UNIT 2: RELAXATION TECHNIQUES

AND EXPOSURE THERAPIES

JACOBSON’S PROGRESSIVE MUSCULAR RELAXATION,

AUTOGENIC TRAINING, YOGA AND MEDITATION

Relaxation Techniques

Relaxation refers to a state of calmness with low psychological and physiological

tension or arousal. Tension and arousal accompany and are part of fear reactions and are

experienced physically as tense muscles and rapid breathing and heart rate. Techniques to

produce relaxation gained wide acceptance in the 1970s as psychological treatments for CERs,

especially anxieties and phobias, and a variety of medical problems, such as asthma, high blood

pressure, migraine and tension headache, and cancer chemotherapy reactions

Relaxation training procedures are strategies that people use to decrease the autonomic arousal

that they experience as a component of fear and anxiety problems (Jena, 2008)

The person engages in specific relaxation behaviours that result in bodily responses opposite

to the autonomic arousal.

Whereas bodily responses such as tense muscles, rapid heart rate, cold hands, and rapid

breathing are part of autonomic arousal, relaxation exercises produce bodily responses such as

decreases in muscle tension, heart rate, and breathing rate and warming of the hands.

Once the person produces these opposite bodily responses, he or she reports a decrease in

anxiety.

Apart from mental and physical relaxation, the individual develops a feeling of control and

starts assuming responsibility for management of his life and health. (Beech et al 1982)
Jacobson’s Progressive Muscle Relaxation

Jacobson’s Progressive Muscle Relaxation (JPMR) is one of the best-known self - relaxation

exercises invented by an American Physician Dr Edmund Jacobson (1938).

It was initially invented as a way to help his patients deal with anxiety. He felt that relaxing the

muscles could relax the mind as well.

It is a type of therapy that focuses on tightening and relaxing specific muscle groups in

sequence. It involves tightening one muscle group, while keeping rest of the body relaxed and

then releasing the tension. By concentrating on specific areas, tensing and relaxing them, one

can become more aware of their body and physical sensations. This helps the person to

understand the difference, when the muscles are tensed and when it’s relaxed.

Muscle pain, tension and stiffness are common symptoms brought on by stress and anxiety.

Jacobson’s Progressive Muscle Relaxation Technique have reverse effect on the body eliciting

the relaxation response, lowering the heart rate, calming the mind and reducing bodily tension.

It can also help a person become more aware of how their physical stress may be contributing

to their emotional state. By relaxing the body, a person may be able to let go of anxious thoughts

and feelings.

To use JPMR, the person must first learn how to tense and relax each of the major muscles of

the body. The person can learn to do this from a therapist, from listening to an audiotape of the

procedure, or from reading a description.

Procedure of JPMR

Conductive Environment:

The setting for relaxation is quiet and free of distraction noises. The client will be in a

physically comfortable in a position either sitting on a chair or lying down (On a rug, mat or

bed).

General Instruction (Before and During Muscle Relaxation Exercise):

• Be calm and comfortable.

• Keep your eye closed.

• Avoid stray thoughts.

• Avoid extra movements of the body.

• As you exercise from head to toe, Observe changes like tightness and the development

of light and soothing sensations.

Benefits

JPMR results in both relaxation of muscles focussed on, and general relaxation.

Reduces anxiety and tension, feeling of well-being, reduces activity of stress hormones,

decreased muscle tension, reducing likelihood of seizures, improve sleep, lowers blood

pressure, decreases frequency of migraine attacks etc. ("Relaxation techniques: Try these steps

to reduce stress", 2021) ("What is Jacobson’s Relaxation Technique?", 2021).

Contraindications

Do not practice JPMR (tense/release) in case of having high blood pressure or other

cardiovascular problems. The isometric contractions involved in contract-relax methods can

temporarily increase blood pressure.

If there are any injuries, or a history of physical problems that may cause muscle pain, it is

advisable to consult the doctor before beginning the relaxation techniques.

If you have any form of chronic medical or psychological health problem check with

your doctor if relaxation is suitable for your particular condition.

In some individuals’ relaxation techniques may enhance the action of certain drugs. It

is advisable to consult the doctor and let them know that the person is regularly practising

relaxation techniques, in case he/she wants to monitor dosage of anti-anxiety, anti-hypertensive

or other medications the person might be taking. ("Cautions/Contraindications - Relaxation",

2021)

Autogenic Training

It is a relaxation technique introduced by German Psychiatrist Johannes Heinrich Schultz

(1932)

It works through a series of self-statements about heaviness and warmth in different parts

of the body through which a positive effect is induced on the Autonomic nervous system. (E.g.,

“My legs are warm” “I am completely calm”.) (Help et al., 2021)

It utilizes the body's natural relaxation response to counteract unwanted mental and physical

symptoms.

It can help people to reduce stress and achieve relaxation of the body and mind through the use

of breathing techniques, Specific verbal stimuli and Mindful meditation.

It restores balance between the sympathetic (fight or flight) and parasympathetic (rest and

digest) branches of the autonomic nervous system.

Training Session

First, the trainee is encouraged to settle into a comfortable position—sitting upright, reclined,

or lying down, whichever promotes relaxation.

In the standard autogenic training procedure, the person listens to instructions from a therapist

or a recording and tries to imagine the events described. The procedure starts by asking the

person to:

1. Adopt a passive and relaxed attitude.

2. Allow changes in his or her bodily processes to evolve naturally.

3. Choose a pleasant, peaceful scene, such as lying on the beach or sitting in a meadow on a

beautiful, warm day.

The therapist begins by using verbal cues to guide the trainee's breathing and direct attention

to certain parts of the trainee's body. The verbal cues can encourage sensations of heaviness

and warmth, which can then lead to deep relaxation. The therapist might lead the cues, have

the trainee repeat them, or have the trainee say them silently, depending on the level of training

the individual has received.

