CBT ASSIGNMENT​

Submitted To,
Mrs. Chinchu

Submitted By,
Mrs.Reshma Krishnan

FLOODING

Flooding is a behavioral approach used in elimination of

unwanted fears or phobias.

Flooding is the process of teaching patients self-relaxation

techniques first and then exposing them abruptly and
directly to the fear-evoking stimulus itself. Classical
conditioning has taught the person to associate fear with
the stimulus, but via flooding the same principles can be
used to extinguish the fear response and replace it with a
feeling of relaxation, thus eliminating the phobia.

Flooding in its purest form involves forced, prolonged

exposure to the actual stimulus that provoked the original
trauma. In real practice, that can be problematic, if not
completely impossible. It isn't really practical to fill a room
with snakes and spiders, for example, and force someone
to sit in it for hours.

In contrast to other slower-paced forms of behavioral

therapy used to treat phobias, like systematic
desensitization, as the name implies, flooding is rapid and
abrupt exposure, yielding relatively quick results. Flooding
is commonly used today by behavioral therapists across the
world.

History

In the 1960s, Thomas Stampfl developed"implosion

therapy" but flooding is the more common name today.
Stampfl bombarded his phobia patients with detailed
descriptions of the situations that they feared for 6-9 hours.
Afterwards, they lost their fear of those situations. Getting
patients to imagine the fearful situation is known as in vitro
therapy.

Zev Wanderer (1991) used biofeedback machines to

monitor patients' blood pressure, perspiration and heart rate
while they listened to descriptions of what they most feared.
Wanderer identified the phrases that sparked the most
intense reactions. By just using these phrases, he reduced
the time needed for the flooding session from 9 hours to 2
hours. Later sessions could be as short as half an hour.
Wanderer's patients would take the tape recordings home
and listen to them as 'homework'.

Components

Flooding is based on classical conditioning and has two

components:
Unavoidable exposure: this involves introducing you to the
thing you fear in the most immediate and unavoidable way.
Extinction: this involves learning to associate the thing you
fear with something neutral

Unavoidable Exposure

Normally, phobia-sufferers run away from the thing they

fear, so they never work through the body's "alarm stage"
and learn to end the association with fear and anxiety. If the
patient can be prevented from escaping the object they
fear, then they can learn to stop fearing it.

In Stampfl's flooding therapy, the patients are bombarded

with tape-recorded descriptions of what they fear. They
can't stop the tape recorder or block out the descriptions.

Other types of flooding involve being surrounded by images

of the feared object (imaginal flooding) or immersed in
virtual reality.

Extinction

When the body's "alarm phase" comes to an end, you feel

emotionally drained but unafraid. If the feared object is still
present, you will learn to associate it with a lack of emotion,
rather than fear. This is called "extinction" or "Pavlovian
extinction".

The idea is that the feared object stops being a conditioned

stimulus (CS) producing a fearful conditioned response
(CR); it goes back to being a neutral stimulus (NS) which
doesn't produce any response at all.

Advantages

The main advantage of flooding is that it is fast, realistic and

relatively ethical.

Exposure therapy can have immediate results: the alarm

stage only lasts about 10-15 minutes and the fear response
can be extinguished within an hour. Flooding takes longer,
with the first session lasting several hours but later ones
getting shorter.

Exposure therapy and flooding present the sufferer with

unavoidable exposure and this is what often happens in
real life. It is argued that this therapy better prepares
sufferers for occasions when they may be confronted
unexpectedly with the object they fear, with no way to get
away from it.

Exposure therapy has ethical problems but flooding is an in

vitro technique that causes less intense distress. Although
exposure therapy works best on simple phobias, like
animals or objects, flooding can be used for more complex
phobias, like social situations. This is because the patient is
listening to descriptions or looking at images, rather than
physically touching the object they fear.

Keane et al. (1989) studied 24 Vietnam veterans with PTSD

(post-traumatic stress disorder). PTSD is experienced by
people who have survived traumatic events like wars,
disasters or crimes; it involves panic attacks and phobias as
well as other symptoms like "numbing" (the inability to feel
normal emotions) and social avoidance (breaking off
relationships).

The soldiers received 14 to 16 sessions of flooding therapy

and they were tested before, after and 6 months later for
symptoms of PTSD. Compared to a control group who
didn't receive therapy, the flooding group had fewer
terrifying flashbacks as well as less anxiety and depression.
The other symptoms of PTSD ("numbing" and social
avoidance) didn't change. This study supports the idea that
flooding can extinguish phobias.
Criticisms

It can be unethical to expose a patient to something they

find distressing. In fact, it could backfire and make the
patient even more frightened of that thing. This is
particularly true of exposure therapy, which can backfire
badly, but even the tape recordings or constant flow of
images involved in flooding can be too much for some
patients.

Wolpe (1969) reported the case of a client who had to be

hospitalised because flooding made her so anxious. This is
one reason why Wolpe preferred systematic desensitisation
to flooding.

