Behavior Therapy and Anxiety

CBT and exposure therapy, a type of behavior therapy, are the two most commonly used interventions in the treatment of anxiety disorders. Exposure therapy has its roots in classical conditioning. In exposure therapy, patients make contact with the feared stimuli and this contact is maintained until the anxiety associated with the contact subsides. This process is termed habituation and it can only occur if the patients are prevented from using their usual escape or avoidance behavior (extinction). Several versions of exposure exist. Systematic desensitization (SD) is on the gentler part of the spectrum. Systematic desensitization (SD) is based on the idea of reciprocal inhibition proposing that two opposite emotions can not co-exist (e.g., fear and relaxation are mutually exclusive). In systematic desensitization (SD), relaxation training is followed by gradual (usually imaginary) exposure to the feared stimuli starting with the least feared stimulus. In contrast, flooding involves immediate exposure to the stimulus. Exposure therapy has been described as the most effective way to treat fear. Research indicates that the efficacy of exposure is optimal when it is graduated, repeated, and prolonged with practice tasks clearly specified.

Let’s look at this case study with Jessica to see this type of therapy in practice.

Behavior Therapy in Action: How Does It Work?

Meet Jessica. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. 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.

But Jessica 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.

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 Jessica 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.

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 Jessica’s therapy to meet her particular needs. It is time to decide how you are going to help Jessica.

Systematic Desensitization

SD works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. The anxiety-producing event is called “progressive exposure.” By learning to cope with anxiety during less-threatening situations first, the person is better prepared to handle the more threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

The first step in systematic desensitization is the development of a “hierarchy of fears.” The hierarchy of fears simply means that you must help Jessica create a list of situations related to her fear of public speaking. Then you create a hierarchy. The creation of the hierarchy means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Jessica’s 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.

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.

So we’re ready to start, right? Wrong!

Behavior therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. The idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.

Jessica’s Treatment

Jessica is an imaginary person, but behavior therapy is used by thousands of therapists with their clients every day. Review the following table to discover how Jessica’s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person’s course of therapy is unique.

Jessica’s Treatment

Flooding

You just learned about systematic desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let’s review a few points from systematic desensitization.

In flooding therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Jessica had mastered relaxation, your first session would require Jessica to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Jessica in situations that she would immediately rate as nine or 10 on the anxiety scale.

Flooding has the potential to be more traumatic for Jessica (for your client), so it must be arranged carefully. But the same principles of learning work for flooding that work for systematic desensitization:

• The person consciously works to replace anxiety and fear with relaxation.
• The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.
• Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.