Topic 7: The Practice of CBT – Behavioral Exposure {by 4/5}

There is one reading due this week (Wright et al. – 1 Chapter).  For this discussion, share at least one main thought: (1) Why is behavioral exposure very effective for certain disorders/types of distress? What are some cautions to consider when implementing behavioral exposure interventions? Your original post should be posted by the beginning of class 4/5. Have your two replies posted no later than 4/7.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

23 Comments (+add yours?)

  1. Teresa DiTommaso
    Apr 04, 2018 @ 15:38:15

    The reason why behavioral exposure is very effective for specific disorders, such as anxiety disorders, is because it intentionally reverts or breaks the behavioral patterns that have developed as the core of the anxiety disorder. Anxiety disorders, in general, are acquired through conditioning of a stimulus which the individual fears. The process begins with an unconditioned stimulus, which is originally what incites fear in the individual (Wright, 2006). This fear, which was naturally triggered by the unconditioned stimulus, becomes the unconditioned response. So, at the beginning of this behavioral sequence, there is just an occurrence that scares the individual. However, this fear or anxiety turns into a disorder when the individual generalizes the fear onto other stimuli and those “associated reminders” become conditioned stimuli, which in turn, produce a conditioned response of fear and anxiety (Wright, 2006). It is this conditioned response that is at the heart of anxiety disorders. Therefore, because the process of developing an anxiety disorder is behavioral in nature, behavioral exposure is effective in relieving individuals of their anxiety. This works because behavioral exposure breaks the connection between the conditioned stimuli and the fear response that follows that stimuli (Wright, 2006). With repeated behavioral exposure to such fears, but with evidence provided that there is no reason to fear said stimuli, the link between the stimuli and response with be broken and the individual should no longer experience his or her generalized anxiety.
    Although behavioral exposure is a very useful tool for treating anxiety disorders, there are important factors the clinician needs to be aware of before engaging in such exposure. Before beginning behavioral exposure, the clinician needs to be aware of all possible avoidant behaviors the individual engages in in order to make sure that the behavioral exposure does not miss an important part of the client’s disordered behavior. Not only does evaluation within the client need to take place, but the clinician needs to be careful to examine the external environment in order to identify the full range of anxiety reinforcers (Wright, 2006). Of course, it is important to be aware of what and how much exposure your client can handle determined by where he or she is in treatment. In order to protect against setting the client up for failure, developing a hierarchy for graded exposure or starting with imaginal exposure can be a cautious first step towards in vivo exposure (Wright, 2006). All in all, there needs to be a safe, yet challenging environment and therapeutic relationship in which the clinician knows when to push the client towards different levels of behavior exposure and when to develop more skills before practicing for the first time.

    Reply

    • Stephanie Mourad
      Apr 07, 2018 @ 13:54:48

      Hi Teresa,
      I like that you mentioned that the clinician should take in the external environmental where the behavioral exposure is being taken place. A client can only take so much exposure, especially during the first trial, so I agree that the clinician and the client need to come up with an agreement as to how much exposure the client can handle. I think its important to come up with a safe word, so that the client knows when to take the cline out of the exposed environment and make sure the client is in a safe place.

