Topic 8: The Practice of CBT – Behavioral Exposure {by 11/2}

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 11/2.  Have your two replies posted no later than 11/4.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

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41 Comments (+add yours?)

  1. Stephanie Welch
    Oct 30, 2017 @ 00:11:40

    Behavioral exposure is very effective for certain disorders or types of distress because it prevents the client from avoiding certain behaviors and situations. Behavioral exposure is effective for anxiety disorders because the individual is forced to confront the feared stimulus. The client is taught relaxation and coping strategies in order to deal with the feared stimulus. Behavior exposure uses imagined and in vivo (in real life) strategies to have the client identify the emotions and bodily sensations associated with anxiety and use certain skills in order to cope with the anxiety.
    Anxiety is developed by an initial situation in which an individual feels fear. Then, the individual overgeneralizes the feared stimulus to include any situation that is similar to the original situation. The individual will then go out of his or her way in order to avoid the feared stimulus so he or she will not experience any feelings of fear. For example, a dog may have jumped on the individual and scared him or her. Now the individual fears all dogs and will avoid any interactions with dogs including people walking their dogs down the street.
    One caution to consider when implementing behavioral exposure interventions is to avoid using stimulus that could be actually deadly to the client. For example, a client who is afraid of drowning may have this fear due to the inability to swim. Teaching the client to swim may be more effective than having the client go underwater. Wright et al points out that the behavioral exposure intervention may have the reverse effect for the client. The client’s avoidance behavior may actually be reinforced by the behavioral exposure interventions.
    Another caution to consider when implementing behavioral exposure interventions is the type of exposure. The client may need in vivo exposure as opposed to imaginal exposure. The in vivo exposure may be difficult if the anxiety is caused by post traumatic stress disorder due to war or perhaps rape. A further caution is the amount of time for the exposure therapy. Behavioral exposure interventions are suppose to be limited to a certain number of sessions. If the client goes too slowly or too fast through the behavioral exposure interventions, then the behavioral exposure interventions may not be effective for the client.

    Reply

    • Chiara Nottie
      Nov 03, 2017 @ 12:28:19

      Hey Stephanie
      I didn’t mention in my blog post the possibility of a feared stimulus being dangerous. It is an important thing for a counselor to keep in mind. Your example, for example is a good one. A counselor should make sure they know the skill level of a client in certain situations, such as swimming. I can easily imagine a therapist jumping the gun for some client fears and assume more than they know, like you mentioned a client with the fear of drowning, a counselor should be sure to inquire how skilled that client is in the water, and not assume they know how to swim. I can see other strong fears clients have that could be dangerous to face, such as a fear of being mugged at night, it would be particularly concerning if a therapist tried to place that client in a threatening environment to test out in vivo therapeutic techniques. I wonder if some feared stimuli that do flirt with danger need to be addressed with exposure therapy at all, or if another therapeutic intervention would be more appropriate?

      Reply

      • Stephanie Welch
        Nov 03, 2017 @ 22:21:01

        Thanks for the feedback. I had wondered the same question. For your mugging example, perhaps a self-defense class and awareness class may be more beneficial. There are also classes in regards to women at night and carrying pepper spray that may put someone more at ease. It is difficult to determine what could be effective for the client especially if the threat is justified as in your mugging example, especially if the client may have witnessed or experienced a previous mugging. Maybe this is a question we can ask to the class.

        Reply

        • Shay Young
          Nov 04, 2017 @ 13:41:27

          Hey steph and sara,
          Interesting discussion here. I wonder that myself, how dangerous of a stimuli or threat can be exposed to the client. I definitely would think that imaginal exposure could be more helpful here. I also think there are ways to eradicate or alleviate fear or anxiety without completely exposing the client to the actual or legitimate fear. For example the client could be exposed systematically and in steps. You don’t necessarily need to have the client go through an actual event or experience to reduce the fear. So to keep consistent with the examples you two engaged with, there are other ways to eliminate or reduce the fear. For drowning for example, maybe have the client slowly exposed to a pool or take swimming lessons first. You can first start with just a toe in, then the legs, the arms etc. You may show them videos or pictures of the pool to reduce the fear. Having a client physically drown is an ethical issue, and I imagine getting a client feeling comfortable in water or with swimming will naturally alleviate that fear. For mugging, I would expose clients to banks, parks or anywhere they potentially may avoid due to that fear. I would maybe have them go somewhere safe at night, with a friend to reduce the fear and help them see that nothing would happen. I also think it may help to do some evidence reasoning with the client, as mugging is realistically not an entirely likely scenario especially depending on where you live.

          Reply

      • Matthew Collin
        Nov 04, 2017 @ 14:57:00

        Hey guys,
        Trailing off of what Chiara was saying, I do think there are situations where some feared stimuli is not best tackled through direct behavioral exposure. Not to say that behavioral exposure isn’t typically the best for every situation, but sometimes it is just not possible and/or ethical to recreate. For instance, if someone is suffering from PTSD from a sexual assault, it’s just not possible to alleviate that fear – it is a legitimate fear. You can’t begin to comprehend to have a client habituate to sexual assault, or put them in environments that could put them at risk for sexual assault. Having the client use imaginative exposure to the images and thoughts of the traumatic event he/she experienced may be a more appropriate avenue to take. It also would be helpful to behaviorally expose him/her to the triggers that may cause him/her to reenact the distressful thoughts/images of the traumatic event.

