Stimulus and Exposure Therapy--Final Project

Running Head: STIMULUS LEARNING & EXPOSURE THERAPY

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Stimulus Learning & Exposure Therapy: Christian Counselors Working with Client Trauma

Tamela M. McGhee

PSYC3500: Learning and Cognition

Unit 10 Final Project

Capella University

March, 2015


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Stimulus Learning & Exposure Therapy: Christian Counselors Working with Client Trauma

Introduction: A Brief Synopsis of Post Traumatic Stress Disorder

Post Traumatic Stress Disorder (PTSD) has risen in awareness over the past several

years, bringing those suffering with traumatic symptoms to urgent attention of clinical

psychology. An estimated 3.6 percent of adults in the United States (ages 18-54) incur PTSD

annually, with women being twice as likely to develop PTSD over their male counterparts

(Nebraska Dpt. of Veterans' Affairs, 2007). PTSD is not only limited to combat exposure, but

also encompasses instances of rape and sexual assault, childhood abuse and/or neglect,

molestation, and physical assault. Such experiences leaves individuals struggling with arousal

symptoms, which when triggered, can rob the ability to manage day-to-day life. Such symptoms

may include irritability, spontaneous angry outbursts, insomnia, impaired concentration, and a

constant sense of threat from one's environment. In severe instances, flashbacks may occur

which propels an individual into a state of experiencing the traumatic event once again.

Avoidance is a common defense mechanism, as acknowledging emotions, feelings, and recalling

events becomes a painful process. Memories may become buried in an effort to forget the

victimization. It is not uncommon for depression to emerge and addiction ensue as an attempt to

cope (Nebraska Dpt. of Veterans' Affairs, 2007).

Given the above information, this paper will examine the rising importance for Christian

counselors to gain credible knowledge in clinical techniques utilized in working with PTSD

clients. Desensitization techniques such as Exposure Therapy and habituation will be explored,

as well as how these techniques can be cross-applied with Biblical principles for those


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individuals seeking a faith-based therapy program. The applicability of this paper's concepts to

future professional goals will also be presented. A discussion summary will lastly be included

presenting further recommendations and final topic conclusions.

Problem Statement and Research Question: Clients May Seek Pastors Before Clinical

Therapists. Can Christian Counselors Properly Implement Clinical Techniques?

When people suffering with PTSD decide to seek help, clinical professionals are vital to

help individuals through a process of desensitization. One technique which may be chosen is that

of exposure therapy to desensitize the cognitive, emotional, and behavioral responses associated

with the traumatic event. However, it is not uncommon for people to first seek help and advice

through their pastors, priests, or rabbis before seeking clinical counseling. Given the fact that

faith-based counseling has gained recognition as the fifth force in mental health care, it is vital

that Christian counselors prepare themselves to incorporate faith-based and psychological

principles into their counseling services (Clinton & Sibcy, 2012).

With the above being said, there will be aspects of clinical counseling which Christian

counselors will need to be aware of, as well as tendencies within faith-based counseling which

will need to find balance when working with clients in need of a combined-therapy approach.

When clients approach a Christian counselor for help and support, there often times may be a

high level of transference present. Since a client may seek this counseling through their church of

choice, a sense of comfortableness and familiarity may already be established. It therefore may

be likely that the client will express many strong feelings of anger, hurt, and fear concerning

their current situation and condition. When this emotional transference occurs, Christian


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counselors must be able to identify this, and subsequently guide the client back to a perspective

of positive objectivity once again. Unless this is done, the counselor will only be listening to the

client's troubles, but not helping them to solve the underlying factors behind the issues (Miller,

2013). When working with clients with PTSD, understanding of clinical techniques will be

paramount to render a more well-rounded counseling service, which is congruent with multi-

modal treatment plans. However, Christian counselors may find themselves challenged to apply

basic clinical applications without losing sight of their own Biblical-based approach. Faith-based

counseling goes a step beyond identifying client needs and uncovering repressed trauma. They

believe that when the true self is revealed, it can then be changed and transformed. By utilizing

the Christian concepts of virtue--warmth, empathy, and genuineness--the Christian counselor

directs expressed feelings back to the client, prompting them to more deeply explore these

feelings for further healing and problem solving. It is during these times, when a counselor may

take the opportunity to incorporate spiritual guidance to bring healing and strength from the

Divine source, as opposed to allowing a client to rely on his/her own limited strength to manage

their condition (Miller, 2013). For this reason, Christian counselors will continually need to

identify and incorporate two different psychological strategies to effectively work alongside their

clinical professional counterparts.

