Topic 8a: Behavioral Exposure {by 3/26}

[Behavioral Exposure] – There is one reading due this week (Volungis – 1 Chapter).  (Judy Beck neglects behavioral exposure in her book.)  For this discussion, share at least two main thoughts: (1) Why is behavioral exposure very effective for certain disorders/types of distress?  (2) What are some cautions to consider when implementing behavioral exposure interventions?

 

[Behavioral Exposure] – Watch PDA-6: Behavioral Exposure – Assessment of Anxious Patterns.  Answer the following (you can be brief): (1) What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?  (2) What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

 

Your original post should be posted by 3/26.  Have your two replies posted no later than 3/28.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

38 Comments (+add yours?)

  1. Monica K Teeven
    Mar 22, 2020 @ 18:25:54

    Behavioral Exposure

    1.Behavioral exposure techniques are very effective for certain disorders such as agoraphobia, social phobia, post-traumatic stress disorder, obsessive-compulsive disorder, and panic disorders. Individuals who are diagnosed with one of these disorders experience negative automatic thoughts and have a higher level of physiological arousal when experiencing anxiety when they perceive a stressful situation. People who have one of these disorders tend to avoid situations that bring about anxiety and when people continue to do this, they learn that when they avoid those situations they are not in “danger”. This provides the individuals with a negative reinforcement because it offers them a sense of relief due to their level of anxiety lowering, which eventually leads them to exhibit avoidant behavior. This is because exposing individuals who have one of these disorders to a situation that causes them distress is the complete opposite of avoidant behavior. Over time, by using behavioral exposure, the clients will learn cognitively that whatever was causing them to experience anxiety is not a real threat. During this time, they also learn coping skills to help regulate possible distress at some point in the future.

    2. Even though exposure techniques will help break the avoidant behavior that a client exhibits, it is also important to identify negative automatic thoughts that are associated with the behavioral avoidance pattern. This is because sometimes negative automatic thoughts appear when a client is experiencing high levels of physiological arousal which is linked to their distress. These negative automatic thoughts are what frequently start and help strengthen the maladaptive behaviors. Being able to pinpoint a specific negative automatic thought will assist in choosing both which method of behavioral exposure and what tools should be employed when using this particular technique. Many of the techniques are often used used by individuals who have anxiety which causes them distress, but these techniques can also be used for individuals who have a hard time relaxing, lack good coping skills, and also lack good social skills.

    Behavioral Exposure-PDA-6

    1. The client’s primary negative automatic thought was that she cannot escape and how will she be able to get help if she has a heart attack.

    2. Her response was to leave the grocery store and go to her husband who was sitting in his car in the parking lot. When she sees her husband, she had a sense of relief because he knows how to help her when she is experiencing a panic attack. Her physiological symptoms began to decrease when she saw her husband, and continued to decrease on the ride home from the grocery store. After her physiological symptoms subsided, she felt silly because it should be easy to go to the grocery store and buy groceries. She cognitively understands that there is no real threat caused by going to the grocery store to buy food, but her physiological symptoms overpowered her adaptive cognitive thoughts.

    Reply

    • Jessica Costello
      Mar 24, 2020 @ 13:53:36

      Hi Monica! You did a great job summarizing how behavioral exposure works. As the client learns that the situation doesn’t pose any danger and develops coping skills, these skills can also be used later on in other areas of their lives. Ideally the client will practice them on their own outside of the behavioral exposures where the therapist accompanies them.

      You also mentioned how negative automatic thoughts can reinforce clients’ avoidance behaviors. This is an important connection to make as identifying their negative automatic thoughts can help both clients and clinicians conceptualize larger styles of thinking that could be holding the client back.

      Good job with your post!

      Reply

    • Melanie Sergel
      Mar 24, 2020 @ 14:04:58

      Hi Monica! Great job discussing how behavioral exposure techniques are effect in treating certain disorders. I like that you mention that during the time of using these techniques the client will learn and develop coping skills. These coping skills will be very useful to the client outside of therapy which is very important to clients who find themselves avoiding situation/events to ease their distress. I agree with you that it is important to consider negative automatic thoughts when using behavioral exposure techniques. You mentioned that this is important because sometimes these thoughts appear when the client is experiencing high levels of physiological arousal which is linked to their distress. That is important for the therapist to know of those thoughts because, like you said, it helps them understand their maladaptive behaviors better and will help the therapist know which type of technique would work best for that client. Great job!

      Reply

  2. Erin Wilbur
    Mar 23, 2020 @ 17:47:08

    Behavioral Exposure
    1. Behavioral exposure is effective for different disorders or types of distress because these individuals often develop maladaptive avoidance patterns to reduce their anxiety and fear, and behavioral exposure techniques help them to confront these patterns. Individuals with disorders like agoraphobia, OCD, panic disorder, PTSD, and social phobia experience anxiety, a cognitive process, and fear, a physiological process. These are typically caused by a situation that the individual perceives as stressful or threatening. In order to avoid the negative automatic thoughts and high physiological arousal that accompany the fear and anxiety, the individual avoids the situation. This then teaches them that they are “safe” from the threat because they have avoided it, and they do not learn how to cope with the distress they feel. Behavioral exposure forces the individual to confront the source of distress and learn coping techniques so that the situations that were threatening now don’t cause the same amount of distress.
    2. Some cautions to consider when implementing these behavioral exposure techniques are to first identify the negative automatic thoughts that may be driving the maladaptive behaviors. This can help the therapist and client to decide on which exposure technique will work best to combat the negative thought and behavior. It is also important to be aware that clients may be hesitant to try some of the techniques presented, like diaphragm breathing, because it seems ineffective or silly. The therapist should remember to explain how these techniques can be helpful and encourage the client to at least try them out.
    PDA-6
    1. The client’s primary negative automatic thought during the event was “I can’t escape” and wondering how she would get help if she were to have a heart attack. In response to the event, her negative automatic thought was “I failed” at going to the grocery store by herself.
    2. The client’s response to her associated automatic thoughts and physiological arousal were to tell herself that she wasn’t having a heart attack and that these were symptoms of a panic attack. When she didn’t feel like this was helping her and she continued to panic, she decided to leave the grocery store and go back to the car where she knew her husband was. She felt relieved when she saw her husband, and as they drove back home, she reported that her symptoms subsided and she felt silly for panicking, but also admitted that it was ambitious of her to try to go shopping alone.

