PSYC 408: Lecture 10

1950, Joseph Wolfe, PTSD, psychoanalysis, military, inhibition, pleasure, relaxation, relaxation, food, extinguished, subjective units, distress scale, SUDS, 0, 100,

History of Exposure therapy:

• developed in the ___s

• ___ ___: developed systematic desensitization after being dissatisfied with existing treatments for ___ which were mostly ___ based.

• Mostly worked with people in the ___.

• Reciprocal ___ → the experience of fear is incompatible with ___/___: pair exposure with ___ techniques

• Pair distressing things with ___: fear response was ___.

• Also developed ___ ___ of ___ ___ (aka ___) (___-___ scale to rate distress during exposure)

Conditioning, neutral, avoidance, escape, neutral, harmful, trauma, bad, generalize, response, benign, cars, location, stimulus

Overview of exposure therapy

How a fear develops → based on ___ principles

1. ___ stimulus evokes a fear response

• ___/___ behaviours maintains fear → because people dont get to learn the stimulus is ___/ not ___

2. ___/___ experience

• ___ from one specific instance so that similar stimuli come to evoke fear → generalization of the ___

• Ex: get bit by a god, come to fear all dogs

• ___ stimuli associated with the event begin to evoke fear response

• Ex: after ca accident, fear response to ___, ___ where accident happened, individuals who were present, etc. → generalization of the ___

Techniques, feared, conditioning, relaxation, systematic desensitization, prevention, compulsions, safety, OCD, diminishes, anxiety, corrective

What is exposure therapy ?

• set of therapeutic ___ used to teach clients to approach ___ stimuli.

• Undo the ___ processes

• May be paired with ___ techniques (such as ___ ___) and/or ___ of ___ or ___ behaviours (for ___)

Goals:

• allow client to learn that fear response ___ over time. Let them experience their ____

• Help client learn ___ info about the feared stimulus

Habituation, diminish, high, arousal, extinction, escape, avoidance, relaxation, association, compulsion, OCD

Mechanisms of change

1. ___: over time, physical sensations associated with fear o anxiety naturally reduce. Heart rate, sweating, mind racing all ___ over time. Can’t maintain such a ___ level of ___ for very long

2. ___: feared stimulus is not longer paired with ___/___ behaviour. Stimulus may be paired with ____ so that new ___ is learned.

• correct for people who always engage in a ___ (especially for ___) so no longer pair these 2 things in their mind

Corrective, happen, unlikely, cognitive expectations, self efficacy, handle, overwhelming

3. Learning of ___ info: over repeated trials, clients learn that feared outcome does not ___, or is very ___. Change in ___ ___!

4. Increased ___ ___: even if fear response is not completely extinguished, client learns that they can ___ feelings. It’s not too ___ anymore, not lead to a reall bad outcome

Graded, difficult, common, hierarchy, bottom, systematic desensitization, relaxation, relaxed, anxious, belly, chest, relaxation

Types of exposure

1. ___ exposure: client slowly exposed to increasingly ___ stimuli.

• ex: fear of heights: start on the 5th floor, move up to the rooftop

• Most ___ form of exposure

• Make up a ___: start at the ___ of the ladder, then move up

2. ___ ___: like graded exposure, but with the addition of ___ techniques

• cannot be ___ and ___ at the same time

• ___ breathing instead of ___ breathing

• Not everyone likes ___ techniques.

Prolonged, PTSD, revisiting, prolonged exposure therapy, PET, details, objects, situations, individuals, threat, emotional processing,

3. ___ exposure: designed to treat ___.

• repeated ___ of traumatic event (___ ___ ___ aka ___)

• Client recounts experience in great ___

• Exposure to ___/___/___ that are reminders of the trauma event, but that do not pose a ___

• Facilitates full ___ ___ of the event

• Revisit the event over and over again so that they dont experience the trauma response anymore

One session, phobias, instruction, modelling, exposure, cognitive, adults, child, adolescent, set up, hierarchy

4. ___ ___: up to 3 hours → for standard ___

• includes ___, ___ (the therapist does the exposure first), ___, ___ challenge

• Shown to be efficacious in ___ populations, some evidence supporting use in ___/___ populations.