Then the training proceeds through a series of six phases, each with a theme regarding the type

of sensation to imagine in the body. Of these themes, the two that are the most commonly used

in therapy involve feeling heaviness and warmth in parts of the body (Lichstein, 1988).

The Six Phases

1. My right arm is heavy (say six times). I am completely calm (say once).

2. My right arm is warm (say six times). I am completely calm (say once).

3. My heart beats calmly and regularly (six times). I am completely calm (say once).
 4. My breathing is calm and regular. It breathes me (six times). I am completely calm (say

once).

5. "My abdomen is warm. “(Six times). "I am completely calm”. (say once)

6. "My forehead is pleasantly cool. “(six times) "I am completely calm. “(Say once).

Each lesson focuses on a different sensation in the body, and there are six established lessons

(techniques) included in autogenic training:

1. Inducing heaviness. Verbal cues suggest heaviness in the body.

2. Inducing warmth. Verbal cues induce feelings of warmth.

3. The heart practices. Verbal cues call attention to the heartbeat.

4. Breathing practice. Verbal cues focus on breath.

5. Abdominal practice. Verbal cues focus on abdominal sensations.

6. Head practice. Verbal cues focus on the coolness of the forehead.

The goal of the session in the end is achieve a sense of calm, better control over unwanted

emotional, physiological, and physical responses to stimuli.

Benefits

One advantage of autogenic training is that it doesn’t require the person to tense and

relax muscles, which is important for people who suffer from medical conditions, such as

severe arthritis or low back pain that make movement painful or difficult.

Autogenic training appeared to be an effective treatment for many different issues,

including migraines, hypertension, asthma, somatization, anxiety, depression and dysthymia,

and insomnia or other sleep issues.

0ther benefits -

 Effective in reducing general symptoms of anxiety, irritability and fatigue

 Increase resistance to stress.

 Reduce sleeping problems.

 Heaviness - Promotes relaxation of the voluntary muscles of the limbs.

 Warmth, which opens the blood vessels in your arms and legs.

 Regular heartbeat, which helps to normalize the heart rate.

 Regular breathing, which helps to normalize breath rate.

 Relaxation and warming of the abdomen - Reverses the flow away from the digestive

system.

 Cooling of the head - Reverses the flow of blood to the brain.

Autogenic training is offered in various parts of the world but is especially popular in

the United Kingdom, Japan, and Germany. The approach might be taught in individual

sessions, group settings, to companies and organizations, or in universities and hospitals.

Limitations

There is some degree of risk associated with attempting autogenic training without any

support from a therapist. If used incorrectly, it could lead to an increased severity of emotional

concerns. Qualified practitioners can ensure that the techniques are taught efficiently and

administered properly so as to decrease the risk of harm.

 Autogenic training professionals indicate several physical and mental health issues that

should not be treated with this approach: severe heart problems, diabetes, symptoms of

psychosis, delusional behaviour, paranoia, and dissociation.

Meditation

A practice where an individual uses a technique – such as mindfulness, or focusing the mind

on a particular object, thought, or activity – to train attention and awareness, and achieve a

mentally clear and emotionally calm and stable state.

Meditation derives from Eastern philosophy and religion, mainly Buddhism (In Zen Buddhism

the purpose of meditation is to stop the mind rushing about in an aimless stream of thoughts)

and produces relaxation and a mindful awareness of the meaning of each experience,

unencumbered by cognitive or emotional distortions.

Yoga asana, accompanied by conscious breathing, conscious concentration, conscious

relaxation, and steady pose and will bring you to the state of meditation.

To help cope with chronic pain conditions, by training these patients to focus on painful

sensations as they happened, rather than trying to block them out, and to separate the physical

sensations from the cognitive and emotional reactions that accompany pain, the patients could

become aware of the pain itself, unaffected by their thoughts or feelings about it. This training

reduced the patients’ reported physical and psychological discomfort.

Meditation should occur in a quiet setting, and the person should sit upright in a relaxed and

comfortable position.

Focuses attention on a visual stimulus (Gazing at any object) an auditory stimulus (Repetitive

mantras Aum - The sound of Aum spans the full range of the human voice, beginning at the
base of the spine, moving up to the navel and slowly vibrating up to the 3rd eye chakra and

beyond) or a kinaesthetic stimulus (one’s own breathing movements)

During meditation, the person’s mind may sometimes wander to other thoughts. At that time,

he or she can simply and gently coax attention back to the meditation stimulus, without getting

intellectually or emotionally involved in intrusive thoughts or becoming annoyed.

Once focused on the object, mantra, or breathing during the meditation exercise, the person’s

attention cannot be focused on stimuli that produce anxiety.

Experimental studies have shown that meditation can produce striking psychophysiological

effects

 alleviation of tension

 lowering of oxygen consumption and metabolic rate

 decrease of cardiac output

Faithful practice of meditation from 20 to 30 minutes daily is usually required for proper

practice toward mastery of tension.

Yoga

The word yoga literally means “to yoke” or “union”. More than just a practice of

physical exercises.

Yoga is the coming together of the individual self or consciousness, with the infinite

universal consciousness or spirit. (Introduction to Yoga, 2017)

It is a body-mind practice, which combines controlled breathing, physical poses, and relaxation

or meditation. It brings about mental and physical disciplines that can help you achieve

peacefulness of mind and body. (Robinson, 2021)

Poses in Yoga

Padmasana/ Lotus pose

Uttanasana/ Standing Forward Bend

Savasana/ Corpse Pose

Asana, the physical postures or exercises that have come to be known as Yoga are really

only the most superficial aspect of this profound science.

The practice of asana can be used to elevate consciousness, help us feel more aligned,

happier, more well-being and more balanced than before our practice. (Introduction to Yoga,

2017)

Chakras

They are the centre points of energy, thoughts, feelings and the physical body.

