 We're back take two for today Take two. We had some audio problems, but we fixed them. So here we are nice and clear and crisp Anyway, thanks for coming back guys Joined as always by my friend Lauren Rosen. I did it wrong. You did it wrong. We practice and I got it wrong anyway Lauren is a licensed marriage and family therapist practicing in Southern, California and specializing in anxiety and anxiety disorders She's the obsessive mind on Instagram. We should check her out And if you're coming from my side, this is the one and only Drill insolata The dot anxious dot truth on Instagram the anxious truth. He writes He's in grad school and he's gonna be a therapist in the great state of New York. So Check him out if you haven't already Thank you. Appreciate it. So we get together once a month and we do these little chats So he's related to anxiety anxiety recovery and that sort of stuff And today we're gonna talk about the RP and ERP and why it is literally the most important part Even though if you're watching right now, you might not know that Yeah, most people are so focused on the exposure part. I think I wonder I'm obviously so curious as to your thoughts on this one of the things that strikes me is that it often when we're talking about Exposure and response prevention We often shorten it to exposure And I think that that leads to a lot of misconceptions about the process. Don't you I Think so because a lot of people hear the word exposure therapy It's exposure therapy and we we leave at the other part And it was interesting because when I was actually writing the anxious truth it dawned on me like oh, wait a minute I have to write about the RP part like everything is ERP. It's not just the RP. It's not just for OCB anymore All exposure is ERP Yes, yeah, yes, including if we look at things like PTSD and and trauma treatment if we're doing prolonged exposure What's Implicit in the discussion are the safety behaviors that people are doing secondary to the sometimes when they are facing triggers Yeah, coming into so I think like kind of the overarching statement or to get us kicked off is a lot of people know Exposure so in my community for sure and I get every day like I don't know. I'm doing all the things I'm doing all the things and nothing is changing and I think the first misconception is No, I'm doing all the things, but I still feel afraid or I still feel discomfort. It's not working So the first misconception about it's ERP or exposure response prevention is that you have to find a way to do the exposure Without being uncomfortable. That's what a successful exposure is That's not what a successful exposure At all, I mean it's a happy thing when it happens. I guess nobody wants to feel like crap, but that's not the goal No, in fact, it can't be effective if it's not and Ultimately, if you're not feeling some anxiety or some discomfort when you're either doing planned exposures or rogue unintentional Wife a.k.a wife exposure. Yeah, exactly But at some point in order to get better at feeling anxious you have to practice feeling anxious differently Yeah So the whole point of the exposure was probably I'm glad we're bringing this up first is to feel uncomfortable You're doing it to feel uncomfortable. I think a lot of people they get confused They think oh exposure is where I learn to do this thing without being afraid or I learn to do it without panic Or I learned to do it without feeling the need to engage with my compulsions But that's that's not how that works at all. You're yeah, you're intentionally trying to come up against that, right? Yeah, you're trying to confront that in a way So the RP what does RP stand for any RP? Well, it stands for response prevention as well, you know But I think respond there yeah, and the responses that we're talking about very in name based on the disorder that you're talking about and OCD and BDD those are compulsions in generalized anxiety social anxiety phobias Agoraphobia panic disorder we call them safety behaviors And ultimately they're the same thing So the response when we're talking about response prevention exposure, we're not talking about prevent the response isn't the anxiety We're not trying to prevent the anxiety or the fear of the discomfort We're trying to prevent the things you do to minimize that Yep. Yeah, exactly. So I mean, what do you think would be helpful for people if we talked about What that can look like depending on the disorder maybe some examples? Yeah, totally. Yeah, absolutely. Let's do it so one example of health anxiety, we might see people as a safety behavior or you know, compulsion depending on the verbiage that you're using either excessively calling a clinician or looking up things repeatedly on Google or for excessive period of time about symptoms that they're having we would consider these to be Safety behaviors because they're intended to keep the person safe from whatever perceived danger. They might be Believe that they're being exposed to What's that? Okay, that's a good one. So if you are for instance, we're dealing with panic disorder and you are Going into situations that you think might