psychotherapy - exposure therapy for anxiety

when was exposure therapy developed?

in the 1950s

who developed exposure therapy?

Joseph Wolpe

why did Joseph Wolpe develop exposure therapy

he was dissatisfied with existing treatments for PTSD

what specifically did Joseph Wolpe develop?

systematic desensitization, reciprocal inhibition, Subjective Units of Distress Scale (SUDS)

how does a fear develop?

a neutral stimulus evokes fear response or trauma/bad experience

what maintains fear when it develops from a neutral stimulus evoking a fear response?

avoidance/safety behavior

what are the two ways fear develops from a trauma/bad experience?

generalize from the experience so that similar stimuli evoke fear and benign stimuli associated with the event evoke fear response

what is exposure therapy

set of therapeutic techniques used to teach clients to approach feared stimuli, may be paired with relaxation techniques and/or prevention of compulsions or safety behaviors

what are the goals of exposure therapy?

allow client to learn that fear response diminishes over time and help client learn corrective information about the feared stimulus

what are the mechanisms of change?

habituation, extinction, learning of corrective information, increased self-efficacy

how is habituation a mechanism of change?

over time, physical sensations associated with fear or anxiety naturally reduce

how is extinction a mechanism of change?

feared stimulus is no longer paired with escape/avoidance behavior, stimulus may be paired with relaxation so that new association is learned

how is learning of corrective information a mechanism of change?

over repeated trials, clients learn that feared outcome does not happen, or is very unlikely

how is increased self-efficacy a mechanism of change?

even if fear response is not completely extinguished, client learns that he/she can handle feelings

what are the types of exposure?

graded exposure, systematic desensitization, prolonged exposure, one-session

graded exposure

client slowly exposed to increasingly difficult stimuli

systematic desensitization

like graded exposure, but with the addition of relaxation techniques

what is the principle behind systematic desensitization?

can’t be relaxed and anxious at the same time

what is prolonged exposure designed to treat?

PTSD

prolonged exposure

repeated revisiting of traumatic event in great detail, exposure to stimuli that are reminders of the event but don’t pose a threat, facilitates emotional processing of event

one-session

one extended session (up to 3 hours), includes instruction, modeling, exposure, cognitive challenge

who is one-session exposure efficacious for?

shown in adult populations, some evidence for use in child/adolescent populations

what are the modes of delivery of exposure?

in vivo, imaginal, virtual reality, interoceptive, modeling

in vivo exposure

exposure to actual feared stimulus, or some approximation, sometimes requires creativity

imaginal exposure

client imagines feared stimulus when it isn’t feasible to do in vivo exposure

who is imaginal exposure used for?

frequently used for PTSD, GAD, phobias of uncommon stimuli

con of imaginal exposure

not all clients able to do this, need to have good visualization skills

virtual reality exposure

used when in vivo isn’t feasible

pro of virtual reality exposure

good alternative to imaginal for clients who have difficulty with visualization

con of virtual reality exposure

becoming more accessible, but still not widely used

interoceptive exposure

exposure to physical sensations, clients learn that symptoms are not dangerous

who is interoceptive exposure good for?

panic disorder or clients who find physical anxiety symptoms to be unacceptable

modeling

not primary intervention, used as adjunct, can help to ease client into exposure and shows client that feared outcome is unlikely/impossible

what were Caroline’s (Himle and Franklin, 2009) problem symptoms?

obsessions about causing harm to other through bad energy or illness, engages in several compulsions to reduce her anxiety

what therapy was chosen for Caroline?

exposure and response prevention (ERP) for OCD

what were the goals for Caroline’s therapy?

teach Caroline to face feared situations, prevent her from engaging in compulsions, work on her maladaptive thinking

what is done in the early sessions of Caroline’s therapy?

assessment of symptoms and interference, psychoeducation, provide rationale for exposure, introduce symptom monitoring and SUDS ratings, construct fear hierarchy, plan exposure exercises, prevention of rituals, build rapport

assessment of symptoms and interference

what symptoms are present and how are they interfering in client’s life?

psychoeducation

describe nature of OCD and explain how compulsions maintain anxiety

provide rationale for exposure

extinction: stop feeding obsessions by engaging in compulsions, describe empirical findings that support the use of exposure, can use example from client’s life

introduce symptom monitoring and SUDS ratings

shows the pattern of anxiety (triggers, thoughts, distress, responses)

how do you construct a fear hierarchy?

use SUDS ratings from monitoring to create hierarchy, start with moderately easy items (SUDS <30) but not too easy

what happens in middle sessions?

in-session exposure, homework, modifying as needed, periodically assess symptoms to track progress

in-session exposure

therapist-guided, prevention of compulsions, client asked for SUDS ratings throughout, don’t move on until client can complete exposure with little effort and without engaging in compulsions

homework

out-of-session exposure, continue symptom monitoring

why do homework?

helps with generalizability and self-efficacy

what are the keys to successful exposure?

manageable, refrain from compulsions, master one step before moving to next, repetition

what is the debate around when to do cognitive restructuring?

if done early, can help clients engage in therapy more readily, but some clients might use cognitive restructuring techniques to neutralize anxiety exposure, so some prefer to do it later

what happens in late sessions?

generalization/maintenance and relapse prevention

generalization/maintenance

want client to continue on their own after termination, have client develop additional hierarchies and response prevention strategies

relapse prevention

predict future challenges, come up with plans to address them, normal to have flare-ups, doesn’t mean progress is undone

advantages of exposure therapy

highly efficacious for various problems and relatively brief

how efficacious is ERP for OCD?

60-90% of individuals show a 50-80% reduction in symptoms, often superior to pharmacological treatment

how brief is exposure therapy?

typically under 15 sessions

disadvantages of exposure therapy

high dropout/refusal rate, some therapists also find it aversive, and barriers to treatment

potential barriers to exposure therapy treatment

noncompliance, subtle avoidance, family involvement, comorbidities