2 Exposure Flashcards
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Exposure based interventions
- Exposure therapy is a method for clients with emotional struggles associated with maladaptive avoidance behaviors.
- Exposure therapy has been successfully applied to clinical problems with emotions of fear and anxiety as central features
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Empirical Basis of Exposure Interventions
• Studies have indicated that prolonged exposure is just as effective in treating PTSD as more complex treatments that include cognitive interventions and coping skills.
• Barlow’s panic control therapy includes two forms of exposure therapy –
1. interoceptive exposure: induce the somatic symptoms associated with a threat appraisal and encouraging patients to maintain contact with feared sensations
2. in vivo exposure: flooding and systematic desensitisation
• success rates of 80% to 100% in reducing the frequency of panic attacks in individuals with panic disorder.
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Defining Exposure Therapy
- exposing clients to stimuli that elicit emotional responses in the absence of negative consequences and
- preventing a behavioral response that is consistent with the emotional response elicited (often avoidance or escape).
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Exposure interventions are used when
Exposure is most appropriate with clients who experience unwanted, dysfunctional, or unjustified emotional responses.
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Unjustified/Maladaptive Emotional Responses
Unjustified Emotional Response
• Emotional reactions that are not warranted by the situation.
• BE CAREFUL: Exposing when an emotional response is justified, will strengthen rather than weaken the fear!
Maladaptive Emotional Responses
• Describes specific instances in which a client’s emotions are intense and associated with problematic action tendencies.
• Maladaptive emotions are those that are excessively intense or associated with response tendencies and are rigid, ineffectual, and resistant to change.
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How do exposure interventions work?
- Counterconditioning
- Extinction of Habituation
- Learning new responses
- Modification of Rules that Influence Avoidance Behaviour
- Emotional Processing
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Primary features of exposure therapy
• Primary features of exposure therapies that account for therapeutic change include the act of repeatedly exposing the client to emotion-eliciting stimuli,
- The prevention of responses that are consistent with the emotional response,
- Then the nonoccurrence of negative consequences during the exposure process.
• Less consensus exists on how or why exposure results in therapeutic change
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Counterconditioning
- substitution of an adaptive alternative response (relaxation) for a maladaptive response (excessive or unjustified anxiety).
- This explanation has been used to account for the effectiveness of systematic desensitization approach for eliminating conditioned fears: presentation of progressively more anxiety-provoking stimuli in imagination while the client is relaxed.
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- The underlying processes of the effects of exposure incorporate both classical and operant conditioning elements.
- Mowrer’s two-factor theory describes classical condition as the process by which people develop fears, and operant conditioning as the process that maintains fears.
- Exposure therapy works through the processes of operant and classical extinction
- To weaken the associations, the individual must repeatedly experience the CS (heights) in the absence of the UCS (falling).
- Over several sessions of prolonged exposure, situational cues (heights) are associated with a decreasing intensity of the emotional response until the situational cues no longer elicit the maladaptive and unjustified emotional responses
- This weakening of the UCS-CS bond only occurs if avoidance behavior is blocked or inhibited, and the individual remains in contact with the CS until the CRs fade or extinguish.
- Criticism: include difficulty distinguishing between UCS and CS in naturalistic environments and rejection of automatic associative processes. So the concept of “habituation” has occasionally been substituted for “extinction”.
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Learning new responses
- Exposure therapy does not involve the elimination of prior learning but promotes new learning.
- A consequence of new learning is that CS can assume multiple associations with the UCS, and CRs will evidence some variability across different contexts.
- There is some evidence of the context specificity of both fear acquisition through conditioning and extinction of fears.
- So exposure scenarios should include as many specific contextual and event features as possible.
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Modification of Rules that Influence Avoidance Behaviour
Exposure therapy results in discarding of inaccurate rules concerning antecedent-behavior-consequence relations in favor of more accurate rules concerning these relations
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Emotional Processing
• Emotional processing theory (EPT) is a cognitively oriented theory regarding the effects of exposure therapy
• In EPT, fear is represented as a memory structure that involves stimuli (heights), responses (avoidance), and cognitive “meaning” elements (danger).