trigger your panic the response prevention the responses that we're trying to prevent you from engaging in would be Calling your significant other or your friend to talk you through or snapping a rubber band or sniffing essential oils or Having your mincer your cold water or running back home Probably the biggest response that we're trying to inhibit is don't run back home and escape the exposure because you feel anxious So the response isn't the anxiety. We want that response. We just don't want you to respond to it Yes, the response that we're looking to prevent is The response to the anxiety not the anxiety itself like you said for sure. Yeah What about an OCD clearly ERP coming out of the OCD community? It's not just for OCD. I'm not kidding. That's not really that's everything is Agreed So in OCD, let's take for instance harm OCD somebody Who? Take specifically hit and run. So if you are you are driving and You feel a bump in the road. Oh my gosh. Does that mean that I hit somebody a Compulsion or the response that we're trying to prevent would involve going back Driving back to check and see if you actually if there are police or there's somebody lying in the middle of the road you might also Check the news when you get home or check your car to see if there were dents in it or You might even just ruminate a whole lot about it They go over and over the memory in your mind to try to make sure Sure that you didn't actually hit somebody We don't want to do that so response prevention is don't do that, right? I know you want to do all those things don't do those things. That's the prevention of the response Yes, because and I think well we can go back we can get to this later But because of the fact that those are the things that are impairing your life Not the thoughts not the feelings of the behaviors that are causing all the trouble and those behaviors also Increase the anxiety and a and a sad turn of events That's true. I mean they may decrease the anxiety immediately on the short term, but on the long term It's pouring gas on the fire, right? And oftentimes even in the short term It doesn't mean which is kind of cruel, but it's true that if you're ruminating about something for instance The the likelihood that you're gonna come to some conclusion that's going to satisfy you and get rid of your anxiety is exceedingly low Hmm, I bet that's probably true in those instances where the anxiety is based on trying to answer the unanswerable or no the unknowable Yeah, like trying low CD or yeah That's absolutely true. What about like social anxiety? What's a good safety behavior and social anxiety? I think so social anxiety is it is it a little bit different sometimes like the more I learned about social anxiety as That sort of shame-based disorder like most people describe social and people way smarter than me have educated me on this I can't take credit for this, but So most people think that social anxiety is the fear of being judged or somehow, you know being Evaluated and so much of it stems from the fact that it's not don't look at me It's don't see me. I don't not don't judge me It's don't see me because I see myself as inherently broken. I see my flaws I see myself as a birdie and if you look at me and examine me, you will see that too So the way that was the way it's been described to me by quite a few people in the social anxiety community That makes a whole lot of sense. So I would think in social anxiety. It is the safety behaviors or that those Responses that we're trying to inhibit would be to try to cover up those perceived flaws I won't speak because I think that I I never make sense. I'm not entertaining enough I'm boring. So I just won't speak. Well in that situation. You'll have to take the risk that you are going to pour somebody So yeah, it could be really nuanced, but I think that's a good social anxiety I won't speak or I won't eat in front of people because then they'll see that I'm not refined or I'm awkward I see myself that way. So I don't want you to see me that way. So I won't eat in social situations Totally My my safe person for reassurance about how I acted in that that the situation And it's such an interesting point that you bring up to you about about shame because I think in some respects Exposure and response prevention here looks like Doing the the talking right that would be at the exposure part and then the response prevent sure prevention rather is not in the aftermath of that that you're not going back and reviewing what the other person's facial expressions were and not Trying to pick apart what all of it meant But I think it we can also look at vulnerability As the practice of vulnerability is an exposure Yeah, yeah for sure and I think in a way when you engage in the RP part and you inhibit those responses that are designed to sue you or find the answer You're you are essentially allowing the worst outcome to be to be true in almost all cases If I panic and I feel like I'm going to have a psychotic break because my panic is too strong Well, if I inhibit my responses, I'm essentially allowing that psychotic break to happen Or at least