The re-analysis of extinction learning to include research findings that support the inhibitory learning hypothesis has resulted in a number of recommendations for changing exposure-based interventions in anxiety disorders and OCD. Understanding that at least some learning occurs even when subjective levels of anxiety do not subside significantly within the exposure session is not difficult to believe. It is also not difficult to incorporate a wider variety of exposures rather than a rigid hierarchical progression, intuitively more likely to promote generalization, and more likely to seem relevant and timely with regard to avoidance behaviors which are meaningful in the patient’s life. 

The recommendation most difficult to absorb by most clinicians is the suggestion that interventions that lower expectations of catastrophic or negative outcomes of exposure should be minimized in order to take advantage of the therapeutic effect of violating expectations. It is suggested that pre-exposure cognitive interventions should be delayed until the after-exposure processing to consolidate the new learning. The question then arises as to how to motivate patients to do the exposure work while in the grip of serious anticipatory anxiety and suffering from the effects of their own anxiety sensitivity. The level of risk they believe they are undertaking is deeply exaggerated. How, while in the grip of anxious imaginings, does one undertake an exposure that feels so dangerous, without at least hoping that the feeling of risk is an illusion created by anxiety and imagination and not a reliable predictor of outcome?  How does any sane person willingly undertake existential danger without resorting to white-knuckling breath-holding compliance and blind exercise of willpower?   

 I am a full believer in the negative reinforcement properties of reassurance-seeking compulsions and how the message of constant avoidance of distress undermines the development of confidence and resilience. Empty, hidden, subtle, and repetitive reassurance-seeking is counterproductive during and after exposure. On the other hand, I also believe that myth-busting, psychoeducation, and metacognitive interventions are critical to the treatment of these disorders — and yes, psychoeducation is a form of reassurance. “I won’t faint?” “This sensation is harmless?” "This does not mean I might be a pedophile?” “I don’t need to control my thoughts?” “This thought that I could jump off a balcony does not mean I am secretly suicidal?” and “My doubts are not red flags?”. 

Pointing out misinformation, false beliefs about thoughts, and confusion about risk and reality in the grip of one’s own anxious imagination indeed intentionally violates catastrophic expectations. Withholding this kind of reassurance — in the service of violating expectations during exposure — is to my mind not only unconscionable but also ineffective at motivating the commitment to “facing your fears".  

It is possible to travel back and forth over the Bay Bridge 50 times in a row without a metacognitive and attitudinal shift — and what one learns is “yes, I can do it, I will survive when I thought I could not, but it is an ordeal every time”.  There is a world of difference between listening to a podcast while actively allowing another part of the mind to think anything it happens to be thinking and listening to a podcast to drown out those very same thoughts.  Without adjustments to the intention of exposure from fixing something to appreciating a metacognitive and attitudinal re-alignment, something vital is lost. 

For decades, I have felt like I have been doing my own personal version of exposure-based therapy because I never could make myself follow the rigidity of a preplanned hierarchy — and because what I found was that the hierarchies all collapsed like a house of cards when the patient grasped the metacognitive shift that I was trying to teach.  The focus of the work has always been, for me, a profound change in the patient’s relationship to their thoughts, feelings, sensations, and imagination.  A shift into a disentangled, observational, open, willingness.  Away from a self-disrespecting, urgent, pathologizing search for “why?” and away from techniques and coping skills designed to avoid distress. Once this relationship with experience has changed, once this shift is achieved, the exposure work is not painful, it is curious, exciting, playful… and often spontaneously self-directed. There is also often a period of grief for opportunities missed and pain endured before this shift happened. 

The metacognitive shift comes in many forms, but here are some examples: “Oh! It’s the thoughts, not the place”, “These are just sensations, I am adding the fear”, “I just made that story up and now I am treating it like it is true”, “ Now I see that anticipatory anxiety is a liar and I am acting like it is a predictor”, “ My feelings about danger have nothing to do with real danger”, “How did I ever believe that thoughts are facts?”, “So the opposite of obsessive doubt is trust of my own wise mind, not certainty?”, “so if I don’t worry, it doesn’t mean I don’t care”, “I am not fragile, I just think I am”. 

I suppose that this essay is a confessional, of sorts, for never having followed protocols the way they were taught. But then again, the focus of therapy has never been to vanquish symptoms. It is, for me, the reduction of suffering.