A few weekends ago, I led a group of twenty psychologists through a four hour primer on Exposure-based therapy for Anxiety Disorders.
Some in the group were students, some recent graduates with a few years experience in independent practice, and some were old hands, in the business of helping people change for more than a few decades.
Each had come along hoping to profit from my experience working with anxiety for more than three decades, yet keeping up to date, and using current edge technologies, such as Augmented and Virtual Reality.
Presenting to peers is different to working with patients, even though the subject matter is similar. Your peers generally cast a more skeptical eye over your work, comparing it to their own, and not always easily accommodating new ideas and ways to do things. This is what I was offering up in the four hour session, and I went in knowing some would be highly challenged in how they work.
(Here are the evaluations: Link)
Part of the workshop process was to utilise a number of “Study Questions” as a pre-test, then repeat again at the end to see how much learning had taken place. I’m not particularly fond of this approach, because it doesn’t necessarily translate into a change of practice. Nor did I include role-plays, an old standby of psychology workshops which eats up time, but is considered to be a reasonable facsimile of the learning process. Nor did I spend time listening to case studies – there simply wasn’t enough time to both get my ideas across and do these other standard components of psychologist workshops.
So I want to share with you some of the major ideas I presented and which I apply in my practice. Whether you’re also a practitioner or someone wishing to change their relationship with anxiety, I think you’ll benefit.
Pre-test questions – what would you answer?
Let’s start with the four pre-test questions (remember they’re aimed at practitioners who have some awareness of the concepts mentioned):
1. Systematic Desensitisation remains the gold standard for anxiety treatment
2. Exposure therapy is most effective when patients are taught to approach their feared situations in a calm manner, using progressive muscle relaxation training
3. For Exposure Therapy to be effective it’s essential that the origins of the fear or phobia be uncovered or become known, otherwise symptom substitution will occur in the future.
4. The Amygdala is the brain’s fear centre
As it turned out, I gave the questions about half way through the session (a small clerical error in procedure) and so the answers to the first two questions had already been offered up: They’re both FALSE.
The answer to Q3 created a little controversy as it’s still a widely held belief for those who come from an insight-oriented model, as many psychologists in the USA and other countries do. But in Australia, with our nationalised medical system under which psychology services are rebated, clinical psychologists such as myself are expected to use evidence-based interventions. Cognitive-behaviour therapy incorporating Exposure work is the expected intervention of choice, not insight-oriented or hypnosis. So I marked Q3 as FALSE.
The question – or answer – that most intrigued the group was Q4. Not all psychologists are well-versed in neuroanatomy or human physiology, so it’s quite easy to use pop psychology references in answering that question.
It too is FALSE, and I based my answer on the revised work of one of the world’s foremost neuroscientists, Joseph Ledoux, from New York University. At one time, his answer would have been true based on his own research, but in recent years – culminating in his 2015 book,
“ANXIOUS” – he has somewhat recanted and has suggested that while the amygdala (so-named by the Ancient Greeks because it has the same shape and size as an almond) has a central role in the setting off of the body’s threat response system, fear is a much more complicated brain response.
All too often, I especially see educators employing terms like “the child’s frontal lobe was hijacked by his amygdala…” when “explaining” errant child behaviour.
(If you’re a psychologist who regularly works in the anxiety domain, you owe it to yourself to refresh your ideas by getting Ledoux’s book, which is a quick download from iBooks or Amazon.)
My intention for the workshop was that it not only serve as a primer for recent graduates, but also as a review of current research for older heads. A principal aim was to guide the attendees in ways to help their patients understand what they were in for, how and why exposure-based methods can be effective, and how to minimise drop-out rates before the work is concluded. For this, I showed some videos I use in my work, which I have previously described on this site.
One of the things I got off my chest early in the workshop was that doing exposure work, despite it meeting gold standards for anxiety treatments, is not for everyone – and that includes both patient and therapist.
And it possesses one of psychology’s dirty little secrets, akin to that of psychiatry and the use of pharmaceuticals: it has a high drop out rate, so not everyone who starts a treatment course will finish it.
(For practitioners, see this review article – clicking it should take you to the original article)
Moreover, these dropout rates are calculated from high quality research studies, where much effort has gone into preventing dropout, since it will lead to less reliable data and conclusions.
Some could say that in the hands of an experienced practitioner working one-on-one with patients there may be less drop out, but I’ve not seen any assessment of this assertion. I’d like to think I can achieve less dropouts because of my clinical acumen, and I seek to measure session by session progress with apps like the TOMS (click the link to go to the iTunes AU store).
So the point of the workshop was to acknowledge this, and find ways to improve compliance and achieve a great result for patients.
Challenging some assumptions
One of the main issues I wanted the workshop psychologists to challenge was the idea their patients must be taught how to be calm or relaxed before, during or after exposure to a feared situation.
