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Exposure- based treatments(Pavlovian conditioning methods • Assumption: Abnormal behaviour is due to inappropriate classical conditioned emotions specially fear and anxiety BEHAVIORAL THERAPY motivating avoidance and rewarded by anxiety reduction. THERAPEUTIC TECHNIQUE • The client is exposed to feared object to increase sense of coping and mastery. • Achieve mental and muscular relaxation Most commonly used: progressive relaxation or muscle relaxation

SYSTEMATIC • – a form of behavioral DESENSITIZATION: therapy in which the survivor confronts feelings or or anxieties about a • Originally called reciprocal inhibition. traumatic event & relives it in the therapy • Developed by session. • “exposure therapy” • Clients are required to expose themselves • The steps involved: to anxiety arousing images to reduce – Relaxation training anxiety gradually / systematically they – Development of an anxiety hierarchy become desensitized or less sensitive to – Systematic desensitization proper the anxiety arousing situation.

Exposure therapy for anxiety Contd… used in OCD, PTSD and

Exposure to anxiety in graded fashion –Learn to master Fear situations that cause mild, then gradually greater, F e a r anxiety. Teach & test a Identify specific goals and break Relax STOP relaxation strategy before R e la x Relax STOP STOP to reduce distress/panic R e la x Relax STOP STOP R e la x during exposure STOP Relax STOP R e la x STOP Relax them into smaller, manageable STOP R e la x STOP Relax –Aim is to achieve relative R e la x

STOP relaxation before next STOP steps step The Principle of Exposure Therapy The Principle of Exposure Therapy

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IN VIVO (Latin, in life) EXPOSURE Flooding and Implosion and FLOODING: They are anxiety-induction therapies for phobias that: • In Vivo Exposure – actual exposure of the client to the anxiety-evoking event • expose the individual to the feared object without • Also called graduated exposure. chance of escape • Example- Fear of flying • designed to extinguish the response • the therapist exposes the person to a highly feared • Flooding – client is flooded with situation and prevents escape or avoidance experiences of a particular kind until becoming either averse to them or • anxiety is encouraged numbed to them. (more on real life • relaxation training is not a part of the procedure exposure)

Concerns About Flooding Implosive therapy • phobias with a more focused CS may be extinguished in one training session • phobias with more diffuse or multi-element CSs may • It is an extension of desensitization work require many sessions and application of research on extinction • the fear-arousing situation can be introduced gradually when it produces an intolerable fear • implosive therapy requires the person to • high anxiety may lead to avoidance of treatment imagine unrealistic, exaggerated, or • the therapist may consider to accompany the client unlikely harmful events that are associated during the most feared encounters with the fear. • flooding appears to be relatively safe • People forced to remain in frightening • in vivo and imaginal flooding are equally effective • in vivo procedures may be difficult to apply situation will have to stop feeling afraid a • flooding is about as effective as desensitization while (20-30 min.)

Difference between Implosive Exposure and Response Therapy and flooding Prevention (ERP)

• Implosive therapy - a form of behavior therapy involving intensive recollection and review of anxiety-producing situations or • This is also an extinction procedure events in a patient's life in an attempt to develop more appropriate Used to treat OCD and Bulimia response (feeling relaxed) to similar situations in the • future.(Imagined) • It involves exposing the client to the

• Flooding- It is sometimes referred to as exposure therapy or stimuli that elicit the compulsive behaviour prolonged exposure therapy. As a psychotherapeutic technique, it and then preventing from engaging in the is used to treat phobia and anxiety disorders including post- traumatic stress disorder.(In vivo) response • It is used only in certain cases.

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Aversion Therapy (use of punishment) Covert Sensitization • It involves the use of an unconditioned aversive stimulus to classically condition It is the use of an imagination of stimulus fear or aversion to a previously attractive • in place of an actual aversive stimulus or stimulus in order to create an avoidance punishment to create new learning response or to suppress undesirable or unwanted operant behaviour. • Opposite to desensitization. • Electric shock or nausea inducing drugs • It may be used to create classically are used as aversive stimulus. conditioned anxiety to teach an avoidance response. • Therapy is used for the treatment of bad habits such as drinking, smoking , nail • Example: Diet control by imagining a biting etc. favourite food with worms all over it.

