Exposure Therapy.pptx

7/30/2019 Exposure Therapy.pptx

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Exposure Therapy


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Exposure Therapy A variety of terms have been used to describe

prolonged exposure to anxiety- provoking stimuliwithout relaxation or other anxiety-reducingmethods, including flooding/ imaginal /in vivo/

prolonged/directed; in this chapter, theseare referred to collectively as exposure (EX). As in systematic desensitization, EX typically begins

with the development of an anxiety hierarchy. In some forms of EX (i.e., flooding), treatment

sessions are begun with exposure to the highest itemon the hierarchy; others begin with items rated asmoderately anxiety provoking.


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EX methods share the common feature of confrontation with frightening stimuli that

continues until the anxiety is reduced. By continuing to expose oneself to a frightening

stimulus, anxiety diminishes, leading to adecrease in escape and avoidance behavior thatwas maintained via negative reinforcement(Mowrer, 1960).

As noted earlier, a different conceptualization of

EX's mechanism of action with the introductionof emotional processing theory for anxietydisorders in general was offered by Foa andKozak (1986) and by Foa and Rothbaum (1998)for PTSD in particular.


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As noted earlier, there are several variants of EX. Inimaginal EX, clients confront their memories of thetraumatic event.

Some imaginal methods (see, e.g., Foa, Rothbaum,Riggs, & Murdock 1991; Foa et al., 1999) involveclients providing their own narrative by discussing

the trauma in detail in the present tense forprolonged periods of time (e.g., 45-60 minutes),with prompting by the therapist for omitted details.

Other forms of imaginal exposure (see, e.g.,Cooper & Clum, 1989; Keane, Fairbank, Caddell, &Zimering, 1989) have involved the therapistpresenting a scene to the client based oninformation gathered prior to the EX exercise.


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The duration and number of EX sessions hasalso varied, sometimes within the same study. These

details are provided in Table 4.1, which summarizesCBT treatment outcome studies for PTSD. Finally, most EX treatments do not consist solely of

exposure but include other components such as

psychoeducation or relaxation training. The treatments that combine such components

typically include vastly more time on Exposure thanon these other components, which are oftenpresented as preliminary ways of building up to theexposure.

Details on the implementation of EX for PTSD have

been provided in Foa and Rothbaum (1998).


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What Is Exposure Therapy?

Exposure therapy is a set of techniquesdesigned to help patients confront theirfeared objects, situations, memories, andimages (e.g., systematic desensitization,prolonged exposure, flooding).


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Theoretical Rationale for Exposure

Therapy

Combination of:

Classical conditioning (traumatic event), e.g., littleHans Instrumental conditioning

Memory of trauma is paired/conditioned to current,

unrelated events, e.g., crowds, restaurants, movies Engagement of avoidance activities to reduce anxiety Result is world starts to shrink


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Theoretical Rationale for Exposure Therapy(cont.)

Imaginal reexposure to memory of trauma insafe setting results indesensitization/habituation of conditionedassociations between traumatic memory andnegative emotions


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Two Exposure Models

Flooding (Keane) Prolonged Exposure or PE (Foa) Both Keane and Foa models use systematic repeated

imaginal exposure to memory of the trauma 1 time telling of trauma--NOT systematic exposure

therapy some desensitization can occur

Examples: Trauma processing (ind/group) EMDR


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Keanes Flooding Model

Once through in 60 min. session Therapist-guided Therapist asks questions on senses (seeing, hearing,

smelling, thinking, feeling) for each step in the trauma Therapist slows story down at worst points Repeated imaginal exposure in subsequent sessions Rating of SUDs (Subjective Units of Distress) on 100

point scale


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Foas Prolonged Exposure

Highly developed protocol Imaginal exposure In-vivo exposure

Prolonged (imaginal) exposure: 10-15 90 minute sessions, more as needed 60 min of repetitions in 1 st session, 45-30 in subsequent Patient instructed to describe event as many times within

allotted time Little or no therapist intervention Later sessions address hot spots Assess SUDS level (scale of 1 to 100) every 5 min.


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Foas Protocols

Prolonged (imaginal) exposure (cont.): Audio tape full session, with separate tape for exposure piece Pt listens to exposure tape daily Pt listens to session 1x Homework, homework, homework

In vivo exposure: Hierarchy of avoided situations listed Rate each on 100 point scale Select 2-3 at 40-60 level Face min of 3x, if not daily in week

Practice breathing exercise daily


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How to address with patients

Education, education, education Introduce as option in 1 st assessment Raise at option at end/beginning each group Use mantra the more you face it the easier it gets; the

more you avoid it, the worse it gets Teach theoretical rationale Always emphasize choice


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Indications:

Single trauma Recent trauma (


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Contraindications

No alcohol/substance use during treatment Recommend no anxiolytics or changes (stable

min. 1 mo.) Not during period of instability as best as

can not during recent loss, no current abuse(e.g., pt. living back at home)

Must be patients choice


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Variations

Traditional individual sessions

Group WSDTTmax. of 3 pts for 6 weeks Long distance monthly visits


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Therapist considerations

Countertransference If you decide to do it, get supervision Consider the message, if you back off

Debriefing after exposure work May experience nightmares

Use same strategies as pt Others?


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Limitations Of Exposure Therapy Some trauma survivors are reluctant to

confront trauma reminders and to tolerate thehigh anxiety and temporarily increased

symptoms that sometimes accompanyexposure.

Thus, not everyone may be a candidate for EX. There is some preliminary evidence that EX is

not effective for perpetrators of harm,especially patients in which guilt is the primary

emotion (Pitman et al., 1991) .


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There is also evidence that individuals whoseprimary emotional response is anger (Foa, Riggs,Massie, & Yarczower, 1995) may not profit asmuch from EX as individuals whose primaryemotional response is anxiety.

However, EX has received the strongest evidencefor PTSD and thus should be considered as thefirst line of treatment unless reasons exist for

ruling it out. Litz, Blake, Gerardi, and Keane (1990)and Foa and Rothbaum (1998) have discussedwhich patients are good candidates for EX.


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Exposure Therapy.pptx

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