Significance of Research Question: Why Faith-Based Counseling with Clinical Applications

Can Offer Optimal Healing for PTSD

A brief synopsis of PTSD was offered in the introduction of this paper, which highlighted

the pain and ongoing repercussions that can heavily linger for those who are victims of


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traumatic circumstances. A traumatic event can result in the formation of an orienting response.

This response, which is a form of stimulus learning, becomes automated in nature and carries

over into everyday life (Terry, 2009). When such a stimulus is negative in nature, individuals

come to lose their self-competency to function and manage their lives in a healthy, positive

manner. Everyday environments may seem threatening, and relationships can suffer at the hands

of depression, mood swings, and unexpected flashbacks in worse-case scenarios. Each time a

negative orienting response is experienced, habituation results, impacting an individual's mental,

emotional, and behavioral well-being by creating an unhealthy response pattern. When these

experiences reach a clinical level of concern, it becomes necessary to seek treatment that will re-

train an orienting response to one of positive reaction, as opposed to one which is fear-based. To

adequately re-train these responses, a technique must be utilized which simultaneously debunks

the three vital factors of cognition, emotions, and behaviors. Desensitization to the root behind

the negative orienting response can be performed through a clinical technique of exposure

therapy, such as systematic desensitization. Such a technique will require courage on the side of

the client, and gentleness on the side of the therapist. A client may be asked to re-count a

traumatic event throughout a day in an effort to diminish the fear reactions and thought processes

that typically accompany it. Exposure therapies are often times utilized with other forms of

therapy, such as Cognitive Behavioral Therapy (CBT), so as to round out a client's sense of self

confidence, control, and competence once again (Terry, 2009).

For those clients seeking a faith-based therapy, a Christian counselor may be chosen to

accompany clinical therapy. A trusted counselor can become an opportunity to further re-count

traumatic events, extending the benefits and practice of clinical therapy in a client's treatment


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plan. Christian counselors can also offer aspects of healing that clinical therapists may not have

the opportunity to address. For example, a PTSD victim may hold underlying aspects of guilt for

perceived sin or wrongdoing in their own involved aspect within a traumatic event. An

individual suffering from war trauma may also feel guilty if they took the life of another person.

A victim of child abuse may feel that they caused the abuse, or a victim of rape may feel a sense

of sexual impurity. These individuals may feel reluctant to talk of these feelings with a clinical

therapist, however may feel comfortable in addressing these with their spiritual counselor. These

feelings lend a great contribution to the three factors which need to be fully addressed for

exposure therapy to be successful. Christian counseling is also an ideal substitute for CBT, as

Christianity seeks to teach people how to think and behave differently through a relationship

with Jesus Christ. Unhealthy behaviors and thought patterns can be easily identified and re-

directed through Biblical scripture (Miller, 2013). A client may be reminded that God is a God of

a sound mind, and Jesus is the Prince of Peace. Though these are brief examples, helping to

alleviate guilt, giving additional opportunity to recount traumatic events, and planting positive

thoughts to replace the negative, can greatly enhance clinical techniques, and are an excellent

choice for combined treatment plans. For this reason, Christian counselors will consistently need

to be steeped in clinical applications so as to consciously incorporate related and cross-therapy

techniques into their counseling practice.

Report of Research Findings: Cross-Applications of Clinical and Christian Counseling

Techniques


6 Exposure therapy and desensitization techniques are still met with some

skepticism as to why they may be an effective treatment for PTSD, and to what extent that

success can be measured. There are some basic explanations which can initially be provided,

along with how these theoretical concepts can be applied in Christian counseling as well as

clinical settings. A theory frequently presented as foundational support for exposure therapy

effectiveness, is that of the Two-Factor Model. This model looks to the concept of classical

conditioning as the core behind the development of PTSD's. Fear is a strong emotion which can

come to condition an individual's response to environmental stimuli. When these fears are

continually experienced, a person may seek to escape this condition through an avoidance

process. This habit of escaping and avoiding fear stimuli can lend strength to fear-based

behaviors and emotions. To debunk this habitual fear process, exposure to a fear stimuli without

avoidance is a crucial component to successful desensitization (Tryon, 2005).

