5a) Exposure therapies - Principles and Applications

Question 1

Define desensitisation (4)

Answer 1

• 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)

Question 2

Identify and describe types of desensitisation/ETs (3;2;1;4)

Answer 2

• 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

Question 3

Provide rationale for use of desensitisation (3)

Answer 3

• • Desensitisation is not something that just occurs in exposure therapy
    o E.g., living near busy road – become desensitised loud noises
• • 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.
• • Exposure is the most validated technique in psychotherapy (100s of studies).

Question 4

Provide rationale for use of desensitisation (3)

Answer 4

• • Desensitisation is not something that just occurs in exposure therapy
    o E.g., living near busy road – become desensitised loud noises
• • 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.
• • Exposure is the most validated technique in psychotherapy (100s of studies).

Question 5

Identify mechanisms of desensitisation (5)

Which one is the most popular?

Answer 5

• Reciprocal inhibition hypothesis
• The extinction hypothesis
• Habituation
• Neural toughening hypothesis
• Cognitive hypothesis, learned self efficacy

Habituation most popular

Question 6

Identify applications of desensitisation. (6; 4; 3; 2)

Answer 6

• 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

Question 7

When can’t desensitisation be applied?

Answer 7

When a situation is actually unsafe - can’t habituate if the situation is unsafe

Question 8

Which protocol is most common for exposure therapy and why? (3)

Answer 8

Habituation/extinction protocol is the most common
o Most empirical data to support it
o Across severity levels
o Across species

Question 9

Describe the habituation process. (4)
Draw out graph.

Answer 9

• 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

Question 10

Identify the 4 stages to exposure therapy.

There are 3 parts to the first stage.

Answer 10

• 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

Question 11

What psychoeducation is involved when preparing clients for ET? (4)

Answer 11

• 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)

Question 12

What is involved in motivation enhancement when preparing clients for ET? (3)

Answer 12

• 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

Question 13

How can you be persuasive about exposure therapy without making the person feel bullied into compliance? (4)

Answer 13

•  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)

Question 14

Why do we need to examine client’s attitude to exposure therapy?

Answer 14

• 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

Question 15

How should we go about contructing a hierarchy for ET? (4)

Answer 15

• 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.

Question 16

Identify some parameters in which discomfort can be varied? (6)

Answer 16

• 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

Question 17

Identify 5 considerations when conducting exposure therapies.

Answer 17

• 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

Question 18

What are the scientific principles of desensitisation? (10)

Answer 18

• 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.

Question 19

What does an assessment of motivation involve? (2)

Answer 19

• 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)

Question 20

How can we manage compliance? (4)

Answer 20

• 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

Question 21

How can we enhance motivation for ET? (5)

Answer 21

• 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

Question 22

How should positive feedback be used in exposure therapy? (4)

Answer 22

• 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

Question 23

Provide 3 reasons why we should supervise exposure programs from time to time

Answer 23

• Supervision used as assessment
• As therapeutic intervention
• Prevent excessive, abnormal behaviour

Question 24

What should we do once objectives of supervision are achieved?

Answer 24

• Phase out reassurance
• phase out supervision

Question 25

How can supervision of exposure programs be used as assessment? (3)

Answer 25

o When the interview yields inadequate or inconsistent data
 When details are unclear (many don’t know answers)
 To clarify inconsistencies (e.g., subjective vs. objective)
o Identify reasons for lack of progress
o To observe directly rituals, client’s reactions, coping and safety behaviours

Question 26

How can supervision of exposure programs be used as therapeutic interventions? (5)
What can replace supervision for some of these objectives?

Answer 26

• Supervision often reduces distress levels (exception anorexia) and makes compliance with exposure more likely
• Modeling appropriate behaviours (participant modeling; not passive modeling)
• Provide support to Ct. when most needs this
• Motivate patient participation.
• Enforce exposure (E&RP) to feared stimuli.

Note: Some of these objectives may be attained with supervision by supportive others

Question 27

In what ways can supervisions be used to prevent excessive, abnormal behaviour? (5)

Answer 27

• Monitor and decrease time spent in rituals.
• Disrupt sequences, mental rituals.
• Disrupt repetitions.
• Interrupt patient’s “absorption” in ritual.
• Prevent counting/checking (verbal, mental, tactile, visual).