    Reply

    • Shelby Piekarczyk
      Mar 24, 2020 @ 10:08:33

      Hi Erin,

      First I completely agree and feel the same that when beginning behavioral exposure techniques with a client they may be hesitant to begin. When the client has gone a long period of time avoiding and escaping their distress it becomes hard to want to confront this head on. Using behavioral exposure techniques the client will have to confront their distress and ultimately learn adaptive coping skills in place of avoiding. The therapist should be aware that this will be hard for most clients. It is also important to look at the negative automatic thoughts of the client when beginning behavioral exposure techniques. This allows the therapist to really understand where this avoidance is coming from and develop a plan of action that will be best suited to their client. Choosing which behavioral exposure technique is very important for future success of the client. Great job!

      Reply

    • Melanie Sergel
      Mar 24, 2020 @ 13:57:08

      Hi Erin! I agree that it is important to consider the negative automatic thoughts that are driving that maladaptive behavior. It is important to be aware of the client’s thoughts and feelings towards techniques because they may be hesitant, as you said. Everyone is different and I think it would be very helpful to evaluate how the client feels towards those techniques because the hesitation is going to differ among clients. It is important for the therapist to be aware of their clients’ hesitation also because it will help them understand the clients’ maladaptive behavior better. I also like that you touched upon the therapist encouraging the technique with their client because if the therapist does not encourage it then the client may think that it will never work. Great job!

      Reply

    • Taylor O'Rourke
      Mar 28, 2020 @ 20:55:40

      Hi Erin!

      I think you did a great job with explaining what behavioral exposure is, and the disorders that it works the best with for intervention. I like how you mentioned that disorders like social phobia and agoraphobia that are treated with exposure have both a cognitive and physiological component. Anxiety and fear definitely play a large role in why exposure works well with clients diagnosed with these disorders. In order to break the pattern of avoidance that people experience, therapists have to work with clients on both the cognitive and physiological symptoms to allow clients to get used to what it feels like and cope through it.

      Reply

  3. Monica K Teeven
    Mar 23, 2020 @ 18:40:47

    Hi Erin! I wanted to comment on your response to the second behavioral exposure question. What you mentioned about being aware that clients may be hesitant to try some of the relaxation techniques is wicked important, especially since whenever I read or hear about the diaphragm technique brought up, I cringe. I know that I should not feel this way towards this particular technique because it can really help some people. Yet, at the same time I am a bit glad that I do feel this way because I know exactly how some people feel when they hear that they should try some of these relaxation techniques. Therapists should tell clients that the likelihood that one of these techniques will help them is high. However, finding out which one will help the client the most is just by trying each technique out and seeing how well it goes for them. By giving the client options of what relaxation technique they first want to try first could help increase the client’s level of motivation of using these techniques because they had a say in which technique they wanted to try. Great job on your post Erin!

    Reply

  4. Robert Salvucci
    Mar 23, 2020 @ 20:47:04

    Behavior Exposure 1st Question Set

    1.Behavioral exposure provides clients with a sense of control, concrete goals, structure, and evidence that they are overcoming their anxieties. Control comes from the collaborative goal setting, and fulfillment of incrementally more difficult behavioral goals. The exposure schedule is also structured, which gives clients a sense of what to expect. The process involves psychoeducation regarding the maintenance of anxiety and the associated physiological and cognitive components. When clients see themselves performing these goals, they have evidence that the behaviors or events aren’t threatening, and their subconscious anxiety processes also become more adapted to these behaviors and scenarios, which results in less initial physical symptoms. Techniques like deep breathing and muscle relaxation offer emotional coping skills that can be used in many settings. They physically calm the symptoms of anxiety and give clients a sense of control as well.

    2.Caution should be taken not to initially overwhelm clients with too many or too difficult goals. This can increase the likelihood that they resort even further into safety behaviors, doubt the effectiveness of behavioral exposure, or damage the therapeutic relationship. The client and therapist should also work together to identify common situations and associated thoughts that trigger anxiety or panic. This can help identify where and when these techniques will be most beneficial.

    Behavior Exposure 2nd Question Set

    1. Her negative automatic thoughts were things like “I’m losing control”, “I needed to get out”, “I can’t escape”, “I’m going to have a heart attack”.

    2.These thoughts arose following symptoms of anxiety – tightness in chest, feeling of being warm, sweating, etc.. Her response was to leave her cart, run out of the store and to her car. She noted that her husband gave her a sense of relief, and they decided to go home. She started to feel the symptoms dissipate by the time they were home. She also noted that she felt a sense of failure knowing she couldn’t do something “as simple” as going to the grocery store.

