I feel so grateful to Dr. Craske for giving us her time to help us learn more about inhibitory learning! I find it difficult to inhibit my original learning (habituation, change in beliefs) about mechanisms of change during exposure, and so reading this article, talking with Dr. Craske, and talking with people here will all help me learn this new model.
I am still working to understand how the inhibitory learning model is related to the intervention of doing behavioral experiments to test beliefs that underpin anxiety and avoidance. Two ideas I am working with are:
A behavioral experiment format for doing exposures is a good way to promote inhibitory learning because the format requires the patient and therapist to beforehand get a very clear idea of what beliefs the patient has that drive his/her fear and avoidance (this is the case conceptualization) and this information helps the patient and therapist identify what new learning the patient needs to get to overcome his/her anxiety. The intervention also emphasizes working actively with the person during and after the exposure to help him/her identify what new learning s/he got from the experience.
One key point I got from Dr. Craske and from her article is that the goal of inhibitory learning is not to change old beliefs. It is to help the patient have new experiences that will create new beliefs. I have always viewed the behavioral experiment as a way to test and disconfirm problematic beliefs. The inhibitory learning model suggests the goal of treatment is not to change old beliefs but to create new beliefs and increase their strength and likelihood of retrieval.
I learned so much from this interview! Wow, thank you both.
It's a dense article, so unpacking the highlights with a conversation is so helpful to clinicians like me who want to use this information in our day to day work. Great idea.
I especially appreciate the clear descriptions of exactly what this means about how to adjust the exposures I'm doing with patients every day. For example, I tend to spend some time and effort -- pre-exposure -- with psychoeducation and cognitive restructuring to challenge ideas like "These sensations will make me go crazy" etc and it tends to feel satisfying (to me!) that my folks often breathe a sigh of relief. Oops. Sounds like I just reduced that contrast effect for violating expectancy, and I don't want to miss the opportunity to create the most potent learning experience. Going forward I won't totally abandon this, but I need to be more thoughtful about that sweet spot, about teaching them just enough to get over that hump of willingness but not too much to miss that tiny shock to the system.
I am aware now (after hearing the interview, rather than just having read the article) that the prediction testing that has been a part of the CBT exposure protocol that I have always followed really is more focused on changing the patient's beliefs than on focusing on the new (inhibitory) learning (that will lead to new beliefs). It's a fine line, but an important one, I think.
Thanks so much for making this research so much more accessible to us (struggling) clinicians!!
Listening to this interview was incredibly helpful. I now feel like I can access the information from Dr. Craske's 2014 article in a way that reading it alone did not initially allow. Thank you for making this interview accessible to us all!
One of the points that I found particularly thought-provoking and useful was the idea that the client's learning and consolidation may happen AFTER the exposure session - - that there is likely an elongated period of processing and consolidation between sessions, a period of reflection. I typically ask my clients immediately after an exposure, when we are back in the office, "So what did you learn from that?" and they don't always have a clear or concise answer at that moment. Rather than have concern that the exposure was not maximally useful, I think I will now devise strategies to maximize their thoughtful processing of the exposure BETWEEN sessions. Writing about the exposure daily before their next session might be one way with a prompt to consider their original expectation and what actually happened. It's encouraging to think of the ways that we can help maximize this learning and consolidation period during the time when the client may not even be doing any new exposures.
Thank you Jackie for making inhibitory learning model much easier to understand and clinically applicable. Especially relevant to me is the idea that new learning is very fragile, and the threat laden beliefs and their corresponding behaviors are quite strong, or potent as Craske states. These new memory structures that are being built through exposures, appear to be more general beliefs, then specific disconfirmation of specific thoughts. For example the idea that the socially anxious client learns rejection does equate never having meaningful relationship.
The language used, in terms of "violating expectancy" makes sense when taken in the context of the surprise element that helps new learning take place. Loved listening to this, and the second time was even better than the first!