®
The Clinician’s guide to supporting the ‘Fears conquered with exposure and habituation’ protocol
Marie Chellingsworth Photography by Andy Poplar [Vinegar & Brown Paper] ®
© 2020 Marie Chellingsworth. The CBT Resource®. 3rd Edition. Last updated May 2020. The right to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. This work is provided under specific license as a read only document for The CBT Resource Annual CPD & Resources membership holders only. It may be used by the membership holder only for their own individual use in 2020/2021, in the original binding. It cannot be downloaded, photographed, sent electronically, hosted electronically or used by any other party under the conditions of membership. This condition must be imposed at all times and this work cannot be sold for profit, used for training others by the member or any other party, edited, copied in full or part, repackaged or amended in any other way without the express permission of the author. The work cannot be circulated for use outside of the individual license holder. The etched glass photography used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper]® and are used with kind permission (see the about the author section for more information about Andy’s work and his own experiences with anxiety and depression). All other images are used with permission from Unsplash in accordance with their policy. We would like to thank the focus groups and various service practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score of the associated patient protocol material is 13.4 and the Flesch reading ease is 80, calculated independently with Readability Studio©. This information booklet has been designed to meet NHS information Standard Principles and conform to good practice guidelines for self-help and patient information. It is designed to be combined with the patient workbook material and support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol alongside this guide. Disclaimer: This Clinician’s guide is to be read and used clinically alongside the patient workbook ‘Fears Conquered with Exposure and Habituation)’. It is provided for information purposes only, in conjunction with training in using the protocol from the author. It is not a substitute for CPD training and should only be used by those suitably qualified to support the protocol. While every reasonable effort has been made to ensure the accuracy of the information, no guarantees, representations or warranties can be given that the information is accurate, free from error or omission, complete or up to date. The assessment and treatment of mental health conditions requires the attention of a qualified medical or mental health professional. We shall accept no liability for any act or omission occurring in reliance on the information or for any consequences of any such act or omission. By using this information, you are agreeing to the provisions of this disclaimer and copyright notice.
© Marie Chellingsworth (2020). The CBT Resource.
Contents
1-2
Introduction
3-4
The ‘Fears Conquered’ with exposure and habituation protocol
5-6
Typical treatment outline
7-14
The physiology of the fear response
15
Panic and the defence cascade
17
The ABC maintenance cycle of panic
18-19
Introducing exposure and habituation
20
Creating the hierarchy
21
The essential conditions
22-23
The importance of homework
24
Manage endings
25
Useful references
26
About the author and Andy Poplar’s work
© Marie Chellingsworth (2020). The CBT Resource.
The 4 essential conditions of exposure and habituation As a practitioner, being able to spot any essential condition problems on planned and completed homework diary visually is important, as well as assisting the patient to draw out the habituation curve for each step as a visual indicator in review.
Graded: The first condition is that exercises are graded. This needs to be so there is enough
anxiety to habituate, but it is not too overwhelming and feels manageable. 50-60% is a good starting exercise, any lower and symptoms are not high enough for the fear cascade response and over learning and habituation to take place, any higher and the response is more likely to lead to a panic attack and disengagement.
Prolonged: The second condition is that each time the patient completes an exercise, that they
need to stay in