Rumination-Focused ERP: Turning Exposure On Its Head

In classical ERP, it is considered important that the patient feel anxious during exposure, because the goal of exposure is habituation.  This is predicated on the assumption that we can habituate to anxiety the way we habituate to fear, and that therefore by exposing someone to something that makes them anxious, we can make them less anxious.  While other rationales for exposure are sometimes included in this model, habituation maintains a central role.

I was trained in the classical model and practiced that way for several years, but I no longer believe in it.  I now believe that anxiety is a consequence of cognitive activity (namely, rumination); that it is therefore not subject to habituation; and that it persists until the cognitive activity is ceased.  In other words, if you’re anxious you’re ruminating, and you’ll continue to be anxious until you stop ruminating.  Habituation is irrelevant.

Reconceptualizing ERP in terms of eliminating rumination as opposed to habituation has subtle but crucial implications for how it is done; the most important of these is that you aim to minimize, not maximize, anxiety during exposure. READ MORE