Imaginal or In Vivo Exposure and Desensitization

Systematic desensitization is a form of exposure treatment. Exposure treatments are based on the principle that clients are best treated by exposure to the very thing they want to avoid: the stimulus that evokes intense fear, anxiety, or other painful emotions. Mowrer (1947) used a two-factor theory of learning, based on animal studies, to explain how avoidance conditioning works. First, he explained that animals originally learn to fear a particular stimulus through classical conditioning. For example, a dog may learn to fear its owner’s voice when the owner yells due to the discovery of an unwelcome pile on the living room carpet. Then, if the dog remains in the room with its owner, fear continues to escalate.

Second, Mowrer explained that avoidance behavior is reinforced via operant conditioning. Specifically, if the dog manages to hide under the bed or dash out the front door of the house, it’s likely to experience decreased fear and anxiety. Consequently, the avoidance behavior—running away and hiding—is negatively reinforced because it relieves fear, anxiety, and discomfort. Negative reinforcement is defined as the strengthening of a behavioral response by reducing or eliminating an aversive stimulus (like fear and anxiety).

Note that exposure via systematic desensitization and the other procedures detailed hereafter are distinctively behavioral. However, the concept that psychological health is enhanced when clients face and embrace their fears is consistent with existential and Jungian theory (van Deurzen, 2010; see online Jungian chapter: Link to be set up**).

There are three ways to expose clients to their fears during systematic desensitization. First, exposure to fears can be accomplished through mental imagery. This approach can be more convenient and allows clients to complete treatment without ever leaving their therapist’s office. Second, in vivo (direct exposure to the feared stimulus) is also possible. This option can be more complex (e.g., going to a dental office to provide exposure for a client with a dental phobia), but appears to produce outcomes superior to imaginal exposure (Emmelkamp, 1994). Third, computer simulation (virtual reality) has been successfully used as a means of exposing clients to feared stimuli (Emmelkamp et al., 2001; Emmelkamp, Bruynzeel, Drost, & van der Mast, 2001).

Psychoeducation is critical to effective exposure treatment. D. Dobson and K. S. Dobson (2009) state:

A crucial element of effective exposure is the provision of a solid rationale to encourage your client to take the risks involved in this strategy. A good therapeutic alliance is absolutely essential for exposure to occur. (p. 104)

Further, D. Dobson and K. S. Dobson (2009) provide a sample client handout that helps inform clients of the exposure rationale and procedure.

Exposure treatment means gradually and systematically exposing yourself to situations that create some anxiety. You can then prove to yourself that you can handle these feared situations, as your body learns to become more comfortable. Exposure treatment is extremely important in your recovery and involves taking controlled risks. For exposure treatment to work, you should experience some anxiety—too little won’t be enough to put you in your discomfort zone so you can prove your fears wrong. Too much anxiety means that you may not pay attention to what is going on in the situation. If you are too uncomfortable, it may be hard to try the same thing again. Generally, effective exposure involves experiencing anxiety that is around 70 out of 100 on your Subjective Units of Distress Scale. Expect to feel some anxiety. As you become more comfortable with the situation, you can then move on to the next step. Exposure should be structured, planned, and predictable. It must be within your control, not anyone else’s. (p. 104)

Massed (Intensive) or Spaced (Graduated) Exposure Sessions

Behavior therapists continue to optimize methods for extinguishing fear responses. One question being examined empirically is this: Is desensitization more effective when clients are directly exposed to feared stimuli during a single prolonged session (e.g., one 3-hour session; aka massed exposure) or when they’re slowly and incrementally exposed to feared stimuli during a series of shorter sessions (such as five 1-hour sessions; aka spaced exposure)? Initially, it was thought that massed exposure might result in higher dropout rates, greater likelihood of fear relapse, and a higher client stress. However, research suggests that massed and spaced exposure desensitization strategies yield minimal differences in efficacy differences (Ost, Alm, Brandberg, & Breitholz, 2001).

