BriefGraduated Exposure Therapy

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Brief/Graduated Exposure Therapy

• Systematic Desensitization and In Vivo Exposure
  Chapter Nine

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Exposure Therapies

• This is the name given to the techniques used to
  treat intense, irrational fears often referred to
  as phobias.
• Provides the client with the opportunity to
  experience events that they perceive to be unsafe
  in a controlled environment.

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Two Basic Models

• Brief/Graduated Exposure Therapy Here the
  client is exposed, for a brief period of time (
  few seconds to few minutes), to a perceived
  threatening thing or event. The exposure is
  brief and incremental.

• Prolonged/Intense Exposure Therapy The exposure
  to the threatening event or thing is for an
  extended period ( 10-15 minutes) with intense
  anxiety being experienced from the outset.

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Implementation can be

• In Vivo Where the client actually encounters the
  feared event or thing.

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• Imaginal Exposure Client forms a vivid mental
  image of the feared thing or event.

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Systematic Desensitization

• Basic Procedures

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Introduction

• The process of reducing phobias, fears and other
  strong aversive emotions which have been
  conditioned through association is referred to as
  systematic desensitization.
• Systematic desensitization replace anxiety with a
  different response, such as relaxation.

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Historical Perspective

• Andrew Salter treated a surgeon suffering from a
  fear of enclosed places (claustrophobia) in 1941.
  
• After 8 session the doctor was cured.
• This was the first documented use of this
  procedure.

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• At the same time, Joseph Wolpe was doing research
  with cats. This became the spring board for what
  we refer to today as systematic desensitization.
• His basic premise was based on the concept of
  Reciprocal Inhibition. That is to say, that you
  can not have two competing response occurring
  simultaneously.

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Alternative behaviors could be

• Deep muscle relaxation
• Assertive Actions
• Sexual Arousal

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Systematic desensitization involves a three step
process

• Learning a competing response (choice tends to be
  muscle relaxation)
• Building anxiety-stimulus hierarchies
• Visualizing the scenes in an ascending order
  while being experiencing the competing response

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Relaxation procedures

• As suggested the most often utilized competing
  response is relaxation
• Relaxation training can and is used as a
  therapeutic tool on its own.
• The assumption being that relaxed muscles equate
  to a reduction in the level of anxiety being
  experienced.
• Should note that there is no research to support
  this position!

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Relaxation Training

• A World Tour

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Three Categories

• Physical
• Unrestrictive Mental Exercises
• Restrict Mental Exercises

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Physical Approaches

• Isometric Squeeze Relaxation Edmund Jacobson
  published a set of relaxation exercises in the
  1930s. This technique involved the tensing and
  relaxing of the major muscle groups, which would
  take up to 200 hours to learn!
• Wolpe devised a shorten version which focus on
  the major muscle groups and take much less time
  to learn.

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• Yogaform Stretching In a sense, this is the
  opposite of the isometric squeeze technique.
  Instead of squeezing and letting go, the client
  slowly stretches and unstretches the muscles.
  Older clients seem to like this approach more
  than the isometric squeeze.

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• Integrative Breathing Developed in the East and
  West, this techniques focuses on helping the
  client learn to breath in a manner that is easy
  and relaxed, even and full.
• Quieting Reflex This is a packaged program
  often utilized with children. Combines breathing
  exercises with imagery as well as body awareness.

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Instant Better Feeling Maneuver

• A simple exercise that allows us to calm down
  quickly without even drawing attention to
  ourselves.
• Just like a fireplace, our bodies need oxygen to
  keep the flame going. With this exercise we
  take away the fuel and put out the fire.

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• Breath normally, and when you exhale now hold
  your breath while you count to yourself.
• Release the breath when it becomes uncomfortable.
  Repeat these steps several times within the
  space of 2-3 minutes.

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Unrestrictive Mental Approaches

• Somatic Focusing (Beginning) We entertain
  thoughts about relaxation by simply letting our
  mind dwell on words and images about relaxation,
  attending to the sensations associated with the
  bodys surface.
• Somatic Focusing (Advanced) Exercises found in
  yoga attend to deeper body sensations I.e. warm
  glow in your heart.

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Hypnosis More than a cheap lounge act!

• Direct and Indirect Approaches
• Traditional approach is direct in nature I.e.
  watch fob
• Indirect approach utilizes the clients
  resistance Milton Erickson.

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• Thematic Imagery Is entirely mental, and is
  found almost everywhere in the world. Most
  people find thematic imagery a easy and enjoyable
  approach.
• Can facilitate the production of images by tying
  in the five senses
• See yourself in the scene
• Hear the sounds of the scene
• Smell the odors of the scene
• Feel the sensations of the scene
• Taste the scene

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Restrictive Mental Approaches

• Contemplation You are asked to consider your
  good points, all the things that would make you
  feel content and accepting of yourself.
• MeditationCentered/Open Focus Simplest and most
  advanced form. Not as active as contemplation,
  doing nothing while attending to something simple.

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Medical note

• Research has demonstrated that meditation, twice
  daily for 20 minutes, has shown to lower your
  blood pressure substantially.

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Guidelines

• Learning relaxation is like learning any other
  skill start with the basics.
• Practice is important for the skill to be
  mastered. Should practice twice a day for 20
  minutes each session.
• Dont expect immediate results the effect will
  be gradual. There may even be a sense of
  uneasiness due to a life long heightened level of
  anxiety.

