5a) Exposure therapies - Principles and Applications Flashcards
Define desensitisation (4)
- Becoming comfortable with the uncomfortable
- therapeutic procedure used in behavioural therapy - subject is made to confront (exposed to) the feared stimulus or situation.
- commonly used to treat anxiety and phobic conditions.
- Mechanism through which Exposure therapy (procedure works)
Identify and describe types of desensitisation/ETs (3;2;1;4)
- In-vitiro (Imaginal)
o Graduated (Systematic Desensitization)
o Exposure to most feared situation (Implosion therapy)
o Exposure to feared images - In-vivo = in person
o Graduated
o Most-feared situation (Flooding therapy) - Interoceptive: exposure to feared sensations
o Feared bodily sensations e.g., high HR, tight chest - Eye-movement desensitization (EMDR; Francine Shapiro)
o exposure to threatening stimuli with rapid eye-movements
o initially controversial technique
o Empirically validated technique for PTSD
o Need specialised training
Provide rationale for use of desensitisation (3)
- Desensitisation is not something that just occurs in exposure therapy
o E.g., living near busy road – become desensitised loud noises
- Desensitisation is not something that just occurs in exposure therapy
- Response decrement with repeated exposure is a well documented phenomenon.
o In humans, demonstrable from “head to toe.”
o Is observed for different sensory receptors, multi-sensory phenomenon.
o In animal, bird, insects, plants.
- Response decrement with repeated exposure is a well documented phenomenon.
- Exposure is the most validated technique in psychotherapy (100s of studies).
Provide rationale for use of desensitisation (3)
- Desensitisation is not something that just occurs in exposure therapy
o E.g., living near busy road – become desensitised loud noises
- Desensitisation is not something that just occurs in exposure therapy
- Response decrement with repeated exposure is a well documented phenomenon.
o In humans, demonstrable from “head to toe.”
o Is observed for different sensory receptors, multi-sensory phenomenon.
o In animal, bird, insects, plants.
- Response decrement with repeated exposure is a well documented phenomenon.
- Exposure is the most validated technique in psychotherapy (100s of studies).
Identify mechanisms of desensitisation (5)
Which one is the most popular?
- Reciprocal inhibition hypothesis
- The extinction hypothesis
- Habituation
- Neural toughening hypothesis
- Cognitive hypothesis, learned self efficacy
Habituation most popular
Identify applications of desensitisation. (6; 4; 3; 2)
- Anxiety disorders: specific phobias, social Phobia, OCD, PTSD, panic and agoraphobia
- When clients wants to escape a fear as it targets avoidance behaviours
- Subclinical anxiety conditions: Test anxiety, Performance anxiety, Driving anxiety. Anxiety that is secondary to medical procedures.
chemotherapy induced side-effects in cancer.
distress induced by medical investigations (CT scans, dental extractions).
secondary to genuine medical conditions: asthma, emphysema. - Non-anxiety conditions: psychogenic vomiting, nightmares, other conditioned emotions (anger control, impulse control)
- preparation for war / high risk sports
When can’t desensitisation be applied?
When a situation is actually unsafe - can’t habituate if the situation is unsafe
Which protocol is most common for exposure therapy and why? (3)
Habituation/extinction protocol is the most common
o Most empirical data to support it
o Across severity levels
o Across species
Describe the habituation process. (4)
Draw out graph.
- If our bodies are in an anxious situation, our bodies can’t stay anxious forever = assuming there is nothing to realistically be afraid forever
- Without avoidance, anxiety plateaus and reduces naturally
- The more it happens, the lower the peak, the smaller the length of time
- Need to repetitively get clients to do it – only then can they become comfortable
Identify the 4 stages to exposure therapy.
There are 3 parts to the first stage.
- 1) Preparation phase:
o Psychoeducation
o Motivation enhancement
o Hierarchy construction - 2)Conducting Exposure Therapy
- 3) Consolidation and generalisation phase
- 4) Termination of Exposure Therapy
What psychoeducation is involved when preparing clients for ET? (4)
- Educate the client on what ET involves
- explain rationale for exposure - empirically validated, habituation
- Get a whiteboard out and draw out the habituation diagram
- Get them to identify a thing that they are no longer afraid of (e.g., driving on the motorway)
What is involved in motivation enhancement when preparing clients for ET? (3)
- Examine client’s attitude to exposure therapy
- Examine past experiences. Make sense of experience
o Why did the past experience of ET not work?
o Is it a client variable? Or a therapist variable? - Be persuasive about exposure therapy without making the person feel bullied into compliance
How can you be persuasive about exposure therapy without making the person feel bullied into compliance? (4)
- Point out differences between programs that do and don’t work
- Use information from patient’s experiences
- Use principles of attitutde change including cognitive dissonance
- Discuss habituation with examples (war, startle response)
Why do we need to examine client’s attitude to exposure therapy?