For the same reason, although it has been shown to work,

psychiatrists are often reluctant to suggest flooding as a
therapy.

There's also a danger of spontaneous recovery, when the

extinguished phobia suddenly returns. This is because the
flooding sessions aren't very long and the therapy doesn't
replace the fear-response with a different response, it just
replaces it with no response.

How is it different from Systematic Desensitization?

Systematic desensitisation involves gradual exposure to the

object you fear, but with flooding you are completely
exposed to it, all at once. It's like going directly to the end of
the stimulus hierarchy and skipping all the stages in
between.

Systematic desensitisation is much more ethical than

flooding, because the participants are only exposed
gradually to the thing that they fear and they only move on
to greater exposure when they feel ready. With flooding, the
patient is exposed to the object they fear all at once, in a
very intense way. This can be distressing.

Both therapies can be carried out in vitro rather than in vivo.

Imagining exposure to the feared object is less distressing.
However, in vitro flooding is still more upsetting that in vitro
systematic desensitisation.

Neither systematic desensitisation nor flooding tackle the

possible underlying problem behind the phobia. They are
both behavioural therapies that only deal with the
symptoms, not the cause. If there is an underlying problem
behind the phobia (like trauma in the patient's past), then
that will still be there and will carry on causing difficulties,
even if the phobia is temporarily eased.

RESPONSE PREVENTION

The Response prevention technique is formally called

exposure and response prevention. Exposure and
Response Prevention (ERP) is a type of Cognitive
Behavioural Therapy (CBT), that was specifically developed
to treat Obsessive-Compulsive Disorder (OCD).

The Exposure in ERP refers to exposing the client to the

thoughts, images, objects and situations that make him
anxious. While the Response Prevention part of ERP, refers
to making a choice not to do an anxiety behavior once the
anxiety or obsessions have been “triggered.”

How the approach is applicable for OCD?

It is widely regarded as the treatment of choice for OCD. In

this treatment approach, patients are exposed to the feared
stimuli in a hierarchical manner, beginning with stimuli that
evoke less anxiety and gradually moving to
more-distressing stimuli. During exposure therapy for OCD,
patients are encouraged to refrain from engaging in any
neutralizing thoughts or behaviors, which is the response
prevention component of the treatment. In vivo exposures
are commonly used, though imaginal exposure is
implemented when in vivo exposure would not be possible
or should not be implemented.

OCD involves having intrusive thoughts, images, or

impulses that one finds distressing. Typically people try to
push these thoughts out of their mind, or perform an action
to “neutralize” the thought. For example, if someone has
intrusive thoughts about germs, they may want to wash
their hands. If they worry about having left the stove on,
they may check the stove.

Ironically, the more people try to repress, neutralize, or get

rid of these distressing thoughts, the more these thoughts
resurface – thereby becoming obsessions. Unfortunately,
the ways that people try to neutralize these thoughts only
works in the short-term. For example, if you feel dirty and
you wash your hands, it does provide temporary relief.
However, you will soon feel dirty again, and will feel the
need to wash your hands again. If you wash it once more,
provides temporary relief. You therefore learn: When I feel
dirty I wash my hands and the dirty feeling goes away.
However, you may become trapped in a vicious cycle of
feeling dirty and washing your hands over and over and
over again, all day long. As you can see, there is a logic to
OCD. However, the logic becomes problematic when it no
longer feels like a choice, and you start to feel trapped in a
cycle you feel you cannot get out of.

Components

The treatment of choice for OCD is exposure and response

prevention (ERP), which not surprisingly, has two main
components: 1) exposure, and 2) response prevention.
Response prevention refers to purposefully inhibiting one’s
rituals, whereas exposure refers to willingly entering
situations that are likely to trigger obsessions. Both
exposure and response prevention elements are necessary
for making meaningful treatment gains.

Response prevention is the critical component in

“short-circuiting” the positive feedback loop in OCD. When
one implements regular response prevention, obsessions
are no longer reinforced and ultimately decrease in
frequency and intensity. This is represented in the upper
half of the included figure. Purposeful exposure provides
further opportunities to break this cycle. The more
exposures you complete, the more the positive feedback
loop degrades. Eventually, with enough practice, you will
become immunized to many of your triggers.

Models explaining the technique

There are two cognitive models which attempt to explain the

mechanism by which ERP for OCD works.
One is the habituation model while the other is the inhibitory
learning model.

Habituation Model

In OCD, habituation refers to the diminishing of an anxious

physiological and fearful emotional response to frequently
repeated stimuli. In ERP, habituation is hypothesized to
work by shifting the overvalued cognitive belief systems
which a patient has (e.g., the overestimation of a threat
when the obsession is regarding accidentally harming
someone nearby) and reducing the link between the belief
and the threat appraisal. Emotion Processing Theory, part
of a Cognitive Behavioral Therapy model, asserts that
patients learn new implicit and powerful lessons when they
engage in ERP treatment. One such lesson is the way in
which the “fight or flight” system works. Patients learn
during ERP that their sympathetic nervous system
responsible for the physiological part of anxiety is unable to
maintain a fight or flight response indefinitely. The
habituation model of ERP suggests that after some time of
doing an exposure, usually at least one hour, the
parasympathetic nervous system is triggered to settle down
the sympathetic nervous system and achieve a more
homeostatic balance for the body regardless of the person’s
cognitive interpretation of what is happening. In response to
this process of achieving homeostasis in the face of a
feared stimuli, the individual incorporates corrective
information into his or her cognitive schemas.

