15

Inhibitory Learning
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Amy R. Sewart and Michelle G. Craske

Exposure, the repeated and systematic confrontation with feared stimuli, is a

central component of cognitive behavior therapy (CBT) for anxiety and threat-
related disorders. Meta-analyses of randomized controlled trials over the past
several decades have demonstrated very large effect sizes for exposure therapy
for anxiety disorders, whether alone or combined with coping strategies such
as cognitive reappraisal or breathing/relaxation training (Cuijpers, Cristea,
Karyotaki, Reijnders, & Huibers, 2016). However, although the majority of indi-
viduals improve within 10 to 20 weekly sessions of typical treatment trials,
only approximately 55% achieve normative functioning (Loerinc et al., 2015),
and a number experience a return of fear, defined as resurgence of fear from the
end of exposure therapy to follow-up testing with the same object that was
targeted during exposure therapy.
Over recent decades, our fundamental knowledge of basic fear learning
processes has significantly evolved and has offered an explanation for return
of fear and its malignant nature. These advancements offer important treat-
ment implications and call for clinicians and researchers to adopt an advanced
theoretical understanding of the mechanisms underlying exposure-based
treatments based in modern associative fear learning. Within the updated inhib-
itory learning model of exposure, extinction is posited to be the critical process
that results in long-term reductions of fear (Craske et al., 2008; Craske, Treanor,
Conway, Zbozinek, & Vervliet, 2014). Understanding the basic role of fear

http://dx.doi.org/10.1037/0000150-015
Clinical Handbook of Fear and Anxiety: Maintenance Processes and Treatment Mechanisms,
J. S. Abramowitz and S. M. Blakey (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
265
 266 Sewart and Craske

extinction in exposure therapy requires a general grasp of fear conditioning

phenomena.
In Pavlovian fear conditioning, a neutral stimulus (conditional stimulus
[CS], e.g., a shape) is coupled with an aversive unconditional stimulus (US,
such as a shock or loud noise). Following a number of CS–US pairing trials
(shape → shock/noise), the presentation of the CS develops into a reliable
predictor of the US. As a result, when the CS is presented, it generates antic-
ipatory fear, or a conditional response (CR, such as eyeblink) that resembles
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the unconditional threat response (UR) to the related US. These phenomena
can be translated to the real world, wherein clinically elevated anxiety can
become associated with fear-relevant situations and stimuli. As an example, a
young woman by the name of Taylor is taking a walk around her neighbor-
hood when—out of nowhere—she is attacked and bitten by a German
Shepherd. Taylor was previously unafraid of dogs, but after being bitten (US,
dog bite) Taylor begins to fear (CR) all dogs (CS) and to avoid public spaces in
which she may encounter them. This fear of dogs and its related avoidance
has caused Taylor clinically significant distress and impairment.
To reduce or eliminate the CR, the CS must now lessen its status as a pre-
dictor of the US. This is achieved by fear extinction, which involves repeatedly
presenting the CS without the US (CS–noUS, shape → / shock/noise). Impor-
tantly, the original CS–US relationship is not erased during extinction, but
rather, a secondary relationship wherein the CS no longer predicts the US
develops as a result of extinction. Under certain conditions, this CS–noUS
relationship can inhibit the original, excitatory nature of the CS–US relation-
ship (Bouton, 1993). In the previous dog bite example, Taylor’s fear of dogs is
extinguished by exposing her to dogs in the absence of being bitten (CS–
noUS). After systematically exposing Taylor to dogs, the notion of dogs being
predictive of dog bite is dampened by new, inhibitory learning that dogs are
not predictive of dog bite. This new, inhibitory learning has extinguished
Taylor’s fear of dogs.
The original excitatory CS–US association, however, can be uncovered in
several ways, including spontaneous recovery (Quirk, 2002)—the reemergence
of a previously extinguished conditioned response after a delay. For example,
after completion of exposure therapy, Taylor’s fear of dogs may return in a
seemingly inexplicable manner. Furthermore, because extinction learning is
limited by context, renewal of conditional fear may occur if the surrounding
context is changed between extinction and retest (i.e., context renewal; Bouton,
2002). This highlights the importance of context variability in exposure therapy,
discussed in further detail later in the chapter. Finally, reinstatement of condi-
tional fear occurs if unsignaled US presentations occur between extinction
and retest (Haaker, Golkar, Hermans, & Lonsdorf, 2014). Clinically translated,
adverse events following exposure therapy may lead to a return of fear of the
previously feared stimulus. Fourth, rapid reacquisition of the CR is seen if the
CS–US pairings are repeated following extinction (Ricker & Bouton, 1996), as
may occur in dangerous environments. In addition to offering an explanation
 Inhibitory Learning 267