A second and vital aspect of working with PTSD is that of rebuilding self-efficacy in a

client. Being conditioned and governed by fears diminishes an individual's belief in their own

abilities to manage and overcome these fears so as to gain their life back once again. Since self-

efficacy becomes congruent with one's ability to effectively cope with their fears, fear reduction

becomes congruent with one's level of formed self-efficacy (Tryon, 2005). This cognitive-based

theory can be achieved through the process of a systematic desensitization technique. As a client

gradually confronts their fears, they simultaneously come to expect that they can overcome each

hurdle. Through each successful desensitization level, self-efficacy is steadily increased and

gains strength (Tryon, 2005). Clients come to "face their giant" with confidence, as opposed to

running from it and living in continual fear. By the conclusion of a successful treatment plan, a


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client should be ready and able to retain a sense of calmness in the face of a once-threatening

fear stimulus in their environments.

Cognitive restructuring and emotional processing may also be utilized to debunk fear

processes and increase measures of self-efficacy. Cognitive restructuring is based on the theory

that how one thinks effects how one behaves. When one comes to think differently about their

own fears, environments, and abilities to effectively manage these, their behavioral and

emotional reactions should change in tandem (Tryon, 2005). Targeting anxiety to restructure

cognitive processes is an integral key in cognitive restructuring. A therapist seeks to cultivate a

new understanding in their client, that situations which trigger their fears really are not as

dangerous or threatening as a client imagines them to be. When applied with systematic

desensitization, a client may come to see the validity in this concept, and come to approach their

fears with greater rationality (Tryon, 2005). Emotional processing targets memory-based

structures of fear by modifying thoughts, feelings, and actions associated with them. This is

achieved through habitually reactivating the network of fears (as opposed to avoiding and

escaping them). In so doing, correcting skewed and fear-based perceptions that are spilling over

into other areas of an individual's life, can aid in revising traumatic memories and keep them in a

proper frame of perspective (Tryon, 2005).

The above basic theories and techniques hold cognitive behavioral components which

Christian counselors can also implement with the proper training. Additionally, Biblical

principles can be incorporated to aid in a cognitive behavioral restructuring process, while giving

a client more opportunity to expose themselves to their own fears by discussing them in a safe


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and comfortable environment. With an expanded therapeutic support system, a client may be

able to more effectively cultivate their self-efficacy while living a happy and balanced life once

again. Though these theoretical techniques have offered a good foundation for working with

PTSD, more needs to be comprehensively explored.

Trauma Adaptive Recovery Group Education and Therapy (TARGET)

Trauma Adaptive Recovery Group Education and Therapy (TARGET) was devised to be

implemented as both a group and individual therapy technique. This technique seeks to educate

clients as to the biological and behavioral factors behind both PTSD and SUD (Substance Use

Disorders) which often times accompany individuals struggling with incurred trauma.

Additionally, clients are offered new emotional processing and self-regulation skills which can

be applied within everyday life and environmental circumstances. This type of therapy may last

anywhere from six months to several years, depending on client need, though this technique can

be structured into a 9-session format if necessary (Ford & Russo, 2006). TARGET seeks to

realign a clients hopes and core values with their healthy personal identities once again. Self-

identity in this case includes self-definition, self-esteem, and self-efficacy. The final goal is to

retrain a client to assess and cope with fear stimuli by preparing for stimulating events and

productively processing these traumatic reminders both internally and externally. Over time,

such fear-based stimuli should diminish in its ability to negatively impact current life situations

(Ford & Russo, 2006). TARGET forms its therapy around a sequence of seven skills called

"FREEDOM". A brief synopsis of FREEDOM is as follows:


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1. Focusing ("F"): focusing revolves around the acronym, SOS which means to slow

down (curb spontaneous reactions), orient (pay attention to the five senses, focusing on

healthy feelings and positive environmental factors), and self-check (conscientiously

monitor stress and perceived self-control). This step is designed to disrupt negative

reactivity and replace it with sound cognitive processing, and can be facilitated by the

client themselves as well as prompted by others around them (Ford & Russo, 2006).