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Warning!

• If the exercise makes the client feel
  uncomfortable, first shorten the time and lessen
  the exertion. If it still causes pain,
  dizziness, etc. stop the exercise!

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The Client

• Make sure the client is in reasonably good health
• Seek medical permission if the client has one of
  the following
• Backaches
• Blackouts
• Diabetes
• Thyroid disorder
• Problems with bones, muscles, ligaments

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Professors note

• The preceding list is not all inclusive. If you
  have any doubts regarding the clients health
  status, have them get medical approval before
  starting.

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• If the client is taking medication, be sure
  he/she has medical approval.
• Relaxation will affect the metabolism rate,
  therefore, the dosage may need to be reduced.

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Who would benefit?

• As always, we need to establish some parameters
  for determining who would be a good candidate for
  this procedure.

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First

• Must determine how many fears/phobias the client
  is suffering from at the present time. This can
  be done by administering a formal fear survey.
• Client with 1-3 fears would be a good candidate.
  More than that would require a different approach.

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• Next, determine if the fear is a result of a
  skill deficit I.e. study skills.
• Determine if the clients arousability is not
  unusually high.
• Can the client produce mental images with the
  appropriate emotions needed. If not can consider
  in vivo or in vitro.

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• In Vivo Therapist presents actual fear stimuli.
  May not always be cost effective.

• In Vitro Therapist presents pictures, slides,
  recordings, video tapes etc.

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• Can deep muscle relaxation, or some practical
  alternative produce relaxation?
• Would the client benefit from cognitive
  restructuring?
• Finally, always offer a therapeutic rationale
  tell them why it works its as much about
  reeducation the client as anything else.

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Traditionally...

• This technique is utilized one on one with the
  therapist, with one to two one hour sessions per
  week. The client plays a passive role with this
  approach.
• Automated utilizes recorded sessions for
  relaxation and hierarchies.

• Massed sessions can be used where the
  client/therapist meet several times a week for
  one to three hours.
• Group sessions can also be used with a standard
  sequence of scenes.

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Anxiety-stimulus Hierarchies

• Systematic desensitization exposes a relaxed
  client to a graded series of imagined scenes
  relating to a specific fear.
• The client imagines themselves in a variety of
  aversive situations while remaining as relaxed as
  possible.
• Generally, this is done step by step. Starting at
  the lowest level of anxiety and gradually moving
  toward the most anxiety provoking scene.

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Several classes of hierarchies

• Those involving distance in time or space from
  the feared object or event. For example, fear of
  tall buildings.

• Those involving a specific theme the anxiety
  focuses around. For example, going to the
  dentist.

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Mixed hierarchies...

• Hierarchies often combine distance and theme
  oriented items. These types of hierarchies offer
  the most flexibility in showing the client
  different dimensions of the particular fear.

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Steps in constructing the hierarchy

• First step, have the client write down irrational
  fears and check for similarities (I.e. fear of
  crowds and public speaking). Can utilize 3 x 5
  cards.
• If there appears to be a group of fears may be
  the result of one large fear. Go with the one
  that is causing the most trouble now.
• Have the client describe the fear in as much
  detail as possible. Other side relaxing scene.

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• The more detail the easier to get them to see
  themselves in the scene.
• Have the client list all the fear producing
  scenes, with as much detail as possible.
• Rank them in order according to how much anxiety
  they produce.
• A good way to do this is to assign Subjective
  Units of Disturbance (SUDS) to each scene

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• In this technique give each scene a score value,
  ranging from 0 to 100 SUDS

Extreme arousal
No anxiety
100
0
SUDS SCALE
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• Afterwards, order the scenes from lowest to
  highest in accordance with their SUDS ranking.
• If the gap between scenes is to large, may not be
  able to move from scene to scene without
  experiencing anxiety.
• May need to add another scene to bridge the gap
• Dont want to have to many scenes or not enough,
  most often 10 to 30 scenes work well.

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• Finally, smooth out the hierarchy. There should
  be roughly the same difference between scenes in
  the hierarchy for best results.
• A good difference between scenes at the beginning
  is about 10 SUDS and about 5 SUDS at the end.

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Steps in Desensitization

• Step One Get the client completely relaxed.
• Step Two Starting with the first scene, have the
  client imagine the scene as clearly as possible
  for about 10 seconds. If they experience any
  anxiety, remove them from that scene and return
  to relaxation.
• Helpful Tip The client can signal if they are
  experiencing any anxiety by raising their index
  finger.

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• If no anxiety is experienced, you can move to the
  next scene, after spending at least two minutes
  relaxing, or however long it takes to gain a
  fully relaxed state.
• Each scene will be presented several times
  without any anxiety before moving to the next
  scene. Remember, the earliest scenes will move
  faster than the later ones.

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More helpful hints...

• Have client relax at least 20 minutes before each
  session.
• Start each session with the last successful scene
  completed
• Imagine each scene at least twice
• Stop session if client cant relax

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Possible problems...

• Secondary gain May not want to give up the
  problem if it results in a fair amount of reward
• Free floating anxiety anxiety that occurs
  regardless of whats going on in the environment.

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• Client cant relax Could use medication or
  another method for relaxation such as hypnosis.
• Problems in visualizing Other techniques such as
  in-vivo or on-vitro may be more applicable.