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FINE TUNING AND TROUBLESHOOTING

WHEN USING PROLONGED EXPOSURE

Some ideas to help “fine tune” treatment

o        People who focus on fear-relevant stimuli and process them visually show the most efficient and greatest reduction in fear (Mohlman & Zinbarg, 2000).

§          Possible Implications: some people may require assistance in focusing on an image of the trauma when describing it.  Also, it is important that people remain focused on only the CS that is being targeted.  If they move to other CSs or associations it may decrease the likelihood of exposure being effective.

o        The more intensive and pervasive the fear, the longer the exposure time required to achieve habituation within sessions (Foa and Kozak, 1986).  (citing Chaplin and Levine, (1980) where it took 25 minutes for speech phobics vs. Foa & Chamberless (1978) where it took 50 minutes for agoraphobics to habituate.  The measure used was heart rate.) 

§          Possible Implication: make sure you schedule a long enough session for habituation.  Foa recommends 90 minutes for exposure for PTSD, but some clients may require more (or less) time.

o        watch for avoidance or lack of CER (conditioned emotional response)

§          Important to make sure that there is activation of the memory structure.  Activation can be gauged through several channels, such as subjective self-report, behavioral, and physiological monitoring or observation (Foa and Kozak, 1986).

o        Citing Grayson et al. (1982): fear remained reduced only in patients who had been encouraged to focus attention on the feared stimuli, whereas fear returned in those who were distracted during exposure.   Degree of attention influenced long-term, but not short term habituation (Foa and Kozak, 1986). 

§          Possible implication: a person may appear to habituate within a session, but show no progress when you track their symptoms and CERs from one session to the next.

Troubleshooting: If a client is not showing a reduction in symptoms or a reduction in SUDS over the course of several sessions, it may be helpful to check on these issues:

o        presentation of a stimulus does not guarantee a CER or full functional exposure

§         possible means of avoiding full activation of the fear structure associated with a stimulus include:

·         distraction or not focusing exclusively on the salient stimulus (resulting from the client distracting her or himself or moving on to associated tangents, and from the therapist not being alert to when the client may be “drifting” from focus on the target stimulus)

·         emotional avoidance of fear through intellectualization, anger, or dissociation

·         levels of arousal that are sufficiently intense to disrupt normal cognitive processes associated with information processing

o        realistic guilt

o        “overvalued ideation” that supports that trauma-related beliefs or meanings that the person has developed

o        if available information about the risk associated with a stimulus does not contradict the person’s fear-related beliefs or systems of meaning, then therapy is unlikely to be successful.

Habituation must occur not only within each session, but also across sessions

(Foa and Kozak, 1986).  

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The information posted on this site reflects our understanding of peer-reviewed research and generally accepted principles in psychology.  It is not intended to be used for self-treatment or as a substitute for individualized assessment and treatment by a licensed professional, and should not be construed as professional advice.

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