When energy becomes blocked in a chakra, it triggers physical, mental, or emotional

imbalances that manifest in symptoms such as anxiety, lethargy, or poor digestion. ("Yoga:

Methods, types, philosophy, and risks", 2021)

Main practices in Yoga (Introduction to Yoga, 2017)

Benefits

 Reduced stress and anxiety

 Sound sleep

 Reduced cortisol levels

 Enhance flexibility and balance

 Lower heart rate and blood pressure

 Reduced muscle tension

 Sense of well being

Caution

 Pregnant women, people with ongoing medical condition, such as bone loss, glaucoma

should consult a healthcare professional before taking up Yoga.

 Advance poses and difficult techniques (Headstand, Lotus pose, forceful breathing) to

be avoided by beginners ("Yoga: Methods, types, philosophy, and risks", 2021)

 EXPOSURE THERAPY- SYSTEMATIC DESENSITIZATION

When something makes you anxious or fearful, the last thing you want to do is re-

experience it. It is the best way to reduce the anxiety or fear. Exposure therapies are used to

treat anxiety, fear, and other intense negative emotional reactions (such as anger) by exposing

clients to the situations or events that elicit the emotional reactions, under carefully controlled

and safe conditions.

We use the terms anxiety and fear interchangeably to refer to intense, inappropriate,

and maladaptive reactions that are characterized by uneasiness, dread about future events, a

variety of physical responses (such as muscle tension, increased heart rate, and sweating), and

avoidance of the feared events. Anxiety becomes problematic when its intensity is

disproportionate to the actual situation and it interferes with normal, everyday functioning.

The goal of exposure therapies is to reduce clients’ anxiety to a level that allows them to

function effectively and feel comfortable.

Systematic Desensitization

Systematic desensitization, developed by Joseph Wolpe more than 50 years ago, was

the first exposure therapy and the first major behaviour therapy. In systematic desensitization,

the client imagines successively more anxiety arousing situations while engaging in a

behaviour that competes with anxiety (such as skeletal muscle relaxation). The client gradually

(systematically) becomes less sensitive (desensitized) to the situations. The therapy involves

three steps:

1. The therapist teaches the client a response that competes with anxiety.

2. The specific events that cause anxiety are ordered in terms of the amount of anxiety they

engender.
3. The client repeatedly visualizes the anxiety-evoking events, in order of increasing anxiety,

while performing the competing response.

Steps in Systematic desensitization:

1. Deep muscle relaxation

Deep muscle relaxation is the most frequently used competing response in systematic

desensitization. Muscle relaxation counters some of the physiological components of anxiety,

including increased muscle tension, heart rate, blood pressure, and respiration. Training in

progressive relaxation involves relaxing various skeletal muscle groups: arms, face, neck,

shoulders, chest, abdomen, and legs. Clients first learn to differentiate relaxation from tension

by tensing and then releasing each set of muscles learn to induce relaxation without first tensing

their muscle. Progressive relaxation training alone can be effective in treating anxiety disorders

and in some cases is as effective as exposure therapy.

After learning the relaxation techniques then the therapist asks the client to make anxiety

hierarchy.

2. Anxiety Hierarchy Construction

Once the client learns the relaxation procedures, the therapist and client develop a hierarchy

of the fear-producing stimuli. An anxiety hierarchy is a list of specific events that elicit anxiety

in the client, ordered in terms of increasing levels of anxiety. To construct an anxiety hierarchy,

clients, often with their therapist’s assistance, identify a number of specific, detailed scenes

that would make them anxious and then order the scenes from highest to lowest anxiety evoked.

The client uses a fear rating scale and identifies the amount of fear that is produced by a variety

of situations related to the feared stimulus. The fear rating scale is called a subjective units of

discomfort scale (SUDS; Wolpe, 1990). If there is a particularly large interval, compared with
the average interval, additional scenes need to be added so that the transition between scenes

is gradual.

 Subjective Units of Discomfort scale

Covert behaviours also can be quantified, as in terms of frequency and duration. Intensity

can be measured on a predetermined scale, such as the Subjective Units of Discomfort scale

used to assess anxiety. The units of this scale, called SUDs, range from 0 to 100 (sometimes 0

to 10). Zero represents no anxiety; 100 represents the highest level of anxiety that the client

can imagine.

Anxiety hierarchies generally consist of events that share a common theme. When a client is

anxious about more than one class of situations, multiple hierarchies are constructed.
3. Desensitization

Desensitizing anxiety-evoking events begins as soon as the client has learned progressive

relaxation (or another competing response) and has constructed an anxiety hierarchy. The

therapist instructs the client, who is seated or reclining comfortably, to relax all of his or her

muscles. The therapist then describes scenes from the anxiety hierarchy for the client to

imagine, starting with the lowest item on the hierarchy. The scenes are described in detail and

are specific to the client. The client imagines each scene for about 15 seconds at a time.

Whenever the client experiences anxiety or discomfort, the client signals the therapist, usually

by raising a finger. When this occurs, the therapist instructs the client to “stop visualizing the

scene and just continue relaxing”; thus, the client visualizes anxiety-evoking scenes only when

relaxed. The aim is for relaxation to replace the anxiety previously associated with the scene.

Each scene in the hierarchy is presented repeatedly until the client reports little or no

discomfort. Typically, clients use SUDs to report the degree of anxiety they feel while

visualizing scenes. When the anxiety associated with a scene has reached a low level, the next

highest scene in the hierarchy is visualized.

Efficiency of Systematic Desensitization

Systematic desensitization is efficient in three ways. First, exposure to problematic

situations in one’s imagination is less time consuming (for both client and therapist) than in

vivo desensitization, which involves venturing into the actual anxiety-provoking situations.
Second, compared with traditional psychotherapies that treat anxiety disorders, systematic

desensitization requires relatively few sessions. Third, the procedures can be adapted for

groups of clients.

Desensitization can be automated by using tape-recorded instructions, written instructions, or

computer programs.

Effectiveness of Systematic Desensitization.

