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Facing Fears - Using Imaginary Exposure

3/27/2015

As mentioned in my two previous posts, exposing someone to an anxiety provoking stimulus using a series of graduated steps paired with relaxation can help a person slowly get over their fear of that object or situation. However, what happens when the anxiety provoking stimulus cannot be presented in a controlled stepwise manner? An example of this could be speaking in public. Unless you are part of a speaking group or class it may be difficult to predict or control when your next public speaking opportunities may be.  When opportunities to encounter the anxiety provoking stimulus are not predictable (as it was with the school bus) then an image of the stimulus can be paired with relaxation in the early steps of the hierarchy until an opportunity for the actual stimulus is available.
    Using the public speaking example, the person could first create an audience in their mind and imagine speaking to them while performing the relaxation. If the person cannot create an image in their mind then a picture of a audience could suffice. If there are specific worries related to the speech, like forgetting what to say, that can be worked into the scene. Once comfortable in that situation, the next step could be making the speech in front of one familiar person, then a small familiar group, gradually leading up to the actual speech.
     A couple of important tips to remember. For every specific worry there needs to be a counter thought or solution. If the worry is forgetting then a solution could be making small cue cards so the person can easily access a way to stimulate their memory. If answering questions is a worry, then help the person come up with specific answers to anticipated questions prior to the speech. If the anxiety is related to a lack of knowledge or skills then those need to be taught first. The other aspect to keep in mind is that desensitization is not a method for encouraging people to perform activities they find unpleasant. This is only to be used when the person wants to do an activity but experiences sensations of anxiety/duress when trying to do so. It is important to respect people's preferences and gain consent prior to starting any exposure procedure.

Steven C. Altabet, Ph.D.

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Facing Fears - Part 2

3/18/2015

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As I mentioned in my previous post, facing fears systematically (in small steps paired with relaxation exercises) can be more effective for people with neurological sensitivities than a more direct exposure approach. In this discussion I will give a specific example where Systematic Desensitization has been helpful. I use an example relating to a specific fear.
      One of my first jobs was as a school psychologist and there was young girl who was terrified of getting on the school bus. The first step was to teach her how to breathe deeply. Once this was accomplished, a task analysis/fear hierarchy was set up to get her to first see the bus from a distance (30 feet away) then, once comfortable, get closer and closer (5 foot increments) until she was able to board the bus and ride the bus home.  Once the hierarchy was set up it was time to implement the plan. It was arranged with the girl's mother to drop off and pick the girl up from school during this process. After that, at the end of the school day, I would escort the girl to the bus loading area. We walked toward the bus until we were 30 feet away.  The girl was then instructed to look at the bus and stay right where she was and breathe slowly until she felt calm. She was assured that she did not have to go any further, but had to stay where she was until she felt calm. The girl agreed and when she looked visibly calm (and stated so) we left the area and her mother took her home. The next day we walked up to 25 feet away and we continued at this rate until she got on the bus. After each session the girl was asked if anything bad had happened during the exposure. She always said no, but if it had we would have addressed her concern. Once she was able to get on the bus, I was prepared to ride the bus with her for support, but the girl wished to ride the bus alone (her mother was waiting for her at home). She reported being able to do the deep breathing while on the bus and made it home without fear. She continued to ride the bus home the rest of the year.
   This happened to be a fairly easy case because her fear was directly about the bus itself and not worrying about something bad happening while on the bus like the bus breaking down or getting off at the wrong stop. In cases like that, in addition to the deep breathing, we would developed a coping thought to address the worry. For example if the client was an adult who was fearful of the getting off at the wrong stop, a coping statement could be "the bus driver will call out when the stop approaches, but if I did miss the stop I could get on another bus to take me to that stop." The other easy aspect of this case was that the feared item was accessible almost daily allowing for a 'real life' exposure that was well controlled.  Exposure to other fears may be more complicated if the feared item is not consistently available or the fear is an imagined situation that may or not happen. Systematic Desensitization can be still be applied to these situations, but the exposure then needs to take place in the person's mind. I'll save that for my next post.

Steven C. Altabet, Ph.D.

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Facing Fears

3/14/2015

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When it comes to fear, the adage is that if you face you are afraid of you will get over your fear. In my years of work with people with Autism I have come to the opinion that this statement is incomplete. Facing a fear all at once without any coping tools or support will not make the fear go away, but typically make the fear stronger leading to an increased likelihood of avoidance or resistance. For people who are emotionally/neurologically sensitive, the physiological effects of the fear response are so intense that prolonged exposure to what you fear stimulus becomes unbearable. To help overcome fears I propose an old school behavior therapy technique.
    Systematic Desensitization is a highly structured stepwise exposure procedure that allows the person to face their fear a little at a time in small manageable steps. Additionally, the exposure is paired with relaxation exercises so the physical intensity of the fear response is lessened. Over time the feared situation is associated with a relaxed feeling rather than a tense one. Doing this involves combining some of the previous behavior training techniques that have been discussed in past posts.

