{"id":4129,"date":"2017-04-04T03:13:09","date_gmt":"2017-04-04T03:13:09","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/waymaker-psychology\/?post_type=chapter&#038;p=4129"},"modified":"2024-05-17T15:18:13","modified_gmt":"2024-05-17T15:18:13","slug":"psych-in-real-life-behavior-therapy","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/waymaker-psychology\/chapter\/psych-in-real-life-behavior-therapy\/","title":{"raw":"Psych in Real Life: Behavior Therapy","rendered":"Psych in Real Life: Behavior Therapy"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li>Explain the basic process and uses of play and behavior therapy<\/li>\r\n \t<li>Describe systematic desensitization<\/li>\r\n<\/ul>\r\n<\/div>\r\n<h2 data-type=\"title\">Psychotherapy: Play Therapy<\/h2>\r\n<span id=\"term1073\" data-type=\"term\">Play therapy<\/span>\u00a0is often used with children since they are not likely to sit on a couch and recall their dreams or engage in traditional talk therapy. This technique uses a therapeutic process of play to \u201chelp clients prevent or resolve psychosocial difficulties and achieve optimal growth\u201d (O\u2019Connor, 2000, p. 7). The idea is that children play out their hopes, fantasies, and traumas while using dolls, stuffed animals, and sandbox figurines.\r\n\r\n[caption id=\"attachment_6602\" align=\"alignright\" width=\"300\"]<a href=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031005\/play.jpeg\"><img class=\"wp-image-6602 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031005\/play-300x200.jpeg\" alt=\"This photograph shows a person playing with objects in a small box filled with sand. The person is organizing these objects and small play figures in a form of treatment called sandplay.\" width=\"300\" height=\"200\" \/><\/a> <strong>Figure 1<\/strong>. This type of play therapy is known as sandplay or sandtray therapy. Children can set up a three-dimensional world using various figures and objects that correspond to their inner state (Kalff, 1991). (credit: Kristina Walter)<span style=\"font-size: 1rem; orphans: 1; text-align: initial; background-color: #ffffff;\">\u00a0<\/span>[\/caption]\r\n<p id=\"fs-idm70760752\">Play therapy can also be used to help a therapist make a diagnosis. The therapist observes how the child interacts with toys (e.g., dolls, animals, and home settings) in an effort to understand the roots of the child\u2019s disturbed behavior. Play therapy can be nondirective or directive. In nondirective play therapy, children are encouraged to work through their problems by playing freely while the therapist observes (LeBlanc &amp; Ritchie, 2001). In directive play therapy, the therapist provides more structure and guidance in the play session by suggesting topics, asking questions, and even playing with the child (Harter, 1977).<\/p>\r\n\r\n<h2>Behavior Therapy<\/h2>\r\n<p id=\"fs-idm113039840\">In\u00a0<span id=\"term1074\" data-type=\"term\">psychoanalysis<\/span>, therapists help their patients look into their past to uncover repressed feelings. In\u00a0<span id=\"term1075\" data-type=\"term\">behavior therapy<\/span>, a therapist employs principles of learning to help clients change undesirable behaviors\u2014rather than digging deeply into one\u2019s unconscious. Therapists with this orientation believe that dysfunctional behaviors, like phobias and bedwetting, can be changed by teaching clients new, more constructive behaviors. Behavior therapy employs both classical and operant conditioning techniques to change behavior.<\/p>\r\n<p id=\"fs-idp42686176\">One type of behavior therapy utilizes classical conditioning techniques. Therapists using these techniques believe that dysfunctional behaviors are conditioned responses. Applying the conditioning principles developed by Ivan Pavlov, these therapists seek to recondition their clients and thus change their behavior. Emmie is eight years old, and frequently wets her bed at night. She\u2019s been invited to several sleepovers, but she won\u2019t go because of her problem. Using a type of conditioning therapy, Emmie begins to sleep on a liquid-sensitive bed pad that is hooked to an alarm. When moisture touches the pad, it sets off the alarm, waking up Emmie. When this process is repeated enough times, Emmie develops an association between urinary relaxation and waking up, and this stops the bedwetting. Emmie has now gone three weeks without wetting her bed and is looking forward to her first sleepover this weekend.<\/p>\r\n<p id=\"fs-idm76222160\">One commonly used classical conditioning therapeutic technique is\u00a0<span id=\"term1076\" data-type=\"term\">counterconditioning<\/span>: a client learns a new response to a stimulus that has previously elicited an undesirable behavior. Two counterconditioning techniques are aversive conditioning and exposure therapy.\u00a0<span id=\"term1077\" data-type=\"term\">Aversive conditioning<\/span>\u00a0uses an unpleasant stimulus to stop an undesirable behavior. Therapists apply this technique to eliminate addictive behaviors, such as smoking, nail biting, and drinking. In aversion therapy, clients will typically engage in a specific behavior (such as nail biting) and at the same time are exposed to something unpleasant, such as a mild electric shock or a bad taste. After repeated associations between the unpleasant stimulus and the behavior, the client can learn to stop the unwanted behavior.<\/p>\r\n<p id=\"fs-idp64292672\">Aversion therapy has been used effectively for years in the treatment of alcoholism (Davidson, 1974; Elkins, 1991; Streeton &amp; Whelan, 2001). One common way this occurs is through a chemically based substance known as Antabuse. When a person takes Antabuse and then consumes alcohol, uncomfortable side effects result including nausea, vomiting, increased heart rate, heart palpitations, severe headache, and shortness of breath. Antabuse is repeatedly paired with alcohol until the client associates alcohol with unpleasant feelings, which decreases the client\u2019s desire to consume alcohol. Antabuse creates a conditioned aversion to alcohol because it replaces the original pleasure response with an unpleasant one.<\/p>\r\n\r\n<h3>Exposure Therapy<\/h3>\r\n<p id=\"fs-idp36302928\">In\u00a0<span id=\"term1078\" data-type=\"term\">exposure therapy<\/span>, a therapist seeks to treat clients\u2019 fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it. This can be done via reality, imagination, or virtual reality. Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behavior therapy. Jones worked with a boy named Peter who was afraid of rabbits. Her goal was to replace Peter\u2019s fear of rabbits with a conditioned response of relaxation, which is a response that is incompatible with fear. How did she do it? Jones began by placing a caged rabbit on the other side of a room with Peter while he ate his afternoon snack. Over the course of several days, Jones moved the rabbit closer and closer to where Peter was seated with his snack. After two months of being exposed to the rabbit while relaxing with his snack, Peter was able to hold the rabbit and pet it while eating (Jones, 1924).