2. Recognizing ("R"): this cultivates client ability to identify fear triggers

(internal/external).

3. Emotions ("E"): this brings client awareness to reactive emotions occurring during a

stimulus process.

4. Evaluations ("E"): this pertains to the cognitive aspects, and brings client awareness to

their thought process during a stimulus process.

5. Definitions ("D"): this refers to a client defining their personal, therapy-related goals.

6. Options ("O"): this is a list of options which the client forms to manage their

behavioral responses.

7. The letter "M" does not hold any meaning, but is added to form a positive acronym for

which to remember steps to manage and re-train fear-based response to trauma.

When a client is recounting a traumatic event or current experience that triggered a

negative reaction, a counselor can utilize the FREEDOM technique to effectively guide the client

through and re-focus their emotions and cognitions to a positive state once again. This allows the


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technique to serve a dual purpose both in and out of a clinical/counseling setting. The

FREEDOM technique is not designed to change traumatic memories from negative to positive,

but rather to enable clients to keep these memories in perspective and find balance in managing

these in everyday life circumstances. It also allows for a personalized one-on-one treatment plan

to be formed, while building a strong, trusting relationship between client and therapist. (Ford

and Russo, 2006).

Combining Attachment-Based Psychotherapy Tasks and Biblical Principles: SECURE

If there is to be success for the therapeutic collaboration of clinical psychologists and

Christian counselors in the future, Christian counselors will need to take their dual roles

seriously, and be prepared to combine psychotherapy theory and techniques with Biblical

principles. This should be designed to aid clients in garnering new ways to manage their

behaviors, how to better relate to others and their environments, as well as how to better

understand themselves through a strengthened relationship with God and Christ.

At least six attachment-based tasks in psychotherapy can also be founded in Biblical

principles. When combined, these can be therapeutically (and theoretically) applied to complex

disorders such as chronic depression and a range of trauma disorders (Clinton & Sibcy, 2012).

These reside under the acronym, "SECURE", and encompass the following:

1. Safety ("S"): safety refers to the nature of the client/therapist relationship, and that

this must mirror a secure-based system. This secure-based foundation should enable the

client to then gain knowledge and understanding that becomes applicable to others (and

life), while simultaneously cultivating a personal relationship with God.


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2. Education ("E"): education is designed to learn new skills through the use of

Dialectical Behavior Therapy. This therapy targets a "re-wiring" process of behavioral

underpinnings such as regulating emotions, increasing stress tolerance, relationships,

problem solving, controlling impulses, balance stimulus exposure/responses, and

developing personal mindfulness/awareness (Clinton & Sibcy, 2012). Meditation,

solitude, prayer, and fasting can also be introduced to a client at this time.

3. Containment ("C"): containment encompasses a counselors ability to effectively

manage negative and intense emotions which may arise when working with trauma

clients, while holding to the principles of maintaining a secure-based relationship that

continues to help the client in a positive manner.

4. Understanding ("U"): understanding refers to the interpersonal aspect of clients and

recounting their traumatic events, or continued stimulus challenges in everyday life.

Through this recounting process, a therapeutic goal should include the client's ability to

identify current patterns of thinking, feeling, and behaving to prior experiences. In so

doing, core schema and implicit memories should see a revision process. During this

time, Christian counselors can continue guiding their client through a Christ-centered

approach of redemption, hope, and restored balance (Clinton & Sibcy, 2012).

5. Restructuring ("R"): restructuring targets negative patterns of thinking, behaving, and

relating to others. By identifying these, a client can replace these destructive patterns with

ones more productive and adaptive. This can further aid in revising core schema, as well


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as debunking fear-based reactions through a desensitization process (Clinton & Sibcy,

2012).

