The Role of Inhibitory Learning

The Role of Inhibitory Learning in the Development and Maintenance of Anxiety Disorders, OCD, and PTSD

Written 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/