for return of fear following exposure therapy, these processes suggest possible
pathways through which exposure therapy can be optimized to reduce the
return of fear (Craske et al., 2014).
Traditional, habituation-based models of exposure therapy (see Chapter 14)
posit that fear reduction during and between exposure trials is required for
lasting changes in the perceived harm associated with a given phobic stimulus.
Thus, habituation-based exposure approaches have focused on fear reduction
within and between sessions as an index of treatment response and success (e.g.,
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Foa, Huppert, & Cahill, 2006; Foa & Kozak, 1986). How­ever, our understanding
of the role of fear reduction—or habituation—in exposure has also evolved with
advances in associative learning theory. The amount that fear has been reduced
by the end of an exposure trial or series of exposure trials is not a reliable pre-
dictor of the fear level expressed at follow-up assessment (Baker et al., 2010;
Culver, Stoyanova, & Craske, 2012; Kircanski et al., 2012; Meuret, Seidel,
Rosenfield, Hofmann, & Rosenfield, 2012). Similar results have been found in
laboratory paradigms with animals and human samples (Plendl & Wotjak, 2010;
Prenoveau, Craske, Liao, & Ornitz, 2013; Rescorla, 2006). To combat return of
fear, inhibitory learning models of exposure do not emphasize fear reduction
during exposure trials and instead focus on optimizing the strength and dura-
bility of the CS–noUS relationship that occurs during extinction learning.
Numerous strategies translated from basic fear learning research can be
implemented during exposure to enhance inhibitory learning. These methods
include enhancing inhibitory learning through (a) expectancy violation,
(b) removal of safety signals, (c) attentional focus, (d) deepened extinction,
(e) stimulus variability, (f) occasional reinforced extinction, and enhancing
retrieval of inhibitory learning via (g) multiple contexts and (h) retrieval cues.
This chapter focuses on ways to implement and capitalize on these strategies
within treatment to achieve superior extinction learning.

IMPLEMENTATION

Expectancy Violation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 2013), anxiety disorders are
associated with the overprediction of aversive, negative outcomes. For exam-
ple, an individual with social anxiety may expect with absolute certainty that
if they were to attend a social gathering they would be rejected by peers.
Similarly, someone with panic attacks may expect with high confidence that
experiencing a rapid heart rate will result in a heart attack. Enhancing extinc-
tion learning during exposure requires that exposure exercises be designed to
maximally violate an individual’s elevated expectancies regarding the fre-
quency or intensity of predicted, aversive outcomes (Davey, 1992; Rescorla &
Wagner, 1972). Based in learning theory, expectancy violation posits that the
 268 Sewart and Craske

mismatch between expectation and outcome for a given situation is critical

for new learning (Rescorla & Wagner, 1972). Specifically, expectancy viola-
tion leads to the development of alternative inhibitory expectancies that will
compete with current excitatory expectancies. In other words, the more the
expectancy can be violated in a given exposure, the stronger the inhibitory
expectancies that compete with excitatory expectancies will be.
Exposure therapy based in inhibitory learning principles requires that
exposures be designed to accommodate what the patient “needs to learn”
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regarding feared outcomes (Craske et al., 2008, 2014). This is in contrast to

traditional habituation-based exposures that focus on fear reduction within
or between exposure exercises or “staying in the situation until fear declines.”
Expectancy violation ties exposure parameters directly to consciously stated
expectancies for aversive events. Within this approach to exposure, CSs are
defined as physical sensations, situations and settings, objects, or thoughts
and images predictive of a defined feared outcome or US. For example, a
patient with panic attacks may predict that an elevated heart rate over 120 BPM
during a panic attack will cause them to faint and injure themselves. Here, the
patient has identified a panic-relevant CS—conditional stimulus—as having
an elevated heart rate and the US—unconditional stimulus—as injury from
fainting. Thus, an exposure exercise for this patient should be designed to
directly violate the patient’s expectancy of fainting and becoming injured
during a panic attack when their heart rate is elevated above 120 BPM. Clini-
cians can use the questions outlined in Table 15.1 to assess fear-relevant CSs.

TABLE 15.1. Questions for Assessing Expectancies of Conditional Stimuli

for Exposure Practices
Excitatory conditional stimuli Assessment question
Physical sensations What physical sensations make you think you are
more likely to experience [defined feared outcome]?
Situations and settings What situations or settings make you think you are
more likely to experience [defined feared outcome]?
Feared objects What objects make you think you are more likely to
experience [defined feared outcome]?
Feared thoughts/images What thoughts or images make you think you are
more likely to experience [defined feared outcome]?
Duration How long do you need to experience the feared physical
sensation, situation, object, or thought until you are
convinced [defined feared outcome] will occur?
Inhibitory conditional stimuli Assessment question
Safety thoughts or behaviors What are some behaviors you engage in to avoid
[defined feared outcome] or that make you think
[defined feared outcome] is less likely to occur?
Safety objects What are some objects that make you think [defined
feared outcome] is less likely to occur (e.g., cell
phone, anxiety pills)?
Safe places What are some places that make you think [defined
feared outcome] is less likely to occur?
Note. From the UCLA Anxiety and Depression Research Center. Reprinted with permission of
Jonathan S. Abramowitz and Shannon M. Blakey.
 Inhibitory Learning 269

Identified CSs should be confronted over the course of exposure therapy.

