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Chapter 28

PSYB45H3 Chapter Notes - Chapter 28: Prolonged Exposure Therapy, Generalized Anxiety Disorder, Cognitive Behavioral Therapy

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Jessica Dere

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Psychological Disorders Treated by Behavioural and Cognitive Behavioural Therapies
In 2005, APA established a task force to make recommendations and provide guidelines on how
best to incorporate scientific research evidence into psychological practice (APA Presidential Task
Force on Evidence-Based Practice, 2006).
A major recommendation of the task force was that clinical psychologists should use empirically
supported treatments (ESTs) —speifi treatets that hae ee sho to e effiaious i
controlled liial trials
Often ESTs are behavioral or cognitive behavioral treatments, primarily because the behavioral
approach emphasizes basing treatments on well-established principles, measuring the outcomes
of treatments in objectively defined behaviors, and altering treatments that are not producing
satisfactory results
Following the report of the above-mentioned task force, the clinical division of APADivision
12,Society of Clinical Psychologyset up the following website to inform a wide audience
including psychologists, potential clients, students, and the general public
For each disorder and treatment listed, two levels of research support are indicated:
o (a) strong research support and
o (b) modest research support.
Strong research support is defied as a treatet for hih ell-designed studies conducted by
idepedet iestigators . . . oerge to support a treatet’s effia.
Modest researh: a treatet for hih oe ell-designed study or two or more adequately
desiged studies … support [the] treatet’s effia.
A treatment not being listed as having research support does not necessarily mean that the
treatment is ineffective. It simply means that there is not enough published research evidence to
support its efficacy at either the first or second levels at this time.
It should also be noted that even if a treatment is listed as having strong or modest research
support for treating a given disorder, this does not mean that it will be effective for all individuals
suffering from that disorder.
It only means that under certain controlled conditions the treatment has been demonstrated to
be more effective than no treatment or an appropriate control procedure.
Given that drugs often have unwanted side effects, it is usually considered desirable to avoid their
use when behavioral or cognitive behavior therapy is a viable alternative.
Co-morbidity: clients having more then one clinical problem
o With this, treatment isn't as straight forward
Specific Phobias
Specific phobia: an intense, irrational, incapacitating fear of a stimulus class.
Specific phobias are classed as:
o Animal type: (e.g., fear of dogs, birds, spiders)
o Natural environment type: (e.g., fear of heights, storms)
o Bloodinjury injection type: (e.g., fear of seeing blood, having an operation)
o Situational type: (e.g., enclosed spaces, flying)
o Other type (any specific phobia not included in the preceding list).
o Systematic desensitization
Joseph Wolpe (1958) developed the earliest behavioral treatment for specific phobias.
He hypothesized that the irrational fear characteristic of a phobia is a respondently
conditioned response to the feared object or situation.
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He decided to treat the phobia by exposing the client to the feared stimulus while
conditioning another response to it (counterconditioning).
A fear-antagonistic response that Wolpe found suitable for this purpose was
relaxation. He further reasoned that when counterconditioning the fear response, the
therapist should be careful not to elicit the fear response all at once in its full
as too much fear in the therapy session would interfere with the process.
Given this rationale, Wolpe might have called his treatment systematic
counterconditioning but named it systematic desensitization
Systematic desensitization: a procedure for overcoming a phobia by having a client in
a relaxed state successively imagine the items in a fear hierarchy.
Fear hierarchy: a list of fear-eliciting stimuli arranged in order from the least to the
most fear-eliciting.
In the first phase of systematic desensitization, the therapist helps the client construct
a fear hierarchya list of approximately 1025 stimuli related to the feared stimulus.
With help from the therapist, the client orders the stimuli from those that cause
the least fear to those that cause the most.
In the next phase, the client learns a deep-muscle relaxation procedure that requires
tensing and relaxing a set of muscles.
This tensionrelaxation strategy is applied to muscles of all major areas of the
body (arms, neck, shoulders, and legs).
After several sessions, the client is able to relax deeply in a matter of minutes.
During the third phase, the actual therapy begins.
At the direction of the therapist, the client while relaxing clearly imagines the
least fear-eliciting scene in the hierarchy for a few seconds, then stops
imagining it and continues relaxing for about 1530 seconds. This is repeated.
Then the next scene is presented and repeated in the same way. This continues
over sessions until the last scene in the hierarchy is presented.
If at any point the client experiences anxiety (communicated to the therapist by
raising the index finger), the therapist returns the client to a previous step or
inserts an intermediate scene.
When all the scenes in the hierarchy have been completed, the client can
usually encounter the feared stimuli without distress.
The positive reinforcement the client then receives for interacting with the
previously feared stimuli helps to maintain continued interactions with those
Although systematic desensitization is normally carried out by having the client
imagine the feared stimuli, it can also be conducted in vivo in the presence of the
actual stimuli that elicit fear in the natural environment.
In vivo exposure is often used when clients have difficulty imagining scenes.
It also has the advantage of eliminating the need to program generalization
from imagined scenes to actual situations.
However, it is usually less time-consuming and less costly for a client to imagine
feared scenes in a hierarchical order than to arrange in vivo hierarchical
exposure to them.
For reasons that are not entirely clear given its proven effectiveness in numerous
studies, systematic desensitization has lost popularity among therapists.
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One reason might be its emphasis on covert or private behavior (i.e., imagery)
as opposed to overt behavior, which tends to be favored by behaviorists.
In addition, because of its stimulus-response emphasis, systematic
desensitization does not appeal to cognitively oriented therapists.
o Flooding
Flooding is a method for extinguishing fear by exposure to a strongly feared stimulus for
an extended period of time.
Whereas the model for systematic desensitization is counterconditioning, the model for
flooding is extinction.
The basic assumption behind flooding is that if the client is exposed to the feared
stimulus, is not allowed to escape from it, and no aversive event follows, then the fear
response to that stimulus will extinguish.
Flooding is carried out either in vivo or through imagery.
In vivo is generally preferred because in theory it should maximize
generalization, there is evidence that both methods are equally effective
The treatment involves eliciting the fear at or close to its full intensity.
However, the procedure may involve graded levels of exposure if the distress
experienced by the client is too overwhelming.
Example: A fear of heights might be treated by having the client look out the
window on the first floor, then the third floor, then the seventh floor, and finally
the top of a 10-story building.
Thus, except for the absence of an explicit relaxation procedure, flooding can be very
similar to desensitization.
o Participation Modeling
Participant modeling: a method for decreasing fear in which a client imitates another
individual approaching a feared object.
Both the client and therapist are participating together in the feared situation.
Participant modeling is typically carried out in a graded fashion.
Example: if a client has a fear of birds, the client watches the therapist observe a budgie
in a cage about 10 feet away. The client is then encouraged to imitate this behavior
and is praised for doing so.
After several trials, the process is repeated at a distance of 5 feet from the bird,
then 2 feet, then beside the cage, then with the cage door open, and finally
edig ith the udgie perhed o the liet’s figer.
o Nonexposure Approaches
Systematic desensitization, flooding, and participant modeling are exposure-based
therapies, in that they involve exposureeither in imagination or in vivo of the
client to the feared stimulus or stimuli.
Although nonexposure methods have been used, they are not listed on the Division 12
website for research-supported treatments as being efficacious.
However, [for example] if an individual with claustrophobia (fear of being in
closed spaces, such as elevators) is making self statements
suh as I’ goig to e trapped or I’ goig to suffoate, ogitie therapy is a
nonexposure therapy that may reduce the believability of these self-statements and
thus eliminate or greatly
reduce the phobia
ACT, another nonexposure therapy, has also been used in the treatment of specific
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