allowing for the possibility. Yeah, correct. Correct And I always say that because there's this brutality when I say that to people You'll have to allow the heart attack. Oh, well, what do you mean? Yeah, but truly I know in your mind You are literally residing yourself to a heart attack. It's like how to break Ostrous being ostracized from your family, you know, whatever that the fear might be So yeah, so RP is tough because It's it's exactly that you want to try to get safe And when you engage in response prevention, you are not trying to seek safety in that moment Which is completely counterintuitive for human beings 100% yeah, it's like let me just and it's interesting the idea of exposure at almost Because when I think of like expo not exposing oneself in like a an elude way Expote like uncovering right like opening up to this experience and there's this great Sculpture, I don't know if I've ever mentioned it to you. It's one of my favorites it's by an artist named Paige Bradley and it's called expansion and In it is a woman who it has all of these cracks in her. She's naked. She's sitting in the lotus position She's got all of these cracks and there's a light coming through those cracks from it within her And it kind of reminds me of the Japanese art of Suzuki Where basically they drop pottery on purpose and then they glue it back together with gold and so It but it's the same idea is that like the beauty comes from the cracks from the opening from from the expansion And I do think that there's a lot that the reason I love one of the reasons I love that statue is it really represents what it's like To do exposure and response prevention. It's it's opening and then staying open Yeah, and we don't want to do that. That's scary. Well, we're trying to prevent the cracks. See this is why you're my people I'm looking at I had a Google ad. It's that's great. That's an amazing piece of art And I love the way you describe it because the exposure we would we don't want to do the exposure because we're trying to prevent the cracks But really and this gets a little philosophical here It's the cracks that make us who we are the cracks are the experiences that we learn from I can I can crack But it just becomes part of me and part of my experience and I incorporated and I learned and I get stronger from the crack So how do you grow if you don't crack? Correct, you wouldn't learn anything if you just try and always just everything needs to be like this. So that's a tough one Let this let's get a little geeky for a second here and talk about the difference between habituation and inhibitory learning This this is part and part rather than a super peak out But people people need to hear this because I think most people understand the concept of habituation And so I get asked all the time. So if I just keep doing this and we just keep driving on the highway What I'll get used to it Yeah, but not if you drive on the highway Loaded up with you know, Xanax and your phone and and you know and a timer to make sure that it's only 60 seconds to the next interchange So you got to have both of those things habituation by itself Which is probably what we were after 25 years ago or 30 years ago. Yeah, it works, but it doesn't appear to be long-lasting Yes, and it doesn't predict long-term recovery, right So which makes total sense to me So just to sort of outline to those who are watching the the main difference, right? Should we yeah, we probably should I think it's people need to know Yeah, so Essentially with habituation like what Drew was talking about is that you go on the freeway over and over again What they found is that over time you get used to it And that's what we talked to kids about right like you get used to it. Goody That's what we used to taught to To teach kids and it's true that that often will happen that being said Oftentimes people do the exposure work with the direct intent of trying to make their thoughts and feelings go away and That can only ever be in my clinical experience a side effect Because the second that we start to aim for thoughts and feelings to go away We are now not actually accepting their presence and developing a different relationship with them That's going to support us in experiencing them and not getting caught up in these behaviors Which again is a as more of a predictor of long-term recovery especially because Anxiety disorders OCD are constantly morphing constantly shifting So the next time that you have a trigger that has nothing to do with whatever you're triggered by now You know if if you are Tied to this habituation model Now you're stuck now. It's like oh, no, but I'm anxious again. What what does this mean? I'm stuck and back Versus of course. I'm anxious again Okay, well, what's it like to feel anxious? Hello anxiety. Good to see you. I've been waiting for you To show up really there's a definitely a different MO Yeah, yeah, there's truth in that because I think you can't and to tie it back into the response prevention You can't have response prevention if all you're trying to do is obituate You will never get used to it if you're not willing to