Intervention in phobias: the exposure technique

This psychotherapy resource makes it possible to find new ways of managing fear and anxiety.

The so-called exposure techniques are defined as the set of psychological and behavioral procedures by which a person can learn to cope with those situations and behavioral procedures by means of which a person can learn to confront those situations that produce intense anxiogenic discomfort.

This type of phenomena is usually related to a specific feared object or situation, from which the person tries to flee or avoid at all costs, even though he/she is aware of the irrational and excessive nature of his/her reaction. The intense aversion suffered or phobia can derive either from internal stimuli, for example, fear of contracting a disease, or external, such as the fear of flying in an airplane.

Although there are many different types of exposure, they are classified according to the place where it takes place (live exposure, imaginary exposure, exposure in virtual reality, etc.), the people who participate in it (self-exposure, group exposure, assisted exposure, etc.), how the gradation of difficulty of the situations to be faced is established (flooding, gradual exposure, etc.). Let's see what the two most common modalities consist of: in vivo exposure and imaginary exposure..

Characteristics of the exposure technique

The ultimate purpose of the technique is to to provide the subject with a variety of cognitive-behavioral resources so that he/she is able to put them into practice in real anxiogenic situations and this allows him/her to remain in the situation without emitting the avoidance response. These resources are mainly cognitive restructuring techniques on the fears experienced, self-instruction training, breathing control techniques, relaxation techniques or modeling and behavioral rehearsal techniques.

Exposure techniques allow learning to reduce the association between the stimuli that generate anxiety and fear, and the negative emotional reactions, as well as facilitating the learning of an alternative way of reacting to the stimuli that initially generated the fear. in the reaction to the initially anxiogenic stimuli typical of phobias..

Thus, it is worked at psychological level to avoid anticipating cognitively to the future development of the feared situation without thinking about the negative consequences and controlling the emotional reactions and the own impulses.

The hierarchy

One of the fundamental elements of the exposure intervention, both in vivo and in imagination, is the prior elaboration of an exposure hierarchy. It records all the situations that generate anxiogenic discomfort to the individual and is sorted by a score in USAs, or Subjective Anxiety Units.is ordered by a score in USAs, or Subjective Anxiety Units (usually 0-10 or 0-100), which indicates the level of perceived anxious distress. (usually 0-10 or 0-100), which indicates the level of perceived anxiogenic distress. Thus, a list of all feared situations is obtained from least to most difficult to cope with.

A relevant aspect is to find a balance in the gradation of the feared situations indicated. It is likely that the less graded exposures present a lower acceptance by the subject and also a higher dropout rate, although possibly faster results are achieved.

On the other hand, an exposure that is too graded can lead to a feeling of personal discouragementThe individual may feel that his or her progress is too slow. Therefore, it seems more effective to begin by exposing oneself to situations with a low level of anxiety (which have a high probability of successful coping) until reaching those situations that the person tends to avoid due to the high level of anxiety they generate (for example, those in which he/she has previously suffered a panic attack).

In the progress from the former to the latter, aspects such as the individual's medical and psychological condition, the time he/she can devote to the exposure and the degree of habituation to the technique must be taken into account. Thus, the hierarchy may be modified as the the hierarchy may be modified as it is progressing in its realization, also taking into account the sensations of the patient.The hierarchy can therefore be modified as one progresses in its implementation, also taking into account the sensations experienced by the subject in each exposure and the personal or environmental factors that influence the coping applied.

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

• One should remain in the situation until the person experiences a reduction in anxiety (40-50 USAs) (40-50 USAs) without expressing a desire to avoid the situation.
• The USAs level should be checked every 5-10 minutes. If the duration has been short, the exposure should be repeated in order to experience a noticeable reduction in anxiety.
• The time spent in coping with the situation should range from 1 to 2 hours per day before moving on to the next situation.
• Each item in the hierarchy should be repeated until two exposures in a row with no to mild anxiety level are achieved.
• The periodicity of the sessions should be between 3-4 days a week.
• After the end of the exposure the subject should leave the situation in order to avoid performing automatic reassurance checks.

Imaginal exposure in phobias

Imaginal exposure involves imagining as realistically as possible the experience of the feared situations or stimuli that cause the subject intense discomfort. This technique has a lower level of effectiveness than in vivo exposure, so the two are usually combined.

Among the factors that cause a lower result of therapeutic success are the difficulty of applying the strategies of exposure in imagination to real situations (generalization of the stimulus) or the problems derived from how to evaluate if the person possesses a good capacity to imagine the feared situations indicated by the hierarchy.

However, imaginal exposure can be useful when:

• The cost of live exposure is not affordable or cannot be scheduled in advance. or cannot be programmed in advance.
• In the event of an incident suffered by the subject during an in vivo exposure that prevents him/her from being able to the subject is unable to cope again with a new exposure in a real context. in real context.
• The person shows reservations and excessive fear to initiate in vivo exposure.
• As an alternative to in vivo exposure in situations where there is lack of compliance or difficulties in habituation to the technique in real context.

Assessment of imaginative competence

As indicated above, the competence available to the individual will be a crucial element in assessing the possibility of applying this type of variant of the exposure technique.

In case of limitations in this ability, prior to the application of the steps listed in the exposure hierarchy, the subject must be evaluated and trained, the subject must be evaluated and trained in this type of procedure.

For this purpose, the therapist proposes a series of visualization exercises in which a series of scenes are presented to the patient, and he/she indicates and guides him/her through the elements that appear in them for approximately one minute. Subsequently, the quality and clarity of the visualization exercised by the subject is evaluated, as well as the factors that have hindered the procedure.

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

1. Fuzzy image.

If the reproduction of the scene is vagueIf the reproduction of the scene is vague, training in imagination is recommended, starting with neutral or pleasant scenes, although it is also possible to enrich the description of the scene with important details and reactions of the client that have been omitted.

2. Temporally limited imagination

The subject is not able to maintain the scene, which can be linked to the desire to escape from the feared situation. In this case, it is useful to remember the justification of the procedure and the need to expose oneself until a bearable degree of habituation is reached. and the need to expose oneself until a bearable degree of habituation is reached. The client can also be asked to verbalize out loud what he/she is imagining or to elaborate a less disturbing scene as a preliminary step.

3. Little detail

Lack of involvement in the scene on the part of the subject. You can propose to enrich the scene with additional descriptive details, with the client's sensations, cognitions and behaviors, and with the consequences that the client fears.

4. Manipulation of the imagined downward.

Modification of the scene that attenuates anxiety. The subject can imagine situations quite different from those described. Thus, they can attenuate the aversivity of a scene by incorporating protective elements (a small light in a dark room) or by eliminating aversive elements (a half-empty subway car instead of a crowded one).

In these cases, the importance of experiencing anxiety in order to to achieve the final habituation of the same and it is emphasized to describe the scenes in a much more specific way.

5. Manipulation of the imagined upward.

Modification of the scene that increases anxiety. The patient can increase the anxiogenic potential of a scene by adding aversive elements or removing aversive elements. by adding aversive elements or removing protective elements. Possible solutions to this include emphasizing the importance of imagining only what is asked for or instructing the person to verbalize aloud what he/she is imagining.

6. Self-absorption

The subject perseverates in the scene despite the indication to end the exposure. In this situation it is useful to propose to the individual to relax the eye muscles or to move or roll the eyes.

Bibliographical references:

• Bados, A. and Grau, E. G. (2011). Exposure techniques. Dipòsit Digital de la Universitat de Barcelona: Barcelona.