        Reply

  2. Olivia Grella
    Oct 31, 2017 @ 21:50:44

    Behavioral exposure is very effective in treating anxiety disorders. The books specifically points out OCD, PTSD, panic disorder, and specific phobias. This is because behavioral exposure helps the client come in contact with their fears and work through them. The chapter discusses how this is approached in a hierarchy system. For example, someone may have a specific phobia of snakes. Through the hierarchy, they would gradually start with smaller things (i.e., standing on the opposite side of a room where a snake is) and moving up to what they consider the worst (i.e., holding a snake). The key is that it is a gradual process because although flooding can be use, gradual systematic desensitization is typically used more. This gets the client to confront what is causing them distress and work through ways to cope with it when it occurs. Also, behavioral exposure is effective because it puts them in the specific situation that is causing them distress. Although some imaginal exposure is used for situations that can’t be replicated, in vivo exposure tends be used more and alongside imaginal exposure because it puts the client directly in the situation. The therapist can also be doing the exposure with the client to make the situation less distressing the first few times and be available to model appropriate responses or help the client cope with what they are feeling. Regardless of what method is used, behavioral exposure helps the clients break certain patterns they have when placed in these distressing situations. For example, someone with panic disorder and agoraphobia has rituals set in place to avoid certain situations that cause them to have a panic attack. Through behavioral exposure, they are being taught the skills to break those avoidance patterns and formulate new skills to possibly relax themselves.

    There are some cautions with implementing behavioral exposure. For one, the therapist has to make sure that they are not making the client move too fast. Although the client should be encouraged to put themselves in a challenging situation, if they move too quickly for things they are not yet prepared for or have the skills to encounter yet than this could be more detrimental than beneficial to their progress. This also ties in how the clients may have fears of things that could be very dangerous and if that’s the case, in vivo exposure should not be used to save them from possible danger. The book also mentions the pros and cons to having the therapist present during exposure and their family present. During exposure, the therapist present may be making it a calmer situation and reinforcing those avoidance patterns (however, the client should be accompanied the first few times during exposure) and family members can do the same. Having support is very beneficial, but it just needs to be double checked that they aren’t reinforcing the avoidance behaviors by being present.

    Reply

    • Liisa Biltcliffe
      Nov 03, 2017 @ 17:41:56

      Olivia,
      I like how you play out the scenario/give the example of the snake and how it’s important to go slowly in doing exposure therapy. I also thought it was important how you pointed out that clients who have phobias or fears of dangerous things/activities should not be exposed to those in vivo. This may seem quite obvious and yet to some people, it may not be something that is thought of, unfortunately.

      Reply

    • Sarah Hine
      Nov 04, 2017 @ 10:57:45

      Olivia,
      You discuss the importance of gradual, systematic desensitization when implementing behavioral exposure. The patterns of behaviors that anxious clients are exhibiting could have been developed over a long period of time, and simply flooding them with their phobias will probably not be effective. Gradual behavioral exposure is effective because it teaches clients skills and methods to use in many areas of their lives, not necessarily with a specific phobia. Clients will not only address the concern they came into therapy for, but will also be more likely to prevent future phobias or avoidance behaviors from occurring.

      Reply

  3. Matt
    Nov 01, 2017 @ 18:18:38

    Behavioral exposure is specifically good for anxiety disorders, because it allows for people with anxiety to confront what causes them fear, and most importantly, disfunction in their lives. Generally, people suffering from an anxiety disorder have the presumption that if they encounter what they fear, they will have a catastrophic, undesirable outcome, that is irreversible, and will threaten their livelihood. It’s important to use behavioral exposure in order to have the client experience the fear, realize they can come in contact with whatever stimulus makes them anxious, and that what they feared would happen if they came in contact with that stimulus/situation is not necessarily true. In essence, behavioral exposure can be a great tool in order to build evidence that is contrary to someone’s negative, and illogical core belief or automatic thought. In other words, they become habituated to the thing that they fear, and what causes them anxiety.
    Some precautions you should take before implementing behavioral exposure to clients is making sure they’re ready for the exposure. Imagine if you were the client, and the first day, the therapist said that you should get ready to be exposed to the very thing that brought you into therapy. I most likely won’t be going back for a second visit. It’s’ important to make sure that the therapeutic alliance/relationship is established before doing such a distressful technique. It also requires a lot of planning, and collaboration with a client. The client and the therapist should be creating a hierarchy of fears, and slowly work up to the thing that makes them most anxious. Not only does the hierarchy start them at a place where they feel comfortable, it also could give them a sense of accomplishment as they move up the hierarchy – it gives them motivation to continue. The hierarchy also gives time for cognitive restructuring to take place, and to be able to digest what the client is thinking when they experience a distressful event.

    Reply

    • Stephanie Welch
      Nov 03, 2017 @ 22:37:28

      Matt,
      I liked that you mentioned that the client needs to be ready for behavioral exposure before implementing it. I especially liked that you gave the example of a therapist just deciding to do exposure therapy and the consequence of the client not returning to therapy. Rushing behavioral exposure is not beneficial to the client and may lead to more stress for the client. I agree that behavioral exposure requires planning, collaboration, and a measure of what the client is comfortable at attempting for the behavioral exposure to be successful and beneficial for the client.

      Reply

    • Luke Dery
      Nov 04, 2017 @ 15:25:34

      Hey Matt,

      I like how you brought up habituation in behavioral exposure therapy. Not only do we have to find evidence against anxiety-producing associations we’ve made, but we also have to replace them with healthier scripts when faced with the same situations in the future. We have to break out of the habits we’ve formed that reinforce our fear-responses, and I think that sometimes becoming habituated and used to the upsetting stimuli helps us along in that process.

