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Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Systems of Psychotherapy:A Transtheoretical Analysis
Chapter 8.Exposure Therapies
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Exposure TherapiesDirectly confront feared stimuli & activate intense emotions
Particularly useful in tx of anxiety & trauma
3 exposure therapies in chapterImplosion (Stampl)
Exposure (Foa)
EMDR (Shapiro)
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
A Sketch of Thomas Stampfl
1923 -
Convinced that avoidance is at heart of psychopathology
Attempted to integrate psychoanalytic and behavioral therapy
First behavioral researcher to demonstrate efficacy of implosion
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Theory of Psychopathology
Symptoms that characterize pathology are learned avoidance responses
Avoidance reduces anxiety in short term, but produces more anxiety in long term
People learn to avoid not only anxious situations but also imagining those situations
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Theory of Therapeutic Processes
Goal: extinction (gradual dissipation of conditioned anxiety due to lack of reinforcement)
Client is asked to imagine in detail the anxiety-provoking situation
The anxiety-producing scene cannot be left until some extinction has occured
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Therapeutic Relationship
Relationship not needed if tapes or films can be used as anxiety-eliciting stimuli
Clients need to trust therapist to experience anxiety-eliciting stimuli long enough for extinction to occur
Empathy offered during evaluation to create effective implosive scenes, but not during implosion itself
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Practicalities of Implosive
Therapists extinguish their own anxiety about scenes to effectively present them to clients
3 to 30, individual sessions
Sessions run over typical 50 minutes
Precautions, such as sound proofing rooms, implemented
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Effectiveness of Implosive Therapy
More effective than no treatment & placebo
Found effective with PTSD combat veterans
Comparable, if not superior, effectiveness with alternative psychotherapies
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
A Sketch of Edna Foa
Born in Israel in 1937
Spent most of education & career in behavior therapy
Collaborated with colleagues in examining exposure therapy for anxiety disorders
Premier proponent of prolonged exposure
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Theory of Psychopathology
Anxiety is conditioned response controlled by two factors: respondent learning & operant learning
Conditioning accounts for acquisition and extinction of fear
Conceptualizes pathology in terms of both behavioral and emotional processing
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Prolonged Exposure
Intensive (direct & immediate exposure) vs. gradual (slow & incremental exposure)
Imaginal (imagining fear stimuli) vs. in vivo (actual place or tactile material)
Total vs. partial response prevention
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Theory of Therapeutic Processes
Clients given clear rationale for tx
Taught anxiety coping skills
Prolonged exposure
Given homework
Maintenance sessions as needed
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Therapeutic Relationship
Exposure therapist acts like an effective, firm parent
Clients trust of therapist allows them to stay in presence of feared stimuli
Therapist models confidence
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Practicalities of Exposure Therapy
Similar to implosive therapy
8 – 12, 1 to 2 hour sessions
Homework assigned
Training widely available from behavior & cognitive therapists
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Effectiveness of Exposure Therapy
Effective in treating PTSD, OCD, specific phobias, and social phobia
Small % of clients experience symptom exacerbation
Low relapse rates
Treatment of choice for many anxiety disorders
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
A Sketch of Francine Shapiro
Discovered deliberate eye movements made her thoughts less distressing
Founder of EMDR Institute & EMDR Humanitarian Assistance Program
Controversial for controlling early EMDR training
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Theory of Psychopathology
Psychopathology occurs when information processing is blocked
Trauma is trapped or locked in the neurophysiology
Everyday stimuli trigger re-experience of traumatic event
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Therapeutic Processes
Adaptive information processing (AIP) model
Counterconditioning via desensitization and cognitive restructuring
Consciousness raising & catharsis operate, but not as central mechanisms
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Phases of EMDR
Client history
Preparation
Desensitization
Installation
Body scan
Closure
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Theory of Therapeutic Relationship
Characterized by empathy, trust, & safety
Clinicians communicate respect for client courage, but not during active processing
Safe haven created through rapport, teaching relaxation, “stop signal”
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Practicalities of EMDR
Typically 4 to 6, 90-minute sessions
Two weekend workshops and supervised practice to acquire competence
Providing pro bono treatment and training in disaster areas
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Effectiveness of EMDR
Outperforms no treatment
As effective as other exposure methods
Listed as “probably efficacious” for civilian PTSD
Eye movements have not been proven necessary component
Remains controversial despite large research base
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Criticisms of Exposure Therapies
From a Behavioral Perspective
From a Psychoanalytic Perspective
From a Humanistic Perspective
From a Cultural Perspective
From an Integrative Perspective
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Future Directions
Implosive losing popularity
Exposure therapy on the rise for tx of intransigent anxiety-based disorders
Virtual reality exposure will gain popularity
Future of EMDR is not clear, but research will compare various processing methods (e.g., eye movements, hand taps)
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
cue exposure
desensitization phase
dynamic cues
emotional processing
exposure therapy
extinction
Eye Movement Desensitization & Reprocessing (EMDR)
adaptive information processing
avoidance conditioning/learning
avoidance repression (cognitive avoidance)
avoidance responsesbreathing retrainingclassical/respondent
conditioningcognitive interweave
Key Terms
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
generalizationhabituationhypothesized avoidance
cuesimaginal exposureimplosive therapyinstallation phasein vivo exposurelooping
neurotic paradoxoperant/instrumental
conditioningpro bonoprolonged exposureresponse preventionsubjective units of
distress (SUD)
Key Terms (cont.)
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Recommended WebsitesCenter for Anxiety and Related Disorders: www.bu.edu/anxiety/
Center for the Treatment and Study of Anxiety (Foa): www.med.upenn.edu/ctsa/
EMDR Institute: www.emdr.com/
Intern Society for Traumatic Stress Studies: www.istss.org/
Virtual Reality Exposure Therapy: www.cc.gatech.edu/gvu/virtual/Phobia/phobia
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.
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