CBI – Literatuur college 1
Exposure and Cognitive Restructuring
Voorbereiding
Chapter 4 – Exposure therapy: Promoting emotional processing of pathological
anxiety (O’Donohue & Fisher, 2012).
Chapter 6 – Cognitive restructuring (O’Donohue & Fisher, 2012).
Chapter 4 – Exposure therapy: Promoting emotional processing of
pathological anxiety
Exposure therapy – A Treatment Principle or a Treatment Procedure?
Treatment principle – a specific mechanism by which a treatment leads to change
Treatment procedure – a protocol through which the underlying mechanism is
targeted and/or modified.
Exposure therapy isn’t a mechanism for symptom reduction, but rather a procedure that is
commonly used in cognitive behavioral therapy (CBT) to reduce pathological fear and related
emotions, such as unrealistic shame and guilt.
This chapter focuses on the use of exposure in CBT treatments for anxiety disorders and the
mechanisms underlying symptom reduction. Anxiety disorders occur when safe stimuli
acquire a meaning of danger and thus elicit irrational fear and avoidance. During exposure for
pathological anxiety, patients intentionally confront feared, but otherwise safe, objects,
situations, thoughts, sensations, and memories for the purpose of reducing fear reactions to
the same or similar stimuli in the future.
Three types of exposure procedures
In vivo (real life) exposure
Imaginal exposure
Interoceptive exposure
Procedural variations
Exposure length – Short versus long
Arousal level during the exposure – Low versus high
Mode of exposure – Imaginal versus in vivo
For example: Systematic desensitization is an imaginal form of exposure that is brief and
minimally arousing, whereas flooding techniques involve in vivo exposure with highly feared
stimuli.
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,Current practice – Exposure therapy is commonly applied in a graded fashion using a
hierarchy to build from moderately feared stimuli to highly feared stimuli. The selection of
the type of exposure is dictated by the pathological characteristics of a given disorder. It is
also often the case that several kinds of exposure are concurrently used in exposure
programs.
The Basic Research Foundations of Exposure
During the 1920s, psychological research focused on learning principles. Exposure
procedures are rooted in the application of learning principles to the understanding and
treatment of pathological anxiety.
A major influence was Mowrer’s two-stage theory (1960) and the application of this
theory to the treatment of pathological anxiety.
A further significant conceptual development of exposure therapy was advanced by
Foa and Kozak’s (1985, 1986) emotional processing theory (EPT). The EPT forms a
framework for understanding anxiety disorders and the mechanisms underlying
exposure therapy.
In this chapter, we use EPT to organize our understanding of how exposure is effectively used
in cognitive behavioral therapies for anxiety disorders.
Classical and operant conditioning
Classical conditioning (Pavlov) – The way in which a previously neutral stimulus
(conditioned stimulus, CS) acquires meaning through association with a significant
stimulus (unconditioned stimulus, US), which invokes an innate behavioral response
(unconditioned response, UR). With repeated pairing of the CS and the US, the two
stimuli become affiliated and the CS begins to produce the behavioral response in the
absence of the US (conditioned response, CR).
In fear conditioning, the CS is presented with a fear-evoking US so that the CS comes to elicit
fear without the US. Stimuli that are similar to the CS also come to elicit fear through a
process called generalization. Fear reactions to the CS and similar stimuli are pathological in
that the CS by itself is not dangerous, only by association with the US, which produces a
legitimate fear reaction. Pavlov demonstrated that pathological behavioral responses to the CS
could be eliminated through extinction in which the CS is repeatedly presented without the
US or counter conditioning in which the CS is repeatedly paired with a pleasant stimulus.
Watson and Rayner (1920) conducted some of the earliest experiments demonstrating the
application of fear conditioning in humans. In the now famous case of little Albert, Watson,
and Rayner instilled a fear of a white rat toy in a 9-month-old child by pairing the toy with a
loud noise. The fear of rats then generalized to a range of white fuzzy objects. In a second
famous case study, Watson’s student, Mary Cover Jones (1924), successfully treated Peter, a
34-month-old boy who was afraid of white fuzzy objects, by pairing the feared objects with
pleasant stimuli (for example, food) and presenting them in a gradual manner.
These two experiments provided a model for behavior therapy of anxiety disorders
that initially assumed that all phobias (pathological anxiety) are acquired through
traumatic conditioning and should therefore be treated through extinction.
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, Mowrer’s two-factor model (1947) – The two-factor model integrated the concept of
avoidance learning( based on Skinner’s principles of operant conditioning) to explain
the maintenance of fear in anxiety disorders.
Skinner demonstrated that organisms learn to modify their behavior based on the
consequences of their actions. The likelihood of a behavior is increased when it eliminates
or reduces aversive experiences following that behavior (negative reinforcement). Fear is a
negative physiological experience that organisms seek to eliminate, thus avoidance of feared
objects is negatively reinforced due to the drop in physiological arousal that occurs. Repeated
avoidance prevents the organism from learning that the CS does not predict harm (that is, the
‘CS–no US’ association), which hinders extinction.
Thus, according to the two-factor theory, fear is originally learned through classical
conditioning and maintained through operant conditioning. This implies that therapy
must not only promote extinction through confrontation with erroneously feared
objects, but also eliminate avoidances that would prohibit extinction from occurring.
Emotional Processing Theory
Foa and Kozak’s Emotional processing theory expanded on these principles of early learning
and Lang’s concept of the fear structure to create a comprehensive model for understanding
pathological anxiety and the mechanisms involved in exposure therapy for anxiety disorders.
Lang’s bioinformational model (1977) – The fear network (or structure) is a
program for escaping or avoiding danger, that includes representations of feared
stimuli, responses, and the meaning of stimuli and responses. This structure is
activated by input that matches the information stored in the structure.
Foa and Kozak (1986) summarized the characteristic features of normal and pathological
fear structures, emphasizing the importance of meaning representations. Although two
structures can share the same stimulus and response elements, the meaning elements
indicating danger distinguish between fear structures that promote escape from threat and
other information structures.
When a person is faced with a realistically threatening situation (for example, an angry
dog), the activation of the fear structure supports adaptive behavior (for example,
muscle tension and increased sympathetic activation).
However, a fear structure becomes pathological when the associations among
stimulus, response, and meaning representations do not accurately reflect reality and
the fear structure becomes activated by harmless stimuli or responses that are
erroneously viewed as dangerous.
Psychological interventions (e.g. exposure) that are known to reduce fear, achieve their effects
by emotional processing. This is the process by which accurate information is incorporated
into the fear structure and modifies the pathological elements in the structure. Exposure
therapy does not alter the existing pathological structure, but rather forms competing
structures that do not include pathological associations among stimulus, response, and
meaning representations.
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