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.