6. Engaging ("E"): engaging combines two principle aspects of growth: support and

challenge. Psychotherapy tends to target emotional dysregulation and avoidance

strategies. Engaging offers a client the opportunity to find healing by feeling their

emotions in a secure-based environment. They further find support to take risks in trying

new coping strategies, expanding spiritually, connecting more deeply in their

interpersonal relationships, and sabotaging avoidance behaviors. This must be

implemented in a step-by-step fashion that increases in challenge as the client becomes

ready to embrace them, while continuing to balance all steps of the SECURE technique

(Clinton & Sibcy, 2012).

With the presentation of the SECURE technique, it becomes more apparent as to the

necessity and opportunities for future Christian counselors to seek specified training if they wish

to continue rising in partnering potential with clinical and other psychological disciplines in the

future.

Clinically Appraising Spirituality: Rapid Assessment Instruments for Christian Counselors

When considering combining a spiritual and clinical treatment approach, it is necessary

to touch base with assessment instruments available for both mental health and Christian

counselors. Rapid Assessment Instruments (RAI's) offer the opportunity to define what a

spiritual-based therapy uniquely means to each client. Such instruments are psychometrically

sound while proffered through a Christian worldview lens (Greggo & Lawrence, 2012). These


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assessment tools are additionally designed to measure a wide breadth of spirituality including

throughout one's lifespan, culturally/traditionally, and in relation to ethnic communities. It also

identifies client expectations as well as allows a client to lend their voice in forming the

parameters of their own faith-based treatment plan. The goal should be a treatment plan that

finds a mutual consent between client and therapists, uniting them in counseling understanding.

Many such assessment tools exist, and though not specifically addressed in this presentation,

some of these include: Religious Commitment Inventory-10 (RCOPE), Religious Support Scale,

Religious Problem-Solving Scale, Spiritual Experience Index (Revised), Revised Religious

Orientation Scale, Spiritual Well-Being Scale, Spiritual Transformation Inventory, and the Brief

Multidimensional Measure of Religiousness/Spirituality, to name a few (Greggo & Lawrence,

2012).

This brief section is presented as a reminder of the importance for Christian counselors to

properly assess their clients spiritually so as to fully align this aspect of therapy to its

psychometric counterpart. If this is not done, a client may become more frustrated with a

treatment plan, reconsider engaging in treatment in the future, and negatively impact their

spiritual relationship with God. All treatment plans should be customized and designed to

maximize healing for a client, while minimizing any potential and unintended harm.

Connection to Personal and Professional Goals: A Pause for Personal Reflection

The next step in my academic journey will lead me to embracing a Master's plan in

Christian Leadership and Ministry, with an emphasis on pastoral care and counseling. With a

Bachelor's in General Psychology coming to completion, I am approaching crossing the river to


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the other side of human counseling and care. I have come to secure a foundational base of

psychological principles, which has lent me greater understanding of human thinking and

behavioral processes. My educational journey has been one guided by the hand of God through

my personal relationship with Him. Now that I have been lead to my next step, it is time to begin

merging the two knowledge platforms into one which will enable me to most optimally serve

others in the future. With the research I have had the opportunity to acquire through this final

course project, it has been elating to see that much opportunity lies for the two platforms to work

very well in tandem. I feel that I am getting to see the dawning of this, and will be very fortunate

to be an active part of this new horizon. Just as I have sought to apply spiritual concepts to my

psychological foundation, I will also seek to apply psychological concepts to my upcoming

spiritual expansion as well. I believe that combining these concepts would enable any counselor

to offer their expanded care to all clients, whether it be in a secular or non-secular setting. Most

everyone holds some form of spirituality. With tools available to adequately assess this, a

counselor can work within these customized parameters, and build a strong relationship with a

well-rounded care plan for many potential clients. Counselors wishing to do this, may be

challenged to not inject their own faith-based beliefs into those of their clients. For those

counselors unable to do this, secular counseling may dictate professional choices in the future. It

is important to self-analyze this before offering care in a way that cannot be rendered properly.

With this being said, all faith-based counselors should consider clinical technique training to

enhance their future careers, and this fact brings me to my conclusion.