Table 15.2 provides an overview of the various methods to enhance inhibi-
tory learning that we discuss in this section.
To facilitate extinction learning, each exposure trial is focused on deter-
mining whether the expected negative outcome occurred or not, or was as
“bad” as expected (i.e., was manageable or not). Following each exposure,
learning is consolidated by asking participants to judge what they learned
regarding the nonoccurrence of the feared event, discrepancies between what
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was predicted and what occurred, and the degree of surprise from the expo-
sure practice (Craske et al., 2014). The phrase “test it out” is helpful to intro-
duce to patients when providing rationale for expectancy violation.
The end of an exposure trial is determined by conditions that violate
expectancies. Furthermore, exposures are continued for the duration deter-
mined to violate expectancies most effectively. An individual with social anx-
iety may avoid one-on-one conversations for fear of rejection. To determine
the duration of a related exposure exercise, the therapist should assess with
the patient how long the patient needs to participate in a one-on-one conversa­
tion until they are convinced that rejection will occur. If the patient states with
certainty that rejection will occur after only 5 minutes of conversation, the
duration of the exposure practice should be constructed to last for more than
5 minutes to maximally violate this excitatory expectancy. Using an inhibi-
tory learning approach, graduated exposure may be used by clinicians to pro-
gressively modulate conditions in which the feared outcome is judged most
likely to occur. For example, one-on-one conversation exposure exercises for
social anxiety may be conducted at increasingly longer trials (e.g., 5 minutes,
10 minutes), regardless of the observed fear reduction, in an effort to further
violate expectancies and extinguish related fear. In several studies, failure to

TABLE 15.2. Strategies for Enhancing Inhibitory Learning

Strategy Description Catchphrase
Expectancy violation Design exposures to violate specific Test it out
expectations
Remove safety behaviors Decrease the use of safety signals and Throw it out
behaviors
Variability Vary stimuli and contexts Vary it up
Deepened extinction Present two cues during the same Combine it
exposure after conducting initial
extinction with at least one of them
Reinforced extinction Occasionally present the US during Face your fear
exposures
Variability Vary stimuli and contexts Vary it up
Attentional focus Maintain attention on the target CS Stay with it
during exposure
Mental reinstatement/ Use a cue present during extinction or Bring it back
retrieval cues imaginally reinstate previous successful
exposures
Note. US = unconditional stimulus; CS = conditional stimulus. From the UCLA Anxiety and Depression
Research Center. Reprinted with permission of Jonathan S. Abramowitz and Shannon M. Blakey.
 270 Sewart and Craske

habituate throughout exposure therapy was not associated with poorer out-
comes (e.g., Culver et al., 2012; Kircanski et al., 2012; Lang & Craske, 2000).
For most anxiety-related disorders, it is indisputable that the defined neg-
ative outcome has not occurred during a given exposure exercise. For exam-
ple, an individual predicts that experiencing panic-related symptoms (e.g.,
rapid heartbeat) will result in a heart attack. Testing out whether or not a heart
attack will occur during an interoceptive exposure practice is straightforward.
Similarly, determining whether or not a dog-phobic individual is actually bit-
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ten in the presence of a dog during an exposure exercise is a clear-cut experi-

mental test. However, certain feared outcomes may be loosely defined by
anxious patients. For example, socially anxious individuals fear being rejected
in social situations. Determining whether social rejection has occurred is more
ambiguous than assessing for other feared outcomes, so it is integral that the
therapist and patient together define the behavioral indicators that represent
social rejection. Rejection indicators to look for in in vivo exposures for feared
social encounters may include a furrowed brow, squinted eyes, eye rolling,
denying a request, and walking away from the patient. After operationalizing
social rejection, an individual with social anxiety is instructed by the therapist
to gather evidence for the presence of rejection by looking for these predefined
indicators of rejection during inter­personal exposure practices.
Another common loosely defined outcome for individuals is that they will
be unable to tolerate the distress (e.g., uncertainty, disgust, stress) associated
with an anxiety-provoking event. This feared outcome is common for indi-
viduals suffering from panic disorder, posttraumatic stress disorder, and
obsessive-compulsive disorder. Therefore, it is important that the expecta-
tions surrounding inability to tolerate distress be clearly defined. For exam-
ple, an individual completing imaginal exposure for trauma may expect that
stress from recounting a trauma may cause them to be unable to function for
the rest of the day or lose control. To test out this feared outcome, a therapist
should have a patient complete minor tasks immediately following a given
exposure to demonstrate that the patient is able to function in the face of dis-
tress. Exhibit 15.1 is a worksheet that can be used when designing and com-
pleting exposure practices as we describe in this section.
Given that extinction learning is enhanced by the mismatch between
expectancy and actual outcome, reducing expectancy prior to a given expo-
sure trial can have a negative impact on extinction learning. Common cogni-
tive restructuring practices designed to lessen probability overestimation (e.g.,
“I am unlikely to be bitten by the dog”) and perceived negative valence (e.g.,
“It is not so bad to be rejected”) may be deleterious to inhibitory learning
when employed prior to or during exposures (Craske et al., 2014). As a result,
cognitive restructuring conducted prior to or during exposure may negatively
impact exposure effectiveness. Therefore, clinicians practicing exposure from
an inhibitory approach should limit cognitive restructuring to the consolida-
tion phase following exposure therapy. However, it should be noted that expo-
sure in and of itself provides experiences that lead to less negative expectancies
 Inhibitory Learning 271

EXHIBIT 15.1

Inhibitory Learning Exposure Worksheet

What feared outcome am I most worried about? or What am I worried I will not be able
to tolerate?
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How am I testing it out (Situations, Settings)?

Strategies for this Session (Check All That Apply):

£ What am I throwing out?

£ How will I stay with it?

£ How will I combine it?

£ How will I face it?