There is no doubt that systematic desensitization is an effective procedure for treating

a variety of anxiety disorders. The findings of hundreds of studies assessing the effectiveness

of systematic desensitization over the past 50 years are overwhelmingly positive. As early as

1969, a review of the controlled outcome studies of systematic desensitization concluded that

“for the first time in the history of psychological treatments, a specific treatment . . . reliably

produced measurable benefits for clients across a broad range of distressing problems in which

anxiety was of fundamental importance.” Seven years and many studies later, another

comprehensive review concluded, “Systematic desensitization is demonstrably more effective

than both no treatment and every psychotherapy variant with which it has so far been

compared.” Moreover, the treatment effects are relatively durable. For example, one study

found that clients with dental phobias still were maintaining regular dental check-ups between

1 and 4 years after being treated by systematic desensitization.

In Vivo Desensitization

In vivo desensitization is similar to systematic desensitization, except that the client

gradually approaches or is gradually exposed to the actual fear-producing stimulus (Walker,

Hedberg, Clement, & Wright, 1981). To use the in vivo desensitization procedure, the client

must first learn the relaxation response. Next, the client and therapist must develop a hierarchy

of situations involving the fear producing stimulus. In the in vivo desensitization procedure,
the client does not imagine each scene in the hierarchy; rather, the client experiences each

situation in the hierarchy while maintaining relaxation as an alternative response to replace the

fear response.

In vivo desensitization has three advantages over systematic desensitization.

First, in vivo desensitization can be effective for clients who have difficulty imagining scenes,

which occasionally occurs with adults and often with young children.

Second, the exposure to the anxiety-evoking events can be monitored directly with in vivo

desensitization; this is not possible with systematic desensitization because the therapist does

not have access to the client’s mental images.

Third, in some instances in vivo desensitization is more effective than systematic

desensitization because the therapy often takes place directly in the anxiety evoking situation,

which eliminates the need for transfer from the imagined to the actual situation.

In vivo desensitization has three limitations.

First, because it frequently involves going to the actual environment where the client’s anxiety

occurs, considerable therapist time is required.

A second limitation is that in vivo desensitization is not feasible with certain anxiety-evoking

events (for example, natural disasters such as floods and earthquakes).

Third, some clients cannot tolerate being in the actual threatening situation, even when

exposure is graduated and the client is engaging in a competing response.

Fifty years after Wolpe developed systematic desensitization, it remains a versatile and

highly effective and efficient treatment that is still widely practiced. However, it is not

applicable to all clients suffering from anxiety. Systematic desensitization was the first
exposure therapy to be developed, and it is still widely used. It is both effective and efficient,

and clients consider it an acceptable treatment.

Group Systematic Desensitization

Groups of clients can be treated using systematic desensitization by making slight

modifications in the standard procedures. Progressive relaxation is simultaneously taught to

the entire group. When the clients share a common problem (such as public speaking anxiety),

a group hierarchy is constructed, which combines information from each client. When a group

hierarchy is not appropriate, individual hierarchies are used; the hierarchy items are written on

cards to which each client refers during desensitization.

When one of the clients signals that he or she is experiencing anxiety, the scene is terminated

and then repeated for all group members. Although this procedure is inefficient for some group

members, it does not decrease the effectiveness of the treatment. Compared with individually

administered desensitization, group desensitization requires less therapist time, and sharing

similar problems and solutions can be beneficial for clients.

Applications

Systematic desensitization can be used to treat anxiety disorders, specific phobias such

as, fears of heights, dogs, snakes, closed spaces, etc. and also used for anger management by

giving laughter as competing response. Self-Managed In Vivo Desensitization in the Treatment

of Sexual Dysfunctions.
 FLOODING

Flooding is one of the form of exposure therapy, which refers to either in vivo or

imaginal exposure to anxiety-evoking stimuli for a prolonged period of time. Flooding is a

behavioural approach used in elimination of unwanted fears or phobias.

As is characteristic of all exposure therapies, even though the client experiences anxiety

during the exposure, the feared consequences do not occur. Presumably, the fear-inducting

stimuli will lose their influence once the individual is fully exposed to them and discovers that

no harm occurs

A patient is taught relaxation techniques and these techniques are then applied to the

most feared situation either through direct exposure, or imagined exposure.

Flooding is based on two-factor learning theory

This theory postulates that individuals learn to escape from situations in which they are

presented with unpleasant stimuli. When a warning stimulus reliably predicts the unpleasant

event, the individual gradually learns to escape when the warning stimulus is presented, thus

avoiding the unpleasant event.

Example - If Dad beats Johnny when he comes home drunk, Johnny leaves the house

whenever Dad comes in, thus avoiding beatings.

According to two-factor theory, the warning stimulus, through pairing with the

unpleasant stimulus, comes to produce anxiety responses in anticipation of the unpleasant

event. Escape from the warning stimulus eliminates these anxiety responses, hence is

negatively reinforced. Research has shown that avoidance behaviours learned in this way are

extremely resistant to extinction, evidently because the person is so effective in avoiding the

unpleasant stimulus. Normally, this is an adaptive response, as when the sight of fire comes to
produce caution appropriate to the capacity of fire to cause painful burns. Not infrequently,

however, through a variety of unfortunate experiences, persons learn to be anxious or fearful

in the presence of relatively harmless stimuli. According to behaviour theory, this is how

phobic responses are initiated.

Animal studies of two-factor learning theory suggest, one effective method for

eliminating fear responses to conditioned aversive stimuli when they are no longer followed

by the unpleasant stimulus is preventing the animal from escaping the warning stimulus.

Prolonged exposure to the warning stimulus without opportunity to escape weakens the escape

response. Flooding is analogous to this procedure. (Bufford, 1999)

In vivo flooding

Consists of intense and prolonged exposure to the actual anxiety-producing stimuli.

Remaining exposed to feared stimuli for a prolonged period without engaging in any

anxiety-reducing behaviours allows the anxiety to decrease on its own. For example, a person

with a phobia of dogs would be placed in a room with a dog and asked to stroke the dog straight

away.

