While dogs instinctively salivate in the presence of food, Pavlov’s dog eventually came to salivate just from the sound of a bell, even when no food was present. This learned response is a result of a process known as Pavlovian conditioning or classical conditioning (Clark 2004). Through this process, the dog’s salivation response became bound to the stimulus (the sound of the bell). Likewise, the feeling state of anxiety becomes bound to our unwanted thoughts. Just as dogs don’t instinctively salivate in response to the sound of a bell, people don’t naturally have an instinctual response of anxiety to their thoughts. The person involuntarily learns over time (via classical conditioning) to have an anxiety response in reaction to thoughts that most other people perceive as benign People act on compulsions in order to relieve their distress. But by relieving our distress, our compulsions actually lead to more compulsions, for the simple reason that we are naturally more likely to repeat any behavior that results in a reduction of discomfort. This is called negative reinforcement, because it involves the removal of a negative experience, such as anxiety.
So while compulsive behaviors temporarily remove the negative experience of anxiety and discomfort,it traps you in a loop of negative reinforcement. Your triggering thought results in distress, which leads you to act compulsively in an effort to relieve that distress, which provides temporary relief but actually “reinforces” the compulsive behavior, thus leading you to do more compulsions the next time your anxiety reappears. This loop is called the obsessive-compulsive cycle:
In the world of behavioral psychotherapy, the commonly accepted viewpoint on the relationship between the brain, the mind, and the self is that you cannot control what thoughts, feelings, and physical sensations you have. Your job is to choose your behaviors.
You may find yourself presented with internal data that seems absurd, horrific, or threatening. The presence or lack thereof of this information isn’t something you can control. When you control your behavior, you teach the mind how to frame the experience.--
You are not your intuition
.. You may be able to dig up thoughts, and this may make you varying degrees of clever, but you didn’t generate the thoughts. You collected them from the soup in your brain. You have no say in what kinds of thoughts happen to occur and what kinds of thoughts your mind’s radar happens to pick up. If you are trying to control your thoughts, by judging them or attempting to suppress them, then you are doing a compulsion. You only get to decide what you do with your thoughts, not what thoughts you happen to have.
The same is true of feelings. Sometimes you feel happy, and it’s not because anything in particular is going your way. You just feel happy. Sometimes you feel fear that’s not necessarily connected to anything important either. Can we better stabilize and regulate our emotions? Sure. Can we keep our emotions from determining our behavior? Absolutely. But if all it took was simply controlling what feelings we had, we’d all be happy all the time. Physical sensations, urges, impulses—these little bits of data we get from the body— also come and go as they please. Their relevance to your life is grounded completely in how you respond to them. Responding to them with distorted thinking or with compulsive behaviors simply highlights their presence in your life. All we have complete control over is our behavior. This is true 100 percent of the time. This is hard to accept at first.
Most of the time, you find yourself doing things precisely because you believe you absolutely have to in order to survive. But ultimately compulsions are behavioral choices—very difficult, painful choices.
move the behavior so that the thoughts and feelings naturally gravitate in that direction. What this means is that you would have to engage in a plan of behaving as if violence was tolerable before you could expect thoughts that its wrong and feelings of danger to lighten up. It might start with something simple, like looking at pictures of violent things. At first look, thoughts and feelings might convey the message, This is too much! But over time, through habituation, thoughts and feelings will begin to communicate, violent pictures are no big deal. In the beginning, it’s a terrible feeling indeed to have your behavior on one end of reality and your thoughts and feelings on another. Typically, the thoughts are the first to join the behavior, and this is where behavioral therapy is the most challenging. Here you are behaving as if violence isn’t so terrible by not avoidingit, and at the same time, you’re thinking, Well, I’m not a fan of violence but I probably won’t puke or get depressed today.
But your feelings, stubborn as they are, still haven’t caught up. They’re still telling you that you’re in danger. They’re begging you to come back to avoidance. Using mindfulness, you dig in and commit to the behavior, independently from the feelings, and you stay with that behavior until your feelings get the idea. And some time may pass before the physical sensations, such as increased heart rate, start to shift as well. But eventually you work up to higher and higher behavioral expressions of acceptance, and guide the thoughts and feelings wherever you believe they are best suited. This is known as “graduated exposure with response prevention,”
Exposure with response prevention (ERP) involves “systematic, repeated, and prolonged exposure to situations that provoke obsessional fear, along with abstinence from compulsive behaviors” (Abramowitz 2006). In short, you purposely get in front of your fears, either in literal, physical terms (for example, touching something that upsets you) or in theoretical terms (for example, imagining a feared situation), and you practice resisting the compulsive response.