      Reply

  2. Tori Bryant
    Apr 04, 2018 @ 16:28:09

    Behavioral exposure is effective, specifically for disorders revolving around anxiety, because it forces clients to address their avoidant, maladaptive behaviors in a direct, proactive manner. Those diagnosed with PTSD, OCD, panic disorder, agoraphobia, and specific phobia often develop coping mechanisms that help clients avoid aversive stimuli or remove the distress they feel quickly when they come into contact with the aversive stimuli. While avoidance is not always incredibly maladaptive, it is not a long-term solution to removing distress from clients’ lives. Behavioral exposure not only addresses avoidant behaviors, but it also provides clients with adaptive coping techniques for when they do feel the urge to perform a ritual, avoid traumatic memories, or avoid social situations as examples.
    Clients can utilize breathing retraining and relaxation techniques to calm their physiological reactions to the anxiety provoking stimulus. Anxiety is typically perpetuated by clients putting a great deal of emphasis on how their body is physically reacting to the conditioned stimulus; for example, they will notice their chest pounding, hands sweating, and shortness of breath and that will further their levels of anxiety and distress. Relaxing their muscles and deepening their breath with help clients regulate their physiological response to the anxiety they are feeling; thus, helping them react in an adaptive way without having to employ avoidance as they have in the past. When clients have mastered this skill, they can utilize it in real-time, readily, and naturally instead of having to plan ahead or not go somewhere due to fear of initiating an anxious response.
    There are many factors to take into considerations when contemplating behavioral exposure with clients. When implementing behavioral exposure techniques, it is crucial to know what clients can handle and where they are at in treatment. If a therapist does an in vivo exposure with his or her client who has an intense specific phobia of dogs immediately, the client will likely be further traumatized and turned off from treatment. It is important to understand clients as individuals; some will move through the steps of behavioral exposure quickly while others will need more preparation and a slower pace. Response prevention is important to go over before behavioral exposure so that clients do not immediately return to their avoidant tendencies; if a therapist feels like his or her client is not prepared to encounter the stimulus without reverting immediately to those maladaptive tendencies, perhaps more work needs to be done so that success is more likely to be achieved and the exposure is positively reinforcing. It is important that therapists have a very thorough and accurate understanding of clients’ triggers and disorders; otherwise, interventions could be unhelpful or even harmful to clients. For example, someone diagnosed with OCD may not want to implement the thought stopping technique because it could further perpetuate their need to fulfill their usual ritual. Therapists may want to consider clients’ environments and how those environments feed into their avoidance. It would be helpful if client and therapist could go over how the client’s environment plays into his or her avoidance and how he or she can move forward through those various obstacles before implementing their plan that they developed collaboratively.

    Reply

    • Aleksa Golloshi
      Apr 07, 2018 @ 13:12:58

      Hey Tori,

      I really enjoyed reading your thoughts on how, as a therapist, it is crucial to understand what a client is able to handle and at what stage they are at in treatment. A therapist should never push a client too far or ask more of them, because this will ruin the therapeutic relationship that has taken so much time and effort to construct. I also enjoyed how you stated that it is important to understand a client as an individual, and therefore each client will require a different pace and perhaps more preparation. This allows a therapist to tailor the sessions towards the client’s needs so that they can receive treatment in an efficient manner. I think it’s important that you stated a therapist should consider a client’s environment and how it affects their avoidance behaviors; I agree and believe it is vital to understand each aspect of a client’s life so that the therapist can be of better assistance.

      Reply

    • Lexie Ford-Clottey
      Apr 07, 2018 @ 19:17:34

      Hey Tori,
      I think it was important to focus a part of your post on the physiological reactions to anxiety provoking situations in order to highlight how these emotions/feelings can impact the daily lives of individuals. This made me realize that many activities such as going to the grocery store or entering a mall come with ease to many, while for others it can be quite debilitating and challenging. Because those who suffer from anxiety disorders often exhibit intense physiological symptoms to unpleasant situations it enables avoidant patterns of behavior. I agree that by practicing relaxation and breathing techniques individuals can allow themselves the opportunity to de-stress and assess the situation from a new perspective. By decreasing the occurrence of these unpleasant emotions these individuals can take control of their lives and no longer allow their fears dictate what they can do.