Generally, highly fearful clients tend to curb their anxiety through the use of

maladaptive behaviours. In flooding, Clients are prevented from engaging in their usual

maladaptive responses to anxiety arousing situations (response prevention). In vivo flooding

tends to reduce anxiety rapidly.

It is crucial to prevent such behaviours because they interfere with exposure therapy.

Response prevention is an essential component of in vivo flooding for obsessive-compulsive

disorder, in which a person is preoccupied (obsessed) with particular anxiety-evoking events

and alleviates the resulting anxiety by performing maladaptive ritualistic behaviours

(compulsions).
Fear of Riding on Escalators Treated by In Vivo Flooding (case example)

The patient was a 24-year-old female student with an intense fear . . . of escalators. She

had developed this phobia about 7 years previously. She had ascended an escalator with some

of her immediate family with relative ease, but had expressed fear of descending because of

the apparent height. The relatives had jokingly forced her on to the escalator, and ever since

she had experienced an aversion toward escalators, always taking the stairs or the elevator.

She had made some unsuccessful attempts to overcome the fear by attempting, in the

company of friends, to get on to an escalator. On those occasions when she could bring herself

to stand at the foot of the escalator, she would not step on [because she feared] . . . that by

holding on to the hand rail she would be pulled downward and so miss her step.

At the single session during which the history of the disorder was obtained, the in vivo

flooding procedure was explained to the patient. She was told that the technique had been

successfully employed in the treatment of numerous phobias and was almost certain to work

in her case. She was also informed that she would experience some emotional distress but was

assured that [the therapist] would be with her throughout the experience to ensure no resulting

adverse effects. [The therapist] then arranged to meet her at a large department store with four

levels of escalators.

Initially, the patient manifested an intense anxiety reaction when requested to approach

the escalator, and it was only through much coaxing, reassurance, and physical [prompting] . .

. that she finally stepped on to it. She then threatened to vomit and seemed at the verge of tears,

all the time clinging tightly to [the therapist’s] shirt. Getting on to the second flight of the

escalator was much easier, but she still manifested the same signs of anxiety.

After 27 minutes of riding up and down the escalator, she was approaching it with

increasing readiness and reported a dramatic decrease in anxiety. She was then instructed to
ride the escalator alone, and did so with relative ease. When she felt that there was no need for

further treatment the session was terminated, after 29 minutes. Six months later the patient

reported that she still experienced no anxiety on escalators except on rare occasions when

descending.

Imaginal flooding

Is based on similar principles and follows the same procedures except the exposure

occurs in the client’s imagination instead of in daily life.

An advantage of using imaginal flooding over in vivo flooding is that there are no

restrictions on the nature of the anxiety-arousing situations that can be treated. In vivo exposure

to actual traumatic events (airplane crash, rape, fire, flood) is often not possible nor is it

appropriate for both ethical and practical reasons.

Imaginal flooding can re-create the circumstances of the trauma in a way that does not

bring about adverse consequences to the client. Survivors of an airplane crash, for example,

may suffer from a range of debilitating symptoms. They are likely to have nightmares and

flashbacks to the disaster, they may Avoid travel by air or have anxiety about travel by any

means, and they probably have a variety of distressing symptoms such as guilt, anxiety, and

depression.

Example of imaginal flooding

Following a discussion of the person’s fears, in a typical flooding procedure the person

is then asked to imagine the most feared situation. The therapist describes the salient fearful

elements to enhance visualization. Thus an individual who is fearful of elevators is asked to

imagine boarding a glass-enclosed high-speed elevator, then watching through the glass as the

elevator rapidly rises from the ground level to the 20th floor.
 Scenes are presented for extended periods, often several minutes at a time so that the

individual experiences the full fear response and it begins to abate. For extinction of the fearful

response to occur, it is important that the scene not be terminated until the anxiety abates.

Terminating too soon may actually strengthen rather than alleviate the fearful response.

Unfortunately, it is sometimes difficult to judge this, and facial and body cues must be

carefully observed. Although there are widespread individual differences in the timing, it is

typical that the client shows an initial increase in anxiety response then a gradual abatement of

anxiety.

Few Research with flooding

The results of experimental studies of flooding are mixed. Barlow (1988) found efficacy

“equivocal”; Ost (1989) found highly favourable outcomes for specific phobias, such as animal

phobias, in 2 hour sessions. The procedures are not standardized; thus procedural variations

may account for inconsistencies in results.

A survey to investigate the widespread belief in the literature that implosive therapy

and flooding may have "serious negative side effects." Clients with no known history of

psychosis were reported to have experienced "acute psychotic reactions" during treatment. Two

known psychotics were also reported to have had similar reactions. "Brief panic reactions"

were reported to have occurred in another 0.14% of the sample. No other serious negative side

effects were reported. (Shipley, 1980).

Flooding may be more effective with mild than with intense fears. Early comparative

studies found systematic desensitization probably is as effective as flooding recent

investigations generally conclude that in vivo exposure is the preferred approach (Emmel

kamp, 1994). Because of the need to present the fear stimulus in its full intensity, flooding is

generally unpleasant.
Advantages of flooding

 One strength of flooding is it provides a cost effective treatment for phobias.

 The individual will experience decreased reactions to triggers, an increased sense of

capability in handling their fears and anxieties, reduced associations of a negative

manner regarding situations or particular stimuli, and increased emotional processing

in regards to fears and the world around them.

 This therapy is effective at removing the symptoms of a disorder without the need for

potentially damaging drugs (anti-anxiety drugs would be given within the Biological

approach) which often cause many side effects (e.g. drowsiness, risk of addiction).

Disadvantages of flooding

 It is highly traumatic for patients and causes a high level of anxiety. This contributes

to premature termination of treatment (Treating Phobias - Flooding, n.d.)

 Flooding is not a treatment appropriate for all individuals and all situations, and not

all mental health professionals choose to use it in therapy.

