A treatment principle is a specific mechanism by which treatment procedures lead to change. Exposure therapy is not a principle as it is not a mechanism for symptom relief, but a procedure to reduce extreme anxiety and related emotions. Irrational fear arises when a sense of danger is given to a safe stimulus. In exposure, a person is exposed to the fearful stimulus to lessen the fear response. There are three types of exposure: in vivo (in real life), imaginal and interoceptive. These types can be applied in various ways, varying in length (short-long), arousal during exposure (low-high), fashion (in vivo-imaginary). Systematic desensitization, for example, is imaginary, short and low in arousal. Flooding, on the other hand, is in vivo and has high arousal. Exposure is usually applied in a hierarchical fashion, starting with the least fearful stimulus and ending with the most fearful stimulus.
Classical conditioning (Pavlov) means that a previously neutral stimulus (CS) acquires meaning through an association with a meaningful stimulus (US), which elicits an unconditioned response (UR). When the CS and US often occur together, the CS also starts to lead to the UR (CR). By generalization, stimuli similar to the CS will also lead to the CR. Pavlov showed that the association could be reversed by a process of extinction (no longer having CS occur with the US) or by counter conditioning (CS is accompanied by a pleasant stimulus). These processes have been shown by Watson, Rayner and Jones in Little Albert and Peter, leading to the assumption that all phobias are caused by traumatic conditioning and that they can be reversed by extinction.
Mowrer's two factor model integrated avoidance to explain fear persistence (based on Skinner's operant conditioning). According to this theory, fear arises from classical conditioning and is maintained by operant conditioning. This leads to the belief that therapy should focus on exposure and stop avoidance. Skinner showed that individuals change behavior based on the consequences of the behavior. Avoiding fear is a negative reinforcer in this, but it does not give the person the chance to see that the stimulus is not scary, which prevents extinction.
Foa and Kozak created their Emotional Processing Theory (EPT) by integrating Mowrer's principles, and components of Lang's concept of fear structures. According to Lang's bio-information model, the fear structure is a way of avoiding or escaping danger. It contains mental imagery representing the fearful stimulus, responses, and information about the meaning of both. When the individual is exposed to an aspect of the imagery, this structure is activated. EPT emphasizes the importance of meaning in the fear structure. Normal fear structures produce adaptive behavior. Pathological fear structures occur when the associations between stimuli, meaning, and response no longer represent reality and the fear structure is activated in harmless situations.
EPT argues that exposure works by activating emotional processing, which stores accurate information in the fear structure. In contrast, Foa and McNally argue that exposure works because alternative structures are created that do not contain pathological elements. With good therapy, these structures become more easily accessible than the pathological structure, thus activating them when exposed to the stimulus.
EPT states that two conditions are required for fear to diminish. Firstly, the fear structure must be activated so that it can be processed, and secondly, new elements must be available to be incorporated into the fear structure. The basis of EPT is therefore the integration of information in conflict with the fear in the fear structure, which leads to fear reduction.
The fear structures differ per disorder, the activation of the network depends on the match between stimuli in the environment and the aspects of the network. So exposure focuses on the pathological features that characterize a particular disorder and on the disappearance of avoidance strategies characteristic of that disorder.
The first successful CBT treatment for anxiety was the exposure-based systematic desensitization of Wolpe. Clients were exposed to the fear in their imagination, in combination with relaxation exercises. This therapy was based on the "theory of reciprocal inhibition", which states that reducing anxiety can only take place by pairing the conditioned (fearful) stimulus with behaviors that go against the fear (such as relaxation). Systematic desensitization became less popular because it had drawbacks, and in vivo exposure proved to be more successful. In the 1950s there was ‘implosive therapy’, which was the basis for flooding techniques because it was believed that a strong response would promote extinction. However, flooding did not survive either, because it was just as effective as graded exposure, but much more burdensome for the client. Since the 1970s CBT (combi cognitive and behavioral therapy) as we see it today is known and used.
Phobias arise when there is a fear of a specific object or situation, often overestimating the likelihood that it could cause harm. This belief leads to avoidance, so that the person is not confronted with disproving information. Exposure is therefore aimed at confrontation with the stimulus so that the fear structure is activated, and disempowering information can be added. In vivo exposure appears to be the most efficacious, and is just as effective as the combination of exposure with cognitive therapy. One exposure session seems to be sufficient (just as succesful as 5 sessions). While group and virtual exposure may also have a good result, observational or "vicarious" exposure seems less effective than in vivo, and for self-directed exposure there are mixed findings.
The fear structure in panic disorders consists of false beliefs about bodily sensations. Panic and fear create physical sensations, so situations that cause panic or fear are avoided (such as in agoraphobia). Exposure consists of confrontation with bodily sensations through interoceptive exposure and with situations that trigger sensations through in vivo exposure. It is also aimed at removing safety signals. CBT with interoceptive exposure appears to be the most effective. The role of in vivo exposure is disputed, as Panic Control Therapy does not use in vivo exposure but is very effective. It is argued that agoraphobia only arises from fear of sensations and if this fear disappears (through interoceptive exposure), agoraphobia also decreases, so that it is no longer necessary in vivo. Medication is not effective in panic disorder, and even increases the risk of relapse. Virtual reality and internet-based programs also appear to be effective.
