Intervention in phobias: the exposure technique

So-called exposure techniques are defined as the set of psychological procedures and behavioral by which a person can learn to cope with situations that produce intense anxiety disorder.

Often such phenomena are related to a certain object or dreaded situation, from which the person tries to escape or avoid as they are, even though they are aware of the irrational and disproportionate reaction. The intense aversion experienced or the phobia can come either from internal stimuli, for example being afraid of contracting a disease, or external ones, like the fear of flying in an airplane.

While there are many different types of exhibitions, classified according to where they take place (live exhibition, exhibition in imagination, exhibition in virtual reality, etc.), the people involved (self-exhibition, group exhibition, assisted exposure, etc.), how is the gradation of the difficulty of the situations to be faced (flooding, progressive exposure, etc.) established. Let’s see what the two most common modalities consist of: in vivo exposure and imaginative exposure.

    Characteristics of the exposure technique

    The ultimate goal of the technique is provide the subject with various cognitive-behavioral resources so that he can put them into practice in real anxious situations and this allows him to stay there without emitting an avoidance response. These resources become cognitive restructuring techniques based on experienced fears, self-study training, breathing control techniques, relaxation techniques, or behavioral modeling and testing techniques, primarily.

    Exposure techniques teach how to reduce the association between stimuli that generate anxiety and fear, and negative emotional reactions, as well as facilitate learning in an alternative way. in the reaction to initially anxious stimuli specific to phobias.

    Thus, one works on the psychological level to avoid cognitively anticipating the future evolution of the feared situation without thinking about the negative consequences and controlling the emotional reactions and one’s own impulses.

    the hierarchy

    One of the fundamental elements of the exhibition intervention, both in vivo and in the imagination, is the preliminary development of an exhibition hierarchy. It records all the situations that generate anxious discomfort in the individualand order using a score you use, or subjective anxiety units (Usually 0-10 or 0-100), which indicates the level of perceived anxiety discomfort. Thus, a list of all the dreaded situations from the least to the most difficult to manage is obtained.

    A relevant aspect becomes to find a balance in the gradation of the feared situations indicated. Low quality exposures are likely to show less subject acceptance and also a higher dropout rate, although faster results may be obtained.

    On the other hand, too graduated exposure can lead to a feeling of personal discouragement, Seeing the individual that his progress is excessively slow. Therefore, it seems more effective to start by exposing yourself to low level anxiety situations (which have a high probability of being successful in coping) to reach the situations in which the person tends to avoid due to the level. high anxiety that these generate. him (for example those in which he has already suffered a panic attack).

    In progressing from the first to the second, aspects such as the medical and psychological state of the individual, the time that can be allocated to the exposure and the degree of habituation in this regard must be taken into account. For that, the hierarchy can be modified as it is created, Also taking into account the sensations felt by the subject at each exposure and the personal or environmental factors that influence the approach applied.

    At the methodological level, Bados (2011) defines the following general guidelines as guidelines to be followed in the application of in vivo exposure techniques:

    • You must stay in the situation until the person feels a decrease in anxiety (40-50 that you use) without expressing the desire to avoid the situation.
    • The level you are using should be checked every 5-10 minutes. If the duration was short, the exposure should be repeated in order to experience a noticeable reduction in anxiety.
    • The dedication time to face the situation it should last for 1 to 2 hours per day before moving on to the next situation.
    • Each item in the hierarchy should be repeated until two consecutive exposures are reached with an anxiety level between zero and mild.
    • Frequency of sessions this should be 3-4 days a week.
    • After the end of the exposure, the subject must leave the situation in order to avoid performing automatic reinsurance checks.

    Imagination exposure in phobias

    Exposure in imagination consists of imagining in the most realistic way possible the experience of the feared situations or stimuli that cause intense discomfort in the subject. This technique has a lower level of efficiency than in vivo exposure, so the two are usually combined.

    Factors that lead to an inferior outcome of therapeutic success include difficulty in applying imaginative exposure strategies to real-life situations (stimulus generalization) or problems with how to assess whether the person has a good ability to imagine the feared situations indicated by the hierarchy.

    However, imaginative exposure can be useful when:

    • The cost of live exposure is not affordable or unable to program in advance.
    • Given the occurrence of an incident suffered by the subject during an in vivo exposure which this prevents him from being able to face a new exposure again in a real context.
    • The person shows reservations and excessive fear to start the live show.
    • As an alternative to in vivo exposure in situations where there is a lack of conformity or difficulty getting used to the technique in a real context.

    Imagination capacity assessment

    As indicated above, the competence of the person will be a crucial element in appreciating the possibility of applying this type of variation of the exposure technique.

    In the event that limitations relating to this skill are presented, prior to the application of the steps listed in the hierarchy of exposure, the subject must be assessed and trained in such proceedings.

    To do this, the therapist offers a series of visualization exercises in which he presents a series of scenes to the patient, indicating them and guiding them to the elements that appear for about a minute. The quality and sharpness of the subject’s visualization are then assessed, along with the factors that impeded the procedure.

    In relation to the latter, Bados (2005) presents a list of possible problems linked to the difficulty in evoking imagined scenes:

    1. Blurry image

    If the scene reading is vague, It is recommended to perform imagination training starting with neutral or pleasant scenes, although it is also possible to enrich the scene description with important details and customer reactions that have been omitted. .

    2. Temporarily limited imagination

    The subject is unable to maintain the scene, which may be related to the desire to escape the feared situation. In this case, it is advisable to recall the justification of the procedure and the need to expose oneself to a bearable degree of addiction. You can also ask the client to verbalize their imagining aloud or to create a less disturbing scene as a prelude.

    3. Small detail

    Lack of involvement in the scene by the subject. It is possible to propose to enrich the scene with additional descriptive details, with the sensations, cognitions and behaviors of the client and with the consequences that the latter fears.

    4. Manipulation of what is imagined down

    Modification of the scene that alleviates anxiety. The subject can imagine quite different situations from the described one. So they can reduce the aversiveness of a scene by incorporating protective elements (A small light in a dark room) or by removing aversive elements (subway car half empty instead of crowded).

    In such cases, we remember the importance of feeling anxious to achieve the final habituation of the same and insists on describing the scenes in a much more specific way.

    5. Manipulation of what is imagined upwards

    Changing the scene that increases anxiety. The patient can increase the anxiety-inducing potential of a scene add aversive elements or remove protective elements. Possible solutions to this occur by emphasizing the importance of imagining only what is asked or by instructing the person to verbalize out loud what they imagine.

    6. Ensimism

    The subject perseveres in the scene despite the indication of the end of the exposure. In this situation it is helpful to suggest that the individual relax the eye muscles or move or rotate the eyes.

    Bibliographical references:

    • Bados, A. and Grau, EG (2011). Exposure techniques. University of Barcelona digital repository: Barcelona.

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