• According to EPT, exposure therapy must involve the presentation of relevant stimulus elements, activation of the memory structure, and the incorporation of information that is incompatible with the fear structure.
• Over time, exposure allows for the client’s integration of new, non-fear-related memories, and the meaning elements related to the client’s fear become divorced from the stimuli that previously elicited them.
• EPT has formed the basis of an empirically supported approach to treating fear related to PTSD, called cognitive processing therapy.
- Implications (finding fear-relevant stimuli and preventing avoidance responses) are similar to the implications of other mechanisms of change.
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General exposure procedures
(a) choosing the appropriate type of exposure for the client;
(b) orienting the client to exposure
(c) assessing factors that may inform the development of exposure scenarios;
(d) selecting an effective format, frequency, and schedule of exposure interventions;
(e) following key guidelines
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Choosing appropriate Type of Exposure
-Imaginal Exposure
-In Vivo Exposure
-Informal Exposure
• Exposing the client to stimuli that elicit emotional responses in an ad hoc manner during therapy sessions, it is less structured.
• During subsequent therapy sessions, if the therapist observes the client avoiding discussions of emotionally difficult material, for example, the therapist might clarify whether, in fact, avoidance is occurring.
• When the client confirms the avoiding, the therapist encourage the client to describe in detail the experience or recollection
-Interoceptive Exposure (bodily sensations)
-Opposite Action and Reversing Emotional-linked Action Tendencies (Acting in a manner that is opposite to the urge that accompanies a particular emotion)
-Cue exposure (especially for substance use)
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Assessing Breadth and Intensity
After the explanation of the exposure interventions, the second step is a solid assessment
(a) the breadth of stimuli the client responds to with unjustified emotional response and
(b) the intensity of the emotional response
• For the breadth of stimuli you should know the range of situations when unjustified emotions are experienced.
• It is important to ensure that all key stimulus elements that elicit fear are captured in exposure.
• For the intensity it is important to know how intense the emotional response is to various situational triggers, for example on a scale from zero to one hundred.
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Deciding Between Graduated Exposure and Flooding
• Graduated exposure (systematic desensitisation) involves creating an exposure hierarchy that ranges from items that are relatively low in SUDS to items that are the highest in SUDS (Subjective Units of Distress).
• Flooding involves exposing to the highest items on the exposure hierarchy first.
1. It is important to determine whether a client is ready for flooding, some clients are too afraid.
2. A second consideration is the efficacy of flooding, it might have better long-term effects than graduated exposure.
3. And third is the length of sessions, flooding sessions need to be scheduled longer, to “come down” before leaving the therapy session.
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Exposure Sessions
whether to conduct exposure in massed format (3-4 hours per day over 5-6 days per week) or a spaced format (30-120 minutes during once-per-week sessions)
->generally have equivalent effects
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Guidelines for Conducting Exposure Interventions
- First the client has been oriented to the exposure, collaboratively decided on the format, schedule and type of exposure.
- The next step is to conduct exposure, four procedural points are:
(a) Conduct Nonreinforced Exposure
(b) Prevention Emotion-Consistent Responses (+Monitor Subjective Units of Distress (SUDS) Ratings repeatedly)
(c) Continue Exposure Until the Client’s Emotional Response Has Habituated
(d) Give Client Control Over Exposure
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Introduction to EX/RP for OCD
• EX/RP refers to a collection of treatment techniques that were borne from behavioral theory
- Aimed at teaching an individual to approach fear producing stimuli coupled with the prevention of fear-neutralising rituals
- Used alongside other techniques which make up CBT- Other techniques viewed as ancillary techniques
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Theoretical Rationale for EX/RP
• Early learning models based on two-factors theory of fear
- When an individual is faced with a situation that elicits a physiological fear or anxiety state, an unconditioned behavioural reaction to escape that state is initiated
- If action reduces anxiety, it is strengthened via negative reinforcement
- Through learning experiences, various internal and external stimuli acquire the ability to elicit anxiety and the ensuring escape response
- When escape response is performed ‘compulsively’ in response to benign stimuli, one is said to suffer from OCD
• EX/RP is based on the assumption that if an individual is systematically exposed to stimuli that elicit obsessional thoughts and associated anxiety, and is prevented from escaping or otherwise neutralizing the anxiety (ritual prevention), the anxiety will diminish over time through the process of extinction and the person will be better able to function in his/her daily life.