      Reply

  3. Matthew L
    Apr 05, 2018 @ 02:24:21

    Cognitive behavioral therapy (CBT) holds the idea that problems and distress come from negative automatic thoughts and more deeply rooted negative core beliefs. In some cases automatic thoughts can be trigger by certain reminders related to particular core beliefs. Such is the case with disorders like anxiety where a particular situation will pull negative automatic thoughts from core beliefs and cause distress. For anxiety and similar disorders CBT utilizes a therapeutic technique known as behavioral exposure. In short behavioral exposure is a technique that involves exposing a client to trigger stimuli to help ease their anxiety. The thought is that by exposing them to what was previously associated with negatives in controlled environments automatic thoughts can be tracked and handled and eventually core beliefs can be altered. But to explain behavioral exposure so simply misses a large part of what makes it so effective. From start to finish behavioral exposure heavily applies the concepts and theories of CBT to full effect in order to break down the source of distress. A client is not immediately thrown in to situations where they must face negative stimuli. Firstly a therapist works with the client to learn more about the particular distress trying to understands its source and make sure the client feels valid in their feelings when under distress. After the source is more properly understood a list is composed of all different kinds of triggers a client may have and to what degree they think they can handle them. After this comprehensive understanding is gathered. The client is walked through situations where they encounter these stimuli but only in their imagination and the safety of an office. Then the client is slowly introduced to the weaker triggers working their way up to larger ones. Behavioral exposure begins with gaining an understanding then leas into psychoeducation. After a client better understands their own distress they are given tasks to help change and alter their automatic thoughts. By tackling the problem slowly and over time behavioral exposure ensures its success.
    While it is incredibly effective behavioral exposure is not without its risks. There are several things a therapist must be cautious of when choosing to utilize this therapeutic tool. To start a therapist must be careful when discussing potential triggers. Some triggers may seem ridiculous and reacting poorly could damage the therapeutic relationship. A therapist must also be careful not to rush the client. Doing so will result in failure and serious distress for the client. Furthermore a therapist must be careful to set goals that are reasonable and attainable. If a therapist sets goals that are to difficult then a client bound to fail and the therapy will not be effective.

    Reply

    • Stephanie Mourad
      Apr 07, 2018 @ 13:59:21

      Hi Matt,
      I like that you mentioned that the therapist should not rush the client. I think as clinicians, we want to see the progress that our client makes but we also need to be aware that this will take time especially with behavioral exposure. Both the client and the clinical should be aware that there is a possibility that the client will experience symptoms int he beginning and may want to leave the experiment early. I also think that rushing the client could potentially harm them, especially when they are experiencing symptoms and this could cause the client to lose some trust in the clinician. When a client says that he or she wants to leave the experiment, it is important to listen to them and have them leave in order to protect them from potential harm. Client do not want to harm the trust and relationship with their clients by rushing or facing them to stay in a situation that they see harmful.

      Reply

  4. Aleksa Golloshi
    Apr 05, 2018 @ 10:10:05

    Behavioral exposure focuses on disconnecting the stimulus-response connection that has been formed with certain disorders and certain types of distress. The main goal of behavioral exposure is to approach the disorder in an active way, rather than avoiding it. This type of intervention allows the client to confront the reinforcement cycle that is causing this avoidance as they use cognitive restructuring and relaxation methods they’ve previously learned through therapy. Exposure has the opposite effect of avoidance because it is intentionally introducing a client to a stressful stimulus that he/she is likely fearful of. However, fear is generally present for a short period of time because a client cannot maintain this intense feeling forever. Fatigue might occur and in the absence of a new source of arousal the client will begin to adapt to his/her surroundings and will not feel fearful anymore. Methods such as the relaxation response and prompting the client to participate in exposure-based interventions can help the client uncouple a fearful response from a stressful stimulus. These methods reduce or shut down negative thoughts, which lower the client’s tension levels and help them reach a relaxed state. Helping a client develop these relaxation techniques, along with discussing their negative automatic thoughts will help the client prepare for exposure interventions.

    A few considerations should be kept in mind when implementing behavioral exposure interventions. Some clients could require one visit to alter a simple phobia while others need extensive, lengthy sessions when diagnosed with disorders such as OCD. Therefore, it is important to take into consideration the speed of exposure therapy as well as the client’s diagnosis. The presence/absence of comorbid conditions, the client’s strengths, and the client’s motivation should also be considered when implementing exposure interventions. Some client’s might have a personality disorder, along with an anxiety disorder, which could affect the intervention’s ability to work. The clinician should also recognize the client’s responses to beginning efforts of exposure protocols so that they have a better understanding of the client’s comfort levels. Some clients will understand exposure concepts quickly and motivate themselves to undertake challenges. Other clients might have more embedded difficulties that will need slow interventions that might need alterations as the sessions continue. Therapists need to ensure that they are not pushing their client beyond their limits and making them feel uncomfortable or cause them to be in distress. The therapist should challenge their client and inspire them to break patterns of avoidance so that the client can conquer their fears, but they need to be cautious as to not harm their client in the process.

