FLOODING and IMPLOSIVE THERAPY Direct Therapeutic Exposure in Clinical Practice FLOODING and IMPLOSIVE THERAPY Direct Therapeutic Exposure in Clinical Practice

FLOODING AND IMPLOSIVE THERAPY Direct Therapeutic Exposure in Clinical Practice FLOODING AND IMPLOSIVE THERAPY Direct Therapeutic Exposure in Clinical Practice

Patrick A. Boudewyns Veterans Administration Medical Center and Mcdiml College of Gcorgiil

and Robert H. Shipley Veterans Administration Mediwl Center lind Duke University Medical Center Durham, North Carolilill

Plenum Press • New Yark and London Library of Congress Cataloging in Publication Data

Boudewyns, Patrick A., 1949- Flooding and implosive therapy.

Bibliography: p. Includes index. I. Desensitization (Psychotherapy). 2. Behavior therapy. I. Shipley, Robert H., 1945- . II. Title. [DNLM: I. Behavior therapy. 2. Anxiety disorders-Therapy. WM 425 B784f] RC489.D45B68 1983 616.89 1 142 8.'>·2380 ISBN-13: 978-1-4684-4372-1

ISBN-13: 978-1-4684-4372-1 e-ISBN-13: 978-1-4684-4370-7 001: 10.1007/978-1-4684-4370-7 1983 Plenum Press, New York Softcover reprint of the hardcover 15t edition 1983 A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher To Mickey, Brian, Patrick, and Erin P.A.B.

To my father, J.B., and Kim R.H.S. PREFACE

Behavior therapists often "desensitize" clients by exposing them to an anxiety-eliciting stimulus such as a phobic object. The premise is that repeated exposures will eventually reduce or extinguish the fear. This process is called therapeutic exposure. Many therapists would agree that therapeutic exposure is an effective treatment for several anxiety disorders. However, the "directness" with which therapeutic exposure should be encouraged for a client is much debated. Many feel that direct therapeutic exposure, more commonly known as flooding or implosive therapy, causes clients an excessive amount of anxiety, and may therefore produce long-lasting and harmful side effects. In response to these concerns, one well-known behavior therapy technique, systematic desensitization, was designed to expose clients to imagined fear stimuli slowly and under relaxing conditions so as not to elicit anxiety. In the first chapter of this book, we show that these concerns are based on false assumptions. When used properly, direct therapeutic exposure is not harmful. In Chapters 2 and 3, we review the literature on the process and outcome of flooding and implosive therapy from a practical, clinical perspective. This literature shows that these treatments are effective and efficient for certain psychiatric disorders. In Chapter 4, we describe the treatments we offer our clients and show how learning theory can be used to help develop the procedure and content of therapy. Chapter 5 provides case examples with transcripts of typical therapy sessions. This book can be used as a handbook for therapists or students. If used as a handbook, we strongly recommend that those not familiar with the theory and rationale read the book thoroughly and try not to learn the technique from the case examples alone. For example, some of the

vii viii PREFACE transcripts in Chapter 5 involve anger, violence, and/or sexual concerns; material that might be upsetting to anyone. However, as shown in Chapter 4, this material is highly idiosyncratic to the client. There is considerable method in what might at first appear to be madness. Finally, one aim of this book is to dispel the common belief that therapists who use direct therapeutic exposure lack empathy and concern for their clients. In fact, because these treatments sometimes provoke anxiety, it is vitally important that the therapist convey support and empathy so that the client is motivated to continue in therapy. We wish to thank several people who helped us in writing this book. First and foremost, we offer our gratitude to our teachers, Thomas Stampfl and Donald Levis. Next, we wish to thank Jeannine Wheless and T. John Rosen for their superb editing, and Kit Chappell, Gill Lunsford, Marge Miles, Amanda Darwin, Paulette Fulghum, and Joan Way for help in preparing the manuscript. Finally, we thank our clients who allowed us to learn from them.

