grade A humans at Merriam Webster, of both dictionary and thesaurus notoriety, defiance and/or defy can be defined as: A.) The act or insistence of defying B.) Disposition to resist and/or a willingness to contend or fight C.) To confront with assured power of resistance D.) To resist attempts at E.) To challenge to do something impossible F.) To combat Well, yikes! Not an overflowing, overabundant amount of positivity in this term defiance, yet, what if I were to spill all sorts of tea everywhere, whether it be chamomile, jasmine, or hibiscus, and shared that there’s actually a defiance that’s, well, positive? What if I were to also be brazen enough to take it a step further and speculate that perhaps this level of, what we’ll call from here on out as positive defiance, is something that can be leveraged fully in your life to use as the very vehicle to guide you from the disappointments of the past and perhaps even present, towards the hope that emerges in the future? All sorts of outlandish, I know, but hear me out on this as there’s more to it than might meet the eye. I’m going to go rogue for a bit here, and make the perhaps emboldened claim, that at some point in your life, dearest and most beloved blog reader on the world wide web, there have been points in your life where negative thing have occurred. Chances are, they weren’t simply negative things, but heavy, emotionally dense things that dragged you to figurative waters that were so deep it was almost impossible to swim within. So what gives? You were dragged to the figurative deep waters but you didn’t drown; neck deep in hardship and circumstances yet still able to carry on, all the same. Chances are, at some level, there was an aspect of positive defiance that emerged against the hardship, where you made a determination that you simply weren’t going to give in. Think about every aspect of your life to this point, whether it was the hardships of an upbringing that saw a level of neglect, abuse or trauma, a situation that happened where something or someone you deeply cared for was ripped away from you, or even just the perpetual disappointments that happen day to day. You got through it. Take a moment to acknowledge that and receive that. You! Got! Through! It! As if that wasn’t enough, this is the potential that positive defiance has in this process, as it allows you to not just get through difficult things, but to actually use the very things that sought to overwhelm and destroy, as the very foundations for continued growth for yourself and others. So let’s take this negative upbringing example that was previously referenced; chances are very high that level of pain and discomfort shaped you, illustrating thoroughly what you’re not seeking for your life or the lives of those significant people that are around you. Positive defiance therein takes this experience, and makes a commitment to not pass along those hurts to others in a way that’s inconceivable, because you yourself can identify the pain, the brokenness and the hurt that emerged from that and couldn’t possibly fathom inflicted that on another. Think of this as the bizarro version of a generational curse, where one generation of a family experiences a particular behavioral pattern and passes it along to other generations in a vicious cycle that leaves a path of dysfunction and brokenness in its aftermath. Positive defiance ends that, all of it. Positive defiance plants a flag and makes the proclamation that one won’t be held to the hurts of the past, but instead will confront them head on, ensuring that others within their relational sphere will not have to encounter them personally. There’s a crux to all of this that’s a vital piece of this positive defiance puzzle: before any positive defiance can be exhibited, there has to be the understanding in place that everything that’s happened in your life has been necessary, as you don’t get the current version of yourself without first walking through the past versions, each & every past version. All of your experiences matter. Not just the ones we proudly speak to, even the ones we’d rather forget, bury deeply within ourselves and attempt to forge ahead in spite of them. Your past can be a prison or a pathway, the decision is yours to make and yours alone. On that pathway though, positive defiance awaits, with the ambition to reshape and repurpose those negative situations into something that stops the harm cycle and ushers in a healing cycle that’s beyond comprehension. So get after it, let’s get defiant with our past! 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. |
OakHeart
|