    Reply

    • Shelby Piekarczyk
      Mar 24, 2020 @ 10:13:29

      Hi Bobby,

      When discussing behavioral exposure techniques I like how you stated that this allows the clients to have a sense of control, concrete goals and structure. I think this is a great way to put it because although it might be scary for the client to begin this therapy, it is also important for them to see that this will really benefit them for the future. Giving them a sense of control and concrete goals of where these behavioral exposure techniques will take them will ultimately help lead them to wanting to continue this therapy. I also like how you talked about psychoeducation, I also agree that this is a very important aspect of behavioral exposure. Helping the client to understand exactly what each technique is and how this will benefit them is a very important part of therapy. Lastly, when talking about what to be cautious of you wrote that the therapist should not give their client too much or overwhelm them. I think this a great point to consider because if you overwhelm your client they may be hesitant to trust you or overwhelmed by the amount of work that needs to be done. Great job!

      Reply

    • Jessica Costello
      Mar 24, 2020 @ 13:27:31

      Hi Bobby! Great job with your explanation of behavioral exposure. You mentioned how the exposure schedule is structured so clients can know when to expect completing the next increasingly difficult task on their hierarchy. Having this knowledge would probably reduce anxiety. You also pointed out the importance of psychoeducation so clients could begin to understand the cognitive and physiological processes that control their own reactions to the situation.

      I also liked how you pointed out the client’s sense of failure in the video when she couldn’t complete her grocery shopping. She felt better when she left and saw her husband, but this was also an example of her engaging in safety behaviors that impeded her from progressing with the exposure. Good work with your post!

      Reply

    • Erin Wilbur
      Mar 28, 2020 @ 15:56:09

      Hi Bobby,
      You make a really good point about not wanting to overwhelm the client with too many goals or goals that seem impossible to reach. That would definitely scare away a client who is already apprehensive about behavioral exposure. I hadn’t thought of this point when brainstorming cautions to take when conducting behavioral exposure. Overwhelming the client can also damage the therapeutic alliance and the rapport that had been built in previous sessions, so it’s very important that we discuss our client’s abilities and limits before setting goals that will take them out of their comfort zones.

      Reply

    • Taylor O'Rourke
      Mar 28, 2020 @ 21:25:37

      Hi Bobby!

      I really like how you mentioned that behavioral exposure provides clients with structure and concrete goals for changing their behaviors. I think this is a great way to put it, and may be an even better way to pitch the idea to clients to get them more engaged in the process. Because this process is so collaborative, it also gives clients a shoulder to lean on with their therapist who can also help to keep pushing them through these challenges. It is also a great way to track their progress through the fear hierarchy, as you mentioned, because they are always attempting to take the next step.

      Reply

  5. Shelby Piekarczyk
    Mar 24, 2020 @ 10:04:40

    1. Behavioral exposure is very effective for certain disorders and types of distress such as anxiety, agoraphobia, obsessive-compulsive disorder, panic disorders, post traumatic stress disorder, and social phobia. When an individual is experiencing anxiety symptoms, they tend to have negative automatic thoughts, leading to the avoidance of specific situations. When they avoid these situations, they are ultimately avoiding their point of distress (cognitively and/or behaviorally). When the individual chooses to avoid these specific situations, they develop this as a coping mechanism and ultimately feel safe from the distress that they were feeling. Because of this the individual gets short-term relief from the distress. However, when avoiding the situation and escaping the distress the individual is developing maladaptive coping mechanisms; harming their long-term skills to handle the stressful situation when it arises by never developing adaptive skills. When using behavioral exposure techniques it forces the individual to deal with this distress and learn/develop coping skills to adaptively handle the situation.

    2. When beginning to use behavioral exposure techniques the therapist should first be aware that the client might be hesitant to begin. Since the client has avoided the situation for a long time and has felt ‘safe’ with this coping skill, challenging this behavior may be difficult. Additionally, it is important to identify the negative automatic thoughts that accompany the individual’s distress. By doing this the therapist will learn what is driving the client’s maladaptive behaviors and what steps to take next. Knowing the negative automatic thought will also help the therapist determine which behavioral exposure technique would be best suited for the client.

    PDA-6
    1. The client’s primary negative automatic thought about the event was that she could not escape and feeling that she would not be able to get help if she were to have a heart attack. Because of this the client felt that she had failed because she was unable to go to the grocery store by herself.

    2. These thoughts began after she started developing symptoms of anxiety. She also stated that she continued to tell herself that she was not having a heart attack, rather she was just experiencing symptoms of a panic attack. Her response to these sensations was to leave the store immediately and go to her husband who was waiting in the car, where she knew she was safe. On their drive home she notices the symptoms began to diminish. She stated that she felt silly for not being able to go to the grocery store alone. In the client situation she knew she shouldn’t be so worried to go to the grocery store but her physiological symptoms became too strong for her to handle.

    Reply

    • Madison Armstrong
      Mar 28, 2020 @ 20:21:48

      Hi Shelby,
      I also think that it’s important to recognize that the client may be hesitant to begin. Its important to be aware of these concerns and make sure that your client is comfortable before trying exposure techniques. One way this could be done is through graded exposure, where the client rates situations in which they are least fearful to most fearful. This would help the client become prepared for the direct exposure of the most fearsome situation.

      Reply

  6. Jessica Costello
    Mar 24, 2020 @ 11:54:49

    Behavioral Exposure
    1. Behavioral exposure is effective for clients who have developed avoidant behavior patterns towards places, people, events, or situations that cause them fear and distress. It is particularly useful for clients with panic disorder, PTSD, OCD, and other anxiety-related disorders.

    By not facing the distressing things, clients are able to relax and feel safe in the moment. However, this avoidance amplifies their long-term distress because they never learn how to cope with the negative thoughts and emotions that the stimulus they avoid would cause. Behavioral exposure breaks this maladaptive pattern by first teaching the client relaxation techniques that they can use when they become distressed and then giving them a safe way to navigate the feared stimulus (i.e. with the calming presence of the therapist, using a calming mantra, or some other technique). By actually confronting the event that they have so long avoided, the client learns that they can handle this situation and it may not be as frightening or threatening as they once believed.

