Exposure therapy

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With exposure therapy (: even confrontation method ) is defined as a psychotherapeutic intervention in the field of behavioral therapies . It has been shown to be effective in a large number of scientific studies, particularly in the treatment of clearly structured phobias . In the case of confrontation (including exposure), only the (motor and cognitive) avoidance reaction should be prevented, with the further emotional and physiological reactions not being prevented.

Terms and Variation

In the behavior therapy literature, the terms exposure and exposure exercises are used synonymously. A stepped stimulus confrontation may be useful if the patient can thus motivate easier. The use of relaxation methods during confrontation ( systematic desensitization ) is assessed to be less effective than pure confrontation. The Anglo-American term exposure-reaction prevention is misleading and the procedure is better described as exposure-reaction management.

Description of the therapy method

The basic principle of this treatment method is exposure to anxiety-inducing stimuli . Such stimuli can be social situations ( social phobia ), department stores, buses, subways etc. ( agoraphobia ) or individual special stimuli such as spiders, high altitude etc. (specific phobia ). In the case of panic disorder , personal body sensations trigger anxiety (e.g. an accelerated heartbeat), as they are assessed as a preliminary stage of a panic attack .

The core feature of most anxiety disorders is the avoidance of the fear-inducing stimuli. Avoidance is understood by behavioral therapists as a condition that maintains the disorder, as it prevents new experiences and thus makes it difficult to cope with the dreaded stimuli / situations.

method

During the exposure, the patient confronts himself with the specific fear-inducing stimuli under the guidance of the psychotherapist . In preparation for the confrontation in the context of psycho-education, an explanatory model for the respective complaints is worked out together with the patient . The confrontation rational is derived from the model using principles of learning psychology : This means that the level of fear cannot rise to infinity, as expected by the patient, but inevitably reaches a plateau over time through getting used to and ultimately drops, even if one receives the feared stimulus not avoid, but “stay in the situation”. Thus the fear can be “forgotten” through the real experience of the confrontation.

Based on the explanatory model, the actual confrontation with the dreaded situations is therapeutically prepared. This includes clarifying and increasing the importance of success for the patient, increasing his or her expectation of being able to cope with the exposure and finally selecting the situations and the specific course of action. A successful confrontation in the sense of “unlearning fear” is therefore a complex psychological process and in no way equates with the fact that the patient “simply has to face his fear”. The first exposure exercises typically take place in the company of the therapist. With increasing confidence on the part of the patient, the latter continues the exercises independently without the accompaniment of the therapist.

Mechanisms of Action

The confrontation should enable a review of the patient's fears. In contrast to avoidance, the approach of confrontation with reality enables the person affected to have new experiences and thus a change in fears and, if successful, a strengthening of his coping skills in the fearful situation. In addition, the continued independent practice of the patients should help them get used to the fear-inducing stimuli and thus further and permanently reduce their fear. Taken together, both ultimately describe a learning experience which, in a comparable way, enables the previously feared challenge to be successfully mastered even with non-disease-related fears.

However, this does not rule out the high risk of recurrence . Massive extinction, the use of safety signals during the exposure therapy session, and extinction in multiple contexts ( multiple context exposure ) are currently discussed approaches to preventing recurrence.

Differentiation of different approaches

Depending on whether the patient confronts his fear in reality or in his imagination, a distinction is made between confrontation in vivo or in sensu . Imagination exercises can make it easier to approach fear, but they can also be used to practice changed reactions. Another possible distinction is made between the massaged and the graduated confrontation . With the massaged confrontation, the patient confronts himself with his greatest fears immediately after the preparation phase in order to achieve the fastest possible success. In the graded confrontation, a fear hierarchy is first created and, in consultation with the therapist, at the beginning of the confrontation exercises, a lighter problem situation is selected in which there are greater expectations of success. An example of a massaged in vivo confrontation is flooding .

literature

Individual evidence

  1. ↑ a b Frederik H. Kanfer, Dieter Schmelzer: Guide to behavior therapy. Psychotherapy as an opportunity. 2nd, corrected edition. Springer 2005.
  2. ↑ a b Gerhard Stumm: Dictionary of Psychotherapy. Springer-Verlag, 2007, ISBN 978-3-211-70773-9 , p. 187 ( limited preview in Google book search).
  3. ^ A b Hans Morschitzky: Anxiety disorders. Springer-Verlag, 2009, ISBN 978-3-211-09449-5 , p. 396 ( limited preview in the Google book search).
  4. ^ Stefan G. Hofmann: Introduction to modern cognitive behavioral therapy. Psychotherapeutic solutions. Springer 2013.
  5. ↑ Anil Batra, Reinhard Wassmann, Gerhard Buchkremer: Behavior Therapy. Basics - methods - areas of application. 4th, completely revised edition. Thieme, 2013.
  6. ↑ Gerhard Zarbock: phase timetable VT: Tasks and structuring aids for therapists and supervisors. Pabst, 2010.
  7. ↑ Wolfgang Senf, Michael Broda (Ed.): Practice of Psychotherapy. An integrative textbook. 4th updated edition. Thieme 2007.
  8. ^ Robert L. Leahy: Techniques of Cognitive Therapy. A handbook for practitioners. Junfermann, 2007.
  9. ↑ Yujuan Choy, Abby J. Fyer, Josh D. Lipsitz: Treatment of specific phobia in adults. In: Clinical Psychology Review. Volume 27, No. 3, April 2007, ISSN  0272-7358 , pp. 266-286, doi: 10.1016 / j.cpr.2006.10.002 ; Joshua D. Lipsitz, Salvatore Mannuzza, Donald F. Klein, Donald C. Ross, Abby J. Fyer: Specific phobia 10-16 years after treatment. In: Depression and Anxiety. Volume 10, 1999, ISSN  1091-4269 , pp. 105-111, doi : 10.1002 / (SICI) 1520-6394 (1999) 10: 3 <105 :: AID-DA3> 3.0.CO; 2-X .
  10. ↑ James C. Denniston, Raymond C. Chang, Ralph R. Miller: Massive extinction treatment attenuates the renewal effect. In: Learning and Motivation. Volume 34, 2003, ISSN  0023-9690 , pp. 68-86, doi: 10.1016 / S0023-9690 (02) 00508-8 .
  11. ^ Douglas C. Brooks, Mark E. Bouton: A retrieval cue for extinction attenuates spontaneous recovery. In: Journal of Experimental Psychology. Animal Behavior Processes. Volume 19, No. 1, 1993, ISSN  0097-7403 , pp. 77-89.
  12. ^ Brian L. Thomas, Drina Vurbic, Cheryl Novak: Extensive extinction in multiple contexts eliminates the renewal of conditioned fear in rats. In: Learning and Motivation. Volume 40, No. 2, pp. 147-159, doi: 10.1016 / j.lmot.2008.10.002 .
  13. ↑ Ann Hackmann, James Bennett-Levy, Emily A. Holmes: Imagination Techniques in Cognitive Therapy. Beltz, 2012.
  14. ↑ Beate Wilken: Methods of cognitive restructuring. A guide to psychotherapeutic practice. 5th, updated edition. Kohlhammer / Urban, 2010.