My main assertion was that calmness is an artefact of the therapeutic process, not the aim. The clinical goal is a patient who can better manage his or her responses to the feared situation: behaviourally (what they do), cognitively (what they say or think), and physiologically (recalibrate their typical scary sensations to a lower level of arousal, or accept they can be at high levels – think heart rate – but not a further source of distress).
The other assertions were about how to do exposure. Typically, psychologists have been trained in a process known as graduated exposure, where they work with the patient to develop a set of increasingly challenging exposures. The patient is asked to rate their subjective distress (which may not necessarily correlate with objective measures such as skin conductance or heart rate variability, as I use own sessions) on a 1 to 10, or 1 to 100 scale. A hierarchy is then formulated and traditionally one exposes the patient in increasing order of difficulty.
I’ve thrown that approach out. My reading of the literature is that this approach is no longer the gold standard, both in terms of efficacious treatment plus long term maintenance once therapy concludes.
What is needed is a formulation of what’s maintaining the fear and then working on new learning so that the patient learns their fear response is inappropriate to the situation and an alternative is a better match. Practising the alternative will get them closer to their therapeutic goals, such as:
- flying in better managed fashion, e.g., no alcohol or meds, no matter the time of day or weather, etc.;
- better preparation and management in an exam, written or oral;
- giving a speech or presentation despite the chances of failure and freezing, or the equipment “going south” unexpectedly;
- going into previously challenging social situations with more accurate predictions of what will happen and working hard to get to the chosen goals such as introducing oneself to three unknown people;
- Most of the graded exposure tasks – also known as Systematic Desensitisation – rely on an old learning principle known as Habituation. This is another way of saying, if you stay in your scary situation long enough, your anxiety will come down all by itself – as long as you don’t leave, or distract yourself or do anything else that would cut you off from feeling anxious.
If you leave early and experience relief before the Habituation has done its job of helping to recalibrate your fear response, you can actually make things worse. This is why some people get worse the more often they enter the scary situation. They leave early – perhaps out of panic – and the relief reinforces the fear response.
So habituation is a session exercise done with the therapist and can use either real situations (going into the elevator), imaginary ones (imaginal exposure), virtual ones (using virtual reality displays), or the use of multimedia like pictures and movies, or sounds and smells. The important thing is the patient must have some arousal experienced, which can then be felt to diminish as they stay in the situation. Some therapists even ask patients to have a caffeine chaser to increase heart rate and emotional reactivity.
Patients are usually asked to keep practising their habituation exercises between sessions, continually challenging themselves to approach, stay and measure their anxiety in given situations. It all sounds very plausible, doesn’t it?
Except some of us don’t believe it necessarily leads to long term, maintained change. In airline fear of flying programs, the work is expected to have achieved its result during the day’s training session (which might be spread over two weekends). But other treatment agents, like myself, believe it’s not the graduation flight that is the measure of success, but what happens in the months or years that follow.
What’s become very clear to me is that the longer time elapses between treatment and the next flight, the less likely the work will generalise to new situations. Indeed, the same anxiety may return just as strongly just with the message of time alone. You must keep your hours up by taking monthly flights, say, just in and out of a city, such as on the weekend.
There can be some very cheap ways to fly to keep hours up. One airline I mainly use for my “graduation flight” with patients, Jetstar, is currently (May, 2016) offering return flights to Launceston from Melbourne for $59, to celebrate its birthday!
There is another approach I want to share with you that makes more sense of the anxiety research scholarship than habituation. It is called Inhibitory Learning and its most famous proponent is an Australian psychologist I have mentioned on this website, Michelle Craske, now based at UCLA. For the mental health professionals visiting, this is the paper to read to get up to date with her research and practice.
Essentially, while habituation within a treatment session is helpful, it may not have lasting consequences. One needs to learn new behaviours which are incompatible with the old habitual ones, and better match the actual likelihood of events occurring.
And then one needs to go out and test these new learning strategies and refine them, so they become “sticky”, meaning they generalise to other similar fearful situations.
In a therapy session, it may mean an initial exposure – in the real space, or virtually – to a known unpleasant, fear-generating situation and allow the person to experience their discomfort without running away, distracting themselves or some other means of “shutting down” the experience. The patient learns that their discomfort is temporary, manageable and will not lead to injury or harm. They might be asked to come back into the situation a second time very soon after, and compare it to the first:
- is it as intense the second time;
- does their fear rating drop more swiftly and to lower levels;
- are they “attacked” by thoughts in the same way as the first exposure;
- can they push back or re-appraise their automatic, often catastrophising thoughts and put them in the place;
- can they better label their feelings, so rather than saying “it feels terrible“, it’s more like “I can feel my heart racing, I have a queasy sensation… but I know what these are (sympathetic arousal) and I can label them and see them for what they are – my threat response system being activated…“
The idea with this type of new learning is for patients to discover their expectations of what will happen to them are violated (yes, it’s sounds unpleasant, but it just means you discover what you held to be true turns out to be untrue). This begins a process of restructuring one’s ideas, beliefs and ultimately, behaviours. Feelings will come along for the ride, and don’t need to be the first things to be aimed to change in therapy. You might be waiting a long time. Better to change thinking and behaving under therapeutic guidance, directing you to what thoughts to challenge and encouraging the trialling of new behaviours. Later, you keep practising in different scenarios without the presence of a therapeutic helping hand or voice. This is where technologies such as smartphones with video conferencing can help to coach the patient, but without the physical presence of the therapist.