fully experience it So I think that's where people get get caught up in it like I'm not getting used to it I've been doing it over and over. Yeah, because you're you're still trying to engineer a specific Emotional and internal experience while you're doing this thing and you can't you just have to let whatever Experience happens happen And then I love the wave Correct to learn to ride the wave So if you are relying only on I will get used to it and I will try to get used to it by making it as comfortable As I can for me with all my safety rituals and devices then You might get used to it But all you do is learn to panic you learn to go to the supermarket without panic is what you learn But with Laura pointed I think is really great if you rely only on her situation you engineer her situation It doesn't become portable across contexts So people will think oh my god, I have to learn how to do everything I have to learn to go to the supermarket again. I have to learn to drive my kids to school I have to learn to fly. No, not really That's not the case Right, but you're not practical No, that wouldn't be practical It would take us all forever to recover that clearly doesn't happen. So why doesn't it happen? So inhibitory learning to you know, we're getting a little geeky here But that's the part where you inhibit your response the rp and you learn the lesson literally inhibitory learning that Whether I do these things or not I wind up. Okay Everything works out. Yeah, I can handle this Yeah, and that I was I'm actually talking about the or I was just talking about this with some colleagues for we're working on a presentation and There's so many cool parts of inhibitory learning I also want to give a nod toward acceptance and commitment therapy because I think it's good It's sort of habituation from the nerdiness point of view habituation leads to inhibitory learning which leads directly into act In terms of an approach to exposure and response prevention. I'll break that down for you guys because I'm not trying to just say We're getting super geeky, but it's okay. We're just trying to push you just saying words now Well, it's just words words, but no it is really important because so if we look at inhibitory learning theory The the model changes from how do we get used to this to how do we get better at feeling distress? how do we get better at the skill of distress tolerance and What happens is that from the habituation standpoint if we The idea is that we extinguish a response So we think Pavlov and his dogs If you ring a bell with the food Right, the dogs are going to begin to salivate when you ring the bell if you stop presenting the food To the dogs with the bell then over time that connection will loosen And they will stop salivating right so that that response will stop From an inhibitory learning perspective, it's not because that that initial Association goes away right the the dog still has this proclivity to Experience the bell as indicative of the food. However, another association becomes stronger Right, that's so important. Right. Yeah, you learn you're learning It's an inhibitory learning theory is really about learning and you're learning over time that that You can feel anxious and terrified when doing this you can laugh and also feel anxious you can Um, not feel anxious you can like they're all of these different experiences that you are capable of having now And there's much more to inhibitory learning theory in terms of unpacking it, but I think that this is where I tend toward the act model because ultimately I don't I think it's less about Even learning that things go differently and just being totally and utterly willing to feel all your feelings and have all your thoughts Yeah, it's a real freedom Yeah, the willingness so it's so important when you're engaging exposure and response prevention It did a podcast episode on this willingness and that's big in the act world is Is such a key component I have to be willing To have a full set of not just external experiences. I'm on the highway or I'm repeating My trigger words in the mirror, but a full set of internal experiences. I feel fear I feel discomfort. I feel uncertainty. You have to be willing to experience all of them and then you will learn from them Yes And then they used to bother you then they can be there and you can non-judgmentally witness them Instead of wishing them away, which is the whole problem from an act perspective is that we're constantly Resisting the presence of these things that are inevitabilities in life And it's interesting. I just was I met with somebody yesterday Who's at a great up point in their recovery where? I can go over the list of exposures that we've worked on and she can say Yeah, so I I totally feel anxious when that comes up and but it's okay and So there's it's not that it goes away. It's that all of a sudden it ceases to matter that you're anxious And that's what leads to the extinguishing or the extinction of the safety behaviors now I don't I don't feel a need to save myself from a panic attack anymore It's a completely different experience for me now than it used