      Reply

  4. Shay Young
    Nov 01, 2017 @ 18:51:16

    Behavioral exposure is typically effective for anxiety. Wright mentions that behavioral exposure and behavioral methods are also used for phobia, panic disorder as well as PTSD. Most of the chapter goes into detail explaining anxiety disorder so that is what I’ll focus on. Those who struggle with GAD, social anxiety or a phobia usually report intense fear as well as physiological symptoms when exposed to the subject or stimulus they fear. The whole premise of behavioral exposure involves confronting that feared stimulus. With repeated exposures, the physiological response to the situation would decrease because the person realizes that he or she can confront the fear, as well as manage the anxiety. The whole concept is to interrupt the chain. A therapist can teach their anxious patients relaxation techniques to help negate the fearful response in patients. To break the unconditioned stimulus/ conditioned stimulus (because fears are usually reinforced and perpetuated in some way, sometimes even by avoidance) a therapist will generally either try reciprocal inhibition or exposure. Reciprocal exposure involves again reducing emotional arousal by helping the patient experience positive emotion. In order to specifically help those with anxiety, first one must assess symptoms, anxiety triggers and if the patient uses any coping strategies. The patient will then be taught specific skills to cope with thoughts, feelings and behavior that characterize the anxiety disorder. Components of Behavioral exposure may be beneficial to some disorders, while others it may not. For instance thought stopping or replacing negative thoughts with more positive ones is found useful for anxiety disorders such as phobias or panic disorder. However when applied to patients with OCD, patients have shown to have an intensity of obsessions. In my opinion, from what I derived from the reading, it seems that behavioral exposure also works well for anxiety disorders because there is an identifiable tangible fear that can be addressed, and therefore exposed especially with in vivo. I could foresee how making a hierarchy to approach a fear would be better for something like anxiety, but may not work for someone with a personality disorder.
    As a clinician, I’d definitely want to make sure my client was in the right place and ready to do behavioral exposure. Behavioral exposure is not something that you necessarily should do on day one. For simple phobias that may not require too much work, sure maybe one session is enough. However you want to make sure you work on explaining the process to the client, developing a hierarchy together, and address the thoughts behind the feared stimulus. I’d want to make sure I felt confident that the client was in a good place where I’d feel they could successfully confront their fears. I imagine jumping in too soon could traumatize the client, and ruin the therapeutic relationship. Of course realistically a client who is afraid of something, will probably never be 100 % optimistic and overjoyed to partake in the exposure process, but as therapist you should be able to lower their opposition and fear. Wright mentions that you should take into consideration the diagnosis, if there are comorbid conditions, patient’s resilience, motivation and readiness for change.
    Aside from this, wright makes a good point about taking all environmental contingences into consideration with exposure. In terms of breaking the “fear chain” there may be other reinforcers that are maintaining the avoidance behavior. If all reinforcers are not considered, the efforts may not be as effective. A therapist has to be sure that they target what is maintaining the fear.

    Reply

    • Venessa Wiafe
      Nov 03, 2017 @ 00:21:46

      Hi Shay,

      I really liked how you mentioned that not all disorders should be treated with the same exposure technique. Each disorder comes with negative affects and should be assessed and treated differently, in order to reach the best outcome. Just because two clients may both be diagnosed with the same disorder, doesn’t mean they will both do well with the same behavior techniques to eradicate negative symptoms. It is vital for the therapist to work in the client’s favor, making sure that he is engaging in a treatment plan and utilizing an exposure technique that will do good for him rather than harm. The exposure technique should align with the client’s pace and readiness for exposure.

      Reply

    • Liisa Biltcliffe
      Nov 04, 2017 @ 14:42:57

      Shay,
      I think it’s important what you pointed out about the different disorders needing different aspects of exposure therapy. So I read about this in the book and did not include it in my post, however, I feel like it is important to mention after all because the clinician should be aware of what works for what disorder and what doesn’t work. I also like what you said about jumping in too soon and possibly traumatizing the client and/or ruining the therapeutic relationship. This was something I also mentioned in my post and feel that it is super important.

      Reply

    • Matthew Collin
      Nov 04, 2017 @ 14:44:23

      Shay,
      I like how you mentioned Wright’s explanation that a clinician must take into account all the environmental contingencies before introducing an assignment of behavioral exposure. Sometimes I think it is too easy to ignore the peripheral stimuli in a given situation, instead of the stimuli the client is looking to habituate, and become less afraid of. Many environmental contingencies can influence any particular situation. It does seem important to take into account the complexity of each environment the client is going into to ensure the best possible outcome.

      Reply

  5. Luke Dery
    Nov 02, 2017 @ 00:22:12

    Exposure therapy is an effective intervention with certain disorders because it allows the individual learn to cope with their problems in real time. Often therapy can be all talk and no action, but exposure gives clients a way to put therapy principles into practice in a controlled and careful real-life setting. Exposure is effective partly due to the fact that it helps individuals build evidence against their negative, often catastrophic, thinking. Often people with anxiety disorders have distorted thoughts and beliefs about the situations that trigger their fear responses. Proper exposure therapy works individuals through a hierarchy from small levels of exposure up to full immersion, which allows clients to both put CBT skills into play and to hopefully realize that some of their thoughts in such situations do not turn out to be true. Exposure also can break negative behavioral patterns that strengthen anxious responses, such as avoidance, by assisting the individual in behaving differently and observing the results of such a change. Exposure techniques can also help individual simply become accustomed to experiencing emotions that they have long been avoiding or suppressing. Learning that emotions are natural, not deadly, and will pass is an important part of therapy.

    There are dangers that come with the use of exposure therapy. It is important not to rush clients into or through exposure. An individual must be prepared for exposure interventions for adequate time beforehand, and must be equipped with some CBT skills to use in the situation. Exposure can be less helpful and potentially harmful if the individual is prepared to face the anxiety-producing stimuli. Additionally, there can be danger in not properly following the hierarchy of exposure and rushing a client through it too quickly. The therapist has to work with the client to judge what level of exposure they are ready to handle so not to flood them and do further harm.

    Reply

    • Olivia Grella
      Nov 02, 2017 @ 21:51:28

      Hi Luke, I like how you incorporated the use of a hierarchy into your explanation. I agree with you that not following the set hierarchy can be a major problem. Moving too quickly or even skipping steps can be very detrimental to the client. Even if they seem to be progressing quickly and doing well overall, a step should not be skipped or rushed through. The hierarchy was set up for a reason and that shouldn’t be forgotten about as therapy progresses.