    2. Some considerations to have in mind when developing behavioral exposures include keeping the client as a partner in the collaboration. If the clinician suggests exposures that are too “difficult” for the client, the client will likely not do them and not improve. This is why it is important to develop a hierarchy of tasks or situations that the client and clinician agree to practice exposing the client to. Another important piece to keep in mind is that the negative automatic thoughts that drive clients’ avoidance behaviors likely show up in other areas of their lives, so it is important to identify these thoughts at work as the client and clinician collaborate on their proposed exposures. Identifying and exploring these thoughts can set the stage for future interventions, going beyond the exposure or exposures.

    PDA-6: Behavioral Exposure – Assessment of Anxious Patterns
    1. The client’s primary negative automatic thought was that she would not be able to escape the store if she had a panic attack. She also mentioned feeling distressed that she was not able to complete a task that is simple for other people, so this may reflect an automatic thought like “I’m stupid for not being able to go to the grocery store.”

    2. The client responded to her physiological symptoms and fear that she was having a heart attack and that no one would help her was to tell herself that there was no evidence she was having a heart attack and that these symptoms were due to her anxieties around being in a place that may be difficult to escape. The symptoms decreased when she went out to the car where her husband was waiting, and after she arrived home, she was able to reflect on how silly her panicking made her feel. However, as Dr. V alluded to in the video, her reliance on her husband for feeling calm shows that she uses his presence as a safety behavior. When he drives her to the store, she can easily leave without finishing her shopping and avoid facing her anxieties. In this way, he is reinforcing her maladaptive avoidance. As they work towards more in vivo exposures, the client will have to fade out her reliance on her husband in order to be able to truly re-learn more adaptive behaviors and practice them on her own.

    Reply

    • Monica K Teeven
      Mar 24, 2020 @ 12:23:59

      Hey Jess! In your response to the second question of Behavioral Exposure, you mentioned an important factor about implementing a behavioral exposure intervention with a client that I did not mention. You discussed how it is important to develop a hierarchy of tasks or situations that the client and clinician agree to practice to expose the client. In addition, to your point about negative automatic thoughts, it also important for therapists to remember that negative automatic thoughts are often what help sort and strengthen the maladaptive behaviors that clients are exhibiting. Great job on your blog post!

      Reply

    • Robert Salvucci
      Mar 24, 2020 @ 20:56:14

      Hello Jess!

      Pointing out the long term amplification of anxiety in safety behaviors is definitely important. The temporary sense of comfort and release paradoxically makes it more difficult to experience comfort in the feared situations in the future. As you mentioned, the confronting of these difficult emotions and thoughts is what leads to progress. Good job highlighting the importance of collaboration in the development of exposure interventions. It is crucial that a client feels like they have control over their goals, and this sets the stage for success and future interventions.

      Reply

    • Ashley Foster
      Mar 26, 2020 @ 20:07:09

      Hey Jess!
      I really like how you bring into your post about relaxation techniques to deal with distressing situations as a first step. I think we can all agree, the exposure process is and can be a longer process, and it does not help when the client is in acute levels of distress in the moment. These skills helps the client calm to a point where they can at least function enough to keep moving forward in the process. Great job with the post!

      Reply

  7. Melanie Sergel
    Mar 24, 2020 @ 13:31:19

    (1) Behavioral exposure is very effective for certain disorders/types of distress like agoraphobia, obsessive-compulsive disorder, panic disorder, and other anxiety-related disorders. Anxiety is distinguished from fear by cognitive and behavioral processes that are future oriented. Whereas fear is a physiological process that happens in the moment. Those who suffer from an anxiety disorder experience increased physiological arousal and negative automatic thoughts which leads the individual to avoid situations/events that cause them distress. This then negatively reinforces avoidance behavior in the individual because now the individual believes that they will not be put in “danger” if they are not exposed to that situation/event and it lowers their anxious and distressful feelings. Behavioral exposure is used to expose a client to what creates their anxiety and distress. By exposing the individual to what is causing them their anxiety helps reduce that anxiety towards that situation/event overtime and it also reduces their avoidance behavior. Through behavioral exposure, individuals will also learn that what causes them that anxiety is really not dangerous.

    (2) When using behavioral exposure there are cautions to consider. One caution to consider is where the client’s therapeutic progress is at before choosing the type of behavioral exposure intervention. It is important to do this because we cannot throw a behavioral exposure intervention at them that they are not ready for because it could cause them to become very overwhelmed. If this client feels this way, they are most likely not going to engage in the behavioral exposure intervention or not do it. Another caution to consider is the automatic thoughts that are associated to that anxious or fearful pattern. This is important to take into consideration because these thoughts will help show how the pattern developed or what is driving these anxious or fearful patters. These thoughts can also help the clinician determine what type of behavioral exposure intervention would work best for the client and will be the most helpful.

    PDA-6

    (1) The client’s primary negative automatic thought was that she could not escape and she was also thinking about how would she get help if she had a heart attack in the aisle.

    (2) The client’s response to her associated automatic thoughts and physiological arousal was that she ran out of the store to the parking lot. She left the carriage where it was, and she kept telling herself that she knew she was not having a heart attack, but she said her body told her to get out. She felt relieved after she saw her husband sitting in the car and that her physiological symptoms quickly decreased. She realizes that she uses her husband as a safety behavior, and she does say that she does not like the idea of working on changing that. Afterwards, she felt like she had failed and also felt silly because she acknowledges that this should be an easy thing to do.