PA TRICK A. BOUDEWYNS ROBERT H. SHIPLEY CONTENTS

Chapter 1 DIRECT THERAPEUTIC EXPOSURE ...... 1 What Is Direct Therapeutic Exposure? ...... 3 For Which Disorders Is Direct Therapeutic Exposure Effective? ...... 5 Early False Assumptions Lead to Concerns about Effectiveness ...... 6 Concerns about Resensitization and/or the Incubation Effect ...... 8 Does Direct Therapeutic Exposure Harm Clients? ...... 11

Chapter 2 RESEARCH ON NONPATIENT POPULATIONS .. 15 Animal Analogue Research ...... 17 The Conditioned-Avoidance Response...... 18 Effect of Amount of CS Exposure during Extinction ...... 20 The Effect of Food ...... 22 Effects of Graded CS Exposure ...... 23 Effect of Drugs ...... 23 Effect of Forced Movement ...... 24 Effect of Flooding to an "Irrelevant" Stimulus .. 24 Serial CS and Resistance to Extinction ...... 25 Summary...... 26 Human Analogue Research...... 27 Duration of Exposure ...... 30 Fear Enhancement (Incubation) with Exposure 31

ix x CONTENTS

Mode of Cue Presentation ...... 34 In Vivo versus Fantasy Exposure ...... 35 The Validity of Using Imagery in Direct Exposure Techniques ...... 36 Scene Content ...... 37 Flooding versus Systematic Desensitization ...... 39 Effect of Drugs ...... 39 Summary ...... 39

Chapter 3 RESEARCH ON PATIENT POPULATIONS ...... 41 Issues in the Treatment of Anxiety Disorders with Therapeutic Exposure ...... 41 In Vivo versus Imaginal (Fantasy) Exposure ..... 41 Optimal Length of Exposure Session ...... 44 Homework Exposure ...... 45 Group versus Individual Treatment ...... 46 The Effect of Group Cohesiveness on Exposure ...... 46 Client Response during Treatment...... 47 Psychotropic Medications with Exposure ...... 48 Graded versus Nongraded Exposure ...... 50 Treating Obsessive Thoughts Unaccompanied by Compulsion ...... 51 Direct Exposure versus Other Psychotherapeutic Techniques in Treating Anxiety Disorders ...... 52 Exposure Techniques Used with Other Disorders ...... 56 Psychiatric Inpatients and Outpatients ...... 56 Agitated Depression ...... 58 Alcoholism ...... 58 Emotionally Disturbed Retardates ...... 59 Heroin Addiction ...... 59 Insomnia ...... 60 Summary...... 60 Case Reports ...... 61 Adult Phobias with Obsessive-Compulsive Features ...... 62 Techniques Using Variations of Flooding or Implosive Therapy ...... 64 CONTENTS XI

Flooding and Implosive Therapy with Children ...... 66

Chapler 4 THEORY AND TECHNIQUE...... 68 Implosive Therapy: Theory and Technique ...... 68 Task of the Therapist...... 69 The Therapist-Client Relationship ...... 69 Informed Consent ...... 70 Detective Work ...... 71 Therapeutic Programming and Initial Diagnostic Interviews ...... 75 Neutral Scene Presentation ...... 78 Implosive Sessions ...... 80 Use of Implosive Therapy with Other Therapies ...... 85 Scene Content Areas ...... 86 The Flooding Technique ...... 98 Imaginal Flooding ...... 98 In Vivo Flooding ...... 98

Chapler 5 CASE EXAMPLES ...... 100 Chronic Posttraumatic Stress Disorder ...... 101 First Interview ...... 103 Second Interview ...... 113 Treatment ...... 126 Simple (Specific) Phobia ...... 141 Heights ...... 142 Flying ...... 145 Insects, Snakes, and Other Small Animals ..... 146 Contamination ...... 147 Automobile Driving ...... 151 Fear of Dental Procedures ...... 156 Medical and Surgical Problems ...... 159 Social Phobia ...... 160 Public Speaking ...... 164 Urinating in Public Restrooms ...... 165 Agoraphobia ...... 167 Panic Disorders ...... 175 Obsessive-Compulsive Disorders ...... 179 xii CONTENTS

Epilogue ...... 216 References ...... 217 Author Index ...... 229 Subject Index ...... 233