1. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Systems of Psychotherapy: A Transtheoretical Analysis Chapter 8. Exposure Therapies

2. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Exposure Therapies Directly confront feared stimuli & activate intense emotions Particularly useful in tx of anxiety & trauma 3 exposure therapies in chapter Implosion (Stampl) Exposure (Foa) EMDR (Shapiro)

3. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. A Sketch of Thomas Stampfl 1923 - Convinced that avoidance is at heart of psychopathology Attempted to integrate psychoanalytic and behavioral therapy First behavioral researcher to demonstrate efficacy of implosion

4. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Theory of Psychopathology Symptoms that characterize pathology are learned avoidance responses Avoidance reduces anxiety in short term, but produces more anxiety in long term People learn to avoid not only anxious situations but also imagining those situations

5. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Theory of Therapeutic Processes Goal: extinction (gradual dissipation of conditioned anxiety due to lack of reinforcement) Client is asked to imagine in detail the anxiety-provoking situation The anxiety-producing scene cannot be left until some extinction has occured

6. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Therapeutic Relationship Relationship not needed if tapes or films can be used as anxiety-eliciting stimuli Clients need to trust therapist to experience anxiety-eliciting stimuli long enough for extinction to occur Empathy offered during evaluation to create effective implosive scenes, but not during implosion itself

7. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Practicalities of Implosive Therapists extinguish their own anxiety about scenes to effectively present them to clients 3 to 30, individual sessions Sessions run over typical 50 minutes Precautions, such as sound proofing rooms, implemented

8. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Effectiveness of Implosive Therapy More effective than no treatment & placebo Found effective with PTSD combat veterans Comparable, if not superior, effectiveness with alternative psychotherapies

9. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. A Sketch of Edna Foa Born in Israel in 1937 Spent most of education & career in behavior therapy Collaborated with colleagues in examining exposure therapy for anxiety disorders Premier proponent of prolonged exposure

10. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Theory of Psychopathology Anxiety is conditioned response controlled by two factors: respondent learning & operant learning Conditioning accounts for acquisition and extinction of fear Conceptualizes pathology in terms of both behavioral and emotional processing

11. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Prolonged Exposure Intensive (direct & immediate exposure) vs. gradual (slow & incremental exposure) Imaginal (imagining fear stimuli) vs. in vivo (actual place or tactile material) Total vs. partial response prevention

12. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Theory of Therapeutic Processes Clients given clear rationale for tx Taught anxiety coping skills Prolonged exposure Given homework Maintenance sessions as needed

13. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Therapeutic Relationship Exposure therapist acts like an effective, firm parent Clients trust of therapist allows them to stay in presence of feared stimuli Therapist models confidence

14. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Practicalities of Exposure Therapy Similar to implosive therapy 8 – 12, 1 to 2 hour sessions Homework assigned Training widely available from behavior & cognitive therapists

15. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Effectiveness of Exposure Therapy Effective in treating PTSD, OCD, specific phobias, and social phobia Small % of clients experience symptom exacerbation Low relapse rates Treatment of choice for many anxiety disorders

16. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. A Sketch of Francine Shapiro Discovered deliberate eye movements made her thoughts less distressing Founder of EMDR Institute & EMDR Humanitarian Assistance Program Controversial for controlling early EMDR training

17. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Theory of Psychopathology Psychopathology occurs when information processing is blocked Trauma is trapped or locked in the neurophysiology Everyday stimuli trigger re-experience of traumatic event

18. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Therapeutic Processes Adaptive information processing (AIP) model Counterconditioning via desensitization and cognitive restructuring Consciousness raising & catharsis operate, but not as central mechanisms

19. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Phases of EMDR Client history Preparation Desensitization Installation Body scan Closure

20. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Theory of Therapeutic Relationship Characterized by empathy, trust, & safety Clinicians communicate respect for client courage, but not during active processing Safe haven created through rapport, teaching relaxation, “stop signal”

21. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Practicalities of EMDR Typically 4 to 6, 90-minute sessions Two weekend workshops and supervised practice to acquire competence Providing pro bono treatment and training in disaster areas

22. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Effectiveness of EMDR Outperforms no treatment As effective as other exposure methods Listed as “probably efficacious” for civilian PTSD Eye movements have not been proven necessary component Remains controversial despite large research base

23. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Criticisms of Exposure Therapies From a Behavioral Perspective From a Psychoanalytic Perspective From a Humanistic Perspective From a Cultural Perspective From an Integrative Perspective

24. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Future Directions Implosive losing popularity Exposure therapy on the rise for tx of intransigent anxiety-based disorders Virtual reality exposure will gain popularity Future of EMDR is not clear, but research will compare various processing methods (e.g., eye movements, hand taps)

25. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. cue exposure desensitization phase dynamic cues emotional processing exposure therapy extinction Eye Movement Desensitization & Reprocessing (EMDR) adaptive information processing avoidance conditioning/learning avoidance repression (cognitive avoidance) avoidance responses breathing retraining classical/respondent conditioning cognitive interweave Key Terms

26. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. generalization habituation hypothesized avoidance cues imaginal exposure implosive therapy installation phase in vivo exposure looping neurotic paradox operant/instrumental conditioning pro bono prolonged exposure response prevention subjective units of distress (SUD) Key Terms (cont.)

27. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc. Recommended Websites Center for Anxiety and Related Disorders: www.bu.edu/anxiety/ www.bu.edu/anxiety/ Center for the Treatment and Study of Anxiety (Foa): www.med.upenn.edu/ctsa/www.med.upenn.edu/ctsa/ EMDR Institute: www.emdr.com/www.emdr.com/ Intern Society for Traumatic Stress Studies: www.istss.org/ www.istss.org/ Virtual Reality Exposure Therapy: www.cc.gatech.edu/gvu/virtual/Phobia/phobia www.cc.gatech.edu/gvu/virtual/Phobia/phobia

28. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.

29. Chapter 8 Copyright © 2007 Brooks/Cole, a division of Thomson Learning, Inc.