      Reply

  6. Sarah Hine
    Nov 02, 2017 @ 06:43:47

    Behavioral exposure is useful for treating anxiety disorders, phobias, and OCD. Oftentimes anxiety disorders are formed through conditional learning; anxiety and fear responses to certain situations become reinforced over time through behaviors like avoidance. Behavior exposure is effective because it breaks the connection between the feared object and the fear response. Clients who are exposed to their feared stimulus have to face their fearful response, unable to engage in avoidance or safety behaviors that keep them from fully experiencing the effect their fears have on them in the face of a stimulus. By facing the discomfort of fearful thoughts, emotions, and physiological feelings in the face of the object/situation of fear until their fear response subsides, many will be able to recognize their ability to manage the situation without encountering serious harm. Systematic desensitization is an effective aspect of behavioral exposure, because oftentimes, simply exposing a client once to a situation is not sufficient for true change. Clients are prepared to face their fears in increments, creating plans and developing skills related to cope with their physical responses and anxious thoughts, gradually being exposed to their fears as they become more equipped to handle them. In CBT, implementing methods of behavioral exposure will lead to more meaningful thought modification, because these learning experiences will help reshape automatic thoughts about the feared situation, and will help with practical application of therapy outside of session.

    Some of the techniques involved in behavioral exposure interventions should be implemented with caution. Techniques must be catered to the individual’s needs and abilities, and using the same techniques for every client may not be effective. For example, thought stopping may actually be counterproductive for an individual with OCD. As Wright points out, clients with OCD who try to stop negative thoughts may increase their worrisome thoughts. Distraction is another technique that may be counterproductive. If anxious clients use distraction to avoid fearful situations rather than to cope with anxious thoughts, they may actually be reinforcing their anxieties through avoidance. Behavioral exposure may also need to be introduced incrementally, and therapists must be cautious in determining how quickly they will expose clients to fears. If someone is exposed to a fearful object or situation too soon, or is not equipped with helpful skills to deal with fearful thoughts, that person’s fear may actually increase. A client thrown into behavioral exposure too soon may leave therapy believing that they cannot trust their therapist. A final caution to consider is that some feared situations may actually involve dangerous, threatening fears that clients should not be re-exposed to. Imaginal exposure may be more appropriate in these cases. For cases where trauma is involved, it is also important to be cautious not to re-expose clients to traumatic event, such as abuse or serious accidents (Wright uses an example of a serious car accident). In these it would be more appropriate to expose clients to objects related to their fears without directly exposing them to the original traumatic event.

    Reply

    • Venessa Wiafe
      Nov 02, 2017 @ 23:17:36

      Hi Sarah,

      I really liked how you incorporated the use of systematic desensitization into your post. I find it to be a great type of behavioral therapy that omits the feared stimuli and instead instill techniques that can allow the client to be physically and cognitively at ease. It is already a big step for the client to have to face a stimulus or situation that they fear the most and have been avoiding just to protect themselves. With that being said, allowing the client to relax as she gets through the exposure process can really help him confront his anxiety or fear-producing stimulus and be at peace. It isn’t just about exposing the client to his fear-provoking stimulus, but making sure the gradual steps being taken towards exposure is done in a manner in which he feels comfortable and safe. I believe that exposure along with relaxation techniques can produce the best outcome for the client.

      Reply

    • Luke Gustavson
      Nov 03, 2017 @ 22:18:18

      Hello Sarah,

      Like you, I have something of a bone to pick with regard to distraction and thought stopping. Admittedly, I have used both of these regularly over the years but I cannot see them being useful in the long run for handling a particularly troublesome anxiety issue. Thought stopping reminds me of that Bob Hope video that is linked on Dr. V’s site: STOP IT! While it might be helpful to catch oneself in the middle of having an automatic thought, does going through the ‘stopping’ process really benefit an individual more than analyzing the negative thought? True, it might be an adequate coping mechanism but I have difficulty seeing the benefit of this practice beyond a certain point. Thought records just seem better.

      As for distraction, I can see these easily becoming avoidance behaviors – something that Wright and his colleagues point out. Ultimately, it feels as though the anxiety or worry is being substituted for something else. Would it not be better to work on the worrisome thoughts with cognitive therapy?

      Reply

      • Luke Dery
        Nov 04, 2017 @ 15:32:33

        Just chiming in on the “stop it”/distraction conversation:

        If I’m not mistaken, the “stop it” concept is ideally supposed to be used in situations of severe racing thoughts, and used as a way to “break away” and then implement some thought challenging/analysis work (thought record, etc). I don’t believe “stop it” is considered a technique on its own, but rather a method to help someone get into a better state to actually do some real cognitive work. For instance, say an individual with OCD is fixated on an obsessive thought and repeatedly performs a compulsive behavior, such as flicking a light on and off. “Stop it” comes in to break the individual out of his/her racing thoughts and repeated light-flicking and get into a mental state to do a thought record. Any thoughts on this?

        Reply

  7. Alana Kearney
    Nov 02, 2017 @ 09:46:00

    Behavioral exposure is a therapeutic technique that is specifically beneficial for clients presenting with anxiety disorders. The book mentions that it is particularly useful for panic disorders, OCD, and PTSD because they each have a certain stimulus that elicits a debilitating fear response. This exposure technique is meant to break the connection between the fearful stimulus and the fearful response so that when a client becomes exposed to the stimulus, he/she does not feel the need to react with a feared response. The goal in the therapeutic relationship at this point is for the therapist to teach proper coping strategies, like breathing techniques, distractions, and thought stopping, to utilize in stressful situations. Once the client has grasped an understanding of these techniques, the therapist and client work on creating a hierarchy of fears so that they can gradually work up from stimuli that causes the least amount of stress to the most feared stimulus for the client. Behavioral exposure is so beneficial because it encourages the client to confront his/her fear and think about the fear in a logical way. It teaches the client that he/she does not need to avoid fear, but instead can recognize fearful situations and overcome them. For example, clients with OCD may feel driven to always perform their compulsions, but through exposure, they can learn to cope through their obsessive thoughts, overcome their fear of not completing their compulsions, and decrease the anxiety that is created when they do not complete the task.
    Although it seems very straightforward and beneficial, clients in exposure therapy can easily become very overwhelmed. It is important to realize that behavioral exposure should be a gradual process. Anxiety not only creates mental blocks that cause clients to avoid things they fear, but it also creates physiological symptoms that inhibit the clients’ ability to appropriately respond to the fearful stimuli. Therapists must be cautious about how much they push their clients in exposure, and rely on the clients to set their own limitations to some extent. Therapists should also be aware that even though they may have taught their clients certain coping strategies, it could be hard to implement these strategies into real life situations at first. Behavior exposure requires therapists to have patience for when the client feels he/she cannot succeed, but to continuously encourage their clients to keep going with the therapy.

