Intervention in phobias: the exposure technique

The so-called exposure techniques are defined as the set of psychological procedures and behavioral through which a person can learn to face those situations that cause intense anxiety.

This type of phenomenon is usually related to a certain feared object or situation, of which the person tries to flee or avoid at all costs, even if he is aware of the irrational and excessiveness of his reaction. The intense aversion suffered or phobia It can be derived either from internal stimuli, for example being afraid of contracting a disease, or external, such as the fear of flying by plane.

Although there are very different types of exposure, which are classified according to the place where it takes place (live exposure, exhibition in imagination, exhibition in virtual reality, etc.), of the people who participate in it (self-exhibition, group exhibition, assisted exposure, etc.), of how the gradation of the 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 imagination exposure.

• You may be interested: "What is systematic desensitization and how does it work?"

Characteristics of the exposure technique

The ultimate purpose of the technique is equip the subject with various cognitive-behavioral resources so that he is able to put them into practice in real anxiety situations and this allows him to remain in it without emitting the avoidance response. These resources become cognitive restructuring techniques on the fears experienced, training in self-instruction, breath control techniques, relaxation techniques or modeling techniques and behavioral rehearsal, mainly.

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

Thus, work is done on a psychological level to avoid cognitively anticipating the future development of the situation feared without thinking about the negative consequences and controlling the emotional reactions and the own impulses.

The hierarchy

One of the fundamental elements of the exhibition intervention, both in vivo and in imagination, is the prior elaboration of an exhibition hierarchy. It records all the situations that generate anxiety to the individual and sThey are ordered by a score in USAs, or Subjective Units of Anxiety (usually 0-10 or 0-100), indicating the level of perceived anxiety distress. Thus, a list of all feared situations is obtained from least to greatest coping difficulty.

A relevant aspect is to find a balance in the gradation of the indicated feared situations. Low-graded exposures are likely to show less acceptance by the subject and also a higher dropout rate, although faster results may be achieved.

By cons, too graded an exposure can lead to a feeling of personal discouragement, seeing the individual that his progress is excessively slow. Therefore, it seems more effective to start by exposing oneself to situations of low anxiety level (which have a high probability of coping success) until reaching those situations in which the person tends to avoid due to the high level of anxiety they generate (for example, those in which he has suffered a panic attack previously).

In the progress to go from the first to the second, aspects such as the medical and psychological condition that Present the individual, the time that he can allocate to the exhibition and the degree of habituation of this respect to the technique. Thus, the hierarchy may be modified as it progresses in its realization, also taking into account the sensations experienced by the subject in each exposure and the personal or environmental factors that influence the applied coping.

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

• You must stay in the situation until the person experiences a reduction in anxiety (40-50 USAs) without expressing desire to avoid the situation.
• The level of USAs should be checked every 5-10 minutes. If the duration has been short, the exposure should be repeated in order to experience a marked reduction in anxiety.
• The time dedicated to coping with the situation it should be between 1 and 2 hours a day before moving on to the next situation.
• Each item in the hierarchy should be repeated until two exposures in a row are achieved with a zero to mild anxiety level.
• The periodicity of the sessions It should be between 3-4 days a week.
• After the end of the exposure the subject must leave the situation in order to avoid performing automatic reassurance checks.

Exposure in imagination in phobias

Exposure in imagination implies imagining in the most real way possible the experience of feared situations or stimuli that cause intense discomfort to the subject. 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 exposure strategies in imagination to the situations (generalization of the stimulus) or the problems derived from how to evaluate whether the person has a good capacity to imagine the feared situations indicated by the hierarchy.

However, imaginative exposure can be helpful when:

• The cost of the live exhibition is not acceptable or it cannot be programmed in advance.
• In the event of an incident suffered by the subject in an in vivo exposure that prevents you from being able to face a new exposure again in real context.
• The person shows reservations and an excessive fear to initiate the live exhibition.
• As an alternative to in vivo exposure in situations in which there is a lack of compliance or difficulties in getting used to the technique in a real context.

Assessment of imagination capacity

As indicated above, the competence available to the person will be an element crucial when assessing the possibility of applying this type of variant of the technique of exposition.

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

For this, the therapist proposes a series of visualization exercises in which he presents a series of scenes to the patient, and he is indicating and guiding him on the elements that appear in it for about a minute. Subsequently, the quality and clarity of the visualization exerted 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 scene playback is vague, it is recommended to carry out a training in imagination starting with neutral or pleasant scenes, although also It is possible to enrich the description of the scene with details and important customer reactions that have been omitted.

2. Temporarily 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 convenient to remember the justification of the procedure and the need to expose oneself until reaching a bearable degree of habituation. You can also ask the client to verbalize out loud what he 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. It can be proposed 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 to the downside

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

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

5. Manipulation of the imagined on the upside

Modification of the scene that increases anxiety. The patient can increase the anxiety potential of a scene adding aversive elements or removing protective elements. Possible solutions to this are to emphasize the importance of imagining only what is asked or instructing the person to verbalize aloud what they are imagining.

6. Absorption

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

Bibliographic references:

• Bados, A. and Grau, E. G. (2011). Exposure techniques. Dipòsit Digital of the University of Barcelona: Barcelona.