<\/p>\r\n\r\n\r\n[caption id=\"attachment_6604\" align=\"aligncenter\" width=\"521\"]<img class=\"wp-image-6604 \" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031018\/ucrcr.jpeg\" alt=\"This figure, titled \u201cExposure Therapy,\u201d illustrates the exposure therapy strategy of Mary Cover Jones to rid a person of the fear of rabbits. The first of four levels depicts an image of a person and a rabbit with an equals sign between them. Under the rabbit reads \u201cconditioned stimulus (CS),\u201d and under the person reads \u201cfear of rabbits.\u201d The second level depicts an image of milk and cookies, labeled \u201cunconditioned stimulus (US),\u201d and on the other side of an equals sign there is a picture of the same person labeled \u201cunconditioned response (UR).\u201d The third level shows the milk and cookies, labeled \u201cunconditioned stimulus (US),\u201d and rabbit, labeled \u201cconditioned stimulus (CS),\u201d to the left and right of a plus sign, with the person on the other side of an equals sign. The label \u201cunconditioned response (UR) is below the person.\u201d The final level shows the person and the rabbit separated by an equals sign. This time the rabbit is labeled \u201cconditioned stimulus (CS)\u201d and the person is labeled \u201cconditioned response (CR).\u201d\" width=\"521\" height=\"625\" \/> <strong>Figure 2<\/strong>.\u00a0<span class=\"os-caption\">Exposure therapy seeks to change the response to a conditioned stimulus (CS). An unconditioned stimulus is presented over and over just after the presentation of the conditioned stimulus. This figure shows conditioning as conducted in Mary Cover Jones\u2019 1924 study.<\/span>[\/caption]\r\n\r\n<div id=\"CNX_Psych_16_02_Conditioning\" class=\"os-figure\">\r\n<div class=\"os-caption-container\"><\/div>\r\n<\/div>\r\n<p id=\"fs-idm14968432\">Thirty years later, Joseph Wolpe (1958) refined Jones\u2019s techniques, giving us the behavior therapy technique of exposure therapy that is used today. A popular form of exposure therapy is\u00a0<span id=\"term1079\" data-type=\"term\">systematic desensitization<\/span>, wherein a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli. The idea is that you can\u2019t be nervous and relaxed at the same time. Therefore, if you can learn to relax when you are facing environmental stimuli that make you nervous or fearful, you can eventually eliminate your unwanted fear response (Wolpe, 1958).<\/p>\r\n\r\n\r\n[caption id=\"attachment_6603\" align=\"alignleft\" width=\"325\"]<img class=\"wp-image-6603 size-full\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031008\/spider.jpeg\" alt=\"A close-up picture of a very large spider on a person\u2019s arm is shown. The person is using its other hand to hold up two of the spider\u2019s legs.\" width=\"325\" height=\"217\" \/> <strong>Figure 3<\/strong>.\u00a0<span class=\"os-caption\">This person suffers from arachnophobia (fear of spiders). Through exposure therapy he is learning how to face his fear in a controlled, therapeutic setting. (credit: \u201cGollyGforce \u2013 Living My Worst Nightmare\u201d\/Flickr)<\/span>[\/caption]\r\n<p id=\"fs-idm89857152\">How does exposure therapy work? Jayden is terrified of elevators. Nothing bad has ever happened to him on an elevator, but he\u2019s so afraid of elevators that he will always take the stairs. That wasn\u2019t a problem when Jayden worked on the second floor of an office building, but now he has a new job\u2014on the 29th floor of a skyscraper in downtown Los Angeles. Jayden knows he can\u2019t climb 29 flights of stairs in order to get to work each day, so he decided to see a behavior therapist for help. The therapist asks Jayden to first construct a hierarchy of elevator-related situations that elicit fear and anxiety. They range from situations of mild anxiety such as being nervous around the other people in the elevator, to the fear of getting an arm caught in the door, to panic-provoking situations such as getting trapped or the cable snapping. Next, the therapist uses progressive relaxation. She teaches Jayden how to relax each of his muscle groups so that he achieves a drowsy, relaxed, and comfortable state of mind. Once he\u2019s in this state, she asks Jayden to imagine a mildly anxiety-provoking situation. Jayden is standing in front of the elevator thinking about pressing the call button.<\/p>\r\n<p id=\"fs-idm99200336\">If this scenario causes Jayden anxiety, he lifts his finger. The therapist would then tell Jayden to forget the scene and return to his relaxed state. She repeats this scenario over and over until Jayden can imagine himself pressing the call button without anxiety. Over time the therapist and Jayden use progressive relaxation and imagination to proceed through all of the situations on Jayden\u2019s hierarchy until he becomes desensitized to each one. After this, Jayden and the therapist begin to practice what he only previously envisioned in therapy, gradually going from pressing the button to actually riding an elevator. The goal is that Jayden will soon be able to take the elevator all the way up to the 29th floor of his office without feeling any anxiety.<\/p>\r\n<p id=\"fs-idp25925152\">Sometimes, it\u2019s too impractical, expensive, or embarrassing to re-create anxiety- producing situations, so a therapist might employ\u00a0<span id=\"term1080\" data-type=\"term\">virtual reality exposure therapy<\/span>\u00a0by using a simulation to help conquer fears. Virtual reality exposure therapy has been used effectively to treat numerous anxiety disorders such as the fear of public speaking, claustrophobia (fear of enclosed spaces), aviophobia (fear of flying), and post-traumatic stress disorder (PTSD), a trauma and stressor-related disorder (Gerardi, Cukor, Difede, Rizzo, &amp; Rothbaum, 2010).<\/p>\r\n\r\n<div class=\"textbox exercises\">\r\n<h3>Link to Learning<\/h3>\r\nVirtual reality exposure therapy is being used to treat PTSD in soldiers. Virtual Iraq is a simulation that mimics Middle Eastern cities and desert roads with situations similar to those soldiers experienced while deployed in Iraq. This method of virtual reality exposure therapy has been effective in treating PTSD for combat veterans. Approximately 80% of participants who completed treatment saw clinically significant reduction in their symptoms of PTSD, anxiety, and depression (Rizzo et al., 2010). Watch this\u00a0<a href=\"https:\/\/www.youtube.com\/watch?v=QCCWH_CNjM0\" target=\"_blank\" rel=\"noopener nofollow\">Virtual Iraq video that shows soldiers being treated via simulation<\/a>\u00a0to learn more.