• Need it to be well ___ ___ because move up the ___ quickly !

In vivo, creativity, imaginal, PTSD, GAD, future, phobias, visualization, recorded

Modes of delivery

1. ___ ___: exposure to actual feared stimulus, or some approximation.

• sometimes requires ___

• Ex: bee phobias: take dead bee to use in session

2. ___: client imagines feared stimulus when it isn’t possible to do in vivo exposure

• frequently used for ___, ___ (___ oriented: ex: getting in a car accident), ___ of uncommon stimulus

• Not all clients will be able to engage in this: need to have good ___ skills.

• Scripts are ___: more and more intense over time

Virtual reality, imaginal, visualization, accessible, interoceptive, panic disorder, anxiety, unacceptable, fear, dangerous, dissipate,

3. ___ ___: used when in vivo is not feasible

• good alternative to ___ for clients who have difficulty with ___

• Becoming more ___, but still not widely used

4. ___: exposure to physical sensations of anxiety

• especially useful for ___ ___ or for clients who find physical ___ symptoms to be ___.

• Fear of ___ → heart races for a random reason, scared something is wrong, gets worse, etc.

• Clients learn that symptoms are not ___ → the sensations will ___.

• Run in place, spin on chair to induce dizziness, etc.

Modelling, ease, impossible, unlikely, wouldn’t do, try out, experience, reasonable, fears

5. ___: not primary intervention: used as an adjunct

• can help to ___ client into the exposure

• Shows client that feared outcome is ___/___

• Shouldn’t ask client to do anything that you ___ ___!

• In fact, good idea to ___ ___ everything that clients will be doing to know what their ___ will be like.

• Hierarchy: go past the ___ to make sure it really sticks with the client. So should also be able to do it. Sometimes, therapist has to work on their own ___ too (because can’t demonstrate fear or anxiety)

Exposure, response prevention, causing harm, bad energy, illness, compulsions, feared, compulsions, maladaptive thinking, obsessions, compulsions, prevent, mental, assessment

Typical course of therapy: ___ and ___ ___ for OCD

Caroline (Himle and Franklin, 2009)

• obsessions about ___ ___ to others though “___ ___” or ___

• Engages in several ___ to reduce her anxiety

• Goals for therapy:

• Teach Caroline to face ___ situations

• Prevent her from engaging in ___

• Work on her ___ ___ (in relation to OCD sx)

Almost all kinds of OCD have pairing of ___ + ___: it is important to ___ the compulsion, even if a ___ one. Needs lots of ___ prior to discover all the Os and Cs

Symptoms, interference, obsessions, compulsions, interfering, time consuming, avoidance

Early sessions

Assessment of ___ (very high focus) and ___

• Caroline reports several ___ related to causing harm to others and ___ aimed at reducing the anxiety they cause

• Her symptoms are ___ with her daily life

• They are ___ ___

• ___ of people/situations

• Common for ppl with OCD to have multiple Os and Cs

Psychoeducation, vicious cycle, obsessions, figures, exposure, extinction, take time, more, empirical, useful, efficacious, life

Early sesssions

1. ___ : describe the nature of OCD (the ___ ___, etc.)

• explain how compulsions maintain ___ → can be presented using ___, etc.

2. Provide rationale for ___ → need to know why because already a hard treatment.

• ___: stop feeding obsessions by engaging in compulsions

• Improvement will ___ ___: will actually experience ___ distress in the short term (because no compulsions to rely on)

• Describe ___ findings that support the use of exposure → ERP has been shown to be very ___ and ___

• Can also use example from clients ___ (ex: going on a first date with husband)

Symptom monitoring, SUDS, pattern, SUDS, subjective units of distress scale, fear hierarchy, SUDS ratings, moderately easy, 30, easy

Early sessions

Introduce ___ ___ and ___ ratings

• shows ___ of anxiety triggers, thoughts, distress, responses)

• ___ = ___ ___ ___ ___ ___ (to monitor symptoms)

Construct ___ ___ → can take a while

• used ___ ___ from monitoring to create it

• Start with ___ ___ items (SUDS <___) but not too ___ !

