FLOODING and IMPLOSIVE THERAPY EXPOSURE THERAPY Exposure treatment is a technique that is widely used in cognitive-behavioral therapy (CBT). Exposure treatment is used for a variety of anxiety disorders, and it has also recently been extended to the treatment of substance-related disorders. Generally speaking, exposure treatment involves presenting a patient with anxiety-producing material for a long enough time to decrease the intensity of their emotional reaction. As a result, the feared situation or thing no longer makes the patient anxious. Exposure treatment can be carried out in real situations, which is called in vivo exposure; exposure; or it can be done through imagination, which is called imaginal exposure. exposure. The category of imaginal exposure includes systematic includes systematic desensitization, desensitization, which asks the patient to imagine certain aspects of the feared object or situation combined with relaxation. Graded or graduated exposure refers exposure refers to exposing the patient to the feared situation in a gradual manner. Flooding refers to exposing the patient to the anxiety-provoking or feared situation all at once and kept in it until the anxiety and fear subside. There are several variations in the delivery of exposure treatment: patient-directed exposure instructions or self-exposure; therapist-assisted exposure; group exposure; and exposure with response prevention. Most exposure therapists use a graded approach in which mildly feared stimuli are targeted first, followed by more strongly feared stimuli. This approach involves constructing an exposure hierarchy in which feared stimuli are ranked according to their anticipated fear reaction. Traditionally, higher-level higher-level exposures are not attempted until the patient’s fear subsides for the lower-level exposure. By contrast, some therapists have used flooding, in which the most difficult stimuli are addressed from the beginning of treatment. In clinical practice, these approaches appear equally effective; however, most patients and clinicians choose a graded approach because of the personal comfort level. In vivo exposure refers to real-world confrontation of feared stimuli. Sometimes, in vivo exposure is not feasible (eg, it would be both difficult and hazardous for someone with combatrelated PTSD to experience the sights, sounds, and smells of combat in real life). In such cases, imaginal exposure can be a useful alternative. In imaginal exposure, the patient is asked to vividly imagine and describe the feared stimulus (in this case, a traumatic memory), usually using present-tense language and including details about external (eg, sights, sounds, smells) and internal (eg, thoughts, emotions) cues.
Theoretical Mechanisms of Exposure Therapy Biologically, the extinction ex tinction of fear appears to be mediated by N-methyl-d-aspartate receptor activity in the basolateral amygdala, a finding that has led to the use of neuroplasticity compounds such as d-cycloserine to augment exposure. There are 4 major theories that attempt to explain the psychological mechanisms of exposure therapy: habituation, extinction, emotional processing, and self-efficacy. Habituation theory purports theory purports that after repeated presentations of a stimulus, the response to that stimulus will decrease. For example, initial exposure to ocean water can be cold. However, over time and with repeated exposures, the water feels less cold as the person acclimates. Similarly, when repeatedly facing a fear-provoking stimulus in exposure therapy, the patient experiences habituation, or a natural reduction in fear response. While many clinicians
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aim for habituation to occur within the session, researchers have found that optimal treatment effects occur during the period of learning consolidation between sessions. Extinction theory emerges from a classic conditioning model in which the unconditioned stimulus is a situation, place, or person that initially caused fear (the unconditioned response) — for example, a dog bites. Through the process of stimulus generalization, fear reactions become learned (conditioned response) and are elicited by other stimuli, such as dogs that are not dangerous (conditioned stimuli). Because of the averseness of the conditioned response, fearful individuals are motivated to avoid the conditioned stimuli, thus reinforcing avoidance behavior as well as the belief that relief from fear only comes from avoidance. Exposure therapy is thought to weaken the conditioned response through repeated exposure to the conditioned stimuli in the absence of the unconditioned stimulus. For example, exposure to dogs (conditioned stimuli) without being bitten (absence of unconditioned stimulus) weakens the relationship between the conditioned stimuli and the fear of conditioned response. One limitation of extinction theory is that most phobic patients do not identify an initial conditioning event. Emotional processing theory suggests that fear is stored in memory as a network of stimuli (eg, social gathering), response (eg, sweaty palms), and meaning (eg, “I’m not good at socializing, I’m a failure”) components. Fearful individuals are thought to ascribe faulty meanings to stimuli in a way that increases fear toward those stimuli. Exposure to fear-provoking stimuli is thought to result in a new way of processing information and to correct the faulty fear structure.36,37 For example, in patients with social anxiety disorder, social interactions can be perceived as rewarding, even if the patients have sweaty palms and feel some anxiety. The self-efficacy theory focuses more on increasing skills and mastery over a situation or performance than on reducing a fear response directly. Persons with anxiety disorders tend to underestimate their capabilities to cope with fear. Therefore, persons able to face their fear and successfully tolerate it without avoiding it or withdrawing from it begin to realize they are more capable and resilient than they had imagined. Thus, they become more willing to face their fears in different contexts, thereby generalizing treatment effects. These theoretical mechanisms of exposure are not mutually exclusive, and all might be correct for any given patient. With repeated exposures, patients experience reduced sensations of fear (habituation), learn a new set of associations (extinction), feel increasingly able to cope with fear (self-efficacy), and generate new interpretations of the meanings of previously feared stimuli (emotional processing).