    Reply

    • Robert Salvucci
      Mar 24, 2020 @ 21:03:20

      Hey Melanie!

      Nice job distinguishing the processes of fear and anxiety from a CBT model. Highlighting the role of worry and automatic thoughts in the process of anxiety and panic is important for clients to be able to identify. A lot of anxiety and panic symptoms result from catastrophizing about horrible events that are very unlikely to happen or misreading physiological symptoms as major health concerns. When creating an exposure plan, you captured how automatic thoughts tie into motivation and can prevent clients from wanting to attempt more scary or difficult tasks. This is why it is important to assess automatic thoughts and work collaboratively, as you mentioned.

      Reply

    • Renee Gaumond
      Mar 26, 2020 @ 17:19:20

      Hi Melanie,
      I like that you mentioned how anxiety is future-oriented and cognitive and behavioral while fear is in the moment and physiological. I’ve heard anxiety be described as fear of the future, which I find to be a simple explanation for it. I also agree with you when you said that using a technique that the client isn’t ready for won’t have a good outcome. If the client gets too overwhelmed, then they will end up being avoidant of the behavioral exposure itself.

      Reply

    • Ashley Foster
      Mar 26, 2020 @ 19:54:31

      Hey Melanie!
      I agree that moving too fast in the exposure process can be detrimental to the client as it can be extremely overwhelming. I also like how you added that the clinician needs to be cautious to consider the automatic thought that is associated with fear or anxiety fueling the disorder/ distress. I agree this is important to better the process that can be individualized to the client so the exposure process is most helpful/ useful.Great job with the post!

      Reply

    • Erin Wilbur
      Mar 28, 2020 @ 16:33:31

      Hey Mel,
      I like your point about assessing the client’s therapeutic progress before deciding on behavioral exposure techniques. It’s really important that we’re on the same page with our clients so we don’t overwhelm them with goals that seem too lofty. If we were to present a goal that was too difficult based on their therapeutic process, they would be reluctant to try these skills again or attempt another behavioral exposure technique, damaging the progress that was made and making it difficult for any future help to be given. Overwhelming the client with a goal like this will make them feel unsafe and have them resort to their maladaptive coping skill of avoidance again. Good point!

      Reply

    • Mariah Fraser
      Mar 28, 2020 @ 23:23:19

      Hi Mel,

      I liked how you distinguished the differences between fear and anxiety, and were able to connect that to behavioral exposure. If a client has a negative association between their physiological experiences and their thoughts, avoiding the situations that produce them is likely the only solution that makes sense in their minds. Obviously, it may be a short-term solution, but it definitely does not solve the problem. As you said, behavioral exposure will teach the client that the situation that is causing them distress isn’t actually dangerous at all. I also liked how you mentioned that meeting the client where they are at is important! The last thing we want to do is overwhelm them and discourage them from trying again!

      Reply

  8. Jenna Nikolopoulos
    Mar 25, 2020 @ 13:39:53

    Behavioral Exposure

    1. Behavioral exposure is a great technique that is used with disorders that produce a great deal of anxiety in people such as social phobia, panic disorder, and obsessive-compulsive disorder. Those who experience any of these disorders, and others that generate a lot of distress, experience negative automatic thoughts and an increased physiological arousal due to their anxiety from stressful situations, which ultimately causes them to avoid the situation(s) that stimulated the distress in the first place. They avoid these certain situation(s) because they perceive them as threatening and by avoiding them, it not only reduces their anxiety, but also allows them to learn that they are safe, which is a form of negative reinforcement. These avoidance behaviors only provides short-term relief, but are not effective long-term because these individuals are not learning the coping skills they need in order to properly deal with the distress they experience. Behavioral exposure is very effective because clients confront the anxiety inducing situation(s) that they are avoiding in order to break the avoidance pattern. Over time, this will allow clients to see that there is no real threat attached to the situation(s) and will help them develop coping skills for dealing with potential future distress.

    2. One thing to consider when implementing behavioral exposure interventions is to make sure that the client is ready to try something like this because their avoided situation(s) can be difficult for them to physically confront and can cause them great distress, so the clinician should be prepared for some hesitation on the client’s part. Also, if the client is not ready to finally confront his/her fear that could potentially do more harm than good. Another thing to consider is that even though the exposure techniques are what really break the behavioral avoidance pattern, the clinician cannot forget about identifying the negative automatic thoughts that are associated with the client’s distress and feared situation(s). These thoughts can initiate and reinforce the maladaptive behaviors that the client engages in so it’s important to recognize these as well. Identifying these thoughts also helps the clinician decide which exposure technique is best to use for the client.

    Behavioral Exposure PDA-6

    1. Her primary negative thought was that she felt like she couldn’t escape. She also wondered “If I was to have a full on heart attack right there in the aisle, how was I going to get help?”.

    2. She initially tried to calm herself down by reminding herself that she wasn’t having a heart attack and recognizing that she was just having symptoms of a panic attack, but since she wasn’t able to reduce her physiological arousal she felt the need to leave the grocery store. She ran to the parking lot to find her husband and once she saw him, she started to calm down a bit. Once she got home and was able to recover from the panic attack, she felt silly for panicking at the grocery store because she feels that going to the grocery store is not something that she should be panicking about. She also felt like she failed in trying to accomplish this on her own, but did recognize that this was an ambitious task for her. I think her husband acts as a safety behavior for her because just the sight of him is able to calm her down immediately, which, like Dr. V said, is something that can be used when she begins to do exposures to help her in the beginning, but then she has to learn to do things on her own without her husband being there.