Virtual Reality Exposure

Technological advancements have led to potential modifications in systematic desensitization procedures. Specifically, virtual reality exposure, a procedure wherein clients are immersed in a real-time computer-generated virtual environment, has been empirically evaluated as an alternative to imaginal or in-vivo exposure in cases of acrophobia (fear of heights), flight phobia, spider phobia, and other anxiety disorders (Krijn et al., 2007; Ruwaard, Broeksteeg, Schrieken, Emmelkamp, & Lange, 2010).

In a meta-analysis of 18 outcome studies, Powers and Emmelkamp (2008) reported a large effect size (d = 1.11) as compared to no treatment and a small effect size (d = .35) when compared to in vivo control conditions. These results suggest that virtual reality exposure may be as efficacious or even more so than in vivo exposure.

Interoceptive Exposure

Typical panic-prone individuals are highly sensitive to internal physical cues (e.g., increased heart rate, increased respiration, and dizziness). They become especially reactive when those cues are associated with environmental situations viewed as potentially causing anxiety (Story & Craske, 2008). Physical cues or sensations are then interpreted as signs of physical illness, impending death, or imminent loss of consciousness (and associated humiliation). Although specific cognitive techniques have been developed to treat clients’ tendencies to catastrophically overinterpret bodily sensations, a more behavioral technique, interoceptive exposure, has been developed to help clients learn, through exposure and practice, to deal more effectively with physical aspects of intense anxiety or panic (Lee et al., 2006; Stewart & Watt, 2008).

Interoceptive exposure is identical to other exposure techniques except that the target exposure stimuli are internal physical cues. There are at least six interoceptive exposure tasks that reliably trigger anxiety (Lee et al., 2006). They include:

  • Hyperventilation
  • Holding breath
  • Breathing through a straw
  • Spinning in circles
  • Shaking head
  • Chest breathing

Of course, before interoceptive exposure is initiated, clients receive education about body sensations, learn relaxation skills (e.g., breathing training), and learn cognitive restructuring skills. Through repeated successful exposure, clients become desensitized to previously feared physical cues (Forsyth, Fusé, & Acheson, 2009).

Response and Ritual Prevention

Mowrer’s two-factor theory suggests that, when a client avoids or escapes a feared or distressing situation or stimulus, the maladaptive avoidance behavior is negatively reinforced (i.e., when the client feels relief from the negative anxiety, fear, or distress, the avoidance or escape behavior is reinforced or strengthened; Spiegler & Guevremont, 2010). Many examples of this negative reinforcement cycle are present across the spectrum of mental disorders. For example, clients with Bulimia Nervosa who purge after eating specific “forbidden” foods are relieving themselves from the anxiety and discomfort they experience upon ingesting the foods (Agras, Schneider, Arnow, Raeburn, & Telch, 1989). Therefore, purging behavior is negatively reinforced. Similarly, when a phobic client escapes from a phobic object or situation, or when a client with obsessive-compulsive symptoms engages in a repeated washing or checking behavior, negative reinforcement of maladaptive behavior occurs (Franklin & Foa, 1998; Franklin, Ledley, & Foa, 2009; March, Franklin, Nelson, & Foa, 2001).

It follows that, to be effective, exposure-based desensitization treatment must include response prevention. With the therapist’s assistance, the client with bulimia is prevented from vomiting after ingesting a forbidden cookie, the agoraphobic client is prevented from fleeing a public place when anxiety begins to mount, and the client with Obsessive-Compulsive Disorder is prevented from washing his or her hands following exposure to a “contaminated” object. Without response or ritual prevention, the treatment may exacerbate the condition it was designed to treat. Research indicates that exposure plus response prevention can produce significant brain changes in as few as three psychotherapy sessions (Schwartz, Gulliford, Stier, & Thienemann, 2005; Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996).


Reflections on Another Counselng and Psychotherapy Video Shoot

Yesterday I got to demonstrate skills associated with four different therapy approaches: Reality therapy, psychoanalytic therapy, cognitive-behavioral therapy, and Adlerian therapy.