    Reply

    • Noella Teylan-Cashman
      Nov 02, 2017 @ 21:21:45

      Alana,

      I like how you discussed setting limits within exposure therapy; I liked how you stated that clients should set their own limits, with the encouragement of the therapist. I felt like this reinforced the collaborative nature of therapy and is a good reminder that the client is the one who knows him/herself best. At the same time, I believe therapists should challenge clients’ limitations because people are often apprehensive to move out of their comfort zones. I think it can be a tricky balance between respecting the boundaries of clients while simultaneously trying to ensure that they are progressing at the fastest possible rate.

      Reply

    • Chiara Nottie
      Nov 03, 2017 @ 12:45:02

      Hey Alana,
      I like that you explained how exposure therapy can impact OCD, a lot of us focused on how it helps anxiety disorders. I can definitely think of some cautions to be aware of when treating individuals with OCD using exposure therapy. For instance, pushing clients too far, or too soon. The biggest risk of all is not setting a client back but stressing them out so much that they are set back in therapy and retract from therapy all together. Although it would not be ideal to cause your client to have a setback in therapy, that would at least be possible to fix, but losing a client would be a guilt-ridden disaster. OCD overall seems approachable to use behavioral exposure techniques on. PTSD however, seems more challenging in regards to cautions the therapist might have to take.

      Reply

  8. Liisa Biltcliffe
    Nov 02, 2017 @ 11:35:02

    The first thing that must be done is to interrupt the connection between the unconditioned stimulus/conditioned stimulus and the unconditioned response/conditioned response by replacing it with more adaptive behavior (Wright, Basco, & Thase, 2006). Exposure has the opposite effect of avoidance in that clients will initially experience fear to the stimulus, but because the body cannot sustain heightened physiological responses for long, fatigue will occur and the clients adapt to the situation. Pairing this with cognitive restructuring can greatly aid in the process. There are different types of exposure including imaginal exposure and in vivo exposure. Clients are asked to do a hierarchy for graded exposure to rate their anxiety level in response to certain activities. Behavioral exposure is so effective for some disorders because it forces clients to feel that anxiety, work through it in the moment, habituate to it, and then come out the other side of it, all while being guided by a skilled clinician. Clients learn through imaginal or ideally, through in vivo exposure, coupled with relaxation or breathing techniques, to manage their anxiety thereby giving them a sense of self-efficacy. It is important to make sure that there is sufficient trust already established before trying exposure. It is also important to be careful of not exposing the client to an activity/fear that is too high on his or her hierarchy for graded exposure. This could traumatize the client and perhaps he or she would not want to try something else, and trust would be lost between the client and clinician. In addition, it mentions in Wright, Basco, and Thase (2006) to pace the sessions according to the client’s needs and to not go too fast as to overwhelm the client. Another caution to keep in mind is when doing in vivo exposure with the clinician present, to make sure that the clinician’s presence does not add to the client’s safety/avoidance factor. In other words, the clinician’s presence should provide just enough guidance as to help the client face the anxiety/fear and then take that on as a homework assignment by his- or herself. This will help clients better master that activity and manage the anxiety on their own.

    Reply

    • Olivia Grella
      Nov 02, 2017 @ 21:58:17

      Hi Liisa, I like how you mentioned how having the clinician present during in vivo exposure can be a potential problem. Like we discussed in class today (and how you mentioned in your post), having the clinician there can be helping the client with their avoidance or safety behaviors. Although the clinician should be present when in vivo exposure begins, they should gradually reduce their presence and involvement during the exposure so that the client can learn how to do so on their own without the “safety” of always having another person present alongside them. This not only teaches them how to use those skills on their own, but it can also be more rewarding to them when they begin to realize they can face these situations without the help of someone else.

      Reply

    • Shay Young
      Nov 04, 2017 @ 13:48:44

      Lisa,
      I liked how you mentioned safety behaviors in your post. I did not entirely understand what the books mention of it meant, but your post as well as our class discussion on safety behaviors really helped to clarify the concept for me. The therapist really needs to be careful about just how hands on they are. Clients will gain more when they feel that the exposure was done mostly independently. Of course at first the therapist will help the client reach a comfort level and will be their rock and support so to speak, but soon enough the client should reach a place where they feel able enough to do it on their own. That’s why it also stresses the importance of the therapist taking a step back, even when physically present. Don’t jump in to soon. Also regarding safety behaviors, I think taking a step back can help illuminate any other potential safety behaviors that the client may be doing. I imagine safety behaviors can take the form of self soothing, and I wonder how much of that to allow?