    Reply

    • Renee Gaumond
      Mar 26, 2020 @ 17:34:31

      Hi Jenna,
      I agree that her husband is a safety behavior for her. Just the sight of him can calm her physiological symptoms. I also think that her escaping the grocery store to see her husband strongly reinforced the behavior. Leaving the store was negatively reinforced due to her escaping what was causing her distress and her husband positively reinforced the behavior by being there to calm her down after the escape.

      Reply

    • Madison Armstrong
      Mar 28, 2020 @ 20:30:30

      Hi Jenna,
      I agree with you that you want to make sure the client is ready for behavioral exposure. I think that it is important to build a strong therapeutic alliance so that the client is able to admit to their concerns regarding this technique. For people who experience symptoms of anxiety, exposure can be frightening because they have adapted to a pattern of avoidance that is causing them the least amount of discomfort. Doing negative automatic thought work first with the client could be a good step into building upon that therapeutic alliance and working toward exposure techniques.

      Reply

  9. Renee Gaumond
    Mar 25, 2020 @ 20:37:36

    1. Behavioral exposure is very effective for certain types of disorders or distress such as agoraphobia and OCD because it attempts to break habits that have been negatively reinforced. It breaks an avoidance pattern. Avoidance behavior gives the individual a moment of relief when the thing that is causing distress isn’t encountered or being experienced. Exposing the person to the distress allows him or her to build up a tolerance and weakens the reinforced avoidance behavior.
    2. Some cautions to consider is negative automatic thoughts and the client’s readiness for the exposure. The client may find exposure difficult since he or she associates avoiding the stimuli with relief of distress. Exposing the client to distressful stimuli too intensely or too quickly may have the opposite effect and create stronger avoidance behavior. It’s important to evaluate the client’s limits and make sure the exposure isn’t too overwhelming.
    Understanding the negative automatic thoughts that are associated with the avoidance behavior will allow the clinician the opportunity to make a choice for what interventions will be most effective with the client. Exploring the negative automatic thoughts will also allow the client to Target the thoughts that reinforce the avoidance behavior.
    1. The client’s primary negative automatic thoughts in response to the event was that she “can’t eescape”and that she will have a heart attack.
    2. Her response to her associated automatic thoughts and physiological arousal was to leave her cart and run out of the store into her car. She felt safe with her husband and decided to go home. When she saw her husband and while driving home her physiological symptoms began to decrease. Once they decreased, she felt like she failed at going shopping at the grocery store. She understands that she was having a panic attack instead of a heart attack, but her physiological symptoms were too overwhelming for her.

    Reply

    • Mariah Fraser
      Mar 28, 2020 @ 23:22:51

      Hi, Renee!

      I liked how you worded your response, that behavioral exposure is helpful with clients who have OCD because it breaks patterns of avoidance. You also said that the exposure helps the client to build a tolerance in a sense, because exposure gradually weakens the avoidance behavior. I agree that if the client is exposed to stimuli that is too intense to begin with, the avoidance behavior may become stronger, because the negative experience does not give the client hope that exposure will be beneficial.

      Reply

  10. Madison Armstrong
    Mar 26, 2020 @ 13:03:42

    [Behavioral Exposure]
    (1) Why is behavioral exposure very effective for certain disorders/types of distress?
    Behavioral exposure is effective for certain disorders/types of distress because it helps those individuals with anxiety disorders and avoidance surrounding their source of distress. Because this source of distress often causes negative automatic thoughts and a physiological arousal, they tend to avoid situations that contribute to the distress to relieve these symptoms. By avoiding it they are not establishing healthy coping skills. Behavioral exposure allows the individual to confront their source of distress and work through the challenging reactions they may have physiologically, emotionally and cognitively. When an individual is avoidant of distressing situations, they are feeling safe from the “danger” presented. This is maladaptive because the individual is not able to adapt to the situation and instead is avoidant. Behavioral exposure will help the individual develop adaptive coping skills to be able to endure the situation they were avoiding.
    (2) What are some cautions to consider when implementing behavioral exposure interventions?
    A caution to consider when implementing behavioral exposure interventions is that the client may be skeptical to begin this intervention. It would be important to build a solid therapeutic alliance with the client before even mentioning this intervention. With a client who is avoidant, they may choose to stop therapy if this is mentioned too early, so they do not have to expose themselves to their distressing situation. It would be beneficial to begin with doing negative automatic thought and core belief work before introducing this intervention because you would want the client to have a good understanding of their self and the way they respond to this distressing situation. This would also allow the therapist to determine which interventions will be most effective and when it is appropriate to implement a behavioral exposure intervention.
    [Behavioral Exposure] – Watch PDA-6: Behavioral Exposure – Assessment of Anxious Patterns.
    (1) What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?
    Lindsey’s primary negative automatic thought was that she “couldn’t escape” and that she would be unable to get help if she had a heart attack in the middle of the aisle.
    (2) What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?
    Her physiological response to these negative automatic thoughts were that she was getting really hot, noticed her palms began to sweat, and felt her chest getting tight. As she began to notice these symptoms, she felt her heart start racing, noticed that people were watching, felt nauseas, felt like she was choking and that she was losing control. She tried telling herself that she wasn’t going to actually have a heart attack and that it was just the panic attack, but her body made her feel like she just needed to get out. As a result, she left her carriage in the aisle and went to the car. She felt a relief when she saw that her husband was sitting in the car and noticed her chest didn’t feel as tight and her symptoms were decreasing. They went straight home and she noticed that her symptoms were completely gone. She had felt like she had failed because she thought she should be able to go to the grocery store by herself.