1. Create a fear hierarchy - For those who are more familiar with Applied Behavior Analysis (ABA) this means creating a task analysis for the fear exposure. Break up the exposure in to a series of small steps starting with a nonthreatening exposure then VERY GRADUALLY increasing the threat until full exposure is achieved. These steps are written out on a list with only one step of the exposure performed each time. A person cannot proceed to the next step until they feel completely comfortable with their current step. If the person is able, have them identify the different aspects/steps of their fear and rate each step to make sure that the steps are being ordered in increasing intensity.

2. Develop a reliable relaxation response - The key is for the person to be physically calm as possible when facing their fear. Prior to any exposure, develop a relaxation response that lowers the person's arousal level and they feel comfortable using. Deep breathing is typically the easiest to learn. Just remember that the breaths need to be not just deep, but slow and soft as well. Timing is important, about 4 seconds in and out. Listening to a recording of ocean sounds can help a person time their breath to the rhythm of the waves.  To help control the force of breath, think of the breathing in like sipping through a straw and breathing out like trying to blow large bubbles or slowly turning a pinwheel. If relaxation cannot be achieved through deep breathing, relaxation may be gained passively by listening to soft music or nature sounds and turning down the lights. Relaxation can be accompanied by positive thoughts such as I am safe, I am comfortable, or even a specific coping strategy ("If I have a problem I can call for help").

3. Perform each step of the hierarchy paired with the relaxation response - Once the person feels comfortable with the relaxation response it is time for the exposure. Start with the easiest/least intense step. After discussing what the exposure plan is and getting the person's consent begin with the relaxation exercise. Once the person appears calm expose them to step 1 of the hierarchy. Exposure can be live (actually seeing what is feared), in the person's imagination (creating a mental picture or thought). Likely the person will feel anxiety symptoms upon initial exposure but should gradually calm as they continue to perform the relaxation. They key is for the person to stay in that step of the exposure until they are completely relaxed. Early escape will only reinforce the fear. Once complete relaxation with that step has been achieved, then the exposure can end. Sometimes you can proceed to the next step if the person wants to, but often a break is needed. If the person gets stuck at a step, that step may need to be broken down further or an additional coping strategy may be needed. I'll give some examples next post.

Steven C Altabet, Ph.D.

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Pleasure Seeking vs. Positive Emotion

3/8/2015

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The last couple of posts talked about increasing positive emotion including increasing opportunities for positive emotion.  typically these activities can fall into one of three categories:
1. Activities for pure pleasure seeking - These activities are typically solitary and while enjoyable do not lead to any personal growth or discovery. Examples include playing video games alone, reading about previously learned material, or engaging in a preferred routine behavior without any changes.

2. Activities for shared enjoyment - These can be any enjoyable activity, but are done with another person. The more physical proximity there is the more positive emotion is derived. For example more positive emotion would be experienced playing video games with a friend in person than would be experienced playing with that same friend online. the same would apply for discussing a topic of shared interest.

3. Activities for personal growth - These are enjoyable activities that involve learning something new or performing a new behavior. For example learning new information about a preferred topic would qualify for this category. Teaching or discussing that information with another interested person would then result in shared enjoyment.

The best way to conceptualize the different types of activities is to think of pleasure seeking activities as a method of coping with the stress of every day life. The other two types of activities are ways of mind expansion either intellectual or social-emotional.  Since mind expansion and coping are both very important activities, the key is to have a balance of both in your daily activity schedule. Two other important things to remember with regard to people with Autism Spectrum Disorder:

A. While pleasure seeking/coping activities are important, doing them for too long a time can make it extremely difficult to want to do other activities, which will inhibit development and result in increased isolation. Also, overuse of pleasurable activities can eventually make them less pleasurable and result in less coping power. While time limits for individual people may vary, a general rule of thumb daily use should fall between 20-40 minutes. If the activity can only be done weekly, then the time limit can increase to 1-2 hours depending on the person's tolerance for stimulation.

B. With mind expansion activities, people with Autism typically can only handle change or social interaction in small increments. While it would still be beneficial for these activities to occur daily, it would be best if they are done in small increments with breaks in between of quiet/solitary activity. For example, a person with Autism could be more productive if their work/school day contains several short breaks scheduled regularly at specific times during the day (typically following stimulating activity).

By striking a balance between pleasure seeking and mind expanding positive activities, you are ensuring the best chance for personal growth with the least amount of resistance. I'll addressed dealing with fear/resistance in my next post.

Steven C Altabet, Ph.D.

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Facing Fears - Using Imaginary Exposure

Facing Fears - Part 2

Facing Fears

Pleasure Seeking vs. Positive Emotion

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