Put it all together: What is my “exposure”?

Prior to How likely is it that what I am most worried about will occur
Exposure: (0 = Not at All, 100 = Certain)?

Now Complete Exposure Practice

After Did what I was most worried about occur? Yes ____   No ____
Exposure:

How do I know?

What did I expect to happen as a result of doing the exposure? What

happened? Did that surprise me?

What did I learn?

Imagine I repeated the same exposure practice. How likely is it that what I was
most worried about before will occur this time (0 = Not at All, 100 = Certain)?
____

Note. From the UCLA Anxiety and Depression Research Center. Reprinted with permission of
Jonathan S. Abramowitz and Shannon M. Blakey.
 272 Sewart and Craske

or appraisals. Although not directly addressed during exposure trials, mal-

adaptive cognitions regarding the probability and perceived negative valence
of anxiety-provoking events are modified through inhibitory learning result-
ing from direct exposure to the events themselves.

Removal of Safety Signals and Behaviors

To maximally violate feared outcome expectancies, safety signals and/or behav-

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iors must be removed during exposure practices. Indicators of safety include

cell phones, another person, and anxiolytic medications, for example. Safety
signals predict the absence of the feared outcome, or US, making safety signals
conditional stimuli of negative predictive value, or conditional inhibitors (CS−).
Thus, when a safety signal (CS−) is presented in concert with a feared condi-
tional stimulus (CS+), the safety signal (CS−) is posited to reduce expectation of
the feared outcome (US; McConnell & Miller, 2010). Therefore, safety signals
are posited to interfere with extinction learning and the development of sec-
ondary inhibitory associations with the presented CS+. This protection-from-
extinction phenomenon in the presence of conditional inhibitors has been
reliably observed in animal studies (e.g., Rescorla, 2003). Similar to safety sig-
nals, safety behaviors are deployed by individuals to avoid excitatory CSs that
are predictive of a feared outcome. As a result, safety behaviors, such as
diverting attention, reduce the salience of excitatory stimuli and interfere
with extinction learning (see Troubleshooting for further information). Safety
signals and behaviors should be discontinued as soon as possible given that
their immediate removal will expedite the formation of inhibitory associations
for excitatory stimuli. However, if a patient is unwilling to discontinue use of
safety signals and behaviors at the beginning of exposure therapy, these can be
gradually phased out over the course of treatment (Hermans, Craske, Mineka,
& Lovibond, 2006).
To assess for safety behaviors and signals, the therapist can query the patient,
“What are some behaviors you engage in to avoid [defined feared outcome]
or that make you think [defined feared outcome] is less likely to occur?”
When explaining the rationale for safety signal and behavior removal during
exposure, clinicians can use the phrase “throw it out.” For example, consider
the following case example and its removal of safety signals and behaviors.
Cameron has been diagnosed with social anxiety disorder.1 Currently, Cameron only feels
comfortable being in group settings with his partner. He feels that being with his partner
in a group reduces the likelihood of being evaluated negatively by others. To increase
expectancy of rejection, Cameron and his therapist have agreed to Cameron’s attending a
friend’s party without the partner present. Cameron will look for behavioral indicators of
rejection while engaging in group conversation at the party. Cameron will also refrain
from using his cell phone during the practice, another safety behavior. Here, Cameron is
“throwing out” safety signals of his partner and cellphone.

All clinical case material has been altered to protect patient confidentiality.
1
 Inhibitory Learning 273

Attentional Focus

One of the critical variables in modern associative learning models is the atten-
tional salience of presented CSs (Rescorla & Wagner, 1972). Thus, within an
inhibitory learning approach to exposure, increased salience of the CS (e.g.,
conspicuous, attention-grabbing; Pearce & Hall, 1980) enhances extinction
learning. To optimize salience and subsequent extinction, directing a patient’s
attention to excitatory CSs during all exposures trials is critical. Given that dis-
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traction is a common avoidant safety behavior, clinicians should encourage

patients to “throw out” any methods they commonly use to divert attention
away from elements of the exposure stimulus in an effort to reduce anxiety
(see Troubleshooting). For example, as a safety behavior, an individual with
social anxiety may avoid making eye contact during social interactions, which
results in reduced attentional salience of the nonoccurrence of behaviors that
violate his feared outcome prediction (e.g., eye rolling). Furthermore, inhibi-
tory stimuli, specifically safety objects, may compete for attention from the
patient, thereby reducing sustained attention directed toward excitatory stimuli
present in a given exposure trial and interfering with extinction learning. Sim-
ilar effects are observed when two highly salient excitatory stimuli are pre-
sented at the same time during a given trial (i.e., overshadowing; cf. Cook &
Mineka, 1987). Considerations for presenting multiple stimuli at the same time
in an exposure trial are outlined in the Deepened Extinction section. The phrase
“stay with it” may be used to convey the rationale behind attentional salience.