FLOODING and IMPLOSIVE THERAPY History Flooding Flooding is a form of behavior therapy based on the principles of respondent conditioning. It is sometimes referred to as prolonged exposure therapy. As a psychotherapeutic technique, it is used to treat phobia and anxiety disorders including posttraumatic stress disorder. It works by exposing the patient to their painful memories with the goal of reintegrating their repressed emotions with their current awareness. This involves intensive rather than gradual exposure to the situations the person fears. The exposure can be in real life or using mental images (imaginal exposure). Flooding was invented by psychologist Thomas Stampfl in 1967.
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It works on the principles of classical conditioning or respondent conditioning — a form of Pavlov's classical conditioning — where patients change their behaviors to avoid negative stimuli. According to Pavlov, we learn through associations, so if we have a phobia it is because we associate the feared object or stimulus with something negative. Flooding uses a technique based on Pavlov's classical conditioning that uses expo sure. There are different forms of exposure, such as imaginal exposure, virtual reality exposure, and in vivo exposure. While systematic desensitization may use these other types of exposure, flooding uses in vivo exposure, actual exposure to the feared stimulus. A patient is confronted with a situation in which the stimulus that provoked the original trauma is present. The psychiatrist there usually offers very little assistance or reassurance other than to help the patient to use relaxation techniques in order to calm themselves. Relaxation techniques such as progressive muscle relaxation are common in these kinds of classical conditioning procedures. As the adrenaline and fear response has a time limit, theoretically a person will eventually have to calm down and realize that their phobia is unwarranted. Flooding can be done through the use of virtual reality and is fairly effective. Psychiatrist Joseph Wolpe (1973) carried out an experiment which demonstrated flooding. He took a girl who was scared of cars, and drove her around for hours. Initially the girl was hysterical but she eventually calmed down when she realized that her situation was safe. From then on she associated a sense of ease with cars. Flooding is a psychotherapeutic method for overcoming phobias. This is a faster (yet less efficient and more traumatic) method of ridding fears when compared with systematic desensitization. In order to demonstrate the irrationality of the fear, a psychologist would put a person in a situation where they would face their phobia at its worst. Under controlled co nditions and using psychologically-proven relaxation techniques, the subject attempts to replace their fear with relaxation. The experience can often be traumatic for a person, but may be necessary if the phobia is causing them significant life disturbances. The advantage to flooding is that it is quick and usually effective. There is, however, a possibility that a fear may spontaneously recur. This can be made less likely with systematic desensitization, another form of a classical condition procedure for the elimination of phobias. Implosive therapy attempts to extinguish the fear response by exposing anxious individuals to fear-eliciting situations and forcing them to remain in those situations until their arousal is reduced or eliminated. It is important to recognize that this approach to fear reduction differs dramatically from desensitization procedures. In systematic desensitization or in vivo desensitization the individual is taught to relax and is exposed in slow, gradual, steps to situations that elicit an increasing level of anxiety; the individual is never allowed to experience more than a low level of anxiety before the situation is withdrawn. In contrast, implosive therapy involves in many respects the opposite approach, essentially starting at the top of the anxiety hierarchy. The individual is not taught relaxation methods; she or he is immediately either exposed to or instructed to imagine her or himself in the most anxiety-inducing situations for a prolonged period of time. Moreover, the patient is instructed to dwell on the worst possible outcome of the situation in order to elicit the greatest level of anxiety. For example, a claustrophobic patient might be instructed to imagine staying in a small room for two hours and to imagine that the room is getting smaller. In implosive therapy, the individual learns that there are no long-term aversive consequences to approaching the feared object or to remaining in the anxiety-inducing situation. People see that they can survive their worst fears, and the feared stimuli lose their potency to elicit anxiety. Martin Seligman of the University of Pennsylvania demonstrated in the 1960s that one effective way of teaching a dog to reenter a cage that had previously been associated with shock 3