to be Although I think that that's more of what happens with the inhibitory learning side of things, right? Is that or with the with the habituation more than the act because And and that's where I I think sometimes you're still going to feel a strong urge to do the behavior but that's a that's a variable thing right like it ebbs and flows and And so it's not like we ever get rid of that that knee jerk reaction to maybe do the behavior It's that over time It gets weaker and weaker and we become it's it's a habit basically Yeah, I have the ability now to feel that strong urge to do the safety behavior if I weren't your experience But but it only lasts for a couple seconds and I can back away from it and put some space between me and it And then make a different choice. That's the difference now Totally, that's it. Yeah, that is exactly it. It's the willingness to have that experience fully and the engagement in the rp Part I stopped trying to save myself that leads you to that so Yeah, that's what our pay matters If you keep doing it, wasn't it you who was saying about the the guy in New Jersey who sits on his porch and and keeps the elephants away with a shotgun That wasn't me, but I now I need to hear about this clearly I was not a real person, but uh, but it's it's tantamount to Having an anxiety disorder or ocd is tantamount to being You know some some dude out on the lawn in New Jersey being like with a shotgun saying I'm keeping the elephants away Somebody might ask like what elephants you would say? Well, I'm doing a good job Yeah, like if I stop doing this the elephants are gonna come which Arguably, I think that'd be way cool because you know elephants Who would want elephants on their front lawn, of course, but hello That's a great. That's a great sort of illustration Yeah, so if we never if we keep doing all of that we keep sitting on the lawn if we keep Calling our doctors repeatedly or Avoiding talking to people because of our social anxiety or What have you then You're never going to learn that that either the bad thing doesn't happen or that you're capable of handling Whatever comes up even if it is not the the Experience that you wanted Yeah, and I think that that varies that's on the spectrum. Sometimes we discover like oh, they're there are no elephants and that's okay Sometimes you do actually Reach a state of certainty that's like, oh that can't happen. That's right. That was just my interest in inventing things I had one moment once who and I tell the story often who was afraid that gravity was going to turn off And I'd haven't counted two people that had that fear But you know in the end, you know, you would reach the conclusion like oh That was just really an oversensitized brain making things up. I know that doesn't really happen I can be pretty sure that that won't happen. It's probably not. Yeah, it's it's highly. It's probably not gonna happen Yeah, yeah, a lot of nature said it's not gonna happen I can recognize that but other things like maybe someone will judge me or say something nasty to me or maybe I will panic And and scream because I panic. Yeah, that could happen, but you'll handle it Yeah, but you don't get to know that you're going to handle it unless you Put yourself in those circumstances and handle it. Yeah. Yeah the rp. It's all about the rp So it's about refraining from those things that you think are supposed to make an exposure easier calm or less anxious You can get through it If you don't if you continue to engage in those safety responses, then you're just teaching yourself how to do things Yep, and and well, I made it this time I made it through because of my cold water immense, but you're always going to make it through even with that Right, and then the responses actually rob you of recognizing your own capacity And I'm feeling really empowered which is interesting right like I I think that you have to be willing to feel your feelings And the the bonus for that is that you end up feeling good not because you get rid of feelings but because you end up feeling really proud of yourself for doing a hard thing and feeling empowered and and Probably reflecting back and recognizing your own courage that that's likely to make you feel good too So yeah, it's it's not about feeling better, but it is a side effect that often Companies going headlong into exposure without doing the responses It's so interesting because it really morphs the same exact experience feeling bad can actually turn out to feel good like It's crazy. It sounds you feel good about feeling bad. Yeah, it's like being makes no sense Right. Yeah, this this hurts like hell, but look at look what I did. Yeah How I mean as a clinician, I know you can appreciate this how exciting is it to see somebody make the turn from I made it to I did it That's like the best high five moment that there is like, yeah, you did it and they're so exciting for them Like, oh my god. I did it like yeah, you did it as opposed to I made it. Yeah, it's so true. That's such a good distinction of like Right the the white knuckles finally released. I made it versus You know what I did that I showed