Thursday, September 16, 2010

Part 2: The History of Exposure Therapy: Albert Bandura and Guided Mastery

Albert Bandura

As I contemplated what to write next in the series on the History of Exposure and Response Prevention Therapy(ERP), I decided to pick the first article in the pile of ones I had found, and came up with Swimming against the mainstream: the early years from chilly tributary to transformative mainstream, by Albert Bandura, Behavior and Research Therapy, 42(2004): 613-30.

I know Bandura's name from being a teaching assistant for a Health Behavior class(an ironic position for a woman with Health Anxiety), and the professor's discussion of Bandura's concept of Self Efficacy: the belief in our own capabilities to get things done. For myself, I had little belief that I could do anything to change my compulsive behaviors or deal with the obsessive thoughts, and this is truly disheartening.

ERP is a form of Behavior Therapy(BT), and Bandura traces his involvement in the history of BT, starting in the 1950's. The dominant form of treatment for psychological problems was Psychodynamic--the descendants of Freud, the heavy dependence on the therapist interpreting what the patient says in terms of things simmering in the unconscious, and searching for underlying meaning.

To directly deal with a behavior that causes suffering was considered superficial, inadequate, but Bandura noticed how people who modified their behavior(ie. stopping drinking) in one way, had changes throughout other aspects of their lives. He published an article in 1963 on psychotherapy as a learning process, and it generated huge interest--including from Victor Meyer, featured in my last post. The response from more traditional psychotherapists was resolutely negative--BT was dangerous! It would lead to "symptom substitutions" and all that unconscious stuff stewing would burst out.

In meeting others with OCD in support groups or at the IOCDF conference, and reading the OCD-Support List, and comments from readers of this blog, I am taken aback by how, in mainstream treatment of OCD by therapists of a general psychodynamic bent, they still want to find the underlying cause of the obsessions and compulsions, to the exclusion of actually addressing the behavior itself. This can lead to OCD hell--especially for those of us with existential OCD questioning of everything we do anyway. And Cognitive Therapy can also fall into the same hell, with analyzing our thought distortions ad infinitum.

This is not to say that the content of our minds was not important: there were those who were also interested in thoughts and beliefs, within the context of BT, and argued that people are self-examiners of their own functioning, that they as self-aware beings, we can influence our own environment, hence adding the "C" to "CBT"--Cognitive Behavioral Therapy.

He worked with people who had phobias, and I recognized the core truth in what he says, "When people avoid what they dread, they lose touch with the reality of what they shun." If a person with agoraphobia can test their dread by leaving the house and surviving, then they can get better, but Bandura understood the reality that
Intractable phobics, of course, are not about to do what they dread.
Yeah. I see myself in this. Bandura endeavored to create an environment where people could move toward that experience of getting back in touch with the reality that they shun. Bandura developed a treatment he called Guided Mastery, which strikes me as having elements of ERP:
  • Modeling of the behavior by the therapist or other support person
  • Following a graduated set of subtasks from easiest to most difficult
  • Joint performance with the therapist of the feared task
  • Performing the feared activity for only a short time, and gradually extending the time
  • Increasingly challenging oneself in order to reclaim life
And then we come back to self-efficacy, which I learned about so many years ago.
Unless people believe they can produce desired effects by their actions they have little incentive to act or to persevere in the face of difficulties. Whatever other factors serve as motivators, they are rooted in the core belief that one has the power to effect changes by ones actions.
He argues that a good therapist arranges things for others in such a way that allows for success and "avoids placing them prematurely in situations where they are likely to fail," and emphasizes that if one can learn to see failure as informative rather than demoralizing, one can become resilient.

What can you do to encourage your own successes?


  1. Wonderful and well-written post!

    I really like the idea that "if one can learn to see failure as informative rather than demoralizing, one can become resilient." I was just talking about something very similar with my therapist. In one of my sessions we discussed how there are different ways to respond to "failures." You can beat yourself up and punish yourself for that failure, or you can take note of what went wrong and try to make a change the next time the situation arises. In the end, the second approach usually works better, because it makes that "failure" an "informative" experience rather than a "demoralizing" one. Instead of seeing the "failure" as something that necessitates punishment in order for it to be learned from, recognizing that you can learn from your mistakes while still being kind to yourself is incredibly helpful.

    So much of the time I feel like the only way to prevent myself from making the same mistake again is to punish myself for it. But really, calmly analyzing what went wrong and how I could make it better is probably more likely to help me get it right the next time. Punishing myself only makes me feel like I am incapable of doing things "right." I end up catastrophizing my mistakes and inferring things about myself as a person from small occurances, instead of calmly thinking about what might have gone wrong and how I could improve. It's so much easier to easier to move forward when you aren't constantly telling yourself how much of a failure you are! I guess it goes back to the importance of having a sense of "self-efficacy." It definitely helps.

  2. Excellent post! I particularly relate to the lack of effectiveness of psychodynamic therapy when treating OCD. I too have Pure O, and also suffer from some Existential OCD, and one of my compulsions is to self-analyze and self-check ad nauseum. Some people believe that obsessions are caused by some other "stressful or unresolved" issue in our lives. This idea is dangerous for me as I immediately start mentally checking and trying to "figure out" what it is that I am doing wrong or missing in my life that has caused me to start obsessing, in order to make them go away. It is true that OCD can worsen with stress, however spending a lot of time trying to figure out exactly what "stress" is causing the OCD has not been a helpful tactic for me. Nor, for the most part, has "blaming" it on some other stress in my life, for I immediately begin to compulsively try to rid myself of that stress. And, as we all know - some stress is unavoidable if you are to live a productive life.

  3. Fellow Sufferer--It still seems alien to me that compassion works more effectively to change my behavior than punishment, but I have come a long way on this, and I hope you do too!

    Anonymous--Yes! I have spent a lot of time in the past trying to figure out which stress correlated to which spike in OCD, and compounding the initial distress. My OCD does get worse sometimes in certain stressful situations, but to pin it down with absolute certainty is not attainable, and like you said, some stress is unavoidable if you want to live a productive life, and just plain stress, without the OCD on top of it, is an improvement.