 Behavioural techniques are not effective for more complex phobias. This is a

problem because by only focussing on the removal of symptoms (as the behavioural

therapists do) rather than in identifying the underlying cause (as Biological and

Cognitive therapists do), a disorder may only be removed temporarily and may

reoccur at a later date ~ often even worse than before (this is called symptom

substitution – e.g., a dog phobia may be replaced with a fear of going out of the

house).
Being ethical

Flooding is frequently used in the behavioural treatment for anxiety-related Disorders,

phobias, obsessive-compulsive disorder, posttraumatic stress disorder, and agoraphobia.

Prolonged and intense exposure can be both an effective and efficient way to reduce clients’

anxiety. However, because of the discomfort associated with Prolonged and intense exposure,

some clients may not elect these exposure Treatments. It is important for the behaviour

therapist to work with the client to create motivation and readiness for exposure. From an

ethical perspective, clients should have adequate information about prolonged and intense

Exposure Therapy before agreeing to participate. It is important that they understand that

anxiety will be induced as a way to reduce it. Clients need to make informed decisions after

considering the pros and cons of subjecting themselves to temporarily stressful aspects of

treatment.

How flooding is different from systematic desensitisation and implosion?

Systematic desensitization and implosion share similar treatment goals with flooding,

but use different approaches. In systematic desensitization the individual is first taught to relax;

treatment then begins with minimally anxiety-inducing stimuli, presents them briefly, and

progresses gradually to more threatening stimuli, maintaining relaxation throughout. In this

way, anxiety is minimized throughout treatment. The elevator scene described above might

serve as the final step in systematic desensitization, whereas it is the beginning point in

flooding. Some theorists use the terms flooding and implosion interchangeably. Implosion, as

developed by Thomas Stampfl, draws heavily on psychoanalytic theory. Implosion focuses on

these underlying conflicts rather than concentrating on the identified, common to dramatize the

scenes.
Applications of flooding

 Flooding As A Treatment For Post-Traumatic Stress Disorder

 Flooding As Treatment for Anxiety.

 Flooding For The Treatment Of Phobias

 Flooding As A Tool To Overcome OCD

Conclusion

Flooding is a form of exposure therapy, its immediate exposure to anxiety-evoking

stimuli for a prolonged period of time. Two types of flooding vivo or imaginal. Flooding is

based on 2 factor learning theory. Response prevention is essential, when there is no option for

avoidance behaviour with that they quickly learn behaviour is harmless. The body can sustain

the fear response for so long-as the physical response to fear decreases so does the anxiety

response. The therapy starts with relaxation techniques thought. Advantages is that it is cost

effective, reduces symptoms of negative reactions thus making capable of handling situation

better, no need to use drugs like anti-anxiety. Disadvantages is that there might premature

termination cause of full exposure intensity seems traumatic, not all can handle and use or

would choose it i.e. therapists and clients and there might be chances of symptom substitution.

Ethically consent should be taken which includes briefing about what will be happening. This

therapy very much effective and applicable for dealing with anxiety, OCD, traumatic events,

phobias.
 IMPLOSION THERAPY

Exposure procedures are used to reduce undesirable behaviours, particularly

conditioned avoidance responses such as phobias, obsessions, and compulsions by exposing

the client to the stimuli that provoke such responses.

Three principal procedures of exposure are used by behaviour therapists such as: (i) flooding,

(ii) implosion, and (iii) aversion relief. These are also called anxiety-induction procedures.

Implosion

Implosion or implosive therapy is a variant of flooding but it takes place at the

imaginary level. Implosive therapy is a behaviour therapy for individuals with anxiety

problems and helping them to respond to future anxiety-producing situations rather

appropriately. Differences in flooding and implosion therapy are minimal; flooding therapy

focuses on the situational or environmental cues in imagery, while implosion therapy focuses

on the cues that elicit the conditioned response (internal representations of the feared stimuli).

The technique was developed by Thomas Stampfl and Donald J. Levis in 1968. It

involves prolonged exposure of the client to relevant negative fantasies connected with an

anxiety-provoking event. The therapist’s task is to describe the scenes in an involved and

dramatic manner repeatedly with variation in order to arouse maximal anxiety, maintaining it

almost at an intolerable level, so that the stress/anxiety caused by it dissipates. (Morganstern

1973; Stampfl and Levis 1967).

For instance, a snake phobic client is asked to imagine a snake coiling around his body

and starting to bite his finger. He is trying to put his finger out, feeling the fangs going right

down into the finger. The terrible pain is spreading throughout the shoulder and the body, and

blood dripping out of his finger. At the next stage, the animal begins to attack his face and other

vital organs of the body.

 The therapist may also assist the client in doing so, instead of directly being engaged in

description of the scenes. It is based on the hypothesis that neurotic and avoidance responses

are perpetuated because they reduce anxiety. Stampfl theorised that the cues from early

traumatic experiences caused by punishment, rejection, deprivation, or humiliation are retained

throughout the lifetime of an individual. Everything associated with these events tends to elicit

anxiety. These ‘neurotic’ behaviours can be treated by recreating the original trauma, or

something quite similar to it in the absence of real punishment, deprivation or rejection. If

intense emotional reactions are made to occur in absence of primary reinforcement, extinction

of neurotic behaviour perpetuated by anxiety would occur (Hogan 1968). In order to measure

the decrease in anxious symptoms, children may be asked to give anxiety ratings while being

exposed to the anxiety-inducing stimulus until the self-reported level of anxiety has decreased.

While explaining implosion, Stampfl combined psychodynamic principles with

behaviour therapy. The unique aspect of this therapy is that the client avoids not only the real

situations or objects but also the thoughts and ideas concerning the event. Implosion is useful

in changing the catastrophic ideas concerning an anxiety provoking stimulus directly.

Implosion differs from flooding in that in flooding, the client is exposed to the fear-provoking

stimuli either in real life or in imagination, whereas in implosion these scenes are presented

verbally in an exaggerated and dramatic manner. The descriptions are rather unrealistic. The

length of imagining anxiety-provoking scenes may be upto two or more hours, although 40 to

60 minutes sessions are more common (Marks 1972).

