1. Cognitive Behaviour Therapy (CBT) Gerhard Ohrband - ULIM University, Moldova 5th lecture Systematic desensitization

2. Course Structure 1. Introduction: What is CBT? What are differences and similarities with other therapy schools? 2. Diagnostics in CBT 3. Classification of Psychological Disorders (ICD- 10, DSM-IV), Clinical Psychology (Etiology, prevalence, comorbidity and symptoms) 4. Etiological concepts in CBT: learning theories (classical and operant conditioning, vicarious learning, Mowrer’s Two-factor theory) 5. Systematic desensitization: in-vivo exposure and imaginatory 6. Aversion training: overt and covert

3. Course Structure 7. Response prevention: treating obsessive-compulsive disorder (OCD) 8. Social skills training: anger management, assertiveness training 9. Rational-emotive Therapy (RET) 10. Beck’s Cognitive Therapy for depression 11. Marital and Sex Therapy 12. Trauma Therapy: Expressive writing, work with affirmations, visualizations; working with victims of crimes, accidents and other difficult life-events 13. Relaxation techniques: yoga, meditation, Alexander technique, Feldenkrais 14. CBT at school: helping children with autism, hyperactivity, social phobia, social adjustment problems, learning difficulties and antisocial behaviour. 15. CBT in treating addiction and substance abuse

4. Content Definition Purpose Description Precautions Normal results Case study: systematic desensitization for agoraphobia Practical exercises

5. Joseph Wolpe

6. Definition Systematic desensitization is a technique used to treat phobias and other extreme or erroneous fears based on principles of behavior modification.

7. Purpose Systematic desensitization is used to help the client cope with phobias and other fears, and to induce relaxation. In progressive relaxation, one first tightens and then relaxes various muscle groups in the body. During the alternating clenching and relaxing, the client should be focusing on the contrast between the initial tension and the subsequent feelings of relaxation and softening that develop once the tightened muscles are released. After discovering how muscles feel when they are deeply relaxed, repeated practice enables a person to recreate the relaxed sensation intentionally in a variety of situations.

8. Purpose After learning relaxation skills, the client and therapist create an "anxiety hierarchy." The hierarchy is a catalogue of anxiety-provoking situations or stimuli arranged in order from least to most distressing. For a person who is frightened by snakes, the anxiety hierarchy might start with seeing a picture of a snake, eventually move to viewing a caged snake from a distance, and culminate in actually handling a snake.

9. Purpose With the therapist's support and assistance, the client proceeds through the anxiety hierarchy, responding to the presentation of each fearful image or act by producing the state of relaxation. The person undergoing treatment stays with each step until a relaxed state is reliably produced when faced with each item. As tolerance develops for each identified item in the series, the client moves on to the next. In facing more menacing situations progressively, and developing a consistent pairing of relaxation with the feared object, relaxation rather than anxiety becomes associated with the source of their anxiety. Thus, a gradual desensitization occurs, with relaxation replacing alarm.

10. Purpose Several means of confronting the feared situations can be used. In the pre-computer era, the exposure occurred either through imagination and visualization (imagining a plane flight) or through actual real-life — or so-called in vivo — encounters with the feared situation (going on an actual plane flight). More recently, during the 1990s, virtual reality or computer simulated exposure has come to be utilized in lieu of in vivo exposure. Research findings indicate that mental imagery is the least effective means of exposure; in vivo and virtual reality exposure appear to be indistinguishable in terms of effectiveness.

11. Description Systematic desensitization is a therapeutic intervention that reduces the learned link between anxiety and objects or situations that are typically fear-producing. The aim of systematic desensitization is to reduce or eliminate fears or phobias that sufferers find are distressing or that impair their ability to manage daily life. By substituting a new response to a feared situation — a trained contradictory response of relaxation which is irreconcilable with an anxious response — phobic reactions are diminished or eradicated.

12. Description This behavior modification technique, which is founded on the principles of classical conditioning, was developed by Joseph Wolpe in the 1950s. Some of the most common fears treated with desensitization include fear of public speaking, fear of flying, stage fright, elevator phobias, driving phobias and animal phobias. Relaxation responses are trained to occur through progressive relaxation training, a technique initially perfected by Edmund Jacobson during the 1930s.