is to force the dog into the cage and prevent its escape. Although the dog initially shows signs of considerable distress, in time the anxiety and emotionality dissipate (extinguish) and the dog is able to enter the cage to obtain food, something it had not been able to do prior to its exposure to the anxiety-provoking situation (Seligman, 1975; Seligman, Maier, & Greer, 1968). The results of a number of studies attest to the effectiveness of exposure-based treatments for fears and phobias. In their reviews of studies examining the efficacy of implosive therapy, Marks (1987) and Spiegler (1998) concluded that exposure is an effective procedure for the treatment of a variety of anxiety disorders and is generally more effective than systematic desensitization. Supporting its effectiveness, DeRubeis and Crits- Christoph (1998) included exposure therapy as an empirically supported treatment for social phobia, agoraphobia, panic disorder, and posttraumatic stress disorder. As you might expect, implosive therapy initially causes more distress among patients than systematic desensitization does, and for that reason alone many therapists are more comfortable using systematic desensitization. In response to this concern, graduated exposure has been used increasingly in behavior therapy. In this procedure, patients are initially exposed to situations that evoke only minimal levels of anxiety and then gradually progress to more stressful and anxiety-producing stimuli. Interestingly, there is now evidence that graduated exposure may be more effective than intensive exposure (Spiegler, 1998). Implosive therapy Implosive therapy (or implosion therapy) is a form of exposure therapy similar to the imaginal form of flooding, with which it can be confused. Although there are similarities, the terms implosive therapy and flooding cannot be used interchangeably. Both implosive therapy and flooding expose the client to anxiety arousing stimuli for prolonged durations. Flooding deals with the actual stimulus or its image, while in implosion therapy anxiety is aroused by only imagining the simuli (without direct contact). Further, implosive therapy involves imagined scenes that are often exaggerated by a therapist and often relate to the client's most feared fantasy. Finally, the anxiety that is provoked during implosive therapy is often addressed using psychodynamic approaches (e.g., addressing an oral fixation). Research on implosive therapy is mixed and the therapy may only temporarily reduce fears and anxiety. In flooding you might be asked to picture spider, perhaps at various distances so that you become desensitized to the image. On the other hand, in implosive therapy, you might be asked to imagine the spider entering your mouth as you sleep if that was an anticipated fantasy aspect of your fear. Implosive therapy is flooding with these characteristics: (a) All presentations of anxiety situations are done by having the client imagine scenes. (b) The imagined scenes are often ones of exaggerated or impossible situations designed to elicit as much anxiety as possible. (c) The scenes are often based on hypothesized sources of anxiety, some of which are psychodynamic in nature. These hypothesized sources of anxiety center around such things as hostility toward parental figures, rejection, sex, and dynamic concepts like Oedipus complex and death wish. Fear
Fear is a time limited response. At first the person is in a state of extreme anxiety, perhaps even panic, but eventually exhaustion sets in and the anxiety level begins to go down. Of course normally the person would do everything they can to avoid such a situation. Now they
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have no choice but confront their fears and when the panic subsides and they find they have come to no harm. The fear (which to a large degree was anticipatory) is extinguished. Prolonged intense exposure eventually creates a new association between the feared object and something positive (e.g. a sense of calm and lack of anxiety). It also prevents reinforcement of phobia through escape or avoidance behaviors.
Goals/ Purpose 1. To decrease a person's anxious and fearful reactions (emotions, thoughts, or physical sensations) through repeated exposures to anxiety-producing material. This reduction of the patient's anxiety response is known as habituation. 2. To eliminate the anxious or fearful response altogether so that the patient can face the feared situation repeatedly without experiencing anxiety or fear. This elimination of the anxiety response is known as extinction. 3. To create a safe environment in which a person can reduce anxiety, decrease avoidance of dreaded situations, and improve one's quality of life.