Deepened Extinction

Extinction learning may also be enhanced through the simultaneous presenta-

tion of multiple feared stimuli during exposure therapy, resulting in a deepened
extinction of conditioned fear. This strategy is achieved by (a) extinguishing the
conditional fear response for each feared stimulus in isolation, followed by
(b) simultaneous presentation of the stimuli during subsequent exposures.
Deepened extinction may also occur by pairing an extinguished fear cue with
a feared stimulus that has not been previously presented. When two feared
stimuli are eventually presented together, expectation that the feared outcome
will occur is intensified. With expectancy elevated, there is a greater mismatch
between predicted and actual outcome and further extinction learning. Wher-
ever possible, clinicians should combine multiple feared stimuli during exposure
after conducting some exposure to each cue, or one cue, in isolation. To deepen
extinction learning, it is integral that the chosen feared stimuli predict the same
feared outcome or unconditional stimulus—US. Clinicians should draw atten-
tion to the increase in expectancy when presenting concurrent excitatory stim-
uli and its subsequent violation. The phrase “combine it” may be used by
clinicians to describe the principle of deepened extinction to patients. Consider
the following case example and its implementation of the deepened extinction
strategy.
Joel has been diagnosed with panic disorder. He is fearful that experiencing panic-related
sensations, specifically lightheadedness and hyperventilation, will result in experiencing a
 274 Sewart and Craske

stroke. Joel has completed exposures for fear of light-headedness with chair spinning exer-
cises and confronted the fear of shortness of breath through straw breathing exercises.
Joel’s therapist may choose to deepen extinction learning by having Joel complete straw
breathing exercises while spinning in a chair.

Stimulus Variability

Research indicates that variable practice enhances the capacity for new learning
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(Bjork & Bjork, 1992, 2006). Variation results in effortful encoding of learning
resulting from exposure trials and gives rise to a schema that may be applied
across a range of fear-provoking situations (Bjork & Bjork, 1992). Importantly,
varied practice has been shown to increase the array of associated cues that
may be present during retrieval (Estes, 1955), making inhibitory associations
of CSs more accessible at a later time. The following example highlights the
importance of stimulus variability during exposure.
Logan presents for treatment of his fear of spiders. To extinguish his fear, Logan’s therapist
conducts multiple exposure trials with the same large tarantula. Logan now reports that
his fear of spiders and avoidance of places where he may encounter a spider has disap-
peared. He and his therapist then terminate treatment. Months later, while hiking, Logan
walks into a golden banana spider’s web. Logan’s fear and avoidance of spiders return.

In this example, when hiking, Logan was unable to access the inhibitory
associations he had developed with his therapist months earlier. This return
of fear is likely due to the fact that inhibitory learning was confined to a
specific type of spider, rather than extended to a general schema of spiders.
Developing multiple retrieval cues and a general inhibitory rule relating to
spiders requires that Logan be exposed to multiple spider types with varying
features.
Variability in exposures can also be applied to exposure duration, timing of
exposures, levels of emotional intensity, and expectancy levels. This approach
is in contrast to moving through exposures in a stepped, hierarchical fashion.
Emphasizing variability has been shown to attenuate fear renewal and result
in superior outcomes at follow-up (e.g., Kircanski et al., 2012; Rowe & Craske,
1998; Tsao & Craske, 2000). “Change it up” is a helpful phrase for presenting
the rationale behind stimulus variability.

Multiple Contexts

Fear may also return when a phobic stimulus is encountered in an environment

that is different from the extinction or exposure context, resulting in context
renewal (Mineka, Mystkowski, Hladek, & Rodriguez, 1999; Mystkowski, Craske,
& Echiverri, 2002; Rodriguez et al., 2004). To buffer from context renewal and
enhance retrievability of inhibitory learning, exposures should be conducted in
multiple different contexts. Variation in contexts during exposure includes con-
ducting exposure in multiple locations, at varying times of day, in unfamiliar
places, and both alone and with a therapist.
 Inhibitory Learning 275

Occasional Reinforced Extinction

Evidence suggests that extinction can be enhanced by occasional paired pre-

sentations (CS–US) of the unconditional stimulus (US) and conditional stim-
ulus (CS) during extinction training (e.g., shape → noise; Bouton, Woods, &
Pineño, 2004). Occasional reinforced extinction is thought to result in an increase
in the salience of the CS or an increase in expectancy during subsequent
extinction trials (see Craske et al., 2014, for more details). Regardless of the
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mechanism, occasional reinforced extinction results in attenuated, subsequent

reacquisition of fear in animals and humans (Bouton et al., 2004; Culver,
Stevens, Fanselow, & Craske, 2018).
Translated to clinical applications, extinction learning during exposure
therapy may be enhanced by occasionally presenting conditional stimuli
with the corresponding predicted feared outcome. For example, social anxiety
exposures may include the occasional presentation of social rejection, and
exposures for panic disorder may involve inducing intense physiological sen-
sations that increase the anticipation of a panic attack. Rapid reacquisition of
fear is most probable for presentations of anxiety in which the individual
might experience repeated aversive outcomes after treatment, such as social
rejection or panic. As a result, planning for occasional reinforced exposure
practices may be most beneficial in the treatment of social anxiety and panic
attacks. Occasional reinforcement may not always be appropriate, and cer-
tainly not when the aversive outcome may cause undue harm to an individ-
ual. As examples, it would clearly not be ethical to reexpose an individual
with posttraumatic stress symptoms to a traumatic experience or to expose
someone with a fear of snakes to an actual snake bite. Furthermore, occa-
sional reinforced extinction should be employed during the later phase of
treatment. When explaining the rationale to patients, we find the phrase “face
your fear” helpful for occasional reinforced extinction.