The fear structure in social anxiety disorder consists of misconceptions about social interactions. These people develop subtle avoidance, for instance little eye contact. It is difficult to undermine beliefs that others criticize them during treatment, because open, harsh criticism is discouraged in society. Clark uses role-play that is recorded and followed by feedback, so that the client can get an idea of how they appear objectively and how others see them in the interactions. Foa and colleagues have added in vivo and imaginary exposure to this. For the role plays and exposure, clients must formulate expectations so that they can be tested. Here too, safety signals are removed. Exposure alone is very succesful, and adding CBT (especially cognitive restructuring is added) is not more effective. It has been thought that group therapy for social anxiety disorder would be beneficial because patients usually do not have a social network for practicing social skills. However, individual therapy appears to be more efficacious.
In GAD there is no specific fear structure, but rather exaggerations in the sense of risk of harm in general, and a lot of worry. Worrying or rumination are perceived as avoidance strategies (avoiding more distressing mental images). In the short term, worry is negatively reinforced by the absence of distress, but in the long term it hinders the emotional processing of frightening stimuli. In addition, people with GAD also avoid situations that they associate with increased danger. Imaginary and in vivo exposure is often used to counter avoidance, stimulate emotional processing, and teach that mental images that cause distress and insecurity are manageable. Exposure is less effective with GAD than with other anxiety disorders.
There are many different fear structures within OCD, but most are characterized by an increased sense of threat and the belief that compulsions are the only way to lower anxiety. Effective exposure consists of: confrontation with fear-provoking stimuli, and prevention of rituals. Adding imaginary exposure improves long-term effects, whereas self-directed treatments are less effective. Training family members as co-therapists has positive effects, not adding medication.
In PTSD there is a specific pathological fear structure in which there are incorrect associations between stimulus, response at the time of the trauma, and their meaning. First, many stimuli are incorrectly associated with danger, often evoking it, and creating the belief that the world is dangerous. Second, there is an image of self-incompetence, due to the memory of how the person acted during the trauma, as well as the PTSD symptoms. These two points lead to the avoidance of anything reminiscent of the trauma, which prevented emotional processing. The goal is to bring disempowering information into the fear structure. Prolonged Exposure Therapy works best, which focuses on promoting safe confrontations with the stimuli to manipulate dysfunctional cognitions. Additions of cognitive therapy do not provide a better effect. Questions have arisen as to whether exposure is tolerable and safe for people with PTSD, but no evidence has been found that it can enhance symptoms or otherwise be detrimental.
In the natural course of life after trauma, people are exposed to trauma-related stimuli. This natural way of exposure ensures that disempowering information comes in and the trauma can be processed. People with (chronic) PTSD push away trauma memories and avoid situations in which they may encounter trauma-related stimuli, which leads to beliefs about the trauma and themselves being maintained, and emotional processing not taking place. They think the fear will last forever when faced with it again and think they can't handle the distress. The purpose of PE (Prolonged Exposure) is to promote emotional processing through gradual exposure to trauma-related stimuli through in vivo (safe situations that the person considers to be dangerous or sees as reminders) and imaginary exposure. Behavioral activation and removal of safety behavior are also parts of the therapy. It is important to teach clients to distinguish between safe and dangerous contexts. In vivo exposure of situations that are considered "safe" by the general population are given up as homework. Imaginary exposure happens in the sessions and is therefore most important, this is used to learn the difference between remembering and reliving, as clients often think that with remembering the fear will last forever and they will be back in the moment. Imaginary exposure is also used for disempowering information and for habituation. It is important that the client is really 'there' during the imaginary exposure because otherwise the fear structure is not activated (underengagement, counteracted by detailed description of trauma) or because disempowering information is not integrated due to high distress (overengagement, countered by keeping an eye open).
Clients with PTSD often have difficulty seeing and integrating disproving information themselves, so after the imaginary exposure the therapist must pay attention to the processing phase. Contradictions are investigated and habituation is examined, so that they understand that exposure ultimately leads to a reduction of distress.
After extinction it is possible to experience a relapse. The fear response (CR) can come back when the US is present without the CS, when the CS occurs in an environment other than the extinction environment or spontaneously. This shows that extinction does not follow the original conditional learning principles.
Exposure can also be used in pathological grief, and depression.
A treatment principle is a specific mechanism by which treatment procedures lead to change. Exposure therapy is not a principle as it is not a mechanism for symptom relief, but a procedure to reduce extreme anxiety and related emotions. Irrational fear arises when a sense of danger is given to a safe stimulus. In exposure, a person is exposed to the fearful stimulus to lessen the fear response. There are three types of exposure: in vivo (in real life), imaginal and interoceptive. These types can be applied in various ways, varying in length (short-long), arousal during exposure (low-high), fashion (in vivo-imaginary). Systematic desensitization, for example, is imaginary, short and low in arousal. Flooding, on the other hand, is in vivo and has high arousal. Exposure is usually applied in a hierarchical fashion, starting with the least fearful stimulus and ending with the most fearful stimulus.