Michelle Craske and her team at UCLA have published some very useful guidelines for therapists working in the area, and I want to share some elements with you. These can be used if you’re wishing to work on your fears yourself, or if you are a patient of mine, you can use these elements between sessions, as well as after our treatment concludes so as to maintain your gains and transfer your new learning to new situations.
An example of the Inhibitory Learning Approach
Have look at the table below from the Appendix of a recent Craske journal publication:
In this table, three sessions of treatment have already occurred establishing the objectives of treatment, as well as some experiments with exposure. In the fourth session guideline above, the patient will be well trained as to the rationale behind exposure, and to go out and conduct an experiment on their own to test out some of the new learning already taking place. The table also contains some practice elements up to session 10.
Let’s have a look at session 4 to begin with, as it sets the pattern for the other session tasks.
- It starts with a BEFORE Exposure goal setting:
What is the goal of today’s practice session? It may be the case that some therapeutic guidance is necessary to begin with so that the patient doesn’t make one or two “mistakes”: either starting off much too easy (not much learning will happen) or much too hard (safety behaviours such as avoidance kick in) and again, not much new learning takes place. This is the clinical art of doing exposure work.
In the example above, the goal of session 4 is to place oneself (this is a dog phobic patient) in the vicinity of a dog for a sustained period of time, in this case 15 minutes.
2. The second task, prior to going to the physical area where a dog will be present, is to appraise what worrying event may happen. In this case, the patient might say, “I’ll be bitten within the 15 minute period of exposure”.
3. The patient is asked for an estimation that this event will happen on a 0 (won’t happen) through to 100 (definitely will happen). In the example above, the patient has rated the chances as almost certain – 99%
4. AFTER the exposure, there is some followup: Did what you think would happen, that is what you worried would happen, actually happen? YES or NO
5. If NO, how did you know it didn’t happen? In this case, the patient remarks a dog didn’t approach and bite her.
6. This very important as a reappraisal of the scenario, couched in terms of what the patient learnt. In this case, the patient states she learnt I can probably go to a dog area and not be bitten.
The same series of steps is performed for more challenging situations in the next several sessions of exposure to more intense stimuli, including increasing time near dogs as well as actually handling dogs.
In my own work with children and dogs, I don’t dilly-dally – I move into an exposure to a dog (my own, a young German Shepherd Dog I’ve names Scout) very early, with the idea we have the dog in the session while we do another activity such as watching a movie, playing a game on the iPad or similar. Invariably, the child’s self-estimated arousal will be markedly different (lower) at the end of the session, with the assumed actions of the dog (“he’s going to jump on me – he’s going to bite me”) turning out to be obviously false. In this case, her fears of what will happen are explicitly violated and new learning can take place. For many children, I’ll eventually add in some breathing retraining as it’s a great tool not just for resetting the arousal set-point, but will also be helpful for other situations like sitting exams, playing sport, and driving lessons, etc.
Indeed, many adults with young children who see me for their own fear treatment will often remark that children ought to be taught these same emotional regulation tools and techniques as part of their school curriculum, and indeed some schools are doing this.
Another example of Inhibitory Learning Protocols
In another paper, Michelle Craske shows us a plan for social anxiety.
It starts with the goal setting exercise with the therapist:
Notice how the new learning paradigm is worded: “What and How am I testing out my assumptions?”
Notice also in this example some additional elements to enhance the learning process:
- What safety behaviours am I challenging?
- How will I stay with my discomfort?
- How will I intensify my distress (and thus take control of it)?
- How will I label what I feel?
After the exposure, the following written protocol can be completed to enhance the new learning:
To sum up, I approach each session of treatment with the idea of what should the patient learn in this session? I will often say “this is your take home message for today” during the session, and then as we finish, ask if they can remember the message(s). (I limit myself to no more than three take home messages).
For me, this is current best practice from an evidence base of what works. It may change in the years to come as new technologies become more effective (such as virtual and augmented reality), but for now exposure work for anxiety remains the Gold Standard, particularly if we can rid ourselves of dogma masquerading as evidence.
(If this information appeals and you’d like to discuss your situation and suitability for treatment, contact me firstname.lastname@example.org or 0413040747. Skype sessions can be arranged but will not attract insurance rebates at this time.)