\r\n\r\n<\/div>\r\n<h3>Operant Conditioning Therapies<\/h3>\r\n<p id=\"fs-idm20076208\">Some behavior therapies employ operant conditioning. Recall what you learned about operant conditioning: We have a tendency to repeat behaviors that are reinforced. What happens to behaviors that are not reinforced? They become extinguished. These principles, defined by Skinner as operant conditioning, can be applied to help people with a wide range of psychological problems. For instance, operant conditioning techniques designed to reinforce desirable behaviors and punish unwanted behaviors are effective behavior modification tools to help children with autism (Lovaas, 1987, 2003; Sallows &amp; Graupner, 2005; Wolf &amp; Risley, 1967). This technique is called Applied Behavior Analysis (ABA). In this treatment, a child's behavior is charted and analyzed. The ABA therapist, along with the caregivers, determines what reinforces the child, what sustains a behavior to continue, and how best to manage a behavior. For example, Nur may become overwhelmed and run out of the room when the classroom is too noisy. Whenever Nur runs out of the classroom, the teacher's aide chases him and places him in a special room where he can relax. Going into the special room and getting the aide's attention are reinforcing for Nur. In order to change Nur's behavior, he must be presented with other options before he becomes overwhelmed, and he cannot receive reinforcement for displaying maladaptive behaviors.<\/p>\r\n<p id=\"fs-idp7004192\">One popular operant conditioning intervention is called the\u00a0<span id=\"term1081\" data-type=\"term\">token economy<\/span>. This involves a controlled setting where individuals are reinforced for desirable behaviors with tokens, such as a poker chip, that can be exchanged for items or privileges. Token economies are often used in psychiatric hospitals to increase patient cooperation and activity levels. Patients are rewarded with tokens when they engage in positive behaviors (e.g., making their beds, brushing their teeth, coming to the cafeteria on time, and socializing with other patients). They can later exchange the tokens for extra TV time, private rooms, visits to the canteen, and so on (Dickerson, Tenhula, &amp; Green-Paden, 2005).<\/p>\r\n\r\n<h2>Behavior Therapy in Action: How Does it Work?\r\n<a href=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/04032038\/7658214720_0936cc407c_z.jpg\"><img class=\"alignleft wp-image-4132\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/04032038\/7658214720_0936cc407c_z.jpg\" alt=\"Smiling picture of a college student with a pen in her mouth.\" width=\"374\" height=\"249\" \/><\/a><\/h2>\r\nMeet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.\r\n\r\nBut Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.\r\n\r\nNow that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.\r\n\r\nYou know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam\u2019s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/e16b253f-2e12-4db5-b906-a6ad883e9618\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/538faf34-10bf-471f-9228-f3c82a2f065e\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/7be398e4-e938-448a-a822-463d245367c6\r\n\r\n<\/div>\r\nSystematic desensitization works by gradually\u2014step-by-step\u2014exposing the person to situations that are increasingly more anxiety-producing. This is called \u201cprogressive exposure.\u201d By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns\u00a0that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.\r\n\r\n<img class=\"alignright wp-image-4133\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/04032241\/7658298768_e4c2c2635e_z.jpg\" alt=\"Same picture of the college student, Miriam, looking confused or frustrated while looking at her notebook.\" width=\"260\" height=\"173\" \/>\r\n\r\nThe first steps in systematic desensitization is the development of a \u201chierarchy of fears.\u201d This simply means that you must help Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.\r\n\r\nFor the next step in this exercise, you will need to take on Miriam\u2019s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/bc55addb-b602-4188-9357-75056918f851\r\n\r\n<\/div>\r\nRemember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.\r\n\r\nSo we\u2019re ready to start, right? Wrong!\r\n\r\nBehavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation\u2014if you are relaxed, you can\u2019t be fully afraid.\r\n\r\nHowever, most people are not very good at relaxing on command. So the behavioral therapist will teach\u00a0the client how to relax effectively. The techniques are ones often used in meditation\u2014slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in <a href=\"https:\/\/www.youtube.com\/watch?v=dXRBNagGxtc\" target=\"_blank\" rel=\"noopener\">this video<\/a>.\r\n<h2>Miriam\u2019s Treatment<\/h2>\r\nMiriam is an imaginary person, but behavioral therapy is used by thousands of therapist with their clients every day. Review the following table to discover how Miriam\u2019s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person\u2019s course of therapy is unique.\r\n\r\nMiriam's Treatment\r\n<table class=\"wbtable \" cellspacing=\"0\" align=\"center\">\r\n<tbody>\r\n<tr>\r\n<th scope=\"col\">Therapy Sessions<\/th>\r\n<th scope=\"col\">Session Description<\/th>\r\n<\/tr>\r\n<tr class=\"e\">\r\n<th scope=\"row\">Miriam's therapy: Preparation<\/th>\r\n<td>Prior to starting progressive exposure, Miriam created her hierarchy of fears. She spent several session working on relaxation. She practiced relaxation at home several times a day until she and you, her therapist, agreed that she was ready to start treatment.<\/td>\r\n<\/tr>\r\n<tr>\r\n<th scope=\"row\">Miriam's therapy: Exposure Session 1<\/th>\r\n<td>The bottom (lowest anxiety) of Miriam\u2019s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a 1 to 10 scale, Miriam said 1: No fear at all.\r\n\r\nMiriam brought two friends with her to the therapy session today. You had them sit in a comfortable part of your office, drinking tea and chatting for 15 minutes. Afterwards Miriam reported her fear level during the chat as a 1 on a ten-point scale: no fear.\r\n\r\nYou then had her sit in a comfortable chair and think about giving a talk about the challenges of her job to a small, friendly audience. At the beginning of this task, she rated her anxiety as 3 on a 10-point scale. As she thought about it\u2014with helpful suggestions from you\u2014she also relaxed, using her relaxation training. After about 10 minutes, she reported her anxiety had dropped to 1, the lowest level of anxiety on your scale.\r\n\r\nYou gave Miriam \u201chomework\u201d\u2014to repeat this exercise twice a day until the next session.