    Reply

    • Sarah Mombourquette
      Apr 07, 2018 @ 12:45:33

      Hi Aleksa, I think that your point about approaching the disorder in an active way is really important to consider when discussing behavioral exposure. Being proactive can be very hard for an individual to originally attempt, so working on behavioral exposure with the therapist is very beneficial for helping to create patterns of action for the individual in the future. I also like that you discussed the importance of the limited amount of time fear will last for. I think this is one of the biggest benefits of behavioral exposure. When we consider various disorders, the anticipation of the emotional and physiological experiences is often the cause for avoidance. If the individual learns that this feeling does not last forever, it will make confronting the feared stimulus easier in the future. Lastly, I agree that a clinician should be sensitive to what the client’s limits are so as not to counteract the effects the clinician is trying to achieve.

      Reply

    • Abbey Lake
      Apr 07, 2018 @ 20:27:48

      Hi Aleksa,

      I enjoyed reading your post because I found the points you made to be right on target. I agree that behavioral exposure is all about disconnecting the stimulus-response connection that occurs with many different disorders. I think behavioral exposure is especially helpful with treating phobias and anxiety disorders. You mentioned the relaxation response method, which I found to be interesting because this type of method is particularly helpful in working with negative automatic thoughts, which may be particularly useful before exposing clients to behavioral exposure interventions. I think it is imperative that clinicians ensure that clients are ready for exposure interventions before conducting this sort of therapy because it is important to set the client up for success.

      Reply

    • Allexys Burbo
      Apr 07, 2018 @ 20:44:51

      Hey Aleksa,

      As you mentioned, the presence of comorbid diagnoses is an important aspect to consider when integrating behavioral exposure interventions into the therapeutic process. Since multiple diagnoses have to the potential to produce differential implications for therapy, awareness of the underlying mechanisms which might drive each presenting disorder will be important to consider. Additionally, as the disorder itself doesn’t provide an entire clinical picture, it will be equally imperative to consider each client’s individual characteristics. Assessing a client’s strengths will ultimately help drive the course of treatment and the introduction to certain behavioral exposure techniques – as one intervention might prove more appropriate in adhering to the individual strengths of a particular client. A client who perceives their own strengths as integral to the therapeutic process might find themselves motivated and willing to proceed through each phase. The client who interprets their role as imperative to positive therapeutic outcomes might find accomplishing seemingly uncomfortable tasks – such as the process of integrating behavioral exposure interventions – a more realistic and attainable pursuit.

      Reply

  5. Abbey Lake
    Apr 05, 2018 @ 12:35:20

    1.) Behavioral exposure is very effective for certain disorders and types of distress for many reasons. Behavioral exposure is particularly effective with anxiety disorders. The reason for this is that behavioral exposure works by having clients face their fears and anxieties by confronting them whereas in the past these clients may have avoided particular anxiety provoking or stress inducing situations. This type of maladaptive behavior may be very distressing for the individual and could be negatively impacting their day to day life. Behavioral exposure provides clients with coping skills for dealing with these particular situations both in the moment and long term. A client may be having negative automatic thoughts associated with a particular situation that they have been avoiding so behavioral exposure is also beneficial in the way it works to change these thoughts that are associated with the client’s anxiety or distress and make them more functional and realistic which leads to more adaptive behavior.
    2.)There are some cautions to consider when implementing behavioral exposure interventions. For example, in order to truly understand the full picture of what is causing and prolonging a client’s distress clinicians must be aware of each of the different avoidance behaviors that the client is partaking in, such as what safety behaviors a client may be using. This is important to be cautious of because safety behaviors may be misunderstood as progress and could be detrimental to more effective goals for the client as they may inhibit avoidance of the problem to some extent, which may even reinforce certain behaviors. Behavioral exposure may cause the client to experience a great deal of stress within the therapy in certain moments and it is therefore important to be mindful of how much exposure a client is ready for. It is important that a client succeeds during behavioral exposure because failure could have potential to reinforce certain behaviors and could also be traumatizing for the client. Therefore, setting a client up for success by accurately determining what they are prepared for and helping to prepare them through methods such as imaginal exposure is imperative for successful therapy. It is important to be mindful of the fact that each client is going to have their own unique pace when it comes to behavioral exposure and the clinician must be cautious to meet the client where they are at and not move too quickly through the process.