Disorders under Which Flooding and Implosive Therapy Can Be Used 1. Panic Disorder Exposure treatment is the central component of cognitive-behavioral treatment for panic disorder. Treatment for this disorder involves identifying specific fears within the patient's experience of panic, such as fears of being sick, fears of losing control, and fears of embarrassment. Once these fears are identified, the patient is instructed to expose himself or herself to situations in which the fearful thoughts arise (walking away from a safe person or place, for example). The rationale behind this instruction is that enduring the anxiety associated with the situation will accustom the patient to the situation itself, so that over time the anxiety will diminish or disappear. In this way, the patient discovers that the feared consequences do not happen in real life. In some patients, physical symptoms of panic lead to fears about the experience of panic itself. Fears related to the physical symptoms associated with panic can be targeted for treatment by inducing the bodily sensations that mimic those experienced during a panic attack . This technique is called interoceptive exposure. The patient is asked to induce the feared sensations in a number of ways. For example, the patient may spin in a revolving chair to induce dizziness or run up the stairs to induce increased heart rate and shortness of breath. The patient is then instructed to notice what the symptoms feel like, and allow them to remain without doing anything to control them. With repeated exposure, the patient learns that the bodily sensations do not signal harm or danger, and therefore need not be feared. The patient is taught such strategies as muscle relaxation and slow breathing to control anxiety before, during, and after the exposure. Interoceptive exposure treatment for panic usually begins with practice sessions in the therapist's office. The patient may be instructed to practice at home and then practice in a less "safe" environment, such as the patient's work setting or a nearby park. The next step is the addition of the physical activities that naturally produce the feared symptoms. Situational or in vivo exposure would then be introduced for patients with agoraphobia combined with panic disorder. The patient would be instructed to go back into a situation that he or she has been avoiding, such as an elevator or busy railroad terminal. If the patient develops symptoms of anxiety, he or she is instructed to use the techniques for controlling anx iety that were previously learned.
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The effectiveness of exposure treatment for decreasing panic attacks and avoidance has been well demonstrated. In research studies, 50% – 90% of patients experience relief from symptoms. 2. Specific Phobia And Social Phobia Graded exposure is used most often to treat specific phobia or simple phobia. In graded exposure, the patient approaches the feared object or situation by degrees. For example, someone afraid of swimming in the ocean might begin with looking at photographs of the ocean, then watch movies of people swimming, then go to the beach and walk along the water's edge, and then work up to a full swim in the ocean. Graded exposure can be done through patient-directed instruction or therapist-assisted exposure. Research studies indicate that most patients respond quickly to graded exposure treatment, and that the benefits of treatment are well maintained. Treatment for social phobia usually combines exposure treatment with cognitive restructuring. This combination seems to help prevent a recurrence of symptoms. In general, studies of exposure treatment for social phobia have shown that it leads to a reduction of symptoms. Since cognitive restructuring is usually combined with exposure, it is unclear which component is responsible for the patients' improvement, but there is some indication that exposure alone may be sufficient. Exposure treatment can be more difficult to arrange for treating social phobia, however, because the patient has less control over social situations, which are unpredictable b y their nature and can unexpectedly become more intense and anxiety-provoking. Furthermore, social exchanges usually last only a short time; therefore, they may not provide the length of exposure that the patient needs. 3. Obsessive-Compulsive Disorder The most common non-medication treatment for obsessive-compulsive disorder (OCD) is exposure to the feared or anxiety-producing situation plus response prevention (preventing the patient from performing a compulsive behavior, such as hand washing after exposure to something thought to be contaminated). This form of treatment also uses a hierarchy, and begins with the easiest situation and gradually moves to more difficult situations. Research has shown that exposure to contamination situations leads to a decrease in fears of contamination, but does not lead to changes in the compulsive behavior. In a similar fashion, the response prevention component leads to a decrease in compulsive behavior, but does not affect the patient's fears of contamination. Since each form of treatment affects different OCD symptoms, a