      Reply

  9. Chiara Nottie
    Nov 02, 2017 @ 11:49:30

    CBT has treatment interventions with an emphasis on behavioral change through exposure and activation. Behavioral exposure interventions work well for avoidant behaviors. This makes behavioral exposure great for treating anxiety disorders, PTSD, and OCD. Individuals with anxiety disorders worry over different things and avoid situations. Behavioral exposure helps these individuals to endure situations they typically worry about, to teach them that feared situations are safe and manageable. Behavioral activation on the other hand is best for treating depressive disorders, because it increases activity to help someone stay engaged in activities and relationships, and help their energy to stay elevated. CBT originally developed treatment interventions inspired by the learning theory model (Wright, 2006). The learning theory model posits that an unconditioned stimulus (UCS) originally frightens an individual. The individual responds to this unconditioned stimulus with an unconditioned response (UCR). Anxiety disorders are complicated by unconditioned stimuli being generalized. This means that anything similar to an original event that caused an individual panic, will be feared as well. These similar situations are called conditioned stimuli (CS) and elicit a conditioned response (CR), a learned response (Wright, 2006). Exposure therapy undoes the learning of conditioned responses, and takes away the power of stimulus generalization. Typically, individuals with anxiety will avoid situations that make them feel nervous, which temporarily provides relief. However, avoidance does not put a permanent end to anxiety. The link between the UCS/CS and the UCR/CR has to be severed for anxiety to reduce. Exposure therapy works on adaptive behavior responses that break the link between UCS/CS and UCR/CR (wright, 2006). If we apply the information from this model towards treating anxiety disorders we can, educate individuals about the origins of their anxiety and the implications of generalization. This knowledge can be very empowering to anxious individuals and instill hope that they can modify and control their anxiety with effort. The model can address generalization and help individuals decrease what they apply anxious feelings towards. And finally, the model can investigate the original stimulus that evoked initial fear in the individual, in order to adapt assessment of this original stimulus and change responses to it.
    Like all therapeutic techniques there are things to remain cautious about. Exposure therapy can be very taxing on an individual emotionally, psychologically, and physiologically, which means there needs to be a lot of trust between a client and therapist before exposure techniques can be implemented. Even if there is trust between a client and a therapist, something else to keep in mind before using exposure interventions is the stages of change. If a client is not ready to start utilizing exposure techniques and is pushed too soon, things can backfire and leave a client more anxious than before. Related to that point, is the knowledge of a client’s limits. In therapy we want to make advances in treatment by pushing beyond what’s comfortable to challenge a client but making sure to not push too far. Challenging comfort is fine but when you challenge a client too much they can retreat from therapy. A final thing to remain aware of regarding treating anxiety disorders is how important physiological symptoms are. Anxiety is significantly influenced by a client’s physiological sensations and how they attend to them. Exposure therapy works on modifying physiological responses to stimuli as a part of treatment. It would be a mistake to not check in with a client about how they are reacting physiologically to situations. Treatment can really fail if physiological sensations are not measured, explored, and modified.

    Reply

    • Julie Crantz
      Nov 03, 2017 @ 15:47:43

      Hi Chiara,
      I appreciate when you mention how exposure therapy can be very taxing on a client in multiple ways. There certainly does need to be a solid and trusting therapeutic relationship established before entertaining the possibility of using a technique like exposure therapy with a client. It would be terrible to proceed with this technique when a client is not ready, and the client becomes worse and more filled with anxiety over the feared stimulus. This could also lead the client to end therapy and give up on facing his or her fears. You also point out the importance of recognizing and acknowledging clients’ physiological responses during the process of exposure therapy. This is a very insightful point to make and a vital part of the process!

      Reply

    • Lindsey
      Nov 05, 2017 @ 11:51:02

      I appreciate your emphasis on checking in with the client about physiological symptoms. We’ve learned a lot about how asking a client “What are you thinking?” can result in a response describing emotions (instead of thoughts) and how asking a client “What are you feeling?” can result in a description of physical symptoms (instead of emotions). All of these responses are valid because they serve as reinforcers to the client’s automatic thoughts. Failure to inquire, acknowledge, or validate a client’s physiological symptoms might create distance between the client and therapist and hinder the client’s ability to progress. Therapists must educate clients on how to respond to physiological symptoms through the promotion of adequate coping skills and breathing techniques.

      Reply

  10. Julie Crantz
    Nov 02, 2017 @ 12:49:50

    Anxiety disorders can be very crippling for people who suffer from them. One effective method for treating anxiety disorders is behavioral exposure. The process of behavioral exposure works by unpairing an unconditioned stimulus/conditioned stimulus and an unconditioned response/ conditioned response through exposing a client to the stressful stimulus they are fearful of. The client would typically engage in avoidance behaviors to stay away from the stressful stimulus. With exposure, the client faces the feared stimulus with the help of a therapist in a controlled manner using cognitive restructuring and relaxation methods (Wright, Basco, & Thase, 2006). Therapists often use the systematic desensitization method in exposure therapy. Systematic desensitization includes developing a hierarchy of the feared stimuli and using this ranking to create a graded exposure procedure. The therapist and client work together using a properly timed approach to gradually tackle each level of the hierarchy. Exposure can be imaginal or in vivo. Imaginal exposure, or using the client’s imagination to deal with the feared stimulus, can be especially helpful for treating clients with PTSD or OCD. In vivo exposure requires the client to directly confront the feared stimulus (Wright, Basco, & Thase, 2006). Exposure therapy overall allows the client to face the feared stimulus head-on with the support and guidance of a trusted therapist versus continuing to live a life of suffering, fear, and avoidance.

    There are cautions to consider when implementing behavioral exposure with clients such as the client’s readiness to face the feared stimulus. Clients must be motivated to deal with their fears, and if they are not willing and prepared to experience the effects of exposure therapy which initially includes anxiety, the treatment will not be appropriate. The anxiety and discomfort that some clients experience during exposure therapy may be too much for them to handle. Pacing of the exposure therapy is critical, making sure the therapist is not moving too quickly for the client (Wright, Basco, & Thase, 2006). When a therapist accompanies a client during the exposure therapy experience, it is important the therapist does not inadvertently prompt the client to engage in avoidance behaviors where the client will only face the feared stimulus with the therapist present. The therapist will need to coach the client on continuing exposure work outside of therapy sessions without the therapist present. A client may confront obstacles when unaccompanied by the therapist during exposure work outside of session, therefore it is vital for the therapist to work with the client in session to discuss adaptive coping strategies to be used when confronted with challenges. It is also important for the therapist to consider the clients’ strengths, diagnosis, and if the client has comorbid conditions when engaging in exposure therapy. It is imperative the therapist gauges the client’s response to exposure therapy appropriately in order to not pressure clients to work at a rate that is beyond their limits (Wright, Basco, & Thase, 2006).