Praying, vacuuming, beyond

Caroline’s compulsions were ___ and ___

• As for the hardest/ highest levels of the hierarchy: have to go over and ___ what ppl would normally do so that it really sticks

Exposure, prevention, rituals, one, obsession, compulsion, rapport, trust, comfortable

Early sessions

Plan ___ exercises, ___ of ___

• create ___ for each ___/___ (combination)

• Example: Caroline visits someone ill, shakes their hand, and does not engage in wiping, watching, cleaning or showering

Build ___

• exposure will be difficult: important for client to ___ the therapist and feel ___ with him/her

Exposure, therapist, compulsions, SUDS ratings, decreasing, graph, little effort, compulsions, repeat

Middle sessions

1. In session ___

• ___ guided

• Prevention of ___

• Client asked for ___ ___ throughout (wanna see that they are ___)

• Can ___ to have visual representation of progress

• Do not move up the hierarchy until the client can complete item with ___ ____ and without engaging in ___: need to ___ the steps multiple times

Homework, generalizability, self efficacy, symptom monitoring, manageable, compulsions, one step, repeated

Middle sessions

2. ___:

• out of session exposure (once able and comfortable doing it in sessions)

• Helps with ___ and ___ ___

• Continue ___ ___

Keys to successful exposure

• ___ (can do them)

• Refrain from ___

• Master ___ ___ before moving to the next

• ___ over time

Modify, symptoms, behaviours, reaction, fast, therapist, perfect, flexible, periodically, symptoms, self report measure, clinician

3. ___ as needed:

• adjust according to changes in ___, new ___, ___ to exposure exercises, etc. (Some ppl move too ___, etc.)

• Provides opportunity for client to practice being their own ___

• Hierarchy may not be___ from the beginning: be ___

• ___ assess overall ___ to track progress: not just day to day: use ___ ___ ___/___ administered measure to see how OCD sx decrease over time

Cognitive restructuring, behavioural, engage, readily, appealing, safe, neutralize anxiety, compulsions, complete

___ ___:

• typically, ERP is very ___

• debate about when to do it

• Can help clients ___ in therapy more ___

• Is more ___ (i.e.: subjectively ___) to clients

• But, some clients might use cognitive restricting techniques to ___ ___ during exposure (instead of not doing the ___): some therapists prefer to save until exposure is mostly ___

Generalization, maintenance, obsession, compulsion, own, termination, hierarchies, response prevention, relapse prevention, plans, future challenges, warning

Late sessions

___ /___:

• likely wont have time to go through every ___/___ in therapy, so important for client t continue on their ___ after ___

• Have client develop additional ___ and ___ ___ strategies

• Generalize learned skills to other O and Cs

___ ___: predict future challenges, come up with ___ to address them

• normal to have ___ ___: doesnt mean progress is undone

• Slips are normal. What are the ___ signs if need to recontact therapist

Efficacious, problems, 60, 90, 50, 80, pharmacological treatment, SSRI, brief, 15, cost

Advantages of exposure therapy

1. Highly ___ for various ___

• ex: OCD: ___-___% of individuals show a ___-___% reduction in symptoms

• Often superior to ___ ___ (___)

2. Relatively ___

• typically under ___ sessions (although some cases may require longer)

• Important consideration in terms of ___

Dropout, refusal, aversive, convince, aversive, barriers, noncompliance, avoidance, family, maintenance, rituals, comorbidities

Disadvantages of exposure therapy

1. High ___/___rate

• client find it ___

• Very hard to ___ ppl to do it

2. Some therapist also find it ___: hard to push client to do something they dont wanna do

3. Several potential ___ to treatment:

• ___ ___

• Subtle ___

• ___ involvement (can be key to the ___ of th problem: reinforce the ___)

• ___: best if straight OCD and nothing more