Discussion, Recommendations, and Conclusions: Teaching Trauma-Focused Exposure

Therapy for PTSD


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Although exposure therapy is one of the most validated techniques for treating PTSD, it

remains one of the least clinically utilized largely due to lack of experience and proper training

(Zoellner, 2011). Two forms of exposure therapy most utilized are Imaginal and In Vivo.

Imaginal therapy is performed in timed sessions (approximately 30-45 minutes), and offers

repeated and increased engagement in traumatic memories. Through verbal recounting, a client is

encouraged to engage in details while noting emotions, thoughts, and feelings which may emerge

in the process. Both client and therapist discuss the procedure afterwards, note progress, and note

patterns which may be surfacing and can be addressed at later times. The goal is to eventually

reach the more painful feelings and triggers, eventually diminishing the pain while developing a

proper current context for placing and coping with the reactive fears (Zoellner, 2011). In Vivo

therapy encourages a client to extend therapy techniques outside of the clinical setting and into

their everyday environments. They are prompted to approach situations (such as at work, in their

communities, or within interpersonal relationships) that cause distress, and begin developing the

self efficacy to effectively manage these aspects of life once again (Zoellner, 2011). The core of

both of these techniques is to bring clients out of avoidance, desensitize negative fear reactions,

and develop new coping strategies and thought patterns. Ultimately, a new belief system can be

formed (Zoellner, 2011).

While mastering such a therapy can challenge even the most capable licensed clinician,

these techniques can be learned, and skill cultivated over time. For those counselors and

therapists interested, there are resources available such as workshops, training seminars, training

manuals, and educational videos. Most importantly, clinicians willing to share their therapy

experiences with one another will learn the most in understanding client applications (Zoellner,


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2011). Many therapists hold a tentative nature concerning exposure therapy expectations. Some

common concerns include client anxiety and stress reaction, how engaged a counselor should be

during therapy, when to apply more direct focus on recounting traumatic memories and when not

to, when to guide and when to let the client guide themselves, as well as the challenges in

maintaining composure when hearing what may be graphic and painful sharing by PTSD clients

(Zoellner, 2011). Indeed exposure therapy is a true balancing act for the counselor. There is a

time to gently guide a client further past their comfort zones to help them strengthen, and there is

a time to not push these limitations. Emotional reactions on the side of clients is an inevitable

part of the healing process, and it is very much needed by PTSD victims. Just as grieving is a

healing process, so is recounting traumatic memories also a unique healing process as well. For

those counselors fully trained and desiring to help such clients, hearing painful memories will

not be disturbing, but rather an opportunity to help a person in pain heal and move forward in

their lives.

All of this being said, I hope and recommend that Exposure Therapy certifications

become an option in the future for all counselors to obtain. While this would not place Christian

counselors on equal professional par as licensed clinicians, it would enable them to extend

exposure therapy needs outside of the clinical setting and into another safe place for healing to

continually occur, guided by the heart of a counselor feeling a dedicated call to lend this service

to others. It will be vital if Christian counselors hope to gain the confidence in partnering with

clinical and other psychological professionals in the future!


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References

Clinton, T., & Sibcy, G. (2012). Christian counseling, interpersonal neurobiology, and the future.

Journal of Psychology and Theology, 40(2), 141-145. Retrieved from

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Ford, J. D., & Russo, E. (2006). Trauma-focused, present-centered, emotional self-regulation

approach to integrated treatment for posttraumatic stress and addiction: Trauma adaptive

recovery group education and therapy (TARGET). American Journal of Psychotherapy,

60(4), 335-55. Retrieved from


Greggo, S. P., & Lawrence, K. (2012). Clinical appraisal of spirituality: In search of rapid

assessment instruments (RAIs) for christian counseling. Journal of Psychology and

Christianity, 31(3), 253-266. Retrieved from


Miller, G. (2013). Crossing the border: pastoral theology and psychotherapy. The Expository

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Nebraska Department of Veterans' Affairs (2007). What is PTSD? Post Traumatic Stress

Disorder. Retrieved from: http://www.ptsd.ne.gov/what-is-ptsd.html

Terry, W.S. (2009). Learning & Memory (Fourth Edition). Boston, MA: Pearson Education, Inc.

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Documents

Stimulus and Exposure Therapy--Final Project