    Reply

    • Noella Teylan-Cashman
      Nov 02, 2017 @ 18:47:57

      Julie,

      I really liked how you touched upon the issue of inadvertent reinforcement. It is important that the therapist does not allow the client to develop a dependence on their presence—the therapist should not be used as a replacement for another “Safety behavior” that the client engages in. Additionally, like you said, because there is a high likelihood for the individual to encounter the feared stimulus while not in therapy, the therapist should provide the client with an initial repertoire of basic coping skills that can be easily implemented at the beginning of therapy before other treatment methods are introduced.

      Reply

  11. Lindsey
    Nov 02, 2017 @ 13:04:12

    Behavioral exposure is very effective for soft-wired fears (i.e. anxiety disorders) that produce a hard-wired response. Learning theory purports individuals who have subjective experiences of fear synced with physiological arousal symptoms are a result of being exposed to a threatening stimulus. It is normative for a frightening UCS to produce an UCR; however, this becomes problematic when stimulus generalization occurs because anything that is seemingly related to the CS develops a CR. Avoidance seems like the most logical response for these individuals because it provides the most instant gratification for relief, yet also reinforces the patient’s cognitive distortion / illogical reasoning. The avoidance pattern must be broken to overcome the feared stimulus. Behavioral exposure separates the stimulus-response connection. First, it is important to learn relaxation and grounding techniques for coping purposes. Secondly, exposing the client teaches the individual that physiological arousal is only temporary because the body will naturally resume homeostasis in the presence of the feared stimulus. This must be done in a careful and collaborative manner by the therapist. When implementing exposure interventions, the clients’ capacity to change must be considered with caution and respect. Therapeutic goals should include inspiring the client to conquer their fears, not violating boundaries that could subject them to harm (i.e. flooding). According to Wright, the speed of exposure therapy should take the client’s readiness for change, intelligence, resiliency, and comorbidity into consideration.

    Reply

    • Stephanie Welch
      Nov 03, 2017 @ 22:51:36

      Lindsey,
      I liked that you pointed out the soft-wired fears producing a hard wired response. I think that it is important to understand how fears develop and are maintained with avoidance when doing behavioral exposure. I also liked that you mentioned the importance of learning relaxation and grounding techniques. Clients with anxiety often feel like they can not deal with the anxiety and therefore benefit from learning coping strategies.

      Reply

  12. Luke Gustavson
    Nov 02, 2017 @ 13:55:01

    Behavioral exposure tends to be extremely effective when treating anxiety and anxiety disorders, such as specific phobias and panic disorder. This tends to hold true due to the nature of anxiety overall. When individuals experience anxiety resulting from some kind of known trigger (for example, dogs), the anxious feelings could cause the individual to engage in avoidance behaviors. These avoidance behaviors allow the individual to avoid the anxiety-causing stimulus that directly leads to a decrease in anxiety.
    Avoidance behaviors, however, function with anxiety utilizing principles of operant conditioning. Specifically, when an individual successfully uses an avoidance behavior they are rewarded by the resultant decrease in anxiety. This functions as negative reinforcement. What this ultimately means is that when avoidance behaviors are successful, their utilization becomes more likely. The more an individual avoids the cause of their anxiety, the more they are likely to fear that cause.
    Behavioral exposure is essentially the uncoupling of the conditioned stimulus (source of anxiety) from the conditioned response (avoidance behavior). By forcing an individual to confront the source of their anxiety and to experience it, they are deliberately exposed to disconfirming evidence that this particular source should produce an anxious response. Therefore, an individual with a fear of dogs is exposed to dogs – gradually – and essentially unlearn the avoidance response. Similarly, psychotherapists can teach or put in place other coping mechanisms as substitutes for maladaptive avoidance. This also brings to mind Response Prevention, which is an addition to Exposure Therapy, which prevents the compulsive behaviors exhibited by individuals with Obsessive-Compulsive Disorder. By preventing the behavior that reduces the obsessive thoughts, response prevention stems the reinforcer of that behavior.
    However, there are circumstances where the usage of behavioral exposure should be cautioned against. One such situation is in the use of flooding. Flooding is a behavioral exposure technique that takes an individual with a fear of dogs and throws them into a room with 20 dogs for 4 hours. This technique is rather drastic, however, as it involves cranking the fear up to 11 almost immediately. This could be extremely distressing to the client, perhaps to the point of injury.
    Similarly, while flooding operates much like in vivo exposure (considered the gold standard of exposure techniques); imaginal exposure tends toward weaker outcomes than in vivo. However, imaginal exposure does have its applications. For instance, some situations may be difficult or impossible to replicate while others could be dangerous or potentially harmful to the client. In such cases, it is recommended to utilize imaginal exposure to reduce the risk of harm.
    Finally, Wright mentions a few behavioral interventions that aren’t necessarily exposure but act more like mental band-aids. One of these that could exacerbate OCD-based obsessions is the usage of thought stopping. Thought stopping does not involve the analysis of negative automatic thoughts as does regular CBT. Instead, thought stopping is simply the concentrated cessation of a negative thought that is replaced with a more positive, calming thought.

    Reply

    • Sarah Hine
      Nov 04, 2017 @ 10:44:32

      Luke,
      Your description of the role of avoidance behaviors in the development of anxiety through conditioning was explained well. Something you brought up that I think is important to consider is how this cycle of reinforcement leads to an increase in avoidance and anxiety. Avoidance acts as both a relief for symptoms and a reinforcer of symptoms. Even though avoidance feels good in the moment, it fails to provide long term relief. However, I think for some clients this spiral can be easy to miss, or can be labeled as helpful, because fear related emotions/thoughts may be so overwhelming and relief of symptoms becomes the priority. It is also important to work with clients to replace these behaviors with more positive coping skills, as you state in your post. I can imagine that without these, clients will easily fall back to the safety of avoidance rather than face their fears empty handed.