Research does not indicate that implosion therapy is better than systematic

desensitisation (Morganstern 1973, 1974). Looking at some research findings, some authors do

not recommend the use of implosive therapy in clinical practice (e.g. Martin and Pear 1992).
Examples:

For example, an individual with fear of public speaking, they may be led into scenes of

being unable to perform in an important meeting, and they are reduced to a blubbering mass.

This in turn incurs negative judgement and derision among the onlookers

For example, a person with an irrational preoccupation with germs might be asked to imagine

being covered with germs as well as cues associated with disease, death, loss of personal

control etc.

Difference between Flooding and Implosive therapy

FLOODING THERAPY IMPLOSION THERAPY

 It refers to in-vivo or It is an imaginal prolonged

imaginal exposure to highly exposure therapy in which the scenes

anxiety-evoking stimuli for a are exaggerated and include

prolonged period of time with hypothesized stimuli related to the

ever experiencing the fear.

negative consequences.

 It is based on the two-factor

 It is based on the
theory of learning.
psychodynamic

approaches.
  Use only symptom-  Routinely exposing clients to

contingent cues. hypothetical fear cues.

 Involves exposure of the  Imaginal scenes may include

client to only those situations hypothesized and

that the client reports as fear “psychodynamic” cues as

producing. well as other material

thoughts relevant by the

therapist.

Advantages

 An advantage of the technique is the use of imagination for purposes of exposure to

stimuli that would be impossible or unethical to expose the client to in reality, such as

past traumatic accidents, or possible future catastrophic events.

 Clients are seen in implosive therapy until their anxiety and anxiety motivated

symptoms decline to their and the therapist's satisfaction.

 Since implosive therapy may reduce negative emotional response but does not address

itself to teaching new behaviours, some clients may benefit from exposure to additional

treatment modalities following the implosive sessions. The use of a rational-emotive

approach is frequently helpful (Ellis, 1962).

  Clients may be instructed to assess their "irrational" belief system in an effort to help

develop new responses to replace those that were extinguished and to prevent the

formation of other avoidance responses as a result of reconditioning to these anxieties

and negative effects.

Disadvantages

 From an ethical point of view, the main problem with implosion therapy is that if the

client decides to discontinue treatment then they can even do more harm than good

since escape from fearful stimulus has been reinforced.

 There are conceptual and ethical problems that must be addressed before implosion can

be safely used with victims of sexual assault. These problems relate to the exclusive

focus on anxiety as the target for extinction, and the possibility that the therapist may

come to represent psychological stress to the victim.

Areas of Application

 The evidence, in general, seems to suggest that Implosive Therapy has been relatively

effective in dealing with a wide variety of human psychopathological disorders: phobias

and phobic-like behaviours (Stampfl, 1967; Hogan, 1967, 1968; Barrett, 1969;

Boulougouris, 1971); compulsions (Hersen, 1968); test anxiety (Prochaska, 1971); and

general inpatients (Boudewyns, 1970) and outpatients (Lewis, 1967). (Gumina, 1976).

 The therapy is confronting in dealing with both the fear and anxiety of detoxification

and the underlying problems of a drug-using person.

 Research has shown implosive therapy to be an effective modality for the treatment of

PTSD.
  Schizophrenia (Hogan, 1966, 1968): The patient, Mrs.S. was classified schizophrenic

reaction, acute undifferentiated type. The psychologist indicated that she was in an

ambulatory psychotic state exhibiting extreme paranoia, hysterical, hypochondriacal

and depressive symptoms. Verbally, the patient expressed hatred and aggression toward

her husband, children, and others in her environment. She had fears of animals, feared

the dark, and had morbid fears of death and of her own impulsiveness. She expressed

feelings of inadequacy and stated she did not feel accepted by others, including her

husband’s family. She thought others were criticizing, her, and she expressed

overwhelming unmet needs for love and affection. The extreme state of her disturbance

is reflected by her MMPI ‘T” scores.

After the first interview session the psychologist felt that the patient tried implosive

techniques. Mrs.S. was given eight intensive therapy sessions, which were followed by a

second administration of the MMPI. The psychologist then interviewed the patient’s husband

and her doctor. And after the 8th session, the family physician stated on post interview that the

depressive and hypochondriacal symptoms were gone, that the patient was in better contact

with reality and seemed to be happier. The client’s treatment pattern was similar to that of less

disturbed neurotic patients treated with implosive techniques. We attribute the success of this

case to four factors: first, the patient was acutely anxious, a motivating force in treatment;

second, she was still trying and willing to cooperate in treatment; third, she had never been

hospitalized and had not learned to be dependent upon an institution; fourth, and most

important, she was not on tranquilizers. Although drugs help in the initial phases of treatment

they also restrict the patient from experiencing a complete emotional reaction which seems to

be necessary in the unlearning of emotional symptoms. Patients imploded under sedation

require additional sessions on the same cues as they are removed from medication.
Conclusion

In sum, Implosive therapy is a variant of flooding but it takes place at the imaginary level.

Implosive therapy is a behaviour therapy for individuals with anxiety problems and helping

them to respond to future anxiety-producing situations rather appropriately. Implosive therapy

is a clinical technique with demonstrated effectiveness in treating phobias, compulsions,

schizophrenia, detoxification in drug abuse and PTSD. It is an intensive technique, and

demands a great deal of energy from both the patient and the therapist. When marked decreases

in longstanding psychopathology result, however, both patient and clinician are likely to be

convinced that the effort was well worthwhile.

 BIOFEEDBACK

Biofeedback is a technique in which an electromechanical device monitors the status or

changes of a person’s physiological processes, such as heart rate or muscle tension, and

immediately reports that information to that individual.