Question 28

Identify common problems in ET (4)

Answer 28

• Worsening of symptoms
• Not progressing at the expected rate
• Drop outs
• Therapist as the problem

Question 29

Provide possible reasons for why symptoms can worsen during ET. (5)

Answer 29

• Anticipatory anxiety => worsening of symptoms, loss of morale.
   The higher the anticipatory anxiety, the worse the ET will be
• Exposure too brief?
• Exposure not graduated? => sensitization.
• Condition where intensity of exposure is difficult to control (Eg. social anxiety, OCD, PTSD).
• Presence of other psychopathology.
   E.g., avoidant personality disorder

Question 30

Provide potential solutions, if worsening of symptoms during ET is observed. (5)

Answer 30

• Cognitive therapy that targets the client’s expectations.
• Supervised exposure sessions for a while.
• Relaxation training.
• Postpone exposure.
• Introduce intermediate steps in the hierarchy - SUDs levels may be beyond what they can handle

Question 31

Provide possible reasons for why progress may not happening at the expected rate during ET. (7)

Answer 31

• principles of scientific exposure therapy not being followed.
• anxieties of therapist about using exposure therapy.
   E.g., PTSD – therapist’s fear of retraumatising the client
• Slow rates of habituation associated with co- morbidity (PD, depression, drugs/alc, etc.)
• unrealistic “expectations” of client/ therapist.
• over-reaction to bad days.
• problems with compliance or understanding of instructions.
• medication complications.
   Benzodiazepines – impacts habituation because they don’t experience anxiety

Question 32

Provide potential solutions, if ET not progressing at expected rate (4)

Answer 32

• Be realistic, set achievable goals
• Supervise exposure sessions
• Monitor exposure sessions
• Set milestones and celebrations

Question 33

Provide possible reasons for why drop outs occur during ET. (3)

Answer 33

• can’t cope with current intensity of exposure task or duration of program
• can’t bear to think about future exposure tasks
• lose faith in program/therapist

Question 34

Provide potential solutions for drop outs (4)

Answer 34

• Allow the client to opt out with “dignity”
• Maintain an open-door policy so that the client can rejoin when more motivated/can access additional resources
• Alternative treatments (medication, psychotherapy)
• combined treatment (medication & CT)

Question 35

Provide possible reasons for why therapist can be the probelm during ET. (3; 2; 2)

Answer 35

Therapist anxiety and discomfort
* Common with beginners
* Therapist anxiety can lead to poor relationship and increase client doubts
* Solution: supervision, desensitisation for therapist

Knowledge factors
* Principles of desensitisations are not followed
* inappropriate selection of problem/case to apply to (e.g., severe personality, drug and alcohol problems)

Deficiency in therapist skills to:
* Motivate client
* Address resistance

Question 36

What to consider when assigning ET as learning/discovery task? (3)

Answer 36

• Integral to the procedure regardless of which paradigm is being adopted
• Set SMART Task (specific, measurable, achievable, relevant and timely)
• Follow best-practice principles (Details in a separate class) of setting learning/discovery tasks

Question 37

Identify some other issues that might occur during ET. (6)

Answer 37

• use of distraction strategies and safety-cues
  o How effective, reliable and portable is this?
  o Usually good to achieve some control over distress
  o Phase out at a later stage
• should “escape” from situation be permitted? No?
• Panic attacks occurs during exposure
• use of medication
  o Possible interactions between benzodiazepines and exposure therapy - “toughening hypothesis”
  o Can use antidepressant medication, SSRIs
  o When to withdraw medication? before exposure programme or when client is okay?
• ethical issues
• possible contra-indications

Question 38

What to do if a panic attack happens during exposure? (10)

Answer 38

• Don’t panic
• Acknowledge distress
• Examine attributions and coping
• De-catastrophize
• Full vs. partial escape responses
• Effect of panic on subsequent sessions
   Organise a celebration when client returns for exp.
   Supervised session if necessary
• Challenge negative attitude affecting therapy.

Question 39

Identify some ethical issues concerning use of ET. (2; 1; 1; 3)

Answer 39

• Is this therapy forced on the client?
  o Does the client feel afraid to refuse this form of therapy on account of the reactions from therapist?
  o Have other options been discussed objectively?
• Confidentiality
  o Content of exposure therapy, especially if using loop tapes, etc.
• Special issues concerning supervision of exposure therapy.
• Duty of care to client
  o not to oneself or one’s profession at the cost of the client
  o has “personal distress” been factored in the cost-benefit analysis
  o are you happy to refer the client on to others, other professionals when appropriate

Question 40

What are some possible contra-indications for ET? (5)

Answer 40

• Psychotic conditions, even when anxiety is a predominant feature.
  o Avoidant PD, schizoid PD
  o Too unpredictable – habituation is quite poor
• Severe personality disorders, where anxiety is unpredictable, and habituation is very poor.
• Conditions where control over aggressive impulses might be difficult to predict.
• Where anxiety is not the predominant problem.
  o E.g., when depression is the main problem
• Anx conditions where desensitisation might not be indicated.
  o Conditions when there is a skill deficit.
  o When anxiety is general and non-specific? Although currently exposure programs are used to treat GAD
  o Poor motivation to commence or sustain a programme of DS.

Question 41

Summary (5)

Answer 41

• Exposure therapy is no longer on trial. There is overwhelming evidence that exposure therapy works
• Wide applications. Integral to treatment of anxiety disorders
• Quick results:
  o Achieving success with exposure programs for most anxiety disorders is fairly easy [Bread and butter stuff]
• Knowledge of principles are important
• Therapist skill to tackle client resistance is important