combination of exposure and response prevention is more effective than either modality by itself. Exposure combined with response prevention also appears to be effective for treating OCD in children and adolescents. Prolonged continuous exposure is better than short, interrupted periods of exposure in treating OCD. On average, exposure treatment of OCD requires 90-minute sessions, although the frequency of sessions varies. Some studies have shown good results with 15 daily treatments spread over a period of three weeks. This intensive treatment format may be best suited for cases that are more severe and complex, as in patients suffering from depression as well as OCD. Patients who are less severely affected and are highly motivated may benefit from sessions once or twice a week. Treatment may include both therapist-assisted exposure and self-exposure as homework between sessions. Imaginal exposure may be useful for addressing fears that are hard to include in vivo exposure, such as fears of a loved one's death. Patients usually prefer gradual
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exposure to the most distressing situation in their hierarchy; however, gradual exposure does not appear to be more effective than flooding or immediate exposure to the situation. 4. Post-Traumatic Stress Disorder Exposure treatment has been used successfully in the therapy of post-traumatic stress disorder (PTSD) resulting from such traumatic experiences as combat, sexual assault, and motor vehicle accidents. Research studies have reported encouraging results for exposure treatment in reducing PTSD or PTSD symptoms in children, adolescents, and adults. Such intrusive symptoms of PTSD as nightmares and flashbacks may be reduced by having the patient relive the emotional aspects of the trauma in a safe therapeutic environment. It may take 10 – 15 exposure sessions to decrease the negative physical sensations associated with PTSD. These sessions may range from one to two hours in length and may occur once or twice a week. Relaxation techniques are usually included before and after exposure. The exposure may be therapist-assisted or patient-directed. A recent study showed that imaginal exposure and cognitive treatment are equally effective in reducing symptoms associated with chronic or severe PTSD, but that neither brought about complete improvement. In addition, more patients treated with exposure worsened over the course of treatment than patients treated with cognitive approaches. This finding may have been related to the fact that the patients receiving exposure treatment had less frequent sessions with long periods of time between sessions. Some patients diagnosed with PTSD, however, do not seem to benefit from exposure therapy. They may have difficulty tolerating exposure, or have difficulty imagining, visualizing, or describing their traumatic experiences. The use of cognitive therapy to help the patient focus on thoughts may be a useful adjunctive treatment, or serve as an alternative to exposure treatment. Many persons who have undergone sexual assault or rape meet DSM-IV-TR criteria for PTSD. They may re-experience the traumatic event, avoid items or places associated with the trauma, and have increased levels of physical arousal. Exposure treatment in these cases involves using either imaginal or in vivo exposure to reduce anxiety and any tendencies to avoid aspects of the situation that produce anxiety (also known as avoidance behavior). Verbal description of the event (imaginal exposure) is critical for recovery, although it usually feels painful and threatening to patients. It is important that the patient's verbal description of the traumatic event, along with the expression of thoughts and feelings related to it, occur as early in the treatment process as possible. It is in the patient's "best long-term interest to experience more discomfort temporarily in order to suffer less in the long run." Prolonged exposure is the most effective non-medical treatment for reducing traumatic memories related to PTSD. It combines flooding with systematic desensitization. The goal is to expose patients using both imaginal and in vivo exposure techniques in order to reduce avoidance behavior and decrease fears. Prolonged exposure may occur over nine to 12 ninetyminute sessions. During the imaginal exposure phase of treatment, the patient is asked to describe the details of the traumatic experience repeatedly, in the present tense. The patient uses the SUDS scale to monitor levels of fear and anxiety. The in vivo component occurs outside the therapist's office; it involves the client exposing himself or herself to cues in the environment that he or she has been avoiding — for example, the place where the motor vehicle accident or rape occurred. The patient is instructed to stay in the fear-producing situation for at least 45 minutes, or until their anxiety levels have gone down significantly on the SUDS rating scale.
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Often patients will use a coach or someone who will stay with them at the beginning of in vivo practice. The coach's role gradually decreases over time as the patient experiences less anxiety.