Retrieval Cues

Given that extinction learning is highly context dependent, the addition of

retrieval cues may also assist with accessing extinction learning after exposure
in completed. Posited to buffer individuals from deleterious context renewal,
a retrieval cue, such as a wristband or mental reinstatement (i.e., cognitive
exercises that retrieve the memory of previous extinction learning; see
Mystkowski, Craske, Echiverri, & Labus, 2006, for details), can be used in
different, unfamiliar contexts once therapy is completed (Brooks & Bouton,
1994; Dibbets & Maes, 2011; Vansteenwegen et al., 2006). Given that retrieval
cues may reduce expectancy during an exposure trial in a new context, they
should be used as a relapse prevention strategy prior to termination of therapy.
Of note, retrieval cues may acquire an inhibitory value and, as a result, become
safety signals (Dibbets, Havermans, & Arntz, 2008). The distinct difference
between retrieval cues and safety signals, however, is that retrieval cues act
 276 Sewart and Craske

to retrieve inhibitory learning, whereas safety signals possess a direct associa-

tive relationship with the nonoccurrence of a given feared outcome (Craske
et al., 2014). For example, a therapist’s office where previous exposure ses-
sions had taken place can act as a retrieval cue for a new exposure, whereas
benzodiazepines (e.g., in the case of panic disorder) can act as a safety signal.
The process of developing retrieval cues with patients should be used spar-
ingly to mitigate the likelihood of retrieval cues becoming safety signals.
Using the phrase “bring it back” has been helpful in explaining this rationale.
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Retrieval cues should be introduced as a relapse prevention strategy toward

the end of exposure therapy. The following is an example of how to explain
the process of mental reinstatement as retrieval cue for a patient with panic
disorder.
Although we’ve conducted many exposure practices over the course of treatment, we may
not be able to completely and permanently overpower the original fear associations that
led to your developing panic attacks. Over time, you may forget the new learning that was
formed during treatment, which can put you at risk for a return of fear. However, we
have a strategy that can help our brains remember our new learning and buffer us from
lapsing back into fear. To help our brains remember our new learning and override our
original fear associations, we can vividly recall an exposure practice that went well.
Think of one of our exposure practices that went especially well. I’d like you to recall this
as vividly as you can . . . the situation . . . the outcome. I’d like you to practice “bringing
it back” three times over the next week prior to conducting an exposure exercise. It is
important that we not rely on this as a safety behavior, though, so we don’t want to do
this every time we do an exposure.

OUTCOME INDICATORS

Given that fear expression during exposure is (a) incommensurate with fear
learning (see Craske et al., 2008) and (b) an unreliable predictor of treatment
outcomes, fear reduction (generally measured by subjective units of distress)
between and within sessions should not be used as an index of inhibitory
learning. Rather, expectancy ratings and their reduction pre- to postexposure
and across exposure trials with the same CSs provide a more appropriate
index of the potential for expectancy violation and extinction learning. Prior
to exposure, patients should give an expectancy rating for a given feared out-
come on a 0-to-100-point scale, where 0 represents the belief that the feared
outcome is not at all likely to happen and 100 is entirely certain the feared outcome
will happen. This rating can be assessed by asking the question “How likely is
it that what I am/you are most worried about will occur?” Using the same
rating anchors, the postexposure expectancy level can also be assessed by
asking, “Imagine you repeated the same exposure practice. How likely is it
that what I was/you were most worried about before will occur this time?”
Self-reported expectancy ratings may not provide a complete representa-
tion of achieved extinction learning during exposure therapy. Additional
measurement methods need to be developed and adopted for a more accurate
index of inhibitory learning that will aid therapists in clinical decision making.
 Inhibitory Learning 277

Personalized implicit association tests administered during treatment are a

promising avenue in the of assessment of inhibitory learning (see Vasey,
Harbaugh, Buffington, Jones, & Fazio, 2012). Such implicit measures may
provide less biased measures of extinction learning by removing demand char-
acteristics that exist in therapeutic settings and may influence self-reported
expectancies.
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EMPIRICAL SUPPORT