Overall the video shoot went well, but I was surprised that of these four approaches, in many ways I felt most comfortable with reality therapy. I hadn’t expected that. Many people don’t “get” reality therapy and think it’s either a form of cognitive-behavioral therapy or a highly confrontational approach wherein therapists sternly confront their clients with cold, cruel, reality.

But reality therapy isn’t a form of CBT and it’s not confrontational. What I found myself doing in the reality therapy demo was following the sage guidance of Robert Wubbolding who formulated four BIG questions that stand at the heart of reality therapy. The questions would be good for everyone to memorize and can, when applied gently and persistently, help get people back onto a positive track. The questions are:

1. What do you want?

2. What are you doing?

3. Is it working?

4. Should you make a new plan?

Wubbolding has written several books on reality therapy and is taking up the torch for William Glasser, who was the original developer of this approach. In particular, I recommend Wubbolding’s books because they will help guide you in how to ask questions to help clients explore these four very important questions. I can even use them right now:

What do I want? — A good night’s sleep.

What am I doing? — Typing up this blog

Is it working? — Nope!

Should I make a new plan? — Good night!


Getting Your Buttons Pushed by Teenage Clients

The following material is adapted from Tough Kids, Cool Counseling.

Although we generally suggest not taking your client’s degrading comments personally, in the real world, we all get our buttons pushed sometimes. A graphic example of a therapist over-reacting to provocative client behavior was captured in the feature film, Good Will Hunting (Van Sant, 1997). 

You may recall the scene. The main character, Will, played by Matt Damon, is an extremely intelligent but emotionally disturbed young man with mathematical genius. His would-be mentor, in an effort to help Will fulfill his potential, sends him to several different counselors, none of whom are able to help Will. Finally, Will ends up in the office of Sean McGuire, played by Robin Williams.

During his initial session with McGuire, Will is his provocative and nasty self. He begins insulting McGuire’s deceased wife which “activates” McGuire’s emotional buttons. The result: McGuire grabs Will around the neck and slams him up against the wall. Of course, McGuire also decides to take on Will as a client and eventually (and rather magically) he successfully helps Will move forward in his life.

We’d like to emphasize two key points related to this excellent example of resistance and countertransference from Good Will Hunting. First, be aware of your emotional buttons. If you’re getting your buttons pushed, seek support and counseling for yourself. Second, no matter how provocative your young clients may act, avoid using Robin Williams’s “Choking the client” technique.  It may play well in Hollywood, but physical contact with resistant, aggressive, and/or angry clients is highly ill-advised. If you think rationally about the “Will Hunting” character and the fact that he had a history of physical trauma, touching him in an aggressive way would be ESPECIALLY contraindicated.

 If you’re having your emotional buttons pushed occasionally by teenage clients or students, consider yourself normal. On the other hand, if the button pushing begins to cause you to contemplate acting on destructive impulses, it’s time to get therapy for yourself, and/or support from a collegial supervision group. Many psychoanalytically-oriented writers have warned about the powerful regressive countransference impulses that young clients can ignite in their counselors (Dass-Brailsford, 2003; Horne, 2001). 

Go Go Gestalt: The Theories Video Shoot, Part I

There’s nothing quite like experiencing embarrassment in the Here and Now.

Today Rita and I started a several day video shoot to produce counseling and psychotherapy demonstrations to go with the second edition of our theories text (Counseling and Psychotherapy Theories in Context and Practice. Rita did demos of Person-Centered and Feminist therapy and I got to do a Gestalt therapy demonstration.

In honor of the Gestalt approach, below I’ve inserted a short excerpt from our text describing the Gestalt principle of the figure-formation process. Tomorrow or the next day or whenever I’ve recovered I’ll post a short description of the Gestalt demonstration for those who may be interested.

The Figure-Formation Process

Humans are able to constantly shift their cognitive or perceptual focus. This may be especially true in our contemporary, media-based society where distractibility is normative. In Gestalt psychology, this is referred to as the figure-formation process.

