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Confronting Emotional Reactions

(5-27-10)

  • Behavioral treatments of phobias and other neurotic (excessive, irrational, nonfunctional emotional responses to stimuli)
    • Distinction between rational (functional) and irrational fears
    • The treatment of reality based fears centers on increasing relevant knowledge and skills
    • Fear of dangerous snakes: identification of snakes, snake handling skills & tools
    • Fear of social embarrassment: enhancement of social perception & skills
  • Models of the genesis of irrational fears
    • Pure conditioning models
      • Little Albert, the Moro reflex, and learning to fear
    • Preparedness models
      • The natural history of fears
    • Psychodynamic models
      • People are funny animals
  • Theoretical models of fear reduction
    • Wolpe’s counterconditioning theory
    • Extinction theory
    • Operant reinforcement of approach behavior theory
    • There is little agreement on theoretical models of either fear acquisition or reduction. All available theories seem unsuccessful in adequately accounting for the available body of reliable knowledge regarding fear behavior.
    • Nevertheless, a number of behavior treatments for phobias and other irrational emotional responses have been empirically validated as effective.

Well supported treatments of phobias and other excessive emotional reactions

Systematic desensitization

  • Standard elements
    • Counterconditioning response
      • PMR and hypnosis
        Assertiveness
        CO2, martial arts, Zen meditation, attention to music, etc.
    • Hierarchy of fear stimuli
      • Conceptualization of fear stimuli/theme/dimension
      • Graded ordering of scenes
      • Issues of number of scenes, magnitude of intervals, thematic cohesiveness/purity
    • Desensitization
      • Relaxation
      • Scene presentation
      • Communication system
      • Response to anxiety
      • Repetition
      • Operationalization of success
      • Pacing within and between scenes
    • Standard elaborations
      • Multiple hierarchies/fears
      • Correction of misconceptions (cognitive restructuring)
      • Assertiveness training
      • In vivo exposure
    • Variations
      • Self-directed desensitization
      • Coping imagery
      • More rapidly progressing desensitization (fewer scenes)
      • Contact (in vivo) desensitization

Flooding

  • Prolonged exposure to maximum fear stimuli
  • A hierarchy may be constructed to facilitate full understanding of the underlying anxiety dimension; therapy starts with the top item
  • Exposure continues until the client notices a diminution of the fear response
  • Repetition is needed to deal with spontaneous recovery
  • Imagery vs. in vivo flooding
  • Advantages: speed of change (and therefore, cost)
  • Possibly the most efficient of the demonstrative effective treatments of anxiety responses
  • Disadvantages
    • Emotional discomfort of patient (and therapist)
    • Potential for iatrogenic effect (you possibly could make the person worse)
    • Difficulty in scheduling due to lack of total predictability in duration of sessions
  • Common elaborations
    • Use of natural partners as coaches
    • Homework tasks in real environment
  • Modeling and guided participation (especially for children)
  • Use of live, videotape, story, and print models selected for similarity and/or prestige to target child
  • Gradual exposure to “real life” situations involving the feared stimulus and children happily/successfully interacting with the stimulus
  • Social reinforcement of approach behavior by child client by therapist, parents/family; possibly augmented by activity, material, or token reinforcement
  • Response prevention (for OCD)
  • A desensitization approach to the anxiety occasioned by compulsive behavior prevention (ritual violation) in individuals with OCD
  • Better results with overt compulsive behavior (hand washing) than cognitive rituals (counting) has been reported. It is not clear whether this has to do more with our ability to monitor compliance with the technique or some substantive difference between behavioral and cognitive compulsions.