- If their GOAL is: not TO SUFFER NO ANXIETY DURING EXPOSURE
This is not the right attitude – client DOES need to have some anxiety for ET to work
ET does not work if the client does not feel anxious – you can’t habituate if you don’t feel anxious
Make them understand the concept of graded exposure
With ET, we ideally don’t want clients to be flooded
Want to start at lowest SUDs that will provide an anxiety experience within a tolerable level, and then make our way up - Most importantly – work with clients
- Need to have a goal in mind when you figure out the first step
o Differentiate between scientific vs. lay opinions about exposure therapy
o Some clients may be daunted vs. be excited
o Some clients have no experience doing structured exposure vs. some others may
How should we go about contructing a hierarchy for ET? (4)
- Items are graduated from low to high ratings of SUDS.
- We don’t exposure lists with too many tasks that it looks daunting - Item numbers range from 8-20
- Ideally break it down into smaller hierarchies
- Items are concrete, specific, real.
Identify some parameters in which discomfort can be varied? (6)
- time before event
- distance from event
- use of multiple sensory modalities
- use of fearful cognitions or fearful sensations
- time projection (now vs. in the past)
- varying measures of control accessible to the subject
Identify 5 considerations when conducting exposure therapies.
- A. Use scientific principles of desensitisation
- B. Manage compliance & maintain/enhance motivation
- C. Supervise exposure programs if necessary
- D. Address common problems in exposure therapy
o Client resistance (anxiety, anger, distrust)
o Other problems - E. Effective use of exposure tasks as homework
What are the scientific principles of desensitisation? (10)
- Prolonged exposure is better than brief exposure
o More exposure, better the outcome
o Because there is more opportunity for client’s anxiety to habituate
o Although the client’s capacity to tolerate exposure is a critical mediating factor - If exposure is very brief, repeat it several times, preferably within the same session
- Regularity: More regular, better outcome
o daily or several times weeks rather than once a week or month - In-vivo exposure is usually better than imaginal exposure (when both modalities are accessible and feasible)
- Graduated exposure is usually preferred to “Flooding therapies”
o Esp. when drop out rates are considered - Terminate exposure when anxiety is low rather than high (to counter appraisal of failure)
- Identify and phase out safety behaviours during the exposure program – informed by knowledge of mechanisms involved (e.g., conditioning/cognitive)
- Combination of in-vivo and imaginal exposure may be required in certain conditions
o esp in OCD when “covert” events including intrusive thoughts and images are the feared stimuli - In certain situations, exposure must be combined with response prevention to produce desired effects (e.g., OCD)
- Exposure must be tailored to fit the motivational status of clients.
What does an assessment of motivation involve? (2)
- Consideration of current motivational status and expectations
- Ability to maintenance motivation over the course of the exposure program (Ct. should not run out of steam before completion)
How can we manage compliance? (4)
- Use monitoring charts
- Use supportive others if applicable
- Supervise sessions from time to time
- Good therapeutic alliance will facilitate more open discussion of problems and therefore ensure better compliance
How can we enhance motivation for ET? (5)
- Expressing empathy: acknowledging distress, avoid arguments
- Use strategies of motivational interviewing
Developing discrepancies (desired goal & current state).
Foster hope - Support self-efficacy
- Deal with unhelpful expectations by:
Anticipating the fears at the top of the hierarchy
Normalise the fact that clients have good days and bad days – some days may be easier, some days may be harder
Prepare client’s for good and bad days - Use positive feedback
How should positive feedback be used in exposure therapy? (4)
- Be generous with positive feedback
- Organise milestones and celebrations
- Examine how positive feedback is received - identify patterns of ‘yes-but’ and challenge attributions
- Use social support - identify supportive vs. unsupportive persons
Negotiate effective, workable strategies to use supportive persons
Provide 3 reasons why we should supervise exposure programs from time to time
- Supervision used as assessment
- As therapeutic intervention
- Prevent excessive, abnormal behaviour
What should we do once objectives of supervision are achieved?
- Phase out reassurance
- phase out supervision