    Reply

    • Teresa DiTommaso
      Apr 07, 2018 @ 13:47:58

      Hi Abbey,

      One of the most important things for us to understand, especially in the beginning of our careers, is something you mentioned: that each client is going to have their own pace when it comes to behavioral exposure. Although this fact seems like an obvious one we should all know, I think there is a difference between knowing something on an academic basis and really engraining it into your clinical practice. It is easy to get caught up in the proper steps we need to take or all of the skills we are supposed to remember that I can definitely see the potential for losing track of the client’s individual needs when it comes to a particular technique. In school and training, you learn techniques through individual steps and in a linear way. I know that we are all capable of understanding that it is not always going to go the “textbook” way, but I also think it is easy to forget in the beginning. So, thanks Abbey.

      Reply

    • Lexie Ford-Clottey
      Apr 07, 2018 @ 17:34:03

      Hey Abbey,
      In your post I think it was important to mention the benefits of a clinician being able to view his/her clients as individuals when attempting to implement effective behavioral exposure techniques. As stated in your post, meeting a client where they are at shows the willingness of a therapist to understand and accept individual differences among their clients, in which it is not assumed that everyone starts therapy in the same spot with the same mindset. I think the best way to learn more about a client is through the therapeutic relationship, where the clinician can gain insight through the process of collaboration in deciding where to begin. I also agree that in order to provide successful treatment and realistic goals the clinician needs to know what his/her clients are comfortable with and capable of at that specific time. Although it may seem at times that progress is not being made, respecting client readiness to engage in such behaviors greatly impacts treatment outcomes for behavioral exposure.

      Reply

    • Allexys Burbo
      Apr 07, 2018 @ 20:18:25

      Hey Abbey,

      You make a great point in addressing the idea that safety behaviors have the potential to be misinterpreted as progress. Through psychoeducation, the goal is to help the client understand that although seemingly helpful their safety behaviors only provide temporary relief and may inhibit their potential to develop effective, long-term coping mechanisms. An accurate account of both the client’s willingness to participate and progress through behavioral exposure interventions will help reinforce positive, adaptive behaviors and help the client understand these as more valuable for long-term success. The clinician who is less responsive to setbacks in the therapeutic process is subject to placing their client at risk. It is essential that, above all else, the clinician is careful in setting their client up for success. Failure to project an accurate account of client progress may result in negative therapeutic outcomes. As you mentioned, client’s who interpret unsuccessful behavioral exposure exercises as failures may be subject to internalizing this experience. As a result, this may not only diminish the client’s sense of self-efficacy, it may also serve to reinforce the distorted cognitive associations and maladaptive behaviors adapted to protect them from experiencing distress in the past.

      Reply

  6. Stephanie Mourad
    Apr 05, 2018 @ 12:37:06

    Why is behavioral exposure very effective for certain disorders/types of distress?
    Patients with anxiety disorders report intense experiences of fear accompanied by physical stimulus of arousal when exposed to a threating stimulus. Symptoms can include panic attacks, quickened breathing, fast heart rate, sweating, clamminess, etc. The feared object or circumstance is the stimulus and the reaction to the anxiety elicited by the stimulus is the response. The original stimulus that frightened the person is called the unconditioned stimulus. The original fearful response to the unconditioned stimulus is called the unconditioned response. Stimulus generalization is used to describe the triggering of anxiety by these associated reminders. These reminders are called conditioned stimulus and the anxiety they elicit is called the conditioned response.
    Exposure uncouples the stimulus-response connection in a different way. As coping strategy, exposure has the opposite effects of avoidance. Fear is generally time limited during exposure because physiological arousal cannot be maintained at a heightened state indefinitely. Fatigue occurs, and in the absence of new sources of arousal, the person will begin to adapt to the situation. Cognitive structuring techniques such as thought stopping are commonly used to accomplish the process of uncoupling a fearful response from a stressful stimulus by facilitating the relation response and by promoting involvement in exposure-based interventions. The deliberate, conscious effort is made to replace fearful cognitions with more pleasant or calming thoughts, such as relaxing mental images.