      Reply

  13. Noella Teylan-Cashman
    Nov 02, 2017 @ 14:45:29

    Behavioral exposure is very effective for anxiety based disorders such as panic disorder, agoraphobia, specific phobia, PTSD, and OCD. As a treatment, behavioral exposure is successful because it allows individuals to confront their feared stimulus with guided help from a trained professional. Through this process, the physiological symptoms of anxiety are activated, which allows the therapist and client to manage/diffuse these feelings. While the experience of these symptoms and the feeling of distress that accompanies exposure may be uncomfortable in the moment, the client is able to utilize coping skills first hand. This prepares clients to eventually overcome stressful situations independently, without the help of a therapist. The process of exposure ultimately challenges/alters the learned fear response that has been developed by the individual, which will lead to the disengagement of avoidance behaviors. Any disturbances in daily functioning should be considerably lessened by eliminating avoidance behaviors.

    While I do think behavioral exposure is an extremely valuable technique, I also believe that it should be used with caution, and only be implemented by trained professionals. Therapists must accurately assess the client’s readiness for change and ability to participate in this particular treatment. Personally, I think the most effective methods in behavioral exposure are systematic desensitization, imaginative exposure, and in vivo exposure. Systematic desensitization is especially helpful because of the hierarchical nature of the method; it is important to gradually introduce the feared stimulus to the client in order to prevent any further distress. Furthermore, imaginative exposure and in vivo exposure allow the client to experience the negative emotions attached to the presentation of their feared stimulus, while still being in the guided presence of the therapist.

    Reply

    • Julie Crantz
      Nov 03, 2017 @ 15:41:03

      Hi Noella,
      I agree with you that systematic desensitization is one of the most effective methods in behavioral exposure. Creating a hierarchy of feared stimuli with the client and then assisting the client with gradually facing each level of the feared stimuli is so much more beneficial than overwhelming the client with the feared stimulus all at once. Step by step the client can overcome the feared stimulus in a safe and supportive setting with the therapist. And, the client is also prepared to contend with the feared stimulus outside of session with coaching from the therapist. I am looking forward to helping clients in the future by using this technique!

      Reply

  14. Venessa Wiafe
    Nov 02, 2017 @ 15:34:58

    Individuals with certain disorders, such as panic disorder, social phobia, and OCD can gain a lot of assistance with reducing symptoms and their overall health through exposure therapy. Individuals with these kinds of conditions tend to avoid what triggers their symptoms because it causes them to feel uncomfortable, stressed, scare, and unsafe. Instead of facing their fears and overcoming them so that they don’t have to continue to engage in avoidant behaviors, they satisfy themselves by making sure they do not experience their negative sensations. These individuals, however, can’t be completely content or function properly if they continue to hide from their triggering stimuli. Behavioral exposure can assist these individuals by effectively exposing them to the source of their stimuli with the aim of not trying to put them in any danger. With this technique, individuals can modify their mindset of not being able to overcome their triggers by eradicating their avoidant behavior and enduring their situations to break the negative cycle that never ends. Behavior therapy helps these individuals reduce their fear and anxious responses as they gradually confront their feared stimuli or issues. The four step process used within this technique includes assessment of symptoms, triggers for anxiety, and coping mechanisms, identification and prioritization of targets for therapy, coaching in basic skills for managing anxiety; and exposure to stressful stimuli until the fear response is significantly reduced or eliminated. These steps that are guided by the therapist in therapy allow clients to take a step by step approach towards eradicating their irrational cognitive processes and behaviors, and moving towards the practice of being exposed to their fears, so that they become less triggered. They will be also to stop allowing their fears and anxiety control their life and instead have authority over them. Some cautions to consider as a therapist when implementing behavioral exposure interventions are to not move in a pace that is beyond the client’s speed, so that they don’t become too overwhelmed. The therapist and client should move simultaneously and collectively so that they are always on the same page. The client should feel comfortable and ready for each next step. Moving rapidly can make the client’s fear worse and be counterproductive to his treatment. The therapist must also make sure that the client is comfortable with the type of exposure technique being used. The in vivo behavioral exposure technique may be too harsh for the client to work with and that can prevent him from wanting to engage in treatment, and further more make matters worse. The therapist should make sure that the client is comfortable with the exposure technique before utilizing it in the client’s treatment process. The therapist should work in the client’s best interest and not employ any strategies that can be detrimental to the client’s well being. It is a graduate process to a better lifestyle of the client and even though CBT is a short therapy process, take it a session at a time can help the client overcome his daily triggers.

    Reply

    • Luke Gustavson
      Nov 03, 2017 @ 20:23:33

      Hello Vanessa,

      You mention that behavioral exposure can be problematic if it progresses faster than what the client is ready for. Specifically, you mention that the client should be comfortable and ready for each step. Given that behavioral exposure is very in tune with anxiety disorders, I believe comfort may be contrary to the purpose of the exposure.
      As you know, anxiety is an uncomfortable thing. Exposure on its own is likely to be an uncomfortable thing as well – and probably should if behavior change is to occur. As a result, you are absolutely correct that a client should be ready for the next step, but I cannot agree that they must necessarily be comfortable. This is probably one of the unfortunate great truths of psychotherapy: there are times when it will be uncomfortable and these moments are typically periods of growth. This does not mean a client should be terrified, but it does mean that the next step in the hierarchy should seem challenging at the very least.

      Reply

    • Lindsey
      Nov 05, 2017 @ 11:29:47

      I appreciate that you mentioned the therapist should make sure the client is comfortable with the exposure hierarchy and exposure process. Collaboration is vital during the use of exposure therapy because it can make or break the client’s outcome for success. Though I can understand where Luke is coming from in terms of challenging the client, the level of discomfort in the exposure hierarchy should be mutually agreed upon for optimal results. It is essential that the therapist prepare the client in ways that promote getting comfortable with discomfort, thus the demand for psychoeducation and skills training (i.e. coping skills, breathing techniques) to work through the discomfort successfully.

      Reply

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Adam M. Volungis, PhD, LMHC

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