This information allows the person to gain voluntary control over these bodily

processes through operant conditioning. If, for instance, we were to use biofeedback to lower

your blood pressure or heart rate and the device reports that the pressure or rate has just

decreased a bit, this information would reinforce whatever you had done to achieve this

decrease.

Specific names are given for biofeedback techniques for different physiological processes.

Here are the names and descriptions of some commonly used techniques:

 BP biofeedback. Gives feedback on the person’s blood pressure (BP) measured with a

sphygmomanometer.

 HR biofeedback. Measures and gives feedback on heart rate (HR), or heartbeats per

minute.

 GSR biofeedback. The galvanic skin response (GSR—also called electro dermal

activity, EDA) is a measure of sweat gland activity assessed with a device that tests

how readily the skin conducts minute levels of electricity: Sweaty skin conducts more

readily than dry skin. GSR level is given as feedback.

 EEG biofeedback. An electroencephalograph (EEG) assesses electrical activity in the

brain, including certain types of brain waves. EEG level is given as feedback.

 EMG biofeedback. An electromyograph (EMG) measures muscle tension by assessing

the electrical activity of muscles when they contract. EMG level is given as feedback.
  Thermal biofeedback. Assessments of skin temperature in a region of the body

measure the flow of blood, which is warm, in that part of the body, such as a foot or

hand. Temperature level is given as feedback.

The Importance of Training and Developmental Level

Learning to regulate one’s own bodily processes with biofeedback usually requires

training, which is most effectively provided by an experienced professional. The training

clients get incorporates a shaping procedure in which tiny physiological changes in the desired

direction are reinforced initially; as the training progresses, larger and larger changes are

required for reinforcement. Clients are usually encouraged to practice biofeedback techniques

at home when they receive training. Home practice appears to enhance the success of

biofeedback in certain applications, such as in treating headache, but it may not help people

learn the methods better or faster during training.

Researchers have proposed that children may be especially good candidates for

treatment with biofeedback. Some evidence supports this view: A study combining data from

prior research found that biofeedback treatment for headache was more successful in reducing

headache pain with children than with adults. Although we aren’t sure why children would

have greater success with biofeedback treatments, two speculations have been offered. First,

children seem to be more interested in and enthusiastic about the equipment and procedure than

adults are. Second, adults appear to be more skeptical about their ability to learn to control their

physiological function and to benefit from doing so.

Biofeedback Applications

1. Treating Hypertension

Hypertension is the medical condition of having blood pressure that is consistently high

over several weeks or more. Medical treatment for hypertension usually starts with having the

person make lifestyle changes, such as by exercising and making dietary changes designed to

lower weight, and often involves taking prescription drugs. Biofeedback can be a useful

supplement to medical treatment, enabling people to control their blood pressure to some

degree, achieve lower blood pressure levels, and use less medication. Drugs used in treating

hypertension can cause side effects, such as increased blood sugar levels or feelings of

weakness or confusion that may be difficult for some patients to tolerate. Using biofeedback,

sometimes with relaxation techniques, may be especially useful for these people in helping to

reduce their blood pressures while minimizing the use of drugs.

2. Treating Seizure Disorders: Epilepsy

Epilepsy is a neurological condition marked by recurrent, sudden seizures that result from

electrical disturbances in the brain. Biofeedback treatment of epilepsy was developed initially

for patients whose seizures were not adequately reduced by medication. EEG biofeedback has

been used successfully with many epilepsy patients in helping them learn to control their brain

electrical activity and reduce their seizures. The general approach in using EEG biofeedback

for people with epilepsy involves training them to decrease certain kinds of brain-wave

activities and increase others in specific areas of the brain. If they can gain some measure of

control over these brain waves in the areas of the brain where the disturbances occur, seizures

should diminish.
 3. Treating Chronic Headache

Two biofeedback approaches have been used for treating patients who suffer from severe,

recurrent headaches. The biofeedback approach used depends on the headache type:

 Tension-type (or ‘‘muscle-contraction’’) headache seems to result from the

combined effects of a central nervous system dysfunction and persistent

contraction of the head and neck muscles. Patients with tension-type headaches

generally receive EMG biofeedback training to control the tension in specific

muscle groups, such as those in the forehead.

 Migraine headache seems to result from the combination of dilation of blood

vessels surrounding the brain and a dysfunction in the nervous system. Patients

with migraine headaches generally receive thermal biofeedback training

(usually monitoring the hand) to help them control the constriction and dilation

of arteries.

4. Treating Anxiety

Two biofeedback approaches have been tested as treatments for anxiety. One approach uses

EMG biofeedback. Progressive muscle relaxation techniques, can reduce anxiety and other

conditioned emotional responses. Because EMG biofeedback can help people learn to relax

specific muscle groups, the second approach tested for treating anxiety uses EEG biofeedback,

such as by increasing the person’s alpha waves; evidence of its effectiveness is not strong.

5. Treating Asthma

Two biofeedback approaches have been applied to reduce the frequency and intensity of

asthma episodes. One approach uses EMG biofeedback, typically for the frontalis muscle,

which is of questionable utility. We’ll focus on the other approach, respiratory biofeedback, in
which airflow is measured with an apparatus as the patient breathes and feedback is given on

respiratory function so that the person can learn to control airway diameter.

6. Treating Neuromuscular Disorders

Neuromuscular disorders are medical conditions that affect the muscles and the nerves that

carry information directing the muscles to move. Some neuromuscular disorders involve

paralysis, which may have resulted from a spinal cord injury or a stroke that damages the brain;

other disorders cause the muscles to become rigid or have spasms. Such conditions have been

treated successfully with EMG biofeedback. This procedure involves monitoring muscles in

the affected body parts, such as the legs, with sensitive electronic equipment to detect tiny

changes in muscular function.

Conclusion

Biofeedback is one option that may help you gain greater control over your physical

responses and behaviours. If biofeedback is successful for you, it might help you control

symptoms of your condition or reduce the amount of medication you take. Eventually, you can

practice the biofeedback techniques you learn on your own.

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