    What are some cautions to consider when implementing behavioral exposure interventions?
    Cautions to consider are safety behaviors that a client may have. Safety behaviors are actions that may fall short of outright avoidance but still perpetuate the anxiety reaction. It is important to identify safety behaviors to prevent, reduce or escape/avoid perceived catastrophic events and associated distress. Some anxiety symptoms such as simple phobias can be treated in a single session with flooding therapy, most exposure therapies may require the systematic desensitization method. This procedure involves the development of a hierarchy of feared stimulus that is then used to organize a graded exposure protocol for overcoming anxiety a step at a time. Tips to develop this helping the patient write out a clear plan, rate steps for degree of difficulty or amount of expected anxiety, develop a hierarchy that has multiple steps of varying degree of difficulties and choosing steps collaboratively. Another caution to consider is proper coping methods. There is a chance that when conducting the exposure therapy, the client will experience symptoms of anxiety or a panic attack. I know this from experience because I have social anxiety disorder and I had gone through some exposure therapy. My exposure was to give a speech in front of a group of people who I’ve never met before. My worst-case scenario thought was that I was going to show symptoms, have a panic attack, and that the people in the crowd will notice what I am going through and I will possibly pass out. With the proper coping methods such as breathing exercises and relaxation techniques, I was able to complete my speech and I still had symptoms of anxiety such as feeling faint and sweating but with proper coping strategies, I was able to decrease some of those symptoms. So it is important for clinicians to review coping strategies and methods with their clients when conducting exposures.

    Reply

    • Teresa DiTommaso
      Apr 07, 2018 @ 13:41:04

      Hi Steph,

      I really think you made an important point in dividing exposure in two different ways. The way you described it really made it clear between the two different ways behavioral exposure works depending on the mechanism. By this, I mean how you explained the fatigue that occurs after the initial fear arousal. The recognition of this fatigue seems to put all of the conditioned responses and stimuli into easier terms to understand. This is also very applicable when trying to explain behavioral exposure to clients who are unfamiliar with the technique. In addition, it was nice to be reminded of the conscious efforts clients can use, such as relaxation techniques.

      Reply

    • Abbey Lake
      Apr 07, 2018 @ 20:38:42

      Hey Steph,
      I think that it is important how you mentioned in your post that behavioral exposure uncouples the stimulus-response in a different way and as a coping strategy exposure has the opposite effects of avoidance. Clients under a significant amount of distress are likely to avoid the things that are causing them distress because they may not have many other coping methods to help them deal with certain situations. Showing clients through behavioral exposure that they can successfully cope with what ever it is that may be causing them distress may make a world of difference to certain clients, such as clients with anxiety disorders or phobias. I enjoyed reading your personal experience with exposure giving a speech in front of strangers. I remember I took a public speaking course in high school and had a similar experience. Learning coping methods and actually practicing speeches in front of people helped me to gain confidence and eventually not be as anxious giving speeches. I strongly agree that it is important for clinicians to review coping strategies and methods with their clients when conducting exposures because if a client is able to use some of the coping strategies that they have learned they are more likely to successfully withstand the exposure.