<\/td>\r\n<\/tr>\r\n<tr class=\"e\">\r\n<th scope=\"row\">Miriam's therapy: Exposure Session 2<\/th>\r\n<td>At the beginning of today\u2019s session, you had Miriam repeat the task from the previous session of thinking about talking about her job to a small, friendly group. At the beginning she rated her fear at 2, but it dropped to 1 within a few minutes.\r\n\r\nNow you took Miriam to the next level. You had her imagine telling a large audience of company executives about some technical problem she was working on at her job. At the beginning, just thinking about doing this led to a fear level of 5. After 10 minutes, her fear level dropped to 2. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session.\r\n\r\nYou gave Miriam homework again\u2014to practice a similar situation at home.<\/td>\r\n<\/tr>\r\n<tr>\r\n<th scope=\"row\">Miriam's therapy: Exposure Session 3<\/th>\r\n<td>You started this situation with a new scenario similar to the one Miriam did in the last session and practiced at home. She was quickly able to drop her anxiety level to 1.\r\n\r\nYou had a professional photography group create a video of someone very similar in appearance and manner to Miriam giving a talk in from of a small friendly audience on a topic similar to one Miriam might give. You asked her to watch this video and imagine herself in the place of the real speaker. She rated this a 6 on the anxiety scale. Over several repetitions, her rating dropped to 2.\r\n\r\nFor homework, Miriam watched the video several times a day. You instructed her in ways to make the video seem MORE REAL, so she could really feel the anxiety of being in front of people.<\/td>\r\n<\/tr>\r\n<tr class=\"e\">\r\n<th scope=\"row\">Miriam's therapy: Exposure Session 4<\/th>\r\n<td>You have had Miriam arrange to give a talk NEXT SESSION to a small group of Miriam\u2019s co-workers. You also had Miriam prepare the talk. Today you practiced the talk with her. At the start of the practice session, with only you there, Miriam rated her anxiety level at 9 out of 10. Over the course of the hour, her anxiety level dropped to 5.\r\n\r\nHer homework was to continue to practice the talk and to work on relaxation.<\/td>\r\n<\/tr>\r\n<tr>\r\n<th scope=\"row\">Miriam's therapy: Exposure Session 5<\/th>\r\n<td>Today, Miriam gave the talk to the small group. Her anxiety rating before she went in front of them was 10. Except for a little stumbling at the start, the 20-minute presentation went well. Miriam reported an anxiety level of 4 after the talk.<\/td>\r\n<\/tr>\r\n<tr class=\"e\">\r\n<th scope=\"row\">We\u2019ll skip a few sessions.<\/th>\r\n<td>We hope you have the basic idea.<\/td>\r\n<\/tr>\r\n<tr>\r\n<th scope=\"row\">Miriam's therapy: Exposure Session 6<\/th>\r\n<td>In this last session, you have arranged for Miriam to be the introductory speaker at a literacy tutoring volunteer organization nearby. Miriam has done a small amount of volunteer work with the organization, but she knows very little about it. With the help of the staff, she prepares a talk during the week before this session.\r\n\r\nThe audience is composed of 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Miriam knows none of them and none of them has ever heard of her.\r\n\r\nMiriam\u2019s introductory comments take about 15 minutes. She rates her anxiety level before going out at 8. After the talk, she rates her anxiety at 2. In fact, she said it was almost fun.<\/td>\r\n<\/tr>\r\n<tr class=\"e\">\r\n<th scope=\"row\">After Therapy<\/th>\r\n<td>Miriam continues to see you for a few more sessions. You give her additional homework and you help her develop a plan that includes arranging to give professional presentations for her job and continuing to give talks at the literacy volunteer organization. Miriam reports that none of these ideas create an anxiety level above 3 when she thinks about doing them.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nYou just learned about Systematic Desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let\u2019s review a few points from Systematic Desensitization.\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/034341ee-ecbc-485f-b38e-dd9f43a9276c\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/c16a4885-e7cf-4e1d-92bc-8ac9dbbf8c4c\r\n\r\n<\/div>\r\nIn flooding\u00a0therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.\r\n\r\nFlooding\u00a0has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding\u00a0that work for systematic desensitization:\r\n<ul>\r\n \t<li>The person consciously works to replace anxiety and fear with relaxation.<\/li>\r\n \t<li>The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.<\/li>\r\n \t<li>Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.<\/li>\r\n<\/ul>\r\n<div class=\"asx \">\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/0e5a8c4d-283d-4c4d-90af-61bccf641600\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/d4755d69-a37a-4198-aadc-210195081ac2\r\n\r\n<\/div>\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li>Explain the basic process and uses of play and behavior therapy<\/li>\n<li>Describe systematic desensitization<\/li>\n<\/ul>\n<\/div>\n<h2 data-type=\"title\">Psychotherapy: Play Therapy<\/h2>\n<p><span id=\"term1073\" data-type=\"term\">Play therapy<\/span>\u00a0is often used with children since they are not likely to sit on a couch and recall their dreams or engage in traditional talk therapy. This technique uses a therapeutic process of play to \u201chelp clients prevent or resolve psychosocial difficulties and achieve optimal growth\u201d (O\u2019Connor, 2000, p. 7). The idea is that children play out their hopes, fantasies, and traumas while using dolls, stuffed animals, and sandbox figurines.<\/p>\n<div id=\"attachment_6602\" style=\"width: 310px\" class=\"wp-caption alignright\"><a href=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031005\/play.jpeg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-6602\" class=\"wp-image-6602 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031005\/play-300x200.jpeg\" alt=\"This photograph shows a person playing with objects in a small box filled with sand. The person is organizing these objects and small play figures in a form of treatment called sandplay.\" width=\"300\" height=\"200\" \/><\/a><\/p>\n<p id=\"caption-attachment-6602\" class=\"wp-caption-text\"><strong>Figure 1<\/strong>. This type of play therapy is known as sandplay or sandtray therapy. Children can set up a three-dimensional world using various figures and objects that correspond to their inner state (Kalff, 1991). (credit: Kristina Walter)<span style=\"font-size: 1rem; orphans: 1; text-align: initial; background-color: #ffffff;\">\u00a0<\/span><\/p>\n<\/div>\n<p id=\"fs-idm70760752\">Play therapy can also be used to help a therapist make a diagnosis. The therapist observes how the child interacts with toys (e.g., dolls, animals, and home settings) in an effort to understand the roots of the child\u2019s disturbed behavior. Play therapy can be nondirective or directive. In nondirective play therapy, children are encouraged to work through their problems by playing freely while the therapist observes (LeBlanc &amp; Ritchie, 2001). In directive play therapy, the therapist provides more structure and guidance in the play session by suggesting topics, asking questions, and even playing with the child (Harter, 1977).