Emphasizing expectancy violation in exposure therapy has demonstrated sim-

ilar to superior outcomes when compared with traditional habituation-based
approaches. For example, exposure durations that exceeded expectancies for
the timing of an aversive outcome in individuals with acrophobia (i.e., specific
phobia of heights) were as effective as standard exposure therapy, even though
exposure was conducted over many fewer exposure trials (i.e., repeated trials
of exposure each day vs. one trial of exposure per 2 days; Baker et al., 2010).
For individuals with elevated anxiety sensitivity, intensive interoceptive expo-
sure that was continued until a patient’s expectancy for a given feared outcome
reached less than 5% outperformed standard interoceptive exposure on vari-
ous outcome measures (Deacon et al., 2013). Of note, one significant limitation
of this study was that the “intensive” group received more trials of exposure,
making it unclear how total duration of exposure, rather than expectancy vio-
lation, affected outcome. Currently, the expectancy violation approach is pri-
marily supported by a substantial body of basic experimental findings (e.g.,
Rescorla & Wagner, 1972; see Craske et al., 2014, for a review).
Other methods employed during exposure trials aimed at optimizing
extinction learning are largely supported by experimental laboratory studies.
Deepened extinction has been shown to reduce spontaneous recovery and
reinstatement of fear in animals (Rescorla, 2006) and humans (Culver, Vervliet,
& Craske, 2015). Similarly, occasional reinforcement during extinction was
found to attenuate subsequent reacquisition of fear in both animal (Bouton
et al., 2004) and human studies (Culver et al., 2018). The strategy of variability
has been directly applied to exposure and examined in fearful samples with
promising results. In spider-phobic individuals, variability of timing between
exposure sessions and of the stimulus itself led to superior outcomes when
compared with nonvariable massed exposure (Lang & Craske, 2000; Rowe &
Craske, 1998; Tsao & Craske, 2000), although a study of contaminant anxiety
showed results only at the trend level (Kircanski et al., 2012).
Findings regarding removal of safety behaviors and signals are less consis-
tent than findings regarding other methods of optimizing extinction learning
(for an inhibitory-learning-based review, see Blakey & Abramowitz, 2016). In
clinical samples, the availability and use of safety signals and behaviors have
been shown to be detrimental to exposure therapy (Sloan & Telch, 2002).
Providing instructions to refrain from using safety behaviors has also been
shown to improve outcomes (Salkovskis, 1991). However, recent data suggest
 278 Sewart and Craske

contradictory findings (Rachman, Shafran, Radomsky, & Zysk, 2011). Specif-

ically, the use of hygienic wipes following exposures for individuals with con-
tamination fears did not lead to any more spontaneous recovery of fear or
disgust than exposure without hygienic wipes. Similarly, continuing to engage
in safety behaviors, or having them available for use, was not observed to
affect outcomes deleteriously (Deacon, Sy, Lickel, & Nelson, 2010; Sy, Dixon,
Lickel, Nelson, & Deacon, 2011). Inconsistent results may be accounted for by
differences in the ratio of safety signal inhibition and excitatory stimuli within
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exposure trials and across studies (see Craske et al., 2014, for a more detailed
explanation). Although these results are currently inconsistent, the general
consensus remains that safety signals and behaviors should be removed sys-
tematically over the course of exposure therapy (Hermans et al., 2006).
Strategies that increase retrievability of extinction learning possess less
consistent results than strategies that enhance extinction learning. Multiple
contexts have been shown to offset context renewal in human laboratory
studies (e.g., Balooch & Neumann, 2011; Balooch, Neumann, & Boschen,
2012) and in a clinical analog study of exposure therapy (Vansteenwegen
et al., 2007). However, one conditioning study with rodents (Bouton, García-
Gutiérrez, Zilski, & Moody, 2006) and another conditioning study with humans
(Neumann, Lipp, & Cory, 2007) failed to demonstrate detectable benefits of
multiple contexts throughout extinction on context renewal, suggesting that
the effects may be unstable. Similarly inconsistent results have been observed
regarding retrieval cues. Mental reinstatement of prior extinction learning
was demonstrated to limit context renewal in spider-phobic individuals
(Mystkowski et al., 2006). The effects of retrieval cues, such as distinctive pen
and clipboard, were found to be very weak in one study for public-speaking-
phobic individuals (Culver, Stoyanova, & Craske, 2011).
In sum, findings from basic research and treatment studies largely support
methods that enhance inhibitory learning (e.g., deepened extinction, occa-
sional reinforcement). Strategies that are geared toward enhancing retrieval
of extinction learning currently show inconsistent results in a limited number
of studies. Overall, additional translational research in clinical samples is nec-
essary to examine the extent to which inhibitory learning-based exposure
strategies enhance treatment outcomes or outperform traditional habituation-
focused exposure therapy.

TROUBLESHOOTING

Avoidance

Individuals with anxiety disorders tend to engage in excessive avoidance

behavior, resulting in limited experiences with situations, stimuli, or sensa-
tions that they perceive as threatening. As a result, avoidance prevents learn-
ing that feared stimuli are actually safe (i.e., inhibitory associations, fear
extinction; Craske, Hermans, & Vervliet, 2018). For these reasons, exposure
 Inhibitory Learning 279