• Foa and Kozak posited that habituation is aided by exposure to corrective info in that the individual learns, through direct experience, the feared consequences do not materialise in the situations that typically evoke obsessional distress
• With repetition, the reduction of anxiety in the previously feared situation makes it easier in the long run to resist the weaker urges to escape and/or ritualize.
• Behavioural conceptualisation focuses on the here-and-now functional relationship between an individual’s obsessions and compulsions, with the assumption that this relationship can be modified in treatment without necessarily understanding ‘cause’ of obsessions.
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Empirical support for EX/RP for OCD
• Strong support for EX/RP as a treatment for OCD
- Effective for 60-90% of individuals with 50% to 80% symptom reduction
- Maintained
• CBT as an effective treatment for reducing OCD in adults and children
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Case Conceptualization
• It is important to note that when cognitive techniques are adopted and utilized in conjunction with EX/RP, the inclusion of cognitive therapy techniques is not meant to change, suppress, or stop the patient’s irrational obsessions in the moment.
• To the contrary, the focus of treatment is to teach Caroline to directly confront the feared stimulus and deliberately elaborate or focus upon the fears in the moment, rather than to engage in attempts to stop obsessions and discomfort from occurring.
• In addition to increasing compliance with EX/RP, this technique is designed to “externalize” OCD and to encourage Caroline to stop “fighting” with her OCD and start “being her own boss.” This places emphasis on trying to change her behavior rather than trying to change her thoughts.
• During EX/RP, emphasis is always placed on the fact that patients with OCD can exercise voluntary control over their rituals but cannot, nor should not, attempt to control their obsessions or the associated distress in the moment.
- In fact, Abramowitz (2006) suggested that two “commandments” of successful EX/RP are that patients should (a) expect to feel uncomfortable and (b) should not try to fight the discomfort.
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Implementation of EX/RP
- The number and length of EX/RP sessions that an individual will need will vary considerably, depending upon the severity of the individual’s OCD symptoms, the person’s availability for treatment, and a host of other factors.
- Avg 12-15 sessions
- The primary components of EX/RP include assessment of OCD symptoms, psychoeducation and treatment rationale, symptom monitoring, developing fear hierarchies, in-session and out-of-session exposure work, relapse prevention, and generalization training.
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Assessment and Review of OCD Symptoms
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which is the gold-standard instrument for assessing OCD symptoms in adults.
- The Y-BOCS has been shown to be sensitive for detecting treatment-related change so it can be administered repeatedly over the course of treatment to assess treatment gains.
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Psychoeducation
- Psychoeducation will be provided during the first few sessions of treatment and periodically throughout treatment as necessary.
- In addition to providing basic information about the disorder, it is also important to provide a working model of OCD that focuses on the here-and-now functional relationship between obsessions and rituals.
- When patients are focused on the cause of their OCD, we find it helpful to explain that OCD is a neurobehavioral disorder whose causes are not yet fully understood.
- Focusing on biological factors helps the patient understand that OCD is a medical illness rather than a “learned habit” that the patient can control with sufficient effort.
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Important Aspects of successful exposure
(a) conduct exposure exercises that are manageable,
(b) refrain from all ritualistic behavior during the exposure,
(c) continue the exposure until it can be performed with relative ease both inside and outside of therapy sessions,
(d) conduct the exposure repeatedly
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Possible Difficulties and Barriers to Treatment
most common barriers to treatment are noncompliance:
- Common reasons include lack of motivation, misunderstanding/ disagreement with the behavioral model, interpersonal factors or poor therapist-client match, moving too rapidly up the stimulus hierarchy, and comorbid or co-occurring psychological issues
- other reasons: involvement of others, comorbid psychological disorder
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Exposure to what?
