Cue Exposure Therapy: What the Future Holds
Exposure Therapy emerged in the 1950s as an intervention to treat panic-phobic disorders. Owing to the abundance of empirical support behind the intervention, Exposure Therapy (ET) has become a staple in the treatment of anxiety disorders.
Eventually, it’s predicted, CET will become as mainstream a practice in the field of chemical dependency as ET in the treatment of anxiety disorders.-Kevin Murphy, Psy.D.Building on that long track record, Cue Exposure Therapy (CET) borrows heavily from the format used in ET, but is specifically designed to treat the cravings that perpetuate substance use disorders. CET acts to de-sensitize the effect of triggers (the feel of a cold bottle, the sight of a sandwich baggie, etc.) that tend to prompt cravings. Research into CET is not nearly as robust as the literature that supports the efficacy of ET. Eventually, it’s predicted, CET will become as mainstream a practice in the field of chemical dependency as ET in the treatment of anxiety disorders.
The biochemical mechanics of a craving, as it is, are similar to those associated with anxiety and panic. Panic represents the most stressful of emotional experiences, with the intensity of the emotion so overwhelming that people often feel as though they might actually die. Withdrawal is an experience that many have described as equally deathly. Those with severe addictive behaviors typically, often daily, battle withdrawal and cravings. Panic and a craving, then, can each be conceptualized as an extreme stress response, with both activating an excitable area of the brain known as the extended amygdala region.
Exposure therapies, in the treatment of either anxiety or addiction, target the limbic system, a potentially volatile area of the brain that encompasses the extended amygdala. An overactive limbic wreaks havoc on the brain, as it hijacks surrounding areas and disrupts communication across the cerebral lobes. Essentially, exposure interventions temper parts of the limbic system that function to excite or, what neurobiologists term, up-regulate the brain. Over the course of an addictive disorder, those areas of the brain (in particular, the extended amygdala and ventral tegmental areas) become primed and hyper reactive to cues to use, firing off with such ferocity and frequency that the brain adjusts upwards its baseline level of stress hormones and excitatory neurotransmitters (i.e., allostatic load). This over-stressed brain becomes less adaptable, as the constant up-regulation of excitable chemicals interferes with the brain’s ability to coordinate an executive response from the prefrontal cortex (PFC) – the area of the brain that reigns in a stress response and problem solves breakdowns in the environment.
CET helps to decondition, or un-learn, those behaviors, so that people respond differently in situations that were once high risk. As a client endures his exposure sessions, and learns to identify cues, verbalizes his body’s reactions to those cues, and practices new responses in those same old situations, CET changes the associations that people learned as they cycled through an addiction.-Kevin Murphy, Psy.D.Traditionally, Alcoholics Anonymous, healthcare providers and drug counselors have categorized addiction as a disease, arguing that an addiction is akin to an incurable medical condition like diabetes. A growing number of practitioners, however, posit that addiction manifests conditioned behaviors, not a medical disorder. CET helps to decondition, or un-learn, those behaviors, so that people respond differently in situations that were once high risk (e.g., a strained marriage, a high pressure job, living alone, etc.). As a client endures his exposure sessions, and learns to identify cues, verbalizes his body’s reactions to those cues, and practices new responses in those same old situations, CET changes the associations that people learned as they cycled through an addiction. CET enhances a client’s stress tolerance, so, in a high-risk situation, s/he responds instead of reacts to a cue, thinking through instead of acting on an urge to use.
As the research behind CET expands in the coming decades, and it is refined as an intervention, it may ultimately be proven that CET changes the brain’s response in stressful situations and/or around activating cues, with the PFC firing off with more dominance than the limbic area after exposure therapy. Mechanically, then, CET attempts to down-regulate the limbic area, and improve communication across the brain, so that a PFC becomes more up-regulated. The more active the PFC, typically the more in control someone will feel in managing the stress inherent in day-to-day life.
It’s a loss of control that is commonly identified as a rudimentary definition of addiction. Many argue that, rediscovering a sense of control in one’s life reflects a quintessential experience in the successful treatment of addictions. CET serves to empower people to control their stress and urges to use, urges that tend to rule the day in the life of a so-called addict.
Sources: Barlow, 2002; Schore, 2001; Gerhardt, 2004; Doidge, 2007; Solms & Turnbull, 2002; Kilts, 2001; Martin-Fardon, Zorrilla, Ciccocioppo, & Weiss, 2010; Koob 2009, 2010, 2013; Horvath 1998/2004