An amazing human quality is the ability to intentionally shift the focus of consciousness. If you’re reading these words your focus (or figure) are the words on this page (or screen) and their meaning. This process puts you in your head—literally. You’re all eyes and intellectual processing.

This visual and intellectual experience is a function of your focus, but you might just as well focus on something else. If, as you read these words you intentionally shift focus to your ears, what happens?  Or, if you are listening to this book instead of reading, shift to the smells in the room.  Can you simultaneously focus completely on every sound wave or every odor bouncing around you without losing your intellectual focus? You may still be seeing or hearing the words, but now they’ve drifted into the background. If you consciously focus on auditory perception, then sound will take over the foreground or figure. And if we take this further we could have you alternate between different sounds and smells in your environment (maybe there’s music or a dull hum of lights, or your breathing, or someone’s perfume or your gym clothes in the corner, or . . .). In each case, your attention is shifting, more or less, and placing different perceptual experiences at the forefront. You’re engaging in a figure-formation process.

Perhaps an everyday example will help even more. Let’s say you’re driving the Interstate in Montana. The speed limit is 75 mph (yes, thanks to the federal Department of Transportation, we do have a speed limit). There aren’t many cars on the road because you’re in Montana. A signal from your cell phone pops into your awareness, triggering a social need, which then produces disequilibrium, and so you decide to take action and check your new text message. You steer with one hand, hold your phone with the other, and shift your eyes back and forth from the road to the phone. Three seconds on the road, 3 seconds reading text on the phone. At first the road and steering wheel is figure and the phone in your hand is background. Then the phone and text message is figure and the road and steering wheel is background.

Suddenly, you have a background thought about what you’re doing. Having passed your driver’s test you possess internal knowledge about how far you travel in three seconds at 75 mph. You’re covering 333 feet—over the length of a soccer or football field—every 3 seconds. This internal memory emerges from background to figure along with a realization that you could have run over 111 deer on the highway standing side-by-side while checking three-seconds of your text message. Another linked thought crystalizes into figure and you can almost hear your parents in your head telling you they love you so much that they’d like you not to text and drive.

The figure-formation voice in your head brings with it a surge of anxiety and you tap your brake and slow down to an unheard of 55 mph so that you’re only covering 243 feet every 3 seconds. Somehow you rationalize and justify that you’re safe enough to text and equilibrium is restored.

The point is not so much that you’re endangering your life and the lives of hundreds of innocent deer, but that you’re always missing something when figure recedes into background and gaining something when figure-formation occurs. This losing or gaining is, to some extent, under voluntary control. You may choose to miss out on the text message or you may choose to miss out on the 333 feet of road—but you can’t have it both ways because something has to be figure and something has to be ground.

From the Gestalt perspective, you’re always just a little bit aware of the ground (or background) and part of the purpose of therapy is to turn up background noise volume by shifting your focus or awareness so you can evaluate whether whatever’s bubbling around in the background might be meaningful or useful. During Gestalt therapy not everything you focus on will be meaningful or useful. However, many parts of your human experience (including unfinished business from the past that’s affecting you in the present) might prove useful and meaningful.

This is the essence of Gestalt therapy: Shift your focus and then shift it again to embrace here and now awareness and the personal development it might stimulate. At the same time, you recognize that not every 333-foot stretch of Montana highway will be immediately and profoundly important, but you stay with that focus because to do otherwise threatens your existence.

The figure-formation perceptual process, as applied to therapy, suggests that the primary or dominant needs of an individual can emerge from background (ground) into focus (figure) at any given moment. This is why Gestalt therapists believe that a client’s unfinished business from the past will inevitably be brought into focus as therapists keep clients in the here and now.

Saturday Morning with Rylee’s Blog

This morning I woke up tumbling through a dream of Margaret and Davis and Chelsea and Seth and Rita. We were all walking together and I got the honor of carrying Margaret on the way home. . . her 21 month old arms around my neck and then—poof—I am awake in Montana and the twins are in Connecticut.

