EMDR FORUM ARCHIVE, 2000
What is exposure therapy?
Cahill · 02/05/03 at 5:44 PM ET
Sandra and McFall: I'd like to make three points here, and I'll try to keep them short. 1. It is true that my position on the role of eye movements (etc) in EMDR has not been adequately demonstrated, which is quite different from saying that they demonstrably don't have any role. It is logically impossible to prove the null. So Sandra is correct on that point. However, what gets left out is the other half of my position: That we operate under the ASSUMPTION of the null until there is adequate evidence to justify rejecting the null. The burden of proof lies with those making the positive claim (i.e., those claiming eye movements improve outcome). And to extend things just a bit further, scientists are human too, and at some point they stop worrying about the logical distinction between accepting the null and failing to reject it. For example, although it can never be proven that the Loch Ness Monster does not exist, in the absence of adequate evidence in support of 'Nessies existance, bioloigists do not waste much time arguing the finner points of logic: They assume the monster doesn't exist and will only re-consider their position if they are provided with new, credible evidence. In short, they act as if the Loch Ness Monster does not exist. 2. I don't recall ever equating eye movements with placebo. I personally strongly object to the use of the term "placebo" in the context of psychological treatments. Let me explain. Technically, the term placebo refers to a specific intervention: a sugar pill that is used in psychopharacology research as a control condition to rule out basic methodogical artifacts (e.g., regression to the mean) and psychological interpretations of any observed improvement. The medication folks want to know whether it is the pharmacolgical effect of the medication that is causing change or the psychological effects of going through a healing ritual with no active pharmacological agent. This distinction makes no sense to me when it is shifted to comparing the effects of psychological treatments. By definition, we are studying psychological means of helping people overcome problems. It makes no sense to relegate one class of psychological effects to the pejorative category of "placebo" and another class to "active component." As a researcher of psychological treatments, I'm interested in whatever psychological mechanisms are involved in helping people to feel better. I personally prefer to use the distinction between "common factors" and "specific factors" if we are discussing say the incremental effects of a specific technique over the effects of entering into therapy. Or I may use the term "non-specifics" when it's not clear what variables are operating or there are no specific hypotheses as to what's operating. Placebos work through psycholgoical mechanisms, exposure therpay works through psychological mechansims, cognitive restructuring works through psychological mechanims, etc. Indeed, some argue that they all work through the same psychological mechanism(s). 3. I actually find Sandra's comments about not being able to distinguish between when you are or are not doing exposure therapy or other specific CBT techniques puzzeling. If we are dealing with "exposure" as a technique or specific procedure, then our method of doing exposure and cognitive restructuring is quite clear. In a typical session (following the Foa model) of exposure therapy for PTSD, the therapist will spend a few minutes just chatting with the patient about recent events, asking about how things are going in general. Very quickly, we move to a review of any homework assignments that were given. If homework was completed, we review the records, discuss any new insights that may have arisen from the exercise, review any patterns of anxiety activation/reduction, etc. If homework was not completed, the therapist reviews any potential hurdles to being able to do the homework and may assist in problem solving. By this, we're about 20 minutes into the session and, in most cases, we move onto doing formal exposure. The therapist reviews general instructions for exposure (close your eyes; recall the memory as vividly as possible; describe out loud what you are thinking, feeling, doing; tell the story in the first person and the present tense) and then any specific information you want to taylor for that person (e.g., we'll work on the first "hot spot" or changing the general instructions to help the patient achieve a happy balance of engaging the memory while not going into a flashback). We then take an inital SUDs level, and then "OK, let's begin...Start to describe what's happening." At that point, the therapist typically does or says very little other than to occassionaly offer a word of encouragement, ask a probe question (e.g., what are you seeing at this moment?), and to obtain a SUDs level about every 5 minutes. When the memory reaches the agreed upon end point, the therapist suggests the person go back to the beginning, and this process of recounting the memory continues for 20-60 minutes. When we conclude the exposure, again it's pretty clear. The therapist will suggest the patient open his/her eyes, perhaps take a deep breath and exhale slowly, and then the two discuss the experience. In a recently completed study, we actually included formal cognitive restructuring ala Beck, using thought records in which people identified automatic thoughts and problematic emotions, followed by listing evidence in for and against the automatic thought, considering a written list of "cognitive errors" and alternatives to them, and then a re-evaluation of the initial event and the emotional impact of this new thought. It was all very formal and there is no way someone watching a therapy session would have mistaken this activity as anything other than cognitive restructuring. In a study we recently completed, we evaluated whether adding this formal cognitive component to treatment improved outcome over exposure therapy alone, and we found no difference. As a result, we generally no longer use the formal thought records and are content with the informal "chat" version of cognitive restructuring. This process of going through the memory followed by discussing the experience of doing the exercise usually leads quite naturally into the task of setting homework goals for the next session. In panic disorder, we implement various exercises to induce specific physiological sensations associated with the person's panic attacks. So they may be instructed to breath through a thin straw to mimic the sensations of not being able to breath, or engagin in rapid exercise to induce their heart to beat fast, increase their breathing and (could we be so lucky) induce some chest pain. The exercises are repeated in a controlled way serveral times until the person learns to tolerate these perfectly normal sensations, stops interpreting them as signs of impending doom, and to extinguish their "fear of fear." All these procedures are extremely easy to operationalize and detect whether or not they are happening. The parameters of exposure therapy are also pretty clear: you want to activate medium high levels of anxiety (80-90 on a 0-100 scale), continue with the exposure while the anxiety gradually decreases, and then repeat the exposure until there is little or no ancticipatory anxiety about doing the exercise and little or no actual anxiety while doing the exposure. The hardest part is helping people to not rely on over-learned safety behaviors (e.g., distracting oneself, rationalizing to one self that things will be OK, reassureing one self or seeking re-assurance from others). The best part is that it really works. Fear reduction through exposure therapy is very reliable and improvements in the patient's mood and functioning can often be seen within a few sessions.
In treating phobias and OCD, the exposure is equally clear. With most phobias, we are actually designing exposures that involve direct contact with the feared object. If you are afraid of snakes, we may set up a hierarchy that involving looking at pictures of snakes, reading stories about snakes and wathcing movies of snakes, and then working our way up to a trip to the zoo to look at snakes and then to the pet store where you (hopefully) wind up holding a snake, wrapping it around your neck, etc. If you have OCD and are afraid that you may cause harm to loved ones by stepping on cracks in the cement, we may go out walking to look for every possible crack in the sidewalk and then intentionally step on the crack while reciting "step on a crack, break my Mother's back." After doing such mischief for 30 or 40 minutes, we may return to the office and, if the person suffers from intrusive images of their loved one being harmed by these activities, we conduct imaginal exposure to these feared thoughts. The patient may be instructed to imagine going home and finding that his/her family has suffered horrible accidents as the result of the patient's stepping on cracks. We keep this up until the patient can have these thoughts without feeling anxious about them and without feeling the need to engage in their compulsive rituals to counter-act the thought. Patients learn that having a thought is not the same thing as the thought coming true, and that their rituals (excessive praying or checking or washing or whatever) are not neccessary and are actually what maintains their fears.
If what I have described does not sound much like how you were taught to do exposure, then perhaps you were not taught exposure the way that it is typically done in efficacy studies and the way which it has been demonstrated to be effective. Exposure therapy is not a haphazzard approach to therapy. It is deliberate, structured, and very carefully planned to help people confront unrealistic fears in a systematic fashion to help them feel less afraid and be able to behave more effectively.
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