13. Precautions Because of the potential for extreme panic reactions to occur, which can increase the phobia, this technique should only be conducted by a well- qualified, trained professional. Also, the relaxation response should be thoroughly learned before confronting the anxiety-provoking hierarchy.

14. Normal results Desensitization is an effective form of therapy. Individuals who have a positive response are enabled to resume daily activities that were previously avoided. The majority of persons undergoing this treatment show symptom reduction.

15. Case study: systematic desensitization for agoraphobia “Sometime around 1984, I discovered what I "had" by means of a talk show here in sunny Florida. Up until that time, from the age of 13 to my mid 30's, I just thought I had some form of mental illness. After all, being afraid of going to my mailbox was a pretty strange thing to have happen to me! Anyway, I saw a local talk show featuring a woman who was talking about a "challenge," just like the one I had. Immediately, I knew she was talking about me! She was offering a self-help group about 15 miles from my house that dealt with something called "Agoraphobia". At long last, I had a name for my "challenge" and I soon learned that I certainly was NOT crazy, that I wasn't alone in my challenge, and that there was help.

16. Case study: systematic desensitization for agoraphobia The program I attended taught the concept of systematic desensitization to deal with agoraphobia. Systematic desensitization involves reducing your sensitivity to certain stimuli in a given anxiety- producing situation in very small, controlled steps. This is done by exposing yourself to the situation a little bit at a time, and never letting yourself get beyond a level of #3 on the anxiety scale (scale goes from 1-10). By doing this, your mind can never remember having a "bad" experience in any given place, and therefore you're more likely to return.

17. Case study: systematic desensitization for agoraphobia Listen to a relaxation tape or use another method of relaxing before going out and trying this method. Doing a trial-run in your mind can also be useful, so that when you actually face the situation, you'll feel that it's a familiar scene that you've already been through successfully. Always keep the "5 R's" in mind. They are: React Retreat Relax Recover Repeat

18. Case study: systematic desensitization for agoraphobia Here's a sample summary of a practice situation: I walked into the supermarket and experienced a #2 anxiety level. I stood and used my tools (talk to self or to partner, count labels, look out the door. Anything to keep anxiety levels down).

19. Case study: systematic desensitization for agoraphobia I proceeded to the middle of the supermarket and checked my symptoms and decided I felt okay and was under a #3. I decided to walk to the back of the store and suddenly my anxiety rose to a #4. Slowly I turned around, verbalized what I was feeling to my support person and walked outside. I went to a "safe place" in my imagination (imagined a quiet, relaxing scene) recovered and relaxed fully. I then decided to try again.

20. Case study: systematic desensitization for agoraphobia I walked back into the supermarket, felt comfortable. Walked to the back of the store and decided to buy ONE item. I got to the checkout line and only felt a #2 anxiety level. I paid for my purchase and left. By going to the supermarket with a short list of have to's, it's easier to relax and do the practice in small steps. You can't do a practice when you have to do your weekly shopping.

21. Case study: systematic desensitization for agoraphobia If you never let yourself get above a #3 anxiety level while practicing, you'll eventually desensitize to the situation! This method can be applied to most life situations, driving, doctor's visits, having company in your home, social situations, etc. If you're willing to go out the next day and practice again in the same situation, you know you've done your practicing correctly! :)

22. Literature BOOKS Craighead, W. Edward (1976). Behavior Modification: Principles, Issues, and Applications. New York: Houghton Mifflin. Wolpe, Joseph (1990). The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press. PERIODICALS North, M. M., S. M. North, and J. R. Coble (1997). "Virtual reality therapy: An effective treatment for psychological disorders." Student Health Technology and Information 44, 59– 70. Rothbaum, B., L. Hodges, S. Smith, J. H. Lee and L. Price (2000). "A controlled study of virtual reality exposure therapy for the fear of flying."Journal of Consulting and Clinical Psychology 68, (6), 1020–1026. Ventis, W.L., Garrett, H. and Murdock, S.A. (2001). Using humor in systematic desensitization to reduce fear. Journal of General Psychology

23. Internet resources http://www.healthyplace.com/Communi ties/Anxiety/ellen/densensitization_tips. htm http://www.healthyplace.com/Communi ties/Anxiety/ellen/densensitization_tips. htm