    Reply

  11. Taylor O'Rourke
    Mar 26, 2020 @ 15:01:49

    1. Why is behavioral exposure very effective for certain disorders/types of distress?

    Behavioral exposure is very effective for certain disorders/types of distress
    because its techniques are derived from learning theories that create behavior therapy. Many disorders respond very well to behavioral therapies but cognitive elements are inputted as well to supplement. Exposure works very well for anxiety disorders because anxiety is both a cognitive and behavioral process that is oriented towards the future, or what has yet to happen. This is very similar to fear, which is a physiological process that actually occurs in the moment something is happening. It is followed by cognitive and behavioral responses. Anxiety causes clients to have negative automatic thoughts and increased arousal, so they end up cognitive and/or behaviorally avoiding their distress because they have perceived it as distressing. Negative reinforcement occurs because they continue to avoid that distress and learn that they are safe. Although this provides short term relief, it is detrimental in the long term because there are no coping skills learned for how to handle the distress. To combat this, behavioral exposure works to confront situations that are usually being avoided. This allows clients to break the avoidance pattern. This can be accompanied by working on identifying negative automatic thoughts as well. This exposure is also helpful with individuals who have difficulty relaxing, do not have adaptive coping or problem-solving skills, and also those who lack social skills.

    2. What are some cautions to consider when implementing behavioral exposure interventions?

    One caution to consider when implementing behavioral exposure interventions
    is having difficulty assessing the anxious or fearful patterns that a person may be experiencing. For example, a clients’ memories or images of their past may trigger anxiety that was not there previously. To try to get at their true patterns, a therapist may want to try to discuss their physiological arousal first because it might be the easiest thing to remember. Safety behaviors should also be identified in order to prevent or reduce associated distress. Another challenge that therapists can face regarding behavioral exposure is when a client is hesitant to begin progressive muscle relaxation or diaphragm breathing. The therapist should provide psychoeducation about these techniques and should encourage the client to “give it a shot” before just shooting down the process. Therapists should also consider that some clients may be hesitant to begin exposure techniques. Therapists may want to begin with guided imagery before moving on to in vivo exposure. Also, very small steps should be taken initially with in vivo exposure. Even smaller steps from a client’s fear hierarchy could be broken down further into two separate steps if needed. It is important not to totally flood the client because this may scare them off or retraumatize them.

    3. What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?

    The client’s primary negative automatic thought in response to the event was
    that she could be having a heart attack in the middle of the crowded aisle. She tried to remember cognitively what she had talked about with the therapist that it was unrealistic that she was actually having a heart attack and would die, but was not able to really feel this and believe it in the moment. She felt that she would be unable to escape the situation if she were truly having a heart attack. She began to feel relief once she got outside of the store and saw her husband in the car in the parking lot.

    4. What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

    The client’s response to her associated automatic thoughts and physiological
    arousal was that she felt kind of silly because she could not even succeed with a simple task like going to the grocery store. She felt that maybe she was a bit too ambitious to head to the grocery store so quickly after therapy. As mentioned previously, she did feel relief once she saw her husband in the car in the parking lot. Lindsey does deserve some credit for being able to take the initiative to go to the store, but she still needs to work on coping skills for her panic attacks and should possibly try some interoceptive exposure. The therapist mentions maybe her husband is a safety behavior, and they should work on doing things without him around to determine how she can cope in other ways. He would be faded out during in vivo exposure.

    Reply

    • Jenna Nikolopoulos
      Mar 27, 2020 @ 16:22:17

      Hi Taylor! I really liked what you said about cautions to consider when implementing behavioral exposure techniques. Identifying anxious and fearful patterns is so important with behavioral exposure because clinicians use those patterns to implement specific techniques that work best to break those patterns. But sometimes it’s hard for clinicians to identify the kind of pattern their client is experiencing, which, in that case, makes it important for the clinician to find the client’s true anxious or fearful patterns before implementing any behavioral exposure techniques to ensure client progress. Additionally, like you said, clients may want to shoot down the use of some techniques at first because it seems awkward or maybe they feel they won’t be able to do it. However, with proper psychoeducation from the clinician, this will provide the client with more information, which will hopefully help the client’s hesitation and give them the confidence to at least try the technique to see if it helps. If it doesn’t, then the client and clinician can work together to find different techniques that might suit the client better.

      Reply

  12. Ashley Foster
    Mar 26, 2020 @ 15:12:15

    Behavioral Exposure

    1. Behavioral exposure is effective for certain types of disorders and types of distress. This type of intervention is ideal for individuals who are suffering from disorders such as agoraphobia, PTSD, OCD, panic disorders, and phobias of any type. The method is to take the fear away through having the client slowly facing their fear with the buildup of fully experiencing it. This method is to calm the physiological responses and tackle the automatic thoughts associated with these responses.

    2. There are a few cautions to consider when implementing behavioral exposure interventions. This is the focus on the timing of the amount of exposure implemented to the client. While implementing this type of intervention, it is important to not rush through this process. It is important to recognize if the client is ready for the next step in the exposure process as it can be easy to overwhelm the client. Moving too fast can also deter the client as the feelings and thought may be too distressing for the individual to endure.

    PDA-11: Exposure: “Easter egg” Mark is there!

    PDA-6: Assessment of Anxious Patters

    1. The client’s primary negative automatic thought is “I can’t escape”, “I’m going to have a heart attack”, “I’m losing complete control”. She is endorsing cognitive distortions of magnification, dichotomous thinking, shoulds and musts, mind reading, and catastrophizing.

    2. The client’s response to her associated automatic thoughts were that she believed that she was having a heart attack due to the panic attack she was experiencing that was being fueled by her negative automatic thoughts. The client’s physiological arousals included her palms got hot, sweats, chest tightened, heart racing, and nausea. Her safety behavior revolves around her husband. Lindsey tends to turn to her husband rather than taking on these skills and exercises on her own.

