Behavioral Interventions

To address behavioral avoidance, the addition of exposure interventions may be especially helpful. For example, in the case of PTSD, patients have difficulty retrieving a complete memory of the trauma, although they involuntarily experience recurrent thoughts and images of the event in a very vivid and emotional way. PTSD is believed to arise because of the poor elaboration and incorporation of the memory of the trauma into autobiographical memory, leading to poor voluntary recall and cueing of intrusions by stimuli that may be temporarily associated with the trauma: thus, one target of PTSD treatment is the patient's systematic exposure to the memory of the event through recall with a therapist (Ehlers & Clark, 2000). In vivo exposure is also used to target avoidance of the current life triggers of PTSD symptoms (Ehlers & Clark, 2000) and to obtain data to disconfirm the misappraisals.

CT for OCD, called exposure and response prevention, includes prolonged exposure to obsessional cues, coupled with procedures to prevent rituals (Foa & Franklin, 2001). Repeated prolonged exposure to the feared thoughts and situations is believed to provide information that disconfirms the mistaken associations and promotes habituation. Exposure is conducted gradually as the patient tackles situations that are increasingly more distressing. The efficacy of exposure plus response prevention has been demonstrated in numerous treatment outcome studies (for a review, see Chambless & Ollendick, 2001).

An intervention also used for GAD, known as worry exposure, involves identifying two or three spheres of worry that are ordered hierarchically. Patients are then instructed to hold the catastrophic images in their minds for 20-30 minutes, then to generate as many alternative outcomes as they can to the worst possible outcome (Brown et al., 2001).

Avoidance can also take the form of safety behaviors that prevent or minimize the feared catastrophe (Clark, 1999). For example, a car accident survivor, extremely vigilant for possible dangerous situations, might drive slowly or avoid crowded streets (Ehlers & Clark, 2000). An individual with GAD may seek reassurance from loved ones regarding their safety. Therapy can also target safety behaviors by teaching the patient to enter the feared situation, while purposefully not using the safety behaviors. To target arousal and physiological symptoms, relaxation training and breathing retraining might also be incorporated.

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