<\/p>\n<h2>Behavior Therapy<\/h2>\n<p id=\"fs-idm113039840\">In\u00a0<span id=\"term1074\" data-type=\"term\">psychoanalysis<\/span>, therapists help their patients look into their past to uncover repressed feelings. In\u00a0<span id=\"term1075\" data-type=\"term\">behavior therapy<\/span>, a therapist employs principles of learning to help clients change undesirable behaviors\u2014rather than digging deeply into one\u2019s unconscious. Therapists with this orientation believe that dysfunctional behaviors, like phobias and bedwetting, can be changed by teaching clients new, more constructive behaviors. Behavior therapy employs both classical and operant conditioning techniques to change behavior.<\/p>\n<p id=\"fs-idp42686176\">One type of behavior therapy utilizes classical conditioning techniques. Therapists using these techniques believe that dysfunctional behaviors are conditioned responses. Applying the conditioning principles developed by Ivan Pavlov, these therapists seek to recondition their clients and thus change their behavior. Emmie is eight years old, and frequently wets her bed at night. She\u2019s been invited to several sleepovers, but she won\u2019t go because of her problem. Using a type of conditioning therapy, Emmie begins to sleep on a liquid-sensitive bed pad that is hooked to an alarm. When moisture touches the pad, it sets off the alarm, waking up Emmie. When this process is repeated enough times, Emmie develops an association between urinary relaxation and waking up, and this stops the bedwetting. Emmie has now gone three weeks without wetting her bed and is looking forward to her first sleepover this weekend.<\/p>\n<p id=\"fs-idm76222160\">One commonly used classical conditioning therapeutic technique is\u00a0<span id=\"term1076\" data-type=\"term\">counterconditioning<\/span>: a client learns a new response to a stimulus that has previously elicited an undesirable behavior. Two counterconditioning techniques are aversive conditioning and exposure therapy.\u00a0<span id=\"term1077\" data-type=\"term\">Aversive conditioning<\/span>\u00a0uses an unpleasant stimulus to stop an undesirable behavior. Therapists apply this technique to eliminate addictive behaviors, such as smoking, nail biting, and drinking. In aversion therapy, clients will typically engage in a specific behavior (such as nail biting) and at the same time are exposed to something unpleasant, such as a mild electric shock or a bad taste. After repeated associations between the unpleasant stimulus and the behavior, the client can learn to stop the unwanted behavior.<\/p>\n<p id=\"fs-idp64292672\">Aversion therapy has been used effectively for years in the treatment of alcoholism (Davidson, 1974; Elkins, 1991; Streeton &amp; Whelan, 2001). One common way this occurs is through a chemically based substance known as Antabuse. When a person takes Antabuse and then consumes alcohol, uncomfortable side effects result including nausea, vomiting, increased heart rate, heart palpitations, severe headache, and shortness of breath. Antabuse is repeatedly paired with alcohol until the client associates alcohol with unpleasant feelings, which decreases the client\u2019s desire to consume alcohol. Antabuse creates a conditioned aversion to alcohol because it replaces the original pleasure response with an unpleasant one.<\/p>\n<h3>Exposure Therapy<\/h3>\n<p id=\"fs-idp36302928\">In\u00a0<span id=\"term1078\" data-type=\"term\">exposure therapy<\/span>, a therapist seeks to treat clients\u2019 fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it. This can be done via reality, imagination, or virtual reality. Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behavior therapy. Jones worked with a boy named Peter who was afraid of rabbits. Her goal was to replace Peter\u2019s fear of rabbits with a conditioned response of relaxation, which is a response that is incompatible with fear. How did she do it? Jones began by placing a caged rabbit on the other side of a room with Peter while he ate his afternoon snack. Over the course of several days, Jones moved the rabbit closer and closer to where Peter was seated with his snack. After two months of being exposed to the rabbit while relaxing with his snack, Peter was able to hold the rabbit and pet it while eating (Jones, 1924).<\/p>\n<div id=\"attachment_6604\" style=\"width: 531px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-6604\" class=\"wp-image-6604\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031018\/ucrcr.jpeg\" alt=\"This figure, titled \u201cExposure Therapy,\u201d illustrates the exposure therapy strategy of Mary Cover Jones to rid a person of the fear of rabbits. The first of four levels depicts an image of a person and a rabbit with an equals sign between them. Under the rabbit reads \u201cconditioned stimulus (CS),\u201d and under the person reads \u201cfear of rabbits.\u201d The second level depicts an image of milk and cookies, labeled \u201cunconditioned stimulus (US),\u201d and on the other side of an equals sign there is a picture of the same person labeled \u201cunconditioned response (UR).\u201d The third level shows the milk and cookies, labeled \u201cunconditioned stimulus (US),\u201d and rabbit, labeled \u201cconditioned stimulus (CS),\u201d to the left and right of a plus sign, with the person on the other side of an equals sign. The label \u201cunconditioned response (UR) is below the person.\u201d The final level shows the person and the rabbit separated by an equals sign. This time the rabbit is labeled \u201cconditioned stimulus (CS)\u201d and the person is labeled \u201cconditioned response (CR).\u201d\" width=\"521\" height=\"625\" \/><\/p>\n<p id=\"caption-attachment-6604\" class=\"wp-caption-text\"><strong>Figure 2<\/strong>.\u00a0<span class=\"os-caption\">Exposure therapy seeks to change the response to a conditioned stimulus (CS). An unconditioned stimulus is presented over and over just after the presentation of the conditioned stimulus. This figure shows conditioning as conducted in Mary Cover Jones\u2019 1924 study.<\/span><\/p>\n<\/div>\n<div id=\"CNX_Psych_16_02_Conditioning\" class=\"os-figure\">\n<div class=\"os-caption-container\"><\/div>\n<\/div>\n<p id=\"fs-idm14968432\">Thirty years later, Joseph Wolpe (1958) refined Jones\u2019s techniques, giving us the behavior therapy technique of exposure therapy that is used today. A popular form of exposure therapy is\u00a0<span id=\"term1079\" data-type=\"term\">systematic desensitization<\/span>, wherein a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli. The idea is that you can\u2019t be nervous and relaxed at the same time. Therefore, if you can learn to relax when you are facing environmental stimuli that make you nervous or fearful, you can eventually eliminate your unwanted fear response (Wolpe, 1958).