    Reply

  13. Mariah Fraser
    Mar 26, 2020 @ 17:39:45

    When clients are anxious, they typically have negative automatic thoughts that occur during the perceived threatening situation. This increases their sense of physiological arousal, which can be intense and frightening because the client may catastrophize the sensations (e.g. think they are having a heart attack or dying). This in turn, may encourage the client to engage in avoidance behavior. Avoiding the source of distress not only reduces the anxiety, but it also teaches the client that as long as they do avoid that particular situation, they are safe, thus becoming a negative reinforcement. Although there is relief as an immediate consequence, the consequence on a larger scale is that the individual does not give herself the opportunity to learn adaptive coping skills. Therefore, when a client and therapist collaboratively establish behavioral exposure techniques, the client will understand that in order to break the pattern of avoidance, the client must be able to confront the situation or object, feel the physiological arousal, and come to an understanding that these sensations are not signs of impending doom, nor are the fears that are triggered by negative automatic thoughts accurate or of value.

    It is important to be cautious in regards to implementing behavioral exposure interventions because as therapists, we want our clients to be successful. In order to establish a sense of self-efficacy when confronting these exposure techniques, it is crucial for the therapist and client to start out with circumstances that set the client up for success (graded exposure). That way, the client will feel more comfortable and confident in making her way up the hierarchy. It is also important to note that, although the therapist doesn’t want to flood the client, which would do severe damage to their mental status and the therapeutic relationship, the therapist should be wanting to ‘push’ the client. Things that are too easy will result in very little progress, but challenging the client is an important balance to establish.

    The client’s primary negative automatic thought was that she failed at going to the grocery store by herself because when she was in the aisle with other people, she was worried about having a way to escape if she had a heart attack. The dichotomous thinking that she was having in regards to ‘failing’ because she didn’t complete the task, is a little maladaptive because it is definitely progress that she was able to even walk in and push the cart around by herself. Even a little bit of progress is better than no progress.

    The client’s response to those negative automatic thoughts and physiological sensations were to give herself a friendly reminder that she wasn’t experiencing a heart attack, instead she was having symptoms of a panic attack. This resulted in her leaving the grocery store, and getting into the car with her husband, who had been waiting for her outside. As expected, her symptoms seemed to diminish and she felt safe having had him with her. She was able to talk in session about how she had felt silly after the fact, and was able to recognize that her husband’s presence serves as a safety behavior because she feels a sense of safety with him being there. The therapist was able to help her talk through the fact that although in the moment, the presence of her husband is comforting, it also serves as a reinforcer of that maladaptive behavior. Towards the end, there was an understanding that as time goes on, the presence of her husband will have to fade out so that she can learn more adapting coping skills on her own.

    Reply

    • Mariah Fraser
      Mar 26, 2020 @ 17:47:19

      Oh! And in the produce section you can see Mark in the background behind Dr. V’s noggin!

      Reply

    • Jenna Nikolopoulos
      Mar 27, 2020 @ 15:52:12

      Hi Mariah! I definitely agree with what you said regarding graded exposure. I think graded exposure is super important because by having the client engage in less intense situations first, they will have gained confidence in their ability to confront situations that induce their anxiety and feel more prepared to use already learned coping skills to engage in more intense situations. Also, like you said, the therapist doesn’t want to overwhelm their client, but still want to push the client to try and engage in these situations for as long as possible. The longer they are able to confront their anxiety inducing situations, the more progress they will make in breaking their established avoidance patterns.

      Reply

  14. Tim Keir
    Mar 26, 2020 @ 21:45:46

    1. Why is behavioral exposure very effective for certain disorders / types of distress?
    Often times, the intense physiological response of anxiety and phobias are due to the development of cognitive certainty that interaction with the feared situation in question can lead to danger of harm or even death. Given that expectation, their intense avoidance and panic is certainly a reasonable response. What behavioral exposure does is subject the individual to the experience in question, with the goal of showing the result. Individuals willing to go through with this sort of exposure are already cognitively primed to change their automatic thoughts towards the situation, as it is impairing their ability to function in some way. By exposing themselves, they allow themselves to relearn the expected outcomes and consequences of the experience – did death occur? If not, then perhaps the intense fear response is unnecessary. Each new experience that does not follow the expectation weakens that expectation until it is capable of being fully rewritten.

    2. What are some cautions to consider when implementing behavioral exposure interventions?
    Exposure therapy is inherently highly uncomfortable for the client. It is direct confrontation of the person’s greatest fears, whether imaginally or in person. Therefore, the clinician must be certain that the client is truly prepared to bear that fear and push past it to create new experiences. For the least painful experience, using graded exposure of less intense scenarios up to the highest sources of anxiety will help the client learn the skills to relax and relearn their responses to these different situations.

    3. What was the client’s primary negative automatic thought in response to this event?
    The client seemed to be quickly overwhelmed by the presence of other people and their perception of her own anxiety. The client was clearly very concerned about being able to escape from a crowd; if she was surrounded by a throng of people, how would she be able to get help if she had a medical emergency? She was concerned that she was having a heart attack in particular. Her bodily reaction of heart palpitations and upset stomach helped push these thoughts even further.

    4. What was the client’s response to her associated automatic thoughts and physiological arousal?
    She felt partially shameful, as she was confident that her knowledge that she wasn’t really having a heart attack would have a greater impact on her body reaction. Yet she still needed to abscond from the situation in order to relieve her panic attack symptoms. She was unhappy that she still experience a panic attack, but was able to properly label the attack for what it was instead of going to the hospital for a feared heart attack. This cognitive difference is large, and made the situation far easier to recover from than otherwise.

    Reply

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Adam M. Volungis, PhD, LMHC

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