      Reply

  7. Sarah Mombourquette
    Apr 05, 2018 @ 12:50:00

    Multiple disorders and kinds of distress are related to the connection between a stimulus and a response to the stimulus. When the response to a stimulus has been negative, it could lead to avoidance of the stimulus by the individual. Therefore, behavioral exposure can be effective because it actively works to disrupt the negative connection between the stimulus and the response. Therefore, behavioral exposure works oppositely from avoidance. When the individual is first reintroduced to the feared stimulus, he or she is likely to have the conditioned response (for example: fear). Although the individual is experiencing fear, behavioral exposure will show the individual that the fear is time limited. Therefore, the physiological arousal will not last forever. Eventually the individual will adapt to the stressful situation. As the individual is continuously exposed to the stimulus, his or her physical reaction will decrease. Ultimately, behavioral exposure techniques are so effective because they help the individual to “relearn” his or her physiological response to the stimulus. What was originally a response in the form of physiological arousal will (ideally) be transformed to a response of relaxation. The various forms of behavioral exposure techniques include graded exposure hierarchies, imaginal exposure, and in vivo exposure.
    Although behavioral exposure interventions can be very effective, there are also precautions to consider when engaging in the methods. For example, when facilitating in vivo exposure, the clinician should not always be with the client during the exposures. This is because the presence of the clinician is likely to make the client feel safer. While this is still a good first step, the most effective interventions will occur if the client is practicing in vivo exposure on his or her own because the therapist will not always be there; the client needs to learn how to face a feared stimulus independently. The clinician should also be cautious about the rate at which he or she implements exposure therapy. For example, the diagnosis should be considered because that could impact how severe the client’s reactions to the stimulus are. Similarly, the clinician should pay attention to other disorders that the client has been diagnosed with because it could be contributing to or interfere with the reaction to the stimulus. A clinician should also have an awareness of his or her client’s intelligence and resilience because this could impact how the client processes the exposure experience. Likewise, if a client lacks motivation, the clinician should consider this in developing the exposure process because it is likely to impact the independent in vivo exposure. Lastly, the clinician needs to pace the exposure process that does not go beyond the client’s capacity for change.

    Reply

    • Aleksa Golloshi
      Apr 07, 2018 @ 13:13:38

      Hi Sarah,

      I think it’s really important that you discussed a therapist should not always be with the client during exposure procedures, to ensure that the therapist is not acting as a safety blanket. I agree with you when you state this is a great first step so that the client has some confidence and does not feel alone while attempting the exposure. However, it won’t be beneficial for the client in the future if they’ve learned to rely on their therapist being present every time they practice a technique. I also enjoyed how you mentioned a therapist should be aware of their client’s motivation levels when developing the exposure process. A therapist should never make their client uncomfortable by asking them to partake in a technique that they are not ready for. Therapists need to be considerate of the client and ensure their well being through all types of exposure procedures.

      Reply

  8. Lexie Ford-Clottey
    Apr 05, 2018 @ 13:11:12

    Behavioral exposure is considered an effective technique for many anxiety disorders (e.g., panic disorder, OCD, phobias) because it focuses on confronting fears, alleviating distress, and strengthening coping strategies that foster adaptive behavior. More specifically, behavioral exposure is based on the belief that a client can break his/her avoidant patterns through direct exposure, in which being immersed in anxiety provoking situations serve a therapeutic purpose. With anxiety disorders, it is common for individuals to adopt patterns of avoidance in order to protect themselves from unwanted/uncomfortable emotions or feelings. By doing this, these individuals are creating a vicious cycle for this behavior to be reinforced, where gained emotional relief is viewed as a solution to the current problem. Although avoidance may establish boundaries and ensure safety for these clients, it only reduces fear and distress temporarily and does not change the behavior in the long run. With this said, behavioral exposure is useful in these situations because it encourages clients to address their avoidant behaviors in order to lead healthier lives and increase well-being. Repeated exposure is set to decrease the physiological response (e.g., sweating, shortness of breath) to the feared stimuli, with the long-term goal of helping people realize that the stimulus can be faced and managed. This shows that fear is time-limited and that physiological arousal does not last forever. Behavioral exposure also fosters positive coping techniques, where the use of breathing retraining and relaxation serve as effective ways to handle physiological arousal. Because anxiety impacts how someone feels physically it is important to maintain a state of mental and physical calmness. By practicing behaviors that involve releasing muscle tension and controlling breathing this aids in one’s ability to establish adaptive ways in how they respond to anxiety provoking situations. Essentially, behavioral exposure allows individuals the chance to regain control over their lives, in which avoidant behaviors are no longer dictating what they can do and where they can go.

