Lang’s (1977) bioinformational theory suggested that emotional images are stored in memory as propositional constructions, networks of propositional units containing information about stimuli, responses (behavioral, verbal, physiological), and interpretations about the meaning of these stimuli and responses related to emotional events. Applying this thinking, Foa and Kozak (1986) formulated emotional processing theory (EPT) and proposed that fear, too, is represented in such memory structures that essentially function as blueprints for fear behavior or programs for avoiding or escaping from danger (Foa, Steketee, & Rothbaum, 1989). The essential feature distinguishing such fear structures from other informational structures are meanings of threat, danger, and escape from threat linked to its constitutive stimuli and responses.
Foa and Kozak (1986) further distinguished between what they called normal and pathological fear structures. While normal fear structures contain realistic and
adaptive representations and associations that promote avoidance of dangerous situations, pathological fear structures are excessively expansive in response elements, resistant to modification, and may contain meaning representations that conflict with or distort reality. They may incorporate beliefs that anxiety will always persist until escape, exaggerated probabilities for psychological or physical harm linked to fear responses, and high negative valence or cost for such potential threats. Applying EPT to PTSD, Foa et al. (1989) suggested that fear structures of trauma survivors who develop PTSD, such as that presented in Figure 2c, show three distinctive features: The particular intensity of the responses, the expansive size of the structure, and its easy accessibility. The monumental traumatic event violates previous beliefs about predictability and safety. The resulting fear structure will therefore link many internal and external stimuli with meanings of danger and threat. Such an expansive fear structure is then easily activated by basically harmless stimuli, resulting in strong responses such as bursts of arousal and startling, re-experiencing the event as flashbacks or nightmares, and only temporarily successful attempts to avoid or escape the fear reaction.
EPT (Foa & Kozak, 1986; Foa et al., 2006) holds that pathological fear structures persist because avoidance and cognitive biases prevent the acquisition of information incompatible with their elements. There are thus two conditions for resolving or emotionally processing the fear structure, and thus, reducing PTSS (Foa & Kozak, 1986). First, the fear structure must become activated with the accompanying evocation of fear and stay activated long enough for habituation to anxiety to occur. Second, corrective information that is incompatible with the propositions contained in the fear structure relating to the experience and its meaning needs to be provided and integrated. This can be interoceptive information about absence or weakening of physiological arousal, or more cognitive information about lack of expected harm. Encoding this incompatible information into the structure weakens the existing links between stimuli and responses and decreases the likelihood that such responses are evoked in the future by information now matching only some elements of the structure. Meanings of threat associated with the fear responses can also diminish, as information about the lack of any real danger and the reduction of fear and anxiety even without avoidance or escape is integrated.
In natural recovery after exposure to trauma, this emotional processing occurs in the daily life of the trauma survivor as she/he engages with thoughts and feelings related to the trauma, sharing them with others and confronting trauma reminders, and thus repeatedly activates and modifies the fear structure (Foa & Cahill, 2001). However, trauma survivors who engage in thought suppression and behavioral
avoidance of trauma-related stimuli will not experience the necessary habituation to their negative emotions nor receive enough disconfirming information in daily situations to challenge their negative posttraumatic beliefs and process the trauma emotionally. They may thus develop chronic PTSS. EPT argues that chronic or more severe traumatic exposure results in fear structures with more stimuli and responses of greater intensity. Such larger structures may require more matching elements to become fully activated and malleable, which is unlikely to happen accidentally in daily life (Foa et al., 1989). The intense responses in turn may mean that when such activation does take place, arousal is excessive and impedes habituation and incorporation of corrective information. This is why recovery from repeated trauma is even more difficult.
In active treatment of PTSD, on the other hand, the fear structure needs to be intentionally activated (Foa et al., 1989). This it achieved by introducing a sufficient number of stimuli or information elements similar to those in the fear structure to the therapeutic context. The full activation of a PTSD-related fear structure, may be more difficult than one related to, for example, a simple phobia. This is because such a large structure is likely less coherent and cohesive and hence more difficult to activate in its entirety, as well as by the trauma survivor’s attempts to avoid activation of strong responses. After the fear structure is activated and the accompanying fear or anxiety evoked, habituation can occur over a prolonged period of exposure. Disconfirming information can be received from both the habituation itself and the repeated activation of the fear structure in the safe and unthreatening therapeutic context, which works to reduce exaggerated probabilities of threat and excessively negative valence of the imagined outcomes.
The inhibitory learning framework to exposure (Craske et al., 2008; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014) has challenged this original formulation of EPT emphasizing the importance of habituation to fear and anxiety during sessions to some extent. This framework suggests that, instead of degradation or replacement of the link between the feared stimulus and the (emotional) response through habituation, learning a new, inhibiting link between the stimulus and lack of threat or danger that competes with the original link is paramount to treating anxiety and fear via exposure. Empirical findings on the relevance of the sort of habituation to fear the original formulation of EPT suggested as crucial to healing from PTSD have also been decidedly mixed. In some studies, within-session habituation has been linked to improvements in symptoms (de Kleine, Hendriks, Becker, & van Minnen, 2017; van Minnen & Hagenaars, 2005), but other studies have not found such a link (Sripada & Rauch, 2015; van Minnen & Foa, 2006).
In a later update to EPT, Foa et al. (2006) acknowledged that empirical research has not supported all aspects of the theory as originally formulated and conceded that within-session habituation may not be a necessary condition or reliable indicator for emotional processing. However, this does not mean the end of EPT, as we may see the modification of problematic and erroneous associations by incorporation of disconfirming information as a crucial underlying mechanism, rather than simple habituation. Foa et al. (2006) further granted that old associations between feared stimuli and emotional responses are not eliminated or replaced during exposure, but rather new competing associations, or possibly a new fear structure, are acquired, and both are retained in memory. Which structure and its associated behaviors, emotions, and cognitions becomes activated is then context-dependent. These updates to EPT bring it in line with the inhibitory learning framework.
The majority of theorizing related to EPT involves adults and adult posttraumatic reactions. However, successful treatment models specific to adolescents have been developed on the basis of EPT, as well, as discussed below in Section 3.1 (Foa, Chrestman, & Gilboa-Schechtman, 2008). Considering younger children, Salmon and Bryant (2002) note particular developmental issues that may affect the development and maintenance of PTSS, as understood by EPT. First, children’s knowledge base and level of language development influence how traumatic events will be encoded and represented in fear structures. For a younger child, the resulting memories may be less detailed and more prone to forgetting, omission, errors, and misleading suggestions, while features of the event beyond the child’s usual experience may not be understood or correctly represented. This holds importance for the subsequent emotional response. On one hand, more limited appraisal and encoding may protect a younger children from realizing the full disturbing extent of an event. On the other hand, the child may be more vulnerable to misinterpretations, misattributions, and unrealistic fears involving additional distress. Second, if pathological fear structures and the associated intrusive thoughts are maintained by avoidant strategies, young children’s limited ability to suppress and manage their thoughts before middle childhood may in fact provide additional opportunities for adaptation in daily life. At the same time, however, with immature understanding of their own thinking and emotions, children may be less capable of reporting their thoughts to others and using more adaptive coping strategies.
Finally, it is important to note that younger children have limited strategies for intentionally retrieving memories on their own (Salmon & Bryant, 2002). Together with limited vocabulary and reduced tendency to initiate conversations, this may deprive children of opportunities for natural recovery from PTSS through
reappraising the trauma and receiving corrective information from others, especially parents. Following a traumatic event, discussions with adults are thus crucial to children’s emotion regulation and coping abilities, improved accuracy of their traumatic memories, and subsequent recovery from PTSS.