In essence, habituation changes behaviors first; in turn,

cognitions are modified due to the behavioral proof; and
emotions change last in response to the altered cognition.

An example of this process would be a patient who is

engaging in an ERP to challenge his obsessions of
contamination by contracting a deadly illness. In the
presence of a therapist, the patient touches sinks,
communal door handles, toilet seats, and bathroom floors
(exposure) and goes to eat lunch without being allowed to
wash his hands (response prevention). The patient initially
experiences heightened spikes of anxiety during this
process but continues to engage in the exposure despite it.
While doing the bathroom exposure, the person’s
physiological signs of anxiety begin to subside despite the
fact that he still cognitively associates bathroom with "dirty"
and with "disease." After doing this exposure and eating
lunch, the patient realizes he or she did not become deathly
ill despite not being able to wash his hands after touching
dirty items, so he modifies the association between
bathroom and illness in his head to lessen the likelihood of
threat in his cognitive schema related to bathrooms. After
repeating this exposure numerous times, the person may
begin to later realize his fearful emotions which used to be
present during bathroom time have now dissipated and in
fact, he may experience excitement instead of fear when
touching bathroom items, knowing he has conquered his
fear. In Emotion Processing Theory of OCD, habituation
plays a strong role in the learning process, as illustrated in
the example above.

Another outcome of habituation learned through ERP

treatment of OCD is with regard to the stimulus itself. By
repeated exposures over time, a patient will begin to learn
that his appraisal of threat is erroneous, and learns that the
likelihood of his worst fear occurring is far less than
previously believed. In some cases, depending on the
obsession, the feared outcome cannot be physically tested
like the more concrete obsessions (e.g. the bathroom
example above). Some may fear going to hell when dying
and become obsessed with such an existential thought. In
these cases ERP allows the patient to learn to tolerate the
uncertainty surrounding the feared outcome, rather than
learning the feared outcome is unlikely to occur. In cases of
habituation in which the patient does find out the feared
outcome is unlikely to occur, this process is thought to be
driven by extinction. In extinction, the stimuli which were
once associated with anxiety and threat estimation (e.g.
conditioned stimuli) no longer carry these association
because the connection is no longer enforced through
rituals and avoidance. This process is an example of implicit
learning because the patient is not able to simply have his
therapist explain that the feared outcome is unlikely to occur
and needs to experience this process firsthand through
exposure and response prevention therapy.

Inhibitory Learning Model

The second cognitive model which is thought to underlie the

mechanisms by which ERP treatment works is the inhibitory
learning model. This model proposes that the fear
associations between the obsession and fear response still
exist and the links are not necessarily abolished, as the
habituation model suggests. Rather, the inhibitory learning
model of ERP suggests that exposures bring new inhibitory
or safety-based associations with the previously feared
stimuli.

The primary goal of this model is for patients to learn that

sometimes their feared outcomes (the unconditioned stimuli
in a Pavlovian model of learning) occur in the presence of
their obsessions, and other times their feared outcomes do
not occur and to develop a cognitive and emotional
flexibility regarding what the outcome will be in the
presence of an obsession (the conditioned stimuli).
Inhibitory learning has been regarded as key to the process
of extinction (Bouton, 1993).

The model asserts that after extinction, the conditioned

stimuli (e.g. a patient’s obsession) has two meanings: it still
holds the original excitatory meaning (the conditioned
stimuli paired with the unconditioned stimuli or the fear
response) but it also holds a new inhibitory meaning which
has been learned through ERP (the conditioned stimuli or
obsession paired with a no fear response). The focus of
ERP through an inhibitory learning lens then becomes more
toward tolerance of distress and contact with what is
occurring in the present moment, rather than waiting for the
natural homeostatic process of habituation to kick in, like in
the earlier model.

Efficiency of the technique

Exposure and response prevention (ERP) is a

well-established treatment for obsessive-compulsive
disorder (OCD). However, it is not completely effective for
many patients, and some do not benefit from or tolerate this
treatment. Over the past 3 decades there has been growing
interest in using cognitive interventions, either as adjuncts
or alternatives to exposure-based treatments such as ERP,
to address these shortcomings. Cognitive therapy and
cognitive behavior therapy for OCD have both
demonstrated greater efficacy than no treatment at all, and
appear to have a lower incidence of dropout than ERP.
Unfortunately, however, for the average OCD patient,
cognitive interventions have not improved treatment
efficacy; that is, cognitive interventions, either alone or
combined with ERP, are no more effective than ERP alone.