up. That was a badass BAM and that feeling comes from Not engaging in the safety behaviors of the rp So we'll wrap it up because we're getting a little close But I know we have to answer this question as anybody watching is going to But how but how Lauren, how do I not call my husband? How do I not snap my rubber band? How do I not run? That's always that The hundred thousand dollar question. Okay, I understand but how how am I supposed to do that? well Get another two hours right but I'm I thought of elephants again and how do you eat an elephant? Yeah, one bite at a time One bite at a time Right. Yeah, we're talking about this on one of one of the episodes that we've done and you were talking about I think was last episode actually taking one step at a time toward Doing the exposure of going into work. That's just yeah, okay right now. I'm just tying my shoes Okay, that's all I'm doing. I'm tying my shoes. So right now Uh, and you know, I'm not calling my husband instead I am Breathing in and then I'm breathing out and then I'm noticing that the tree is swaying in the breeze and I'm you know what I mean Yeah, yeah That's really great. How do you do it is break it down if you have to there's no harm in that Because anytime that you do even part of that and move toward Because people will say like, oh my god, how am I ever going to go back to work and sit for eight hours? That seems impossible. Well, that's because you're imagining a full eight hour shift five days a week full time Like you went from housebound immediately to back to work if you build it back up It doesn't matter how small the step is if you're experiencing fear and discomfort while you take it You're learning. It's okay. You're making progress. So one little bit at a time and You've got to be brave. There's no There's no way around that there's some courage in this For sure Yeah, the courage to to feel your feelings and to tolerate the unknown Which we're doing all the time anyway, but this is where Sorry, I know I go off on attendance, but no, it's okay The the courage piece, right like that's where if we reorient toward Showing up in a courageous way that also empowers us instead of like I want to Feel sure I want to show up in a way that even even if I don't feel sure I'm just I'm still doing it anyway because I want to live my life Yeah, that's really good. It's really good. That was where the price of admission right there That's a whole of the conversation. We could probably do an episode on that like selective Tolerance of uncertainty and unsureness We're uncertain about 95 percent of the universe most of it. We're like we don't even think about that uncertainty But some gets sticky we can talk about that in another one. Why is that a good why right? Why do we only tolerate certain unknowables? Yeah, I I totally agree and I'm wondering too there might be another RP and ERP one that where we talk about What the problem is with the responses? Yeah, that's good. Yeah. Why are the responses problematic? What does that do? All right, so that might be the next one. We'll follow up with with why are the rps? Why are the Rs bad? Why do we marvel the line through it? Why do we not want the Rs? Exactly. All right, that'll be our next one. Good. We already have a topic. So we have two topics to talk about It's good. We're all set. We're good until like august now damn Anyway, those of you who yeah hung on hung on through the whole 30 minutes. We appreciate that Hopefully it's been helpful. This is always on my youtube So I mean I I don't bother posting them on instagram because instagram hates 30 minute video I know it's gonna watch it. So I put them on youtube. They're always going to be here You can always come back ask questions or whatever if it's a question for lauren. I'll try to relay it over And I've been trying to post on my page too. So on on youtube, but so yeah, yeah, I'll do that Oh, yeah, put them up. Uh, so for sure if you're watching on youtube, I'll put a link You have you have a youtube done. I do. All right. So I'll put a link to lauren's youtube You can find them there too post them there. We should totally do that Anyway, if you guys have questions or comments, let us know and if you're not following miss lauren on instagram She is at the obsessive mind. You should totally do that. And that's your website too the obsessive mind dot com It is that thank you and uh, andrews the anxious truth dot com and you really should follow him on instagram He comes up with great content all the time And the dot anxious dot truce And here we are and one day we'll do an episode on I just remember the first time You were literally sitting in a charity thing in your office holding up a whiteboard with a sign on it that was like Yes, what's on that sign? That was like two years ago and I followed you when we just started communicating back and forth. They're like she gets it She gets it. This is a good one. So I'm so happy to be able to do these with you It's one of the coolest parts of the month. So it's really great. All right guys Yeah, thanks for coming by. We'll see you on the next one. Later. See you then. Bye