And Rylee is in Scotland.

This past Thursday, as a part of my closing Keynote speech for the Montana Prevent Child Abuse and Neglect Conference, I managed to weave in a 90 second video clip of my grandson Davis walking around with a bucket on his head. I thought my speech was awesome. I was on fire, stringing together clear, clean, and polished sentences. But afterwards most people seemed to think the best part was watching that little boy with the bucket on his head.

This morning instead of reading and grading papers I’m reading Rylee’s blog.

Yesterday we Skyped, which was fine, but sometimes it’s even better to sift through her blog and catch a little glimpse of what she’s thinking, feeling, and doing across the pond. Freud said “Words were originally magic.” This morning my little Rylee’s magical words make me smile and miss her more than usual.

What makes people so desperate and disturbed that they would abuse children? I have a few academic answers to that question. Maybe it’s their old abuse history, their new stress, emotional troubles, needs for power and control, frustration, misdirected anger, twisted inner worlds of confusion about what they want and what they’re doing. But you know what they say: There are many good excuses, but no good reasons.

On this rainy Missoula morning I’m missing the children in my life and wanting to offer tribute to the human service providers and foster parents I met this past week in Helena who have dedicated their lives to protecting children from abuse and neglect. You all deserve a raise. Even better, you deserve to have your dream of preventing child abuse and neglect come true.

Heading to the 2012 Prevent Child Abuse and Neglect Conference in Helena, MT

Thanks to Mary Peterson, who asked if I could return to Helena again this year to do a break-out session and closing keynote, I’m heading to Helena tomorrow morning for the 2012 Prevent Child Abuse and Neglect Conference. This is a conference attended by an array of social workers, foster parents, and a ranger of other professionals who work hard to prevent and reduce child abuse in Montana. This is a fantastic group of people and I’m honored to spend a few hours with them tomorrow and Thursday. The title of my break-out session is: “How to Get Parents to Listen to your Excellent Advice” and the Keynote is “Your Wild and Precious Life” (in honor of the Mary Oliver poem). Wherever you are and whoever you are spend a moment to think about how to contribute to reducing child abuse . . . an all too frequent and disturbing pattern of behavior that gets very little focus or attention in the media.

A Tradition Like All Others

The big sports event of this past weekend was the Master’s Golf Tournament at Augusta National Golf Course in Augusta, GA. As usual, the hyped advertising slogan included the phrase, “A tradition like no other.” This is especially ironic and basically such a good lie that would make post-modern theorists proud.

In fact, the Master’s is a tradition like nearly all other traditions. It’s run by an all male club that doesn’t allow women to be members and only allowed Blacks membership in 1990. It’s about money and power and exclusivity. According to Wikipedia (I know I’m not elevating my research reputation here), “. . . club co-founder Clifford Roberts is reputed to have said, ‘As long as I’m alive, golfers will be white, and caddies will be black.'”

This year’s Master’s champion got $1,440,000. When Martha Burk tried protesting the tournament in 2004, tournament officials decided to air the entire tournament without commercials. This is just a taste of the money and power linked to these particular links.

Now don’t get me wrong. I like sports. I enjoy golf. I even get excited about watching a bit of the Master’s golf tourney on television. It’s good theater, a beautiful venue, and there are some amazing golfers out there. But it’s a little hard to justify Augusta not allowing women members. . . and I say this not because I think men only and women only organizations shouldn’t exist . . . but because excluding women from something that is so prestigious and so associated with money and power smacks too much of discrimination. When I watch the Master’s I always feel a little dirty. 

And so I’m hoping that one of these years an excellent golfer (think Tiger or Phil) will decide to skip a tourney held at a club that wouldn’t let their daughters, girlfriends, wives, mothers, or grandmothers be members. Somebody besides Martha Burk and this insignificant blogger should take a stand to do the right thing. Please pass this message the next time you bump into a great professional golfer.

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