Exposure Therapy

Exposure Therapy
A variety of terms have been used to describe prolonged exposure to anxiety- provoking stimuli without relaxation or other anxiety-reducing methods, including flooding/ imaginal /in vivo/ prolonged/directed; in this chapter, these are referred to collectively as exposure (EX). As in systematic desensitization, EX typically begins with the development of an anxiety hierarchy. In some forms of EX (i.e., flooding), treatment sessions are begun with exposure to the highest item on the hierarchy; others begin with items rated as moderately anxiety provoking.

 EX methods share the common feature of confrontation with frightening stimuli that continues until the anxiety is reduced. By continuing to expose oneself to a frightening stimulus, anxiety diminishes, leading to a decrease in escape and avoidance behavior that was maintained via negative reinforcement (Mowrer, 1960). As noted earlier, a different conceptualization of EX's mechanism of action with the introduction of emotional processing theory for anxiety disorders in general was offered by Foa and Kozak (1986) and by Foa and Rothbaum (1998) for PTSD in particular.

 As noted earlier, there are several variants of EX. In imaginal EX, clients confront their memories of the traumatic event. Some imaginal methods (see, e.g., Foa, Rothbaum, Riggs, & Murdock 1991; Foa et al., 1999) involve clients providing their own narrative by discussing the trauma in detail in the present tense for prolonged periods of time (e.g., 45-60 minutes), with prompting by the therapist for omitted details. Other forms of imaginal exposure (see, e.g., Cooper & Clum, 1989; Keane, Fairbank, Caddell, & Zimering, 1989) have involved the therapist presenting a scene to the client based on information gathered prior to the EX exercise.

 The duration and number of EX sessions has also varied, sometimes within the same study. These details are provided in Table 4.1, which summarizes CBT treatment outcome studies for PTSD. Finally, most EX treatments do not consist solely of exposure but include other components such as psychoeducation or relaxation training. The treatments that combine such components typically include vastly more time on Exposure than on these other components, which are often presented as preliminary ways of building up to the exposure. Details on the implementation of EX for PTSD have been provided in Foa and Rothbaum (1998).

What Is Exposure Therapy?

Exposure therapy is a set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, prolonged exposure, flooding).

Theoretical Rationale for Exposure Therapy

Combination of:
Classical conditioning (traumatic event), e.g., little Hans Instrumental conditioning
Memory of trauma is paired/conditioned to current, unrelated events, e.g., crowds, restaurants, movies Engagement of avoidance activities to reduce anxiety Result is world starts to shrink

Theoretical Rationale for Exposure Therapy (cont.)

Imaginal reexposure to memory of trauma in safe setting results in desensitization/habituation of conditioned associations between traumatic memory and negative emotions

Two Exposure Models

Flooding (Keane) Prolonged Exposure or PE (Foa) Both Keane and Foa models use systematic repeated imaginal exposure to memory of the trauma 1 time telling of trauma--NOT systematic exposure therapysome desensitization can occur Examples:
Trauma processing (ind/group) EMDR

Keanes Flooding Model

Once through in 60 min. session Therapist-guided Therapist asks questions on senses (seeing, hearing, smelling, thinking, feeling) for each step in the trauma Therapist slows story down at worst points Repeated imaginal exposure in subsequent sessions Rating of SUDs (Subjective Units of Distress) on 100 point scale

Foas Prolonged Exposure

Highly developed protocol
Imaginal exposure In-vivo exposure

Prolonged (imaginal) exposure:

10-15 90 minute sessions, more as needed 60 min of repetitions in 1st session, 45-30 in subsequent Patient instructed to describe event as many times within allotted time Little or no therapist intervention Later sessions address hot spots Assess SUDS level (scale of 1 to 100) every 5 min.

Foas Protocols
Prolonged (imaginal) exposure (cont.):

Audio tape full session, with separate tape for exposure piece Pt listens to exposure tape daily Pt listens to session 1x Homework, homework, homework
Hierarchy of avoided situations listed Rate each on 100 point scale Select 2-3 at 40-60 level Face min of 3x, if not daily in week

In vivo exposure:

Practice breathing exercise daily

How to address with patients

Education, education, education
Introduce as option in 1st assessment Raise at option at end/beginning each group Use mantra the more you face it the easier it gets; the more you avoid it, the worse it gets

Teach theoretical rationale Always emphasize choice

Setting the Stagesafety nets

At home:
Inform family next 2 months will be rough Ask for support from family/friends ahead of time Find safe place in home to write

By therapist:
Tell pt AND be available for same day calls Give pt option of coming in for 2nd session in a week Give pt option of phone therapy session, even if brief

Indications:
Single trauma Recent trauma (<1 year) Multiple traumas
Select worstdecide this with the patient One that causes most current distress If all else equal, the 1st one in series Years of trauma (e.g., childhood sexual abuse)

Contraindications
No alcohol/substance use during treatment Recommend no anxiolytics or changes (stable min. 1 mo.) Not during period of instabilityas best as cannot during recent loss, no current abuse (e.g., pt. living back at home) Must be patients choice

Variations
Traditionalindividual sessions GroupWSDTTmax. of 3 pts for 6 weeks Long distancemonthly visits

Therapist considerations
Countertransference
If you decide to do it, get supervision Consider the message, if you back off

Debriefing after exposure work May experience nightmares Use same strategies as pt Others?

Limitations Of Exposure Therapy

Some trauma survivors are reluctant to confront trauma reminders and to tolerate the high anxiety and temporarily increased symptoms that sometimes accompany exposure. Thus, not everyone may be a candidate for EX. There is some preliminary evidence that EX is not effective for perpetrators of harm, especially patients in which guilt is the primary emotion (Pitman et al., 1991) .

 There is also evidence that individuals whose primary emotional response is anger (Foa, Riggs, Massie, & Yarczower, 1995) may not profit as much from EX as individuals whose primary emotional response is anxiety. However, EX has received the strongest evidence for PTSD and thus should be considered as the first line of treatment unless reasons exist for ruling it out. Litz, Blake, Gerardi, and Keane (1990) and Foa and Rothbaum (1998) have discussed which patients are good candidates for EX.

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