<\/p>\n<div id=\"attachment_6603\" style=\"width: 335px\" class=\"wp-caption alignleft\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-6603\" class=\"wp-image-6603 size-full\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/11031008\/spider.jpeg\" alt=\"A close-up picture of a very large spider on a person\u2019s arm is shown. The person is using its other hand to hold up two of the spider\u2019s legs.\" width=\"325\" height=\"217\" \/><\/p>\n<p id=\"caption-attachment-6603\" class=\"wp-caption-text\"><strong>Figure 3<\/strong>.\u00a0<span class=\"os-caption\">This person suffers from arachnophobia (fear of spiders). Through exposure therapy he is learning how to face his fear in a controlled, therapeutic setting. (credit: \u201cGollyGforce \u2013 Living My Worst Nightmare\u201d\/Flickr)<\/span><\/p>\n<\/div>\n<p id=\"fs-idm89857152\">How does exposure therapy work? Jayden is terrified of elevators. Nothing bad has ever happened to him on an elevator, but he\u2019s so afraid of elevators that he will always take the stairs. That wasn\u2019t a problem when Jayden worked on the second floor of an office building, but now he has a new job\u2014on the 29th floor of a skyscraper in downtown Los Angeles. Jayden knows he can\u2019t climb 29 flights of stairs in order to get to work each day, so he decided to see a behavior therapist for help. The therapist asks Jayden to first construct a hierarchy of elevator-related situations that elicit fear and anxiety. They range from situations of mild anxiety such as being nervous around the other people in the elevator, to the fear of getting an arm caught in the door, to panic-provoking situations such as getting trapped or the cable snapping. Next, the therapist uses progressive relaxation. She teaches Jayden how to relax each of his muscle groups so that he achieves a drowsy, relaxed, and comfortable state of mind. Once he\u2019s in this state, she asks Jayden to imagine a mildly anxiety-provoking situation. Jayden is standing in front of the elevator thinking about pressing the call button.<\/p>\n<p id=\"fs-idm99200336\">If this scenario causes Jayden anxiety, he lifts his finger. The therapist would then tell Jayden to forget the scene and return to his relaxed state. She repeats this scenario over and over until Jayden can imagine himself pressing the call button without anxiety. Over time the therapist and Jayden use progressive relaxation and imagination to proceed through all of the situations on Jayden\u2019s hierarchy until he becomes desensitized to each one. After this, Jayden and the therapist begin to practice what he only previously envisioned in therapy, gradually going from pressing the button to actually riding an elevator. The goal is that Jayden will soon be able to take the elevator all the way up to the 29th floor of his office without feeling any anxiety.<\/p>\n<p id=\"fs-idp25925152\">Sometimes, it\u2019s too impractical, expensive, or embarrassing to re-create anxiety- producing situations, so a therapist might employ\u00a0<span id=\"term1080\" data-type=\"term\">virtual reality exposure therapy<\/span>\u00a0by using a simulation to help conquer fears. Virtual reality exposure therapy has been used effectively to treat numerous anxiety disorders such as the fear of public speaking, claustrophobia (fear of enclosed spaces), aviophobia (fear of flying), and post-traumatic stress disorder (PTSD), a trauma and stressor-related disorder (Gerardi, Cukor, Difede, Rizzo, &amp; Rothbaum, 2010).<\/p>\n<div class=\"textbox exercises\">\n<h3>Link to Learning<\/h3>\n<p>Virtual reality exposure therapy is being used to treat PTSD in soldiers. Virtual Iraq is a simulation that mimics Middle Eastern cities and desert roads with situations similar to those soldiers experienced while deployed in Iraq. This method of virtual reality exposure therapy has been effective in treating PTSD for combat veterans. Approximately 80% of participants who completed treatment saw clinically significant reduction in their symptoms of PTSD, anxiety, and depression (Rizzo et al., 2010). Watch this\u00a0<a href=\"https:\/\/www.youtube.com\/watch?v=QCCWH_CNjM0\" target=\"_blank\" rel=\"noopener nofollow\">Virtual Iraq video that shows soldiers being treated via simulation<\/a>\u00a0to learn more.<\/p>\n<\/div>\n<h3>Operant Conditioning Therapies<\/h3>\n<p id=\"fs-idm20076208\">Some behavior therapies employ operant conditioning. Recall what you learned about operant conditioning: We have a tendency to repeat behaviors that are reinforced. What happens to behaviors that are not reinforced? They become extinguished. These principles, defined by Skinner as operant conditioning, can be applied to help people with a wide range of psychological problems. For instance, operant conditioning techniques designed to reinforce desirable behaviors and punish unwanted behaviors are effective behavior modification tools to help children with autism (Lovaas, 1987, 2003; Sallows &amp; Graupner, 2005; Wolf &amp; Risley, 1967). This technique is called Applied Behavior Analysis (ABA). In this treatment, a child&#8217;s behavior is charted and analyzed. The ABA therapist, along with the caregivers, determines what reinforces the child, what sustains a behavior to continue, and how best to manage a behavior. For example, Nur may become overwhelmed and run out of the room when the classroom is too noisy. Whenever Nur runs out of the classroom, the teacher&#8217;s aide chases him and places him in a special room where he can relax. Going into the special room and getting the aide&#8217;s attention are reinforcing for Nur. In order to change Nur&#8217;s behavior, he must be presented with other options before he becomes overwhelmed, and he cannot receive reinforcement for displaying maladaptive behaviors.<\/p>\n<p id=\"fs-idp7004192\">One popular operant conditioning intervention is called the\u00a0<span id=\"term1081\" data-type=\"term\">token economy<\/span>. This involves a controlled setting where individuals are reinforced for desirable behaviors with tokens, such as a poker chip, that can be exchanged for items or privileges. Token economies are often used in psychiatric hospitals to increase patient cooperation and activity levels. Patients are rewarded with tokens when they engage in positive behaviors (e.g., making their beds, brushing their teeth, coming to the cafeteria on time, and socializing with other patients). They can later exchange the tokens for extra TV time, private rooms, visits to the canteen, and so on (Dickerson, Tenhula, &amp; Green-Paden, 2005).<\/p>\n<h2>Behavior Therapy in Action: How Does it Work?