What is being avoided or prevented to happen?
- Situations? e.g. social interaction
- Emotions? e.g. fear
- Bodily sensations? e.g. palpitations
- Cognitive contents? e.g. memories
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Reality of exposure therapy
- PTSD: only 17% uses imagery exposure (Becker e.a. 2003)
- When therapists say they do CBT
o -PD: meditation and self-hypnoses > interoceptive exposure
o SAD: breathing and relaxation > exposure
o OCD: breathing and relaxation = exposure with respons prevention (Freiheit e.a., 2004)
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Key question in Treatment Design
- CS (Shaking hands)
- UCS (Serious illness)
- CR (Fear)
! Exposure is to the CS, NOT the UCS
!During anxiety dis amygdala (fight or flight) is very active
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Types of Exposure
- Exposure in vivo (e.g. agoraphobia)
- Exposure in vitro / imagery exposure (e.g. PTSD)
- Interoceptive exposure (e.g. panic disorder; hypochondrias
- Cue exposure (e.g. bulimia and addictive behaviors)
- Exposure with response prevention
- Social mishap exposures (social phobia)
- Therapist-assisted or self-directed exposure
- Virtual reality exposure therapy (VRET)
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Interoceptive exposure in action
CS: dizziness
UCS: Fainting, Going crazy, losing control, Heart-attack
CR: fear
Examples for hyperventilation provocation: • breathing through straw • walking the stairs • shaking your head • spinning around • holding your breath • looking at stripes
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Typical analyses for social anxiety disorder (SAD)
CS: Social mishap
UCS: Rejection
CR: fear
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Mowrer’s two-factor theory
- Classical conditioning to develop fear
* Operant conditioning to maintain fear
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Safety behaviour
DEF: Behaviors that predict safety (absence of UCS) and that are related to the prevention of the feared outcome.
- Safety behavior = R (operant)
• Safety signal:
- Predictors of the absence of UCS
- Safety signal = CS-
• Avoidance behaviour:
- Passive avoidance: avoiding situations or objects to prevent the expected feared outcome to occur
- Active avoidance: escaping from (leaving) the anxiety provoking situation (and therefore the feared outcome)
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Functional analyses
Sd: Hand shaking situation
R: Avoidance beh
SR: wont get ill, relief
S: strengthening of CS-UCS association ->more fear in the long run
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OCD
- Obsessions that give rise to anxiety
- Compulsions that function as a mean to diminish this anxiety
- Treatment of choice: Exposure with response prevention
- (60%-90% response rate, 50%-80% symptom reduction common)
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General: Response prevention
- Principle: Giving up anxiety maintaining behaviour; i.e. escape -, avoidance -, or safety behaviours
- Application: in e.g. OCD and related disorders
- So: stop checking, washing, counting etc…
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Treatment plan
- Assessment of ocd symptoms
- Psychoeducation and treatment rationale
- Symptom monitoring
- Developing fear hierarchies
- In-session and between-session exposure work
- Relapse prevention
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Response prevention: variants
• Prevention of entire behaviour
- E.g. protective measures, such as checking, ordering
• Decrease of frequency, amount, or duration of behaviour
- E.g. prolonged washing, repetitive checking
• Delay of unavoidable behaviour
- E.g. washing hands, cleaning, checking
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Response prevention: rationale
- You have been struggling with various rituals for a very long time.
- These rituals take up much of your time
- You have not been able to postpone or give up the rituals
- These rituals are meant to make you feel less distressed or anxious or to prevent the feared consequences.
- In the short run, this has been successful. But in the long run the rituals contribute to the maintenance of the OCD.
- In this treatment we’re going to break down the rituals one by one, in order to make you more in control over your life and to decrease the OCD related distress
- For that purpose we are going to make a list of rituals that you are going to work with
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Conclusion
- Exposure therapy is the most effective treatment of anxiety disorders
- Exposure is often combined with response prevention
- The principle looks deceptively simple, ‘just do it!’
- Design an effective exposure therapy is a very precise job
- Mind specific threat expectancies, design precise exercises, facilitate generalisation
