Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Systems of Psychotherapy: A Transtheoretical Analysis Chapter 8. Exposure

Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.

Systems of Psychotherapy:A Transtheoretical Analysis

Chapter 8.Exposure Therapies


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)


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


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


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


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


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


Effectiveness of Implosive Therapy

More effective than no treatment & placebo

Found effective with PTSD combat veterans

Comparable, if not superior, effectiveness with alternative psychotherapies


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



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


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


Theory of Therapeutic Processes

Clients given clear rationale for tx

Taught anxiety coping skills

Prolonged exposure

Given homework

Maintenance sessions as needed


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


Practicalities of Exposure Therapy

Similar to implosive therapy

8 – 12, 1 to 2 hour sessions

Homework assigned

Training widely available from behavior & cognitive therapists


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


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



Psychopathology occurs when information processing is blocked

Trauma is trapped or locked in the neurophysiology

Everyday stimuli trigger re-experience of traumatic event


Therapeutic Processes

Adaptive information processing (AIP) model

Counterconditioning via desensitization and cognitive restructuring

Consciousness raising & catharsis operate, but not as central mechanisms


Phases of EMDR

Client history

Preparation

Desensitization

Installation

Body scan

Closure


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”


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


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


Criticisms of Exposure Therapies

From a Behavioral Perspective

From a Psychoanalytic Perspective

From a Humanistic Perspective

From a Cultural Perspective

From an Integrative Perspective


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)


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


generalizationhabituationhypothesized avoidance

cuesimaginal exposureimplosive therapyinstallation phasein vivo exposurelooping

neurotic paradoxoperant/instrumental

conditioningpro bonoprolonged exposureresponse preventionsubjective units of

distress (SUD)

Key Terms (cont.)


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



Documents

Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Systems of Psychotherapy: A Transtheoretical Analysis Chapter 8. Exposure