Treatments with some empirical &/or clinical support

  • Mindfulness
    • Meditation may help people with anxiety responses by addressing no so much the content of thought but the process of thought (metacognition). Individuals may come to see their thoughts of as thoughts (images, feelings etc.), rather than as a reality that much be responded to
  • Emotive Imagery
    • Imagery procedure for children which pairs weak stimuli for fear response with strong stimuli for pleasant/capable/successful/exciting feelings
    • The imagery is gradually altered to increase the strength of the fear stimuli
    • The child should experience little to no anxiety while eventually being able to tolerate vivid and intense scenes involving the previously feared stimuli
  • Implosive Therapy
    • Flooding in imagery with elaboration of the scenes to include stimulus elements not necessarily identified by patient but suggested by a psychodynamic understanding of the case
  • Cognitive therapies
    • RET and other cognitive therapies (al la Beck) call for a rational analysis of fear behavior, a passive (accepting) attitude, self-observation of internal responses, avoidance of catastrophic thinking, and a focus on adaptive behavior
    • Although the theory makes little sense—most perspectives on phobias for instance would suggest that these are largely subcortical responses and cognitive therapy clearly focus on cortical processes—these interventions do sometimes work for clients
    • Agoraphobia in particular is often conceptualized as a “fear of fear”: over interpretation of internal arousal cue as reflective of dire and dangerous potentials: “My heart is beating fast: I’m going to have a heart attack and die right now!”
  • Anxiolytic and antidepressant medications
    • A wide range of prescription, over-the-counter, licit, and illicit chemicals affect our anxiety responses. Although rift with difficulties and potential complication (dependency, abuse, habituation and loss of effect, cost, availability, and potential drug interactions to name a few), it would not be responsible to deny the benefits for some clients with anxiety disorders of anxiolytic and antidepressant medications (almost all antidepressant medications have some anxiolytic properties; the most obvious exception are the mood stabilizers—Lithium and the anticonvulsant medications).
    • From a behavioral perspective, it has been my experience that anxiolytic medications tend to interfere somewhat with behavioral treatments of anxiety. Therapy can still progress and the client benefit, but treatment is slower and more sessions are needed.
    • Finally, it is worth carefully and possibly repeatedly reviewing the clients use of the entire range of chemicals (alcohol, tobacco, caffeine, St. John’s Wart, cannabis, allergy medications, etc.) as this may interact with environmental and treatment variables in the anxiety responses.

Other emotional problems

Depression

  • Emotions:
    • Dysphoria, anxiety, sadness, irritability
    • Negative affect
    • Anhedonia
  • Cognitions:
    • Negative views of self, world, future
    • Pessimism, hopelessness, helplessness
    • Poor problem solving, irrational thinking, impaired attention/concentration
  • Actions:
    • Decrease in frequency, intensity, speed, duration, persistence of behavior
    • Decrease in reinforcement seeking behavior
    • Ineffective, alienating, oppositional, negativistic behavior

Lewinsohn’s skill deficit treatment model of depression

  • Planning (instill hope, counter ambivalence & lethargy)
  • Learning relaxation (reduce anxiety, manage stress)
  • Pleasant activities (improve mood, increase activity)
  • Learning social skills (enhance social exchanges)
  • Increasing social interaction (improve mood, increase activity)
  • Controlling negative thinking/increasing positive thinking (improve mood, decrease ambivalence & lethargy)
  • Disputing irrational thinking (improve mood, decrease self-defeating behavior)
  • Coaching self: self-instructional techniques (increase use of positive behaviors for change)
  • Maintaining gains: self-monitoring and preparation for cyclical difficulties
  • Changing personality: adopting positive roles (changing long term patterns and habits toward more adaptive and self-rewarding responses)

Hypomania

  • Emotions:
    • Elation, confidence, grandiosity, excitement, irritable
    • Hedonistic
  • Cognitions:
    • Decreased critical thinking, over confidence
  • Actions:
    • Increased goal seeking behavior, impulsive, energetic

Anger

  • Emotions:
    • Anger, rage, hostility
  • Cognitions:
    • Paranoid, projection, threat sensitive
  • Actions:
    • Verbal and physical threats, derogation, aggression

Deviant sexual arousal

  • Emotions:
    • Paraphilic arousal
  • Cognitions:
    • Obsessive
  • Behavior:
    • Compulsive

Hyposexual arousal

  • Emotions:
    • Low arousal & pleasure
    • Anxiety, shame, guilt, ambivalence, anhedonia
  • Cognitions:
    • Negative attitudes and beliefs
    • Avoidance
  • Behavior:
    • Low frequency of approach behavior
    • Avoidance

Other applications of emotional conditioning

  • Self-defeating approach behavior: alcohol, drugs, tobacco, gambling
    • Covert sensitization and other aversive conditioning techniques
    • Skill training approaches
  • Repetitive or dangerous behaviors
    • Satiation for hoarding, playing with matches
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