EYE MOVEMENT DESENSITIZATION & REPROCESSING (EMDR): Eight Phases of Treatment:

• Developed by: Francine Shapiro (2001) • First phase – history-taking session where • A form of exposure therapy that involves: therapists assesses client’s readiness for EMDR & develops a treatment plan. - imaginal flooding • Second Phase – therapist ensures that the - client has adequate methods of handling - the use of rapid rhythmic eye emotional distress and coping skills. movements • Third to sixth phase – a target is identified and processed using EMDR. • For clients with traumatic stress

• Seventh Phase – closure. Client is asked SKILLS TRAINING (Operant to keep a journal during the week Conditioning) • Eighth Phase – re-evaluation of the previous work and of progress since the • Assumption: Abnormal behaviour (e.g. shyness, schizophrenia)are due to lack of skills or poor previous session environment or both. Needed skills can be taught. EMDR treatment ensures processing of all • For individuals with psychosocial problems related historical events, current incidents • Anger management training that elicit distress, and future scenarios • Assertion training-teaching people to be that will require different responses. assertive in a variety of social situations

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Assertiveness Training • Social skills such as conversation, asking for dates, saying no, dealing with bosses, (Behavioural modification) negotiation are rewarded by praise by the • These methods involve the planned use of therapists. rewards to increase wanted behaviour and • Sociall skills vary according to the needs of of extinction to decrease unwanted clients. behaviour. • Techniques: modeling, psycho education, shaping or successive approximation , behavioral rehearsal, role playing, • Used in different settings like families, feedback business, schools, institutions of mentally • Attributes of therapist. retarded and prisons etc. • Most social skills therapy includes practicing the skills in the real world.

Patterson’s Program of Parent Steps Training • Worked with school children with behavioural • Parents are taught to reward behaviour problems (i.e. aggressiveness, temper tantrums, they want in their children. stealing, fighting, lying etc.) • There are cultural differences in the use of • Both parent and child negotiate the goals of reward and punishment. program and its mode of implementation. • Time out is used to eliminate unwanted • Several reasons to avoid punishment: behaviour. - Parents are paired with pain • Time out is used in non threatening and - Children learn to imitate their parents frightening ways but must be consistently used. - Need for constant policing function - A vicious cycle of aversive control is developed.

Time Out Evaluation • Time out is used to eliminate unwanted • Parents feel happier and more competent behaviour by removing the rewarding after treatment. situation. • They may use for other behaviours as • It can be viewed as an extinction well. procedure or negative punishment. • Teachers may clollaborate with parents to • Place for time out may be uninteresting improve school behaviours. but safe and non-threatening. • Siblings also improve. • Duration may vary with age and behaviour • Well conducted behaviour management of child during time out. program at schools are effective for • It should be used consistently for better students better conduct and results. achievements.

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Token Economies Contingency Contracting • Tokens are given in place of actual rewards which are later exchanged for desired rewards. • Individual program • Ted Ayllon (1968),one of the pioneers, used for developed by the client and therapist. disturbed schizophrenics. • A contract is developed about • Can be used in classrooms, psychiatric wards and mentally retarded persons. consequences of certain acts by the client, e.g. fee reduction, buying a new cycle, • Food, deserts, cigarettes, nicotine can be used as tokens but it seems manipulative. new dress etc. • Defenders argue that token economies mimic • Positive reinforcers (tokens, points or the real world. privileges) are withdrawn to suppress unwanted behaviors.

Self Management • Client uses techniques to modify ones own Contd… behavior. • Coping imagery exercise can be used. • Self- monitoring, self-reward, problem solving Therapist and client review possible and contingency contracting are used. • coping strategies for the client's problem. • Self awareness is created by keeping track of the targeted behavior (smoking reduction, study • The client imagines using them in various for long hrs.). situations. • Steps of problem solving techniques are • Therapist may teach coping skills the followed- Define the problem, recognize the client lacks. reaction, generate the solutions, evaluate the solutions and act, Assess the effect of attempts. • Self management is now being used in business and education to improve company functioning and student learning.

Punishment • Punishment for operant behaviour is rarely used for ethical concerns • It is used when other methods fail, like quickly suppress self injury in psychiatric or autistic children. • Imagining the consequences of a punishment in place of actual, e.g. kleptomania. Therapist may help in imagination. • Self punishment may be used to overcome bad habits- smoking (use of rubber band to snap)

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