Therapist’s Behavior During Flooding In this treatment the therapist is of necessity very active. His task is to prevent avoidance behavior, to stimulate approach behavior, and to preserve a therapeutic alliance with the patient. A. Command Behavior Command behavior refers to anything implying sternness, disapproval, or the arousing of shame or guilt. This would include remarks such as, “You’re stalling. Let’s get on with it.” Patients sometimes ask pleadingly, “Do I have to do this?” To which therapists would reply, “No. Only if you want to get over the phobia.” One patient exclaimed, “What in the hell am I doing here? This is the craziest thing I ever did in my life!” The therapist responded quietly but with a touch of sarcasm, “No it’s the second cr aziest. The craziest was to be so afraid of snakes all your life.” B. Seduction Although seduction has connotations which do not apply, it has others which do. Patients were not induced to do things which they did not consciously intend to do, nor were they lured unsuspecting into acts which served the ends of the therapist rather than their own. On the other hand, the therapist, like the seducer, always assumed that “No” meant “Maybe.” He wheedled, cajoled, and negotiated, seeking alternate routes to his goal if the one he was pursuing appeared blocked. If the patient would not move any closer to a cage containing a snake, perhaps she would keep the same distance while the therapist removed the snake and held it in his own hands. If she would not touch the snake with her hand, perhaps she would allow the tail to lie in her lap while the therapist held the head. Another seduction type behavior is to move ahead faster than the patient fully realizes or intended. For example, while allowing her to adapt to motion and changes of position of the object, as in moving it from her left to her right and back again, the therapist might simultaneously work his way gradually closer to her. C. Cheerleading Cheerleading behavior refers to enthusiastic and rapid-fire urging to greater effort such as, “That’s it! Good! Keep going! No! Don’t pull back! Keep going! Good! Now do it again !” Therapist would in fact at times literally break into cheers when a long-resisted goal was reached. D. Navigation Navigation behavior refers to giving orienting information. Many patients have tried to treat themselves by flooding, but gave up too quickly because they could see no progress and had no way of knowing that persistent effort would pa y off. The therapist provides this information, and early in the treatment is usually able to demonstrate progress which the patient is not aware of. For example, she may have been near panic when the phobic object first entered the room. If she is still near panic, but now only a few inches from the object, she may not realize that progress has been made, but can readily do so if the object is taken again to the entrance of the room, demonstrating that her fear is now much less than originally. The numerical self-ratings of anxiety are a great aid to navigation. In the late 8
phases of the treatment, navigation becomes unnecessary because the patient can readily see what ground has been covered and what remains to be done. E. Mothering Mothering behavior usually occurs at times when patient distress is especially high and effort especially intense. The tone and manner of the therapist become less rousing, commanding, or cajoling and more comforting and caressing. One patient, on being asked to enter the room where the phobic object was, halted just outside the door and burst into tears. The therapist put an arm around her and said “Don’t worry it’ll be okay. Now let’s go in and see.” Still sobbing the patient accompanied him into the room, and in a few minutes treatment was underway in a routine manner.
Patients’ Responses During Treatment Anxiety Anxiety is usually quite pronounced and frequently truly dramatic during the course of this treatment. Manifestations include screaming, weeping, running from the room, gooseflesh, chattering of teeth, gross tremors, tachycardia, and hyperventilation. Associations Most of the patients did not produce much in the way of psychodynamic associations, but an occasional one did. One, for example, whose phobia was for dead birds, especially if the feathers were plucked from the head and neck, began during the treatment to talk of male genitals, and recalled both fear and sexual excitement on an occasion when a man exposed himself to her on the bus. She also related the phobia to an early memory of a cat attacking a bird and biting its head off while she screamed and cried in terror. Some of the other types of behavior described below might, however, be taken in a psychodynamic sense and thus considered as indirect associations. “Perceptual Defense” Looking away is almost universal during the early part of treatment and was always discouraged. While looking at the object, patients frequently reported feeling as though it were not there, that they had “focused it out,” or were “looking through it” without actually seeing it. We have the impression that this experience sometimes comprises a true negative hallucination As treatment progresses, these phenomena subside and finally disappear. Hallucinations Two patients, both with spider phobias, began to scratch vigorously as they approached spiders. Both reported that they felt spiders crawling under the skin. One patient, with serious intent, asked if the therapist felt it too. The sensations lasted only a few minutes, and the patients showed no other suggestion of psychosis. Feelings and Behavior Toward Therapist Most of the therapist-directed behavior and feelings seen in other forms of psychotherapy were also observed with this method. They included trust, distrust, affection, hostility, submissiveness, obstinacy, dependency, idealization, and belittling, in practically all combinations. Usually they were shifting and unfocused, but occasionally, rather specific 9
experiences and feelings from the past were “generalized” or “transferred” to the therapist. For example, one patient as a little girl had repeatedly been chased with snakes by little boys who threw them on her and laughed at her terror. At the end of the treatment, she remarked, “You know, I had the feeling all the way through that you were going to throw it on me and laugh, and I would be humiliated.” This patient had come for treatment because she feared her young son would bring a snake home someday. Transformation of Affect Fear of the object was often mixed with disgust, revulsion, affection, anger, pity, or fascination. In the midst of the procedure, the affect of two patients shifted abruptly and dramatically from intense anxiety to intense anger, during which they reported an urge to seize the object and tear it to bits or pound upon it. Within a few minutes, these feelings subsided or shifted back to anxiety. Two patients continued to experience affection or fascination for the object long after treatment was finished and the anxiety response had been eliminated.