treatments are designed to help the patient approach situations that have been
avoided. Patients are likely to engage in avoidance behaviors during exposure
treatment, resulting in an insufficient response or nonresponse to exposure
therapy.
Avoidance of feared stimuli during exposure therapy may be conspicuous
and easily identified by the therapist. Most commonly, patients engaging in
avoidance return to session with unfinished exposure assignments. Similarly,
to reduce the likelihood of a given feared outcome, patients engaging in avoid-
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ance may only partially complete exposure assignments. For example, a patient
with panic disorder may be absolutely certain that hyperventilating for 1 minute
will result in a stroke. To violate this expectation, the patient’s therapist assigns
the patient to hyperventilate in 15-second intervals for 2 minutes as a take-
home exposure assignment. The patient returns next session reporting that they
completed the assignment but were able to hyperventilate for only 45 seconds.
In this example, the avoidance has reduced the potency of the learning expe-
rience because the patient did not exceed the duration that was defined to
result in a stroke (i.e., 1 minute). As a result, the patient’s new inhibitory
associations formed from the exposure were restricted and extinction learn-
ing suboptimal when compared with the initial planned exposure.
Patients may also engage in discreet avoidance or escape behaviors during
a given exposure trial. These behaviors may not be as easily observed and
therefore require therapists to watch attentively for their potential interfer-
ence. A common inconspicuous avoidance behavior often shown by patients
with anxiety disorders during an exposure is shifting attention away from
feared stimuli. In the absence of engagement with a feared stimulus, an indi-
vidual is likely to not notice whether or not the negative event they expected
even occurred. Unquestionably, this behavior compromises the development
of new inhibitory learning. Several studies in anxious adults have shown that
individuals who selectively attend toward threat (e.g., Price, Mehta, Tone, &
Anderson, 2011) or demonstrate greater difficulty disengaging from threaten-
ing stimuli (Barry, Sewart, Arch, & Craske, 2015) in laboratory tasks prior to
CBT show greater improvement of symptoms when compared to those who
show no bias or avoid threat.
For example, individuals with severe social anxiety may avoid eye contact
with other individuals as a safety behavior. As aforementioned, abstaining
from eye contact with others allows socially anxious persons to avoid salient
behavioral indicators of rejection, such as squinted eyes or a furrowed brow,
and may reduce distress associated with the event—which is likely to have an
added predictive value of rejection (e.g., “If I make eye contact, I will see
someone is judging me, which will make me anxious. This anxiety will lead
me to blush and stutter during the conversation. If I blush and stutter, people
will think I’m weird and reject me”). Thus, expectancy violation is limited
during an exposure in which avoidance of eye contact is employed by a
socially anxious patient. Individuals with specific phobia are likely to avoid
looking directly at phobic stimuli. Similarly, persons with panic disorder may
avoid internal physiological sensations related to panic by shifting their atten-
tion to other stimuli, internal or external.
 280 Sewart and Craske

If a patient does not report reductions in expectancies for feared outcomes

during the course of treatment, avoidance may partially account for observed
treatment stagnation. Therefore, it is essential that therapists practicing expo-
sure from an inhibitory learning perspective provide substantial psychoedu-
cation on the role of avoidance in anxiety disorders. Together, therapists and
patients should identify pernicious avoidance behaviors at the first session and
continually monitor for their occurrence over the course of treatment. Fur-
thermore, therapists should constantly monitor for unidentified avoidance
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behaviors that may reduce expectancy and interfere with new learning.
When new avoidance behaviors are identified, therapist and patient should
discuss how to monitor, reduce, and eliminate their future occurrence.
After the conclusion of exposure therapy, the return of previously extin-
guished fear responses is not uncommon. However, return of fear posttreat-
ment is problematic only when accompanied by escape or avoidance
behaviors. Return of fear itself is a transient state with limited clinical impli-
cations (Craske et al., 2018). In the absence of escape or avoidance, return of
fear is followed by additional experience that provides extinction learning
and eventual fear reduction. Prior to the conclusion of exposure therapy,
therapists should highlight the inevitability of residual anxiety and stress to
patients that continued exposure practice to feared stimuli following treat-
ment is essential in maintaining treatment gains.

Integration of Family Members

For anxious patients, family members or significant others may inadvertently

reinforce avoidance behaviors and, as a result, interfere with extinction learn-
ing. Aiding in avoidance is an understandable solution that reduces signifi-
cant anxiety from a family member’s or significant other’s perspective. Seeing
an anxious loved one in distress urges individuals to engage in and reinforce
behaviors that reduce the loved one’s negative outcome expectancies. How-
ever, an individual facilitating reduction of expectancy may acquire an inhib-
itory value and develop into a safety signal. If family members and significant
others are aiding in avoidance behaviors, therapists should incorporate
removal of these behaviors into exposure practices. Therapists should encour-
age patients to discuss the rationale for safety behavior removal with loved
ones. If loved ones continue to reinforce safety behaviors during treatment, it
may be beneficial to request that they attend a limited number of sessions so
that therapists may directly provide further treatment rationale and psycho-
education on anxiety disorders.

CONCLUSION

Advances in research on associative fear learning suggest that extinction learn-

ing, achieved through repeated presentation of a given CS without the US
(i.e., CS–noUS), is likely a critical mechanism underlying exposure therapy
 Inhibitory Learning 281

(Craske et al., 2008, 2014; Rescorla & Wagner, 1972). Development of CS–
noUS associations must occur to inhibit—not erase—existing excitatory asso-
ciations (CS–US) that are responsible for maladaptive fear responding and
anxiety (CR). To maximize treatment outcomes and maintain long-term
gains, this theoretical understanding of exposure therapy requires clinicians
to emphasize therapeutic strategies that increase inhibitory learning. Such
strategies translated from basic associative learning theory include expec-
tancy violation, immediate removal of safety behaviors and signals, stimulus
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variability and multiple contexts, deepened extinction, attentional focus,

occasional reinforced extinction when appropriate, and retrieval cues. Inhib-
itory learning-focused strategies are distinct from traditional, habituation-
based exposure practices that aim to decrease fear responding (e.g., staying in
a situation until fear sufficiently declines). Evidence supporting inhibitory
learning-based exposure strategies is currently limited, and further research
is warranted to determine the extent to which inhibitory learning-based
exposure strategies enhance treatment outcomes or outperform traditional
habituation-focused exposure therapy. Overall, the translation of inhibitory
learning principles into exposure therapy is an exciting and critical step for-
ward toward science-driven practice.

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