<br \/>\n<a href=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/04032038\/7658214720_0936cc407c_z.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-4132\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/04032038\/7658214720_0936cc407c_z.jpg\" alt=\"Smiling picture of a college student with a pen in her mouth.\" width=\"374\" height=\"249\" \/><\/a><\/h2>\n<p>Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.<\/p>\n<p>But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.<\/p>\n<p>Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.<\/p>\n<p>You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam\u2019s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.<\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_e16b253f-2e12-4db5-b906-a6ad883e9618\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/e16b253f-2e12-4db5-b906-a6ad883e9618?iframe_resize_id=assessment_practice_id_e16b253f-2e12-4db5-b906-a6ad883e9618\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_538faf34-10bf-471f-9228-f3c82a2f065e\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/538faf34-10bf-471f-9228-f3c82a2f065e?iframe_resize_id=assessment_practice_id_538faf34-10bf-471f-9228-f3c82a2f065e\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_7be398e4-e938-448a-a822-463d245367c6\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/7be398e4-e938-448a-a822-463d245367c6?iframe_resize_id=assessment_practice_id_7be398e4-e938-448a-a822-463d245367c6\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<p>Systematic desensitization works by gradually\u2014step-by-step\u2014exposing the person to situations that are increasingly more anxiety-producing. This is called \u201cprogressive exposure.\u201d By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns\u00a0that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-4133\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/855\/2017\/04\/04032241\/7658298768_e4c2c2635e_z.jpg\" alt=\"Same picture of the college student, Miriam, looking confused or frustrated while looking at her notebook.\" width=\"260\" height=\"173\" \/><\/p>\n<p>The first steps in systematic desensitization is the development of a \u201chierarchy of fears.\u201d This simply means that you must help Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.<\/p>\n<p>For the next step in this exercise, you will need to take on Miriam\u2019s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.<\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_bc55addb-b602-4188-9357-75056918f851\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/bc55addb-b602-4188-9357-75056918f851?iframe_resize_id=assessment_practice_id_bc55addb-b602-4188-9357-75056918f851\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<p>Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.<\/p>\n<p>So we\u2019re ready to start, right? Wrong!<\/p>\n<p>Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation\u2014if you are relaxed, you can\u2019t be fully afraid.<\/p>\n<p>However, most people are not very good at relaxing on command. So the behavioral therapist will teach\u00a0the client how to relax effectively. The techniques are ones often used in meditation\u2014slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in <a href=\"https:\/\/www.youtube.com\/watch?v=dXRBNagGxtc\" target=\"_blank\" rel=\"noopener\">this video<\/a>.<\/p>\n<h2>Miriam\u2019s Treatment<\/h2>\n<p>Miriam is an imaginary person, but behavioral therapy is used by thousands of therapist with their clients every day. Review the following table to discover how Miriam\u2019s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person\u2019s course of therapy is unique.<\/p>\n<p>Miriam&#8217;s Treatment<\/p>\n<table class=\"wbtable\" style=\"border-spacing: 0px; margin: auto;\">\n<tbody>\n<tr>\n<th scope=\"col\">Therapy Sessions<\/th>\n<th scope=\"col\">Session Description<\/th>\n<\/tr>\n<tr class=\"e\">\n<th scope=\"row\">Miriam&#8217;s therapy: Preparation<\/th>\n<td>Prior to starting progressive exposure, Miriam created her hierarchy of fears. She spent several session working on relaxation. She practiced relaxation at home several times a day until she and you, her therapist, agreed that she was ready to start treatment.<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Miriam&#8217;s therapy: Exposure Session 1<\/th>\n<td>The bottom (lowest anxiety) of Miriam\u2019s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a 1 to 10 scale, Miriam said 1: No fear at all.<\/p>\n<p>Miriam brought two friends with her to the therapy session today. You had them sit in a comfortable part of your office, drinking tea and chatting for 15 minutes. Afterwards Miriam reported her fear level during the chat as a 1 on a ten-point scale: no fear.<\/p>\n<p>You then had her sit in a comfortable chair and think about giving a talk about the challenges of her job to a small, friendly audience. At the beginning of this task, she rated her anxiety as 3 on a 10-point scale. As she thought about it\u2014with helpful suggestions from you\u2014she also relaxed, using her relaxation training. After about 10 minutes, she reported her anxiety had dropped to 1, the lowest level of anxiety on your scale.<\/p>\n<p>You gave Miriam \u201chomework\u201d\u2014to repeat this exercise twice a day until the next session.<\/td>\n<\/tr>\n<tr class=\"e\">\n<th scope=\"row\">Miriam&#8217;s therapy: Exposure Session 2<\/th>\n<td>At the beginning of today\u2019s session, you had Miriam repeat the task from the previous session of thinking about talking about her job to a small, friendly group. At the beginning she rated her fear at 2, but it dropped to 1 within a few minutes.<\/p>\n<p>Now you took Miriam to the next level. You had her imagine telling a large audience of company executives about some technical problem she was working on at her job. At the beginning, just thinking about doing this led to a fear level of 5. After 10 minutes, her fear level dropped to 2. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session.<\/p>\n<p>You gave Miriam homework again\u2014to practice a similar situation at home.<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Miriam&#8217;s therapy: Exposure Session 3<\/th>\n<td>You started this situation with a new scenario similar to the one Miriam did in the last session and practiced at home. She was quickly able to drop her anxiety level to 1.<\/p>\n<p>You had a professional photography group create a video of someone very similar in appearance and manner to Miriam giving a talk in from of a small friendly audience on a topic similar to one Miriam might give. You asked her to watch this video and imagine herself in the place of the real speaker. She rated this a 6 on the anxiety scale. Over several repetitions, her rating dropped to 2.<\/p>\n<p>For homework, Miriam watched the video several times a day. You instructed her in ways to make the video seem MORE REAL, so she could really feel the anxiety of being in front of people.