Techniques under Flooding and Implosive Therapy Flooding is based on Classical Conditioning, and has two components: 1. Unavoidable Exposure This involves introducing you to the thing you fear in the most immediate and unavoidable way. Zev Wanderer (1991) used biofeedback machines to monitor patients' blood pressure, perspiration and heart rate while they listened to descriptions of what they most feared. Wanderer identified the phrases that sparked the most intense reactions. By just using these phrases, he reduced the time needed for the flooding session from 9 hours to 2 hours. Later sessions could be as short as half an hour. Wanderer's patients would take the tape recordings home and listen to them as 'homework'. In the 1960s, Thomas Stampfl bombarded his phobia patients with detailed descriptions of the situations that they feared for 6-9 hours. Afterwards, they lost their fear of those situations. Getting patients to imagine the fearful situation is known as in vitro therapy. 2. Extinction This involves learning to associate the thing you fear with something neutral. A stimulus is constantly applied and more extreme responses encouraged until there is a sudden reversal and the stimulus no longer has any effect. When the body's "alarm phase" comes to an end, you feel emotionally drained but unafraid. If the feared object is still present, you will learn to associate it with a lack of emotion, rather than fear. This is called "extinction" or "Pavlovian extinction". The idea is that the feared object stops being a conditioned stimulus (CS) producing a fearful conditioned response (CR); it goes back to being a neutral stimulus (NS) which doesn't produce any response at all. A variant of implosive therapy, known as response prevention, has been used successfully in the treatment of obsessive-compulsive disorder (e.g., Salkovskis & Kirk, 1989). Patients with obsessive-compulsive disorder (OCD) are characterized by unwanted thoughts and behaviors that they cannot stop. In response prevention, patients are exposed to the stimuli that elicit their obsessive thoughts but are prevented from engaging in the compulsive behavior that they use to reduce the anxiety associated with the stimuli. For example, in the case of an obsessive10
compulsive hand washer, response prevention treatment might consist of exposing the patient to dirt and then preventing the patient from washing his or her hands. Typically, exposure and response prevention sessions are continued for extended periods of time (e.g., 2 hours per day over several weeks) and are combined with homework assignments.
Treatment Guidelines The first step in successful exposure therapy is the development of an exposure hierarchy. The patient and clinician brainstorm as many feared external and internal stimuli as possible and then rate them in order of difficulty. The most common ranking method is the Subjective Units of Discomfort (SUD) scale, which assigns a 0 to 100 numeric value to each item. The next step is to conduct exposures in a gradual and systematic manner . Repeated use of the SUD scale will help track the patient’s fear level as it increases and decreases. Typically, a higher item is not attempted until the patient’s SUD level decreases significantly for a lower ranked item. During exposure therapy, safety behaviors should be eliminated to the extent possible. Safety behaviors refer to all unnecessary actions the patient takes to feel better or to prevent feared catastrophes. Left unchecked, safety behaviors can undermine the process of exposure therapy by teaching the patient a rule of conditional safety (eg, “The only way to be safe during a panic attack is to have my medication with me”) rather than a rule of unconditional safety (eg, “Panic attacks will not harm me, regardless of whe ther I am carrying my medications”). Cognitive restructuring may also be used as an adjunct to exposure therapy. Cognitive restructuring refers to identifying and challenging irrational, unrealistic, or maladaptive beliefs. In patients with anxiety disorders, 2 of the more common faulty thinking patterns (ie, cognitive distortions) are probability overestimation and catastrophizing. Probability overestimation refers to the over prediction of unlikely outcomes, such as the belief that a commercial flight is highly likely to crash. Catastrophizing refers to the magnification of the consequences of aversive outcomes, such as the belief that making a mistake during a speech will lead to a lifetime of ridicule and ostracism. During the process of exposure exercises, the therapist helps the patient identify these cognitive distortions; examine the evidence for and against the beliefs; and rehearse new, more realistic ways of thinking.
Step by Step Procedures of Flooding and Implosive Therapy 1. Informed Consent and Medical Documents 2. Prior to treatment, patients are told that the phobia persisted because the frightening object is always avoided. If they would maintain contact with it steadily and for a long enough period of time, the anxiety would diminish and they would become comfortable with it. 3. The therapist will maintain a basic stance of low key, matter-of-fact supportiveness, helpfulness, and nonjudgmental objectivity. 4. Promise is made and kept that patients would know beforehand everything that is going to happen; there would be no surprises. 5. They would not be forced to progress faster than they could tolerate, but would be constantly urged to push themselves to the limit, maintaining anxiety at the maximum tolerable level.
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6. The phobic object is then brought and moved rapidly closer to the patient until he or she either refused to have it brought closer, or is jud ged to be on the verge of running away. 7. Repeatedly throughout the treatment, patients are asked to rate the intensity of anxiety on a scale of 0 (none) to I00 (maximum). 8. Modeling is regularly employed, meaning that the therapist demonstrated holding and handling the phobic object. 9. All tendencies to withdraw or look away were discouraged, and each step of progress is praised enthusiastically. As soon as one step is completed, another is urged
Limitations Exposure treatment is generally a safe treatment method; however, some patients may find that the level of anxiety that occurs during treatment sessions is higher than they can handle. Some studies of exposure treatment have reported a high dropout rate, perhaps because the method itself produces anxiety. In addition, exposure treatment is not effective for all patients; after treatment, some continue to experience anx iety symptoms. Although there is a great deal of research to support the efficacy of exposure therapy, there are some notable limitations of the treatment. Sources report that in spite of the welldocumented success rate of exposure therapy, many professional counselors and therapists do not implement it. Some speculate that this is because the availability of specialized training is limited. Additionally, a survey of psychologists who treat PTSD revealed that many believe exposure therapy may exacerbate symptoms. Beliefs that exposure therapy might make things worse may prevent many professionals from using it. According to Mark Pfeffer, director of the Panic and Anxiety Center in Chicago, IL, exposure therapy is difficult work that causes people to feel things they have worked hard to avoid. Because of this, if not implemented properly, exposure therapy's positive effects can wane. That is why, even if you start to feel better, it is important to participate in treatment to the fullest extent and follow the prescription of a well-trained therapist. For many people, the effects of exposure therapy are lasting, and research continues to support its efficacy for treating anxiety, phobias, and many other mental health issues. Flooding is rarely used and if you are not careful it can be dangerous. It is not an appropriate treatment for every phobia. It should be used with caution as some people can actually increase their fear after therapy, and it is not possible to predict when this will occur. Wolpe (1969) reported the case of a client whose anxiety intensified to such as degree that flooding therapy resulted in her being hospitalized. Also, some people will not be able to tolerate the high levels of anxiety induced by the therapy, and are therefore at risk of exiting the therapy before they are calm and relaxed. This is a problem, as existing treatment before completion is likely to strengthen rather than weaken the phobia. However one application is with people who have a fear of water (they are forced to swim out of their depth). It is also sometimes used with agoraphobia. In general flooding produces results as effective (sometimes even more so) as systematic desensitization. The success of the method confirms the hypothesis that phobias are so persistent because the object is avoided in real life and is therefore not extinguished by the discovery that it is harmless. For example, Wolpe (1960) forced an adolescent girl with a fear of cars into the back of a car and drove her around continuously for four hours: her fear reached hysterical heights but then receded and, by the end of the journey, had completely disappeared. 12
References Websites: https://www.psychologistworld.com/behavior/flooding.php http://www.mindfulexposurebook.com/exposure-therapy-implosion/ http://uwf.edu/wmikulas/Webpage/behavior/chapterfour.htm https://en.wikipedia.org/wiki/Flooding_(psychology) http://www.simplypsychology.org/behavioral-therapy.html Books: th Theory and Practice of Counseling and Psychotherapy by Gerald Corey, 7 Edition (2006) Sundel, Martin; Stone-Sundel, Sandra (2005). Behavior Change in the Human Services. SAGE. pp. 241 – 242. Kosslyn, Stephen M.; Rosenberg, Robin S. (2007) Fundamentals of Psychology In Context. Boston: Pearson. Journal: Jaeger, J.A.; Echiverri, A.; Zoellner, L.A.; Post L. & Feeny, N.C. (2009). Factors Associated with Choice of Exposure Therapy for PTSD. International Journal of Behavioral Consultation and Therapy, 5(2), 294 – 310 Solter, A. (2007). A case study of traumatic stress disorder in a 5-month-old infant following surgery. Infant Mental Health Journal, 28(1), 76-96. Eftekhari, A.; Stines, L.R. & Zoellner, L.A. (2005). Do You Need To Talk About It? Prolonged Exposure for the Treatment of Chronic PTSD. The Behavior Analyst Today, 7(1), 70 – 7
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