    Although behavioral exposure is a useful technique in the treatment of anxiety disorders, clinicians should use caution when implementing these interventions to clients. One factor a clinician should take into consideration is the individual differences between his/her clients. When implementing such techniques the therapist needs to realize that not everyone learns at the same pace or is ready for the same types of interventions. This shows that where a client is at in therapy is very important because some individuals may require more time than others in feeling ready enough to confront such fears. By developing a hierarchy for graded exposure, the clinician is able to gain insight as to what situations/events are most troublesome to the client as well as the rated level of difficulty. By knowing what a client can handle is useful in deciding where to begin, in which starting with imaginal exposure and gradually working up to in vivo exposure is ideal for some clients. Essentially, the main goal is to meet the client where he/she is at and to not implement certain strategies that will set the individual up for failure. Another factor to consider is the therapeutic relationship, in which the therapist has to make sure that he/she is listening to the client and validating their feelings. If a client feels their therapist is not on the same page or is rushing progress these factors can threaten the therapeutic relationship, leading to termination of therapeutic services or less gains being made during sessions. When both the client and therapist work together in setting goals and establishing the necessary steps towards exposure, this facilitates a mutual understanding between both parties. Clinicians should also use caution when providing positive reinforcement to clients, in which certain types of praises for adaptive behavior can make the client feel they no longer need the therapist, which may not be true. Praising when necessary is effective for therapy but knowing when and how to incorporate such feedback is key.

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  9. Allexys Burbo
    Apr 05, 2018 @ 15:33:04

    Behavioral exposure interventions are often effective for anxiety related disorders because, although cognitively derived, they result in overt behavioral responses. Often, in an attempt to reduce the possibility of experiencing distress, the individual will implement coping techniques consistent with the deliberate avoidance of anxiety producing stimuli. While, on the surface, avoidance seems and effective/appropriate method for diminishing the occurrence of stress provoking encounters (as the individual experiences immediate relief in the absence of the fear producing stimulus), this type of response does not prove a successful long-term solution. The rationale behind implementing behavioral exposure interventions, in this instance, is that in encouraging the individual to confront the intentionally avoided anxiety/fear producing stimulus, he/she may develop the tools necessary for adopting adaptive coping strategies in their presence. By introducing behavioral exposure interventions to the treatment process the goal is that, in doing so, clients will learn to disassociate the fear inducing stimulus from the related distorted cognition (cognitive restructuring), in turn, altering the behavioral response.

    When implementing behavioral exposure interventions, it is important to consider possible barriers to successful outcomes. Although regarded as significantly effective, these techniques can also prove intimidating for the individual who experiences significant distress in the presence of their associated anxiety producing stimulus. If behavioral exposure techniques are not monitored – that is, the clinician is not careful in exercising their clinical judgment in evaluating the treatment process (i.e., exposure to new techniques) and the client’s [successful] progression through each phase – the client may perceive the process as too intense, too fast. It is imperative that clinicians are vigilant in assessing the needs of their clients throughout the treatment process (and during the introduction/implementation of new techniques). The client who feels confident in their ability to implement new tools and challenge cognitive distortions will be more likely to utilize exposure techniques outside of the therapeutic setting. The client who is apprehensive in confronting the very source of their fear related response (that is, the anxiety producing stimulus) may require more support, encouragement, and psychoeducation. It is essential, then, that the clinician is flexible in meeting the needs of their client and sensitive to their progression through each phase of the treatment process. In some instances, the emergence of an anxiety related disorder derives from the experience of a traumatic event. For the client who has experienced trauma as the source of his/her anxiety related behavioral response, it is important to be mindful that the behavioral exposure process might prove especially intense. Meeting the needs of the client is the primary concern throughout the treatment process. It is imperative that clinicians remain aware of the specific needs of the individual keeping in mind that, although effective in most cases, behavioral exposure interventions may not be appropriate in all instances of anxiety related disorders.

    Reply

    • Sarah Mombourquette
      Apr 07, 2018 @ 12:52:34

      Hi Allexys, I like that you emphasized the detrimental effects of avoidance. As you said, it can be seen as positive for the individual because he or she does not have to experience the negative emotions that result from the stimulus. However, you pointed out that the long-term effects of avoidance will result in more negative than positive outcomes. The positive outcomes that result from behavioral exposure will allow the individual to cope with the anxiety in the face of the feared stimulus in the future. I also think that your point about why a client might be apprehensive is very important. Instead of assuming that the client is not ready, a clinician should look at the reasons for why he or she is nervous about proceeding. These reasons, as you mentioned, could include something like psychoeducation because it might be that the client does not understand why or how the process of behavioral exposure works.

      Reply

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Adam M. Volungis, PhD, LMHC

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