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.

So how do you do exposure this way?  First of all, you don’t start exposure until the patient knows how to eliminate rumination. Once they know how to do this, you do exposures in the context of not ruminating.  Here’s what that looks like:

We’ve agreed that you’re going to use a sharp knife while the kids are in the room.

Let’s start by making sure you’re not ruminating about what you’re about to do.

Now let’s do it without ruminating about it.

I want you to chop those vegetables without ruminating about the fact that you’re holding a sharp knife around your kids.  We are aware of it, but we’re not ruminating about it.

What’s your anxiety level?  Higher than zero or one?  I think you’re ruminating.  Don’t engage.

Is your anxiety back down?  Excellent.

(Let’s say we did this for 5 minutes, while making sure anxiety levels stayed close to zero.)

Okay, so you saw that even when you were doing something really scary, as long as you refrained from ruminating about it, you didn’t feel very anxious.

So this week, you’re going to stop avoiding using a knife while the kids are around, and you’re going to make sure not to ruminate about it while you’re doing it.

Here’s another example:

We’ve agreed that you’re going to stop keeping track (i.e., paying attention, which is a form of rumination) of what is and is not contaminated, because that is actually what makes you feel anxious.

So you’re going to take this contaminated towel and walk around the house touching as many things as possible with it.  While you’re doing that, you’re not going to ruminate about what you’re doing, or pay attention to what has been contaminated.

All done, good job.  Now we’re going to hang out and not ruminate; you’re not going to figure out what is or isn’t contaminated, or try to figure out a plan for decontaminating things, or try to figure out how you’re going to handle this later.  Just hang out and don’t ruminate.

What’s your anxiety level?  Higher than zero or one?  I think you’re ruminating.  Don’t engage.

Is your anxiety back down?  Excellent.

Okay so you see that even when things are contaminated, if you don’t ruminate about the situation, you don’t feel very anxious.

So this week, you’re going to repeat this twice a day, and anytime you see something that isn’t contaminated, you’re going to contaminate it.  And most important, you are going to eliminate any rumination about contamination, not just during the exposure but at all times.

Rumination-Focused ERP is obviously less distressing to patients.  This is not only an inherent advantage, but also a major boon to treatment compliance.

In addition to making ERP much more palatable, this approach has the invaluable added benefit of showing a person that they can control their anxiety by controlling their rumination.  For individuals who have felt constantly at the mercy of their anxiety, the significance of this cannot be overstated.

RF-ERP is ERP inasmuch as it involves confronting triggers and anything avoided while eliminating compulsions.  But it’s also true that this approach is significantly different, in both theory and practice, from the original ERP, and that a distinction between the two is therefore warranted.

Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship.