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Section 17
Exposure Therapy for Phobias

Question 17 | Test | Table of Contents

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In the last section, we discussed 2 techniques for overcoming social phobias.  The two techniques discussed in this section are decentering and time projection. 

In this section, we will discuss exposure.  Three techniques regarding exposure will be presented in this section.  The three techniques for exposure are the initiation technique, cognitive avoidance, and the critical decision technique. 

Presenting an experimental rationale grading task, and making a task fail proof are all ways to motivate clients to approach or stay with their phobias.  As the client gets closer to a phobic situation, his resolve to confront the feared event fades.  Can you make use of these different techniques and strategies to help your phobic client act against the behavioral inclination toward phobic reactions?

♦ #1  Initiation Technique - Stated Intentions
First, let’s discuss the initiation technique.  How might you encourage your phobic client to take a first step that will lead to direct contact with the feared situation.  Tammy, age 32, experienced a phobia of confrontation.  Tammy stated, "I have a very problematic relationship with one of my coworkers.  But I’m so afraid to say anything!"  How might you have encouraged Tammy to initiate exposure to her feared stimulus? 

I stated, "I know you don’t feel like trying this now, but if you make some move toward confrontation, such as telling a close friend when you are going to do it, that in itself can become a powerful motivation."  What clients like Tammy are doing is using a lower motivating affect, like shame, to develop a higher motivation such as courage.  Tammy later told her sister that she was going to confront her coworker.  At a later session, Tammy stated, "I wasn’t going to follow through, but I remembered what I told my sister." 

I find that when implementing the initiation technique some care may need to be taken.  Do you recall my agoraphobic client, Pam, from section 8?  Pam broke a stated intention to make a crosstown trip.  Pam stated, "I let everyone down.  Now I just feel depressed." 

I stated to Pam, "Commitments can never be more than serious intentions.  The unexpected can get in the way of even the most serious intentions.  While we try to follow through on our serious intentions, it is not always possible to do so."  Would you agree that while public commitments or stated intentions can motivate clients, private commitments or commitments to the therapist are also helpful?

♦ #2  Cognitive Avoidance
Next, let’s discuss cognitive avoidance.  Do you find that even when clients do approach a feared situation alone, many use cognitive avoidance strategies to shut out the anxiety?  Cognitive avoidance strategies may include self talk, such as ‘Don’t think about it.’  I find that while such strategies can initially allow a client to stay in a situation, they soon lose their benefit.  Clients are encouraged to expose themselves mentally, physically, and emotionally. 

Would you consider telling your phobic client to experience the fear and not try to avoid it through thought stopping?  Perhaps you could implement the thought-feeling-action triangle.  In my practice, I draw a triangle with the client’s thoughts, feelings, and optional actions at the three points.  Then, by drawing arrows between these points, I stress the importance of getting all three systems going in the same direction.  How might this technique benefit your phobic client?

♦ #3  The Critical Decision Technique
The critical decision technique can help phobic clients face their fears.  As you know, the behavioral disposition of the phobic client leads to a chain of behavior which includes a decision and self instruction.  I find that the last chance at intervention occurs at the decision point.  Once the client is exposed to the situation he perceives as dangerous, he begins to act on this perception.  At this point, would you agree that it is difficult to challenge or modify the beliefs through verbal methods? 

Clearly, when the client is in the process of preparing to escape action, he is unlikely to question the original conclusion that the situation is dangerous.  You may consider telling your phobic client that even though going with feelings or instincts is a good idea most of the time, critical decision phobic situations may require the client to do the exact opposite.  For example, social phobic Ted from section 13 often found himself talking to someone and wanting to back away and hide. 

I stated to Ted, "It’s better to force yourself to move forward.  Approach instead of avoid.  When you want to protect yourself, you make yourself more vulnerable."  Think of your Ted.  How might you help your phobic client look for those moments when he or she can choose to act against his or her strong inclination to escape?

In this section, we have discussed exposure.  Three techniques regarding exposure will be presented in this section.  The three techniques for exposure are the initiation technique, cognitive avoidance, and the critical decision technique. 

- Dubenetzky, Salome. Differential Diagnosis of Anxiety Disorders. Annals of Psychotherapy & Integrative Health. Summer2013, Vol. 16 Issue 2, p40-46. 7p.

- Jensen, Vicki L.; Hougaard, Esben; Fishman, Daniel B. Sara, A Social Phobia Client with Sudden Change After Exposure Exercises in Intensive Cognitive-Behavior Group Therapy: A Case-Based Analysis of Mechanisms of Change. PCSP: Pragmatic Case Studies in Psychotherapy. 2013, Vol. 9 Issue 3.

Update
Experiences of Patients and Therapists Testing
a Virtual Reality Exposure App for Symptoms
of Claustrophobia: Mixed Methods Study

- Mayer, G., Gronewold, N., Polte, K., Hummel, S., Barniske, J., Korbel, J. J., Zarnekow, R., & Schultz, J. H. (2022). Experiences of Patients and Therapists Testing a Virtual Reality Exposure App for Symptoms of Claustrophobia: Mixed Methods Study. JMIR mental health, 9(12), e40056.

Peer-Reviewed Journal Article References:
Anderson, P. L., Price, M., Edwards, S. M., Obasaju, M. A., Schmertz, S. K., Zimand, E., & Calamaras, M. R. (2013). Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 81(5), 751–760.

Erceg-Hurn, D. M., & McEvoy, P. M. (2018). Bigger is better: Full-length versions of the Social Interaction Anxiety Scale and Social Phobia Scale outperform short forms at assessing treatment outcome. Psychological Assessment, 30(11), 1512–1526.

Katz, A. C., Norr, A. M., Buck, B., Fantelli, E., Edwards-Stewart, A., Koenen-Woods, P., Zetocha, K., Smolenski, D. J., Holloway, K., Rothbaum, B. O., Difede, J., Rizzo, A., Skopp, N., Mishkind, M., Gahm, G., Reger, G. M., & Andrasik, F. (2020). Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Stewart, E., Frank, H., Benito, K., Wellen, B., Herren, J., Skriner, L. C., & Whiteside, S. P. H. (2016). Exposure therapy practices and mechanism endorsement: A survey of specialty clinicians. Professional Psychology: Research and Practice, 47(4), 303–311.

Zoubaa, S., Dure, S., & Yanos, P. T. (2020). Is there evidence for defensive projection? The impact of subclinical mental disorder and self-identification on endorsement of stigma. Stigma and Health. Advance online publication.

QUESTION 17
What are three techniques for client exposure? To select and enter your answer go to Test.