ERP is about demonstrating for your mind what it needs to better process the false information about the things you fear. If you want to stop obsessing about something, you have to stop responding to thoughts and feelings about that thing as if they were important.
But to do that takes practice. You have to expose yourself to the things you are afraid of (which may be actual things or just thoughts and feelings), and you have to prevent yourself from the automatic response, which would be the compulsion to neutralize, suppress, or otherwise undo whatever your brain is presenting to you.
Mindfulness is exposure. It’s exposure to what happens when you experience a thought, accept its presence as a thought, and then don’t do compulsions. It’s exposure to what happens when you let a terrifying thought go, as if it didn’t matter that it was terrifying, without insisting on ascertaining the meaning of that thought. It’s exposure to feeling terrified and not allowing this to determine your behavior. Perhaps your constant battle with a particular idea—whether it’s contamination, harm, relationships, sexual orientation, or anything else—is consuming your every waking moment. You need to change the role that this obsession plays in your life.
Exposure means that you are opening up to something, as a camera lens exposes to light. Response prevention means that you are stopping something from happening in connection with your exposure. In simple terms, what you are trying to accomplish by doing ERP is getting some time in the ring with your fears instead of constantly running. Your mind has learned that obsessions must be followed by compulsions. It has calculated this carefully based on your observed behavior. If you can demonstrate to your mind that you are capable of being in front of your fears without doing compulsions, then your mind has to admit that compulsions are a choice. If that’s true, it must mean that the obsessions are not as automatically important as previously assumed. If that’s true, then they may not be worth any response, let alone a compulsive one. You may have seen some portrayals of ERP in the media in which people were forced to do disgusting things, dangerous things, and ridiculous things all at once. This is not ERP. While exposure definitely involves pushing your limits, it’s not about learning to swim by being shoved into the deep end of the pool while your therapist yells at you to swim. We’re building brain muscles here. If we were building body muscles, we wouldn’t start with a two-hundred-pound barbell. You’ll put your back out and stop coming to the gym. We also don’t waste too much time with empty gestures in ERP. You may lift a two-pound dumbbell at the gym, but don’t delude yourself into thinking that this will give you bulging biceps. What you want is to start somewhere challenging but achievable, and you want to do this thing until it’s no longer too challenging—and then you raise the weights.
The first step to doing ERP is to know what you’re up against. You will need a list of things to do exposure with and responses to be prevented if you are going to do ERP
1)
List any compulsion that you do. This includes any physical or mental ritual that you engage in to make yourself feel okay when you’re faced with a conviction. Also include any routine behavior that you do excessively and any ways in which you seek reassurance related to your obsessions (for example, asking others about your obsessions, confessing your thoughts, visiting websites related to your obsessions, and so on). 2 ) List anything that you avoid because of your conviction. You may rarely avoid some things because you seldom see them, but the idea of seeing them triggers a strong urge to avoid (for example, pornography involving a different sexual orientation from your own, horror movies, and so on).
Now take a look at each item on your list and consider what it would be like to be in front of your trigger without doing that compulsion. How hard would it be? How much discomfort would you feel? You can give it a numeric value if that helps. Don’t worry about accuracy. You are likely to change your mind about the difficulty level and move it up or down many times during your ERP experience.
This is what you are up against. Generally, you want to keep in mind that the things you are exposing yourself to, whether they are images or physical items, are just things. You may not be as afraid of these things as you believe. What’s more likely is that you are afraid of how bad you feel when you are around these things. To do exposure effectively, it needs to generate that feeling that you are so invested in avoiding. You need to participate in generating this feeling. If you didn’t feel such pain in the presence of a trigger, you wouldn’t consider it important to avoid that trigger. The goal is not to enjoy the thing you are exposing to, although in some cases, you may become an aficionado of things that previously frightened you (such as scary movies or guns). The goal is actually mindfulness itself. It’s freedom from the automatic reaction. It’s creating a space that allows the mind to view the trigger as a thing. Through repetition, all things return to their natural place in the universe. Today the doorknob to a public restroom may appear to be a radioactive, festering E.coli factory. But through repeated contact, it eventually becomes a doorknob again. What may be on the doorknob remains uncertain, but your increased tolerance of uncertainty allows for that. So what you are trying to win back through ERP is the ability to be mindful, to see things as they actually are instead of only what you fear they could be If your compulsion is to avoid being triggered by violent imagery, think of things with violent imagery that you can handle. It could be watching the local news or watching a trailer for a horror film. Take a moment to make some notes next to each of your entries with ideas for exposures. Don’t worry if they don’t make much sense. You may never do any of them, or you may do all of them. You may do one and find that it was harder than you anticipated, and then go back to working on something easier. You are in control of your behavior, and you are in control of your treatment.
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