The so-called exposure techniques are defined as the set of psychological procedures and behavioral through which a person can learn to face those situations that cause intense anxiety discomfort.
These types of phenomena are usually related to a specific feared object or situation, from which the person tries to escape or avoid at all costs, even if they are aware of the irrational and disproportionate nature of their reaction. The intense aversion suffered or phobia can arise either from internal stimuli, for example being afraid of contracting a disease, or from external ones, such as the fear of flying on an airplane.
Although there are very different types of exhibition, which are classified depending on the place where it takes place (live exhibition, exhibition in imagination, exhibition in virtual reality, etc.), the people who participate in it (self-exhibition, exhibition group, assisted exposure, etc.), of how the grading of the difficulty of the situations to be faced is established (flood, gradual exposure, etc.). Let’s see what the two most common modalities consist of: in vivo exposure and imagination exposure
The ultimate purpose of the technique is provide the subject with various cognitive-behavioral resources so that you are able to put them into practice in real anxiety-inducing situations and this allows you to remain in it without emitting the avoidance response. These resources become cognitive restructuring techniques for experienced fears, self-instruction training, breathing control techniques, relaxation techniques or behavioral modeling and rehearsal techniques, mainly.
Exposure techniques allow learning to reduce the association between stimuli that generate anxiety and fear, and negative emotional reactions, and also facilitate learning in an alternative way. in the reaction to initially anxiogenic stimuli typical of phobias
Thus, work is done at a psychological level to avoid cognitively anticipating the future development of the feared situation without thinking about the negative consequences and controlling emotional reactions and one’s own impulses.
The hierarchy
One of the fundamental elements of the exposure intervention, both in vivo and in imagination, is the prior elaboration of an exposure hierarchy. In it, all situations that generate anxiety discomfort in the individual are recorded andand ordered by a score in USAs, or Subjective Anxiety Units (usually 0-10 or 0-100), which indicates the level of perceived anxiety distress. Thus, a list of all the feared situations is obtained from least to greatest difficulty in coping.
A relevant aspect is to find a balance in the gradation of the indicated feared situations. It is likely that poorly graded exposures will present lower acceptance by the subject and also a higher dropout rate, although faster results may be achieved.
On the contrary, too graduated exposure can lead to a feeling of personal discouragement, the individual seeing that his progress is excessively slow. Therefore, it seems more effective to start by exposing oneself to situations with a low level of anxiety (which have a high probability of coping success) until reaching those situations in which the person tends to avoid due to the high level of anxiety that they generate. (for example those in which you have suffered a panic attack before).
In progressing from the first to the second, aspects such as the individual’s medical and psychological condition, the time they can allocate to the exposure and their degree of habituation with the technique must be considered. Thus, The hierarchy may be modified as progress is made in its implementation also taking into account the sensations experienced by the subject in each exposure and the personal or environmental factors that influence the coping applied.
At a methodological level, Bados (2011) sets out the following general guidelines as indications to follow in the application of in vivo exposure techniques:
Exposure in imagination in phobias
Exposure in imagination involves imagining in the most real way possible the experience of the feared situations or stimuli that cause intense discomfort to the subject. This technique has a lower level of effectiveness than in vivo exposure, so both are usually combined.
Among the factors that cause a lower therapeutic success result are the difficulty of applying exposure strategies in imagination to real situations (stimulus generalization) or the problems derived from how to evaluate whether the person has a good ability to imagine situations. feared things indicated by the hierarchy.
However, imagination exposure can be useful when:
Evaluation of imagination capacity
As indicated above, the competence available to the person will be a crucial element when assessing the possibility of applying this type of variant of the exposure technique.
If you have limitations related to said ability, prior to applying the steps listed in the exposure hierarchy, the subject must be evaluated and trained in these types of procedures.
To do this, the therapist proposes a series of visualization exercises in which he presents a series of scenes to the patient, and indicates and guides him about the elements that appear in it for approximately one minute. Subsequently, the quality and sharpness of the visualization exercised by the subject is evaluated, as well as the factors that have hindered the procedure.
In relation to the latter, Bados (2005) presents a list of possible problems related to the difficulty in evoking imagined scenes:
1. Diffuse image
If scene playback is vague it is recommended to carry out imagination training starting with neutral or pleasant scenes, although it is also possible to enrich the description of the scene with important details and reactions of the client that have been omitted.
The subject is not able to maintain the scene, which can be linked to the desire to escape from the feared situation. In this case, it is worth remembering the justification of the procedure and the need to expose oneself until reaching a tolerable degree of habituation. You can also ask the client to verbalize out loud what he imagines or create a less disturbing scene as a preliminary step.
3. Little detail
Lack of involvement in the scene on the part of the subject. You can propose enriching the scene with additional descriptive details, with the client’s sensations, cognitions and behaviors, and with the consequences that the client fears.
4. Manipulation of the imagined downwards
Modification of the scene that reduces anxiety. The subject can imagine situations quite different from those described. Thus, they can mitigate the aversiveness of a scene by incorporating protective elements (a small light in a dark room) or eliminating aversive elements (a half-empty subway car instead of a crowded one).
In these cases, remember the importance of experiencing anxiety to achieve the final habituation of it and it is emphasized to describe the scenes in a much more specific way.
5. Manipulation of the imagined upwards
Modification of the scene that increases anxiety. The patient can increase the anxiety potential of a scene adding aversive elements or removing protective elements. Possible solutions to this are to emphasize the importance of imagining only what is requested or instructing the person to verbalize out loud what they are imagining.
6. Self-absorption
The subject persists in the scene despite the indication to end the exposure. In this situation it is useful to ask the individual to relax the eye muscles or to move or rotate the eyes.