<\/td>\n<\/tr>\n<tr class=\"e\">\n<th scope=\"row\">Miriam&#8217;s therapy: Exposure Session 4<\/th>\n<td>You have had Miriam arrange to give a talk NEXT SESSION to a small group of Miriam\u2019s co-workers. You also had Miriam prepare the talk. Today you practiced the talk with her. At the start of the practice session, with only you there, Miriam rated her anxiety level at 9 out of 10. Over the course of the hour, her anxiety level dropped to 5.<\/p>\n<p>Her homework was to continue to practice the talk and to work on relaxation.<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Miriam&#8217;s therapy: Exposure Session 5<\/th>\n<td>Today, Miriam gave the talk to the small group. Her anxiety rating before she went in front of them was 10. Except for a little stumbling at the start, the 20-minute presentation went well. Miriam reported an anxiety level of 4 after the talk.<\/td>\n<\/tr>\n<tr class=\"e\">\n<th scope=\"row\">We\u2019ll skip a few sessions.<\/th>\n<td>We hope you have the basic idea.<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Miriam&#8217;s therapy: Exposure Session 6<\/th>\n<td>In this last session, you have arranged for Miriam to be the introductory speaker at a literacy tutoring volunteer organization nearby. Miriam has done a small amount of volunteer work with the organization, but she knows very little about it. With the help of the staff, she prepares a talk during the week before this session.<\/p>\n<p>The audience is composed of 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Miriam knows none of them and none of them has ever heard of her.<\/p>\n<p>Miriam\u2019s introductory comments take about 15 minutes. She rates her anxiety level before going out at 8. After the talk, she rates her anxiety at 2. In fact, she said it was almost fun.<\/td>\n<\/tr>\n<tr class=\"e\">\n<th scope=\"row\">After Therapy<\/th>\n<td>Miriam continues to see you for a few more sessions. You give her additional homework and you help her develop a plan that includes arranging to give professional presentations for her job and continuing to give talks at the literacy volunteer organization. Miriam reports that none of these ideas create an anxiety level above 3 when she thinks about doing them.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>You just learned about Systematic Desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let\u2019s review a few points from Systematic Desensitization.<\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_034341ee-ecbc-485f-b38e-dd9f43a9276c\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/034341ee-ecbc-485f-b38e-dd9f43a9276c?iframe_resize_id=assessment_practice_id_034341ee-ecbc-485f-b38e-dd9f43a9276c\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_c16a4885-e7cf-4e1d-92bc-8ac9dbbf8c4c\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/c16a4885-e7cf-4e1d-92bc-8ac9dbbf8c4c?iframe_resize_id=assessment_practice_id_c16a4885-e7cf-4e1d-92bc-8ac9dbbf8c4c\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<p>In flooding\u00a0therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.<\/p>\n<p>Flooding\u00a0has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding\u00a0that work for systematic desensitization:<\/p>\n<ul>\n<li>The person consciously works to replace anxiety and fear with relaxation.<\/li>\n<li>The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.<\/li>\n<li>Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.<\/li>\n<\/ul>\n<div class=\"asx\">\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_0e5a8c4d-283d-4c4d-90af-61bccf641600\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/0e5a8c4d-283d-4c4d-90af-61bccf641600?iframe_resize_id=assessment_practice_id_0e5a8c4d-283d-4c4d-90af-61bccf641600\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_d4755d69-a37a-4198-aadc-210195081ac2\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/d4755d69-a37a-4198-aadc-210195081ac2?iframe_resize_id=assessment_practice_id_d4755d69-a37a-4198-aadc-210195081ac2\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-4129\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Original<\/div><ul class=\"citation-list\"><li><strong>Authored by<\/strong>: Patrick Carroll for Lumen Learning. <strong>Provided by<\/strong>: Lumen Learning. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>College student with a pen. <strong>Authored by<\/strong>: CollegeDegrees360. <strong>Provided by<\/strong>: Flickr. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.flickr.com\/photos\/83633410@N07\/7658214720\/in\/photostream\/\">https:\/\/www.flickr.com\/photos\/83633410@N07\/7658214720\/in\/photostream\/<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Introduction to Psychology. <strong>Provided by<\/strong>: Open Learning Initiative. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/oli.cmu.edu\/jcourse\/workbook\/activity\/page?context=df3e76840a0001dc5e332d14dc6dd7c3\">https:\/\/oli.cmu.edu\/jcourse\/workbook\/activity\/page?context=df3e76840a0001dc5e332d14dc6dd7c3<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-nc-sa\/4.0\/\">CC BY-NC-SA: Attribution-NonCommercial-ShareAlike<\/a><\/em><\/li><li>Types of Treatment. <strong>Provided by<\/strong>: OpenStax College. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/openstax.org\/books\/psychology-2e\/pages\/16-2-types-of-treatment\">https:\/\/openstax.org\/books\/psychology-2e\/pages\/16-2-types-of-treatment<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em>. <strong>License Terms<\/strong>: Access for free at https:\/\/openstax.org\/books\/psychology-2e\/pages\/1-introduction<\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">All rights reserved content<\/div><ul class=\"citation-list\"><li>Deep Breathing to Relax. <strong>Provided by<\/strong>: Center for Cognitive and Behavioral Therapy of Greater Columbus. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=dXRBNagGxtc\">https:\/\/www.youtube.com\/watch?v=dXRBNagGxtc<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section>","protected":false},"author":29,"menu_order":8,"template":"","meta":{"_candela_citation":"[{\"type\":\"copyrighted_video\",\"description\":\"Deep Breathing to Relax\",\"author\":\"\",\"organization\":\"Center for Cognitive and Behavioral Therapy of Greater Columbus\",\"url\":\"https:\/\/www.youtube.com\/watch?v=dXRBNagGxtc\",\"project\":\"\",\"license\":\"other\",\"license_terms\":\"Standard YouTube License\"},{\"type\":\"cc\",\"description\":\"College student with a pen\",\"author\":\"CollegeDegrees360\",\"organization\":\"Flickr\",\"url\":\"https:\/\/www.flickr.com\/photos\/83633410@N07\/7658214720\/in\/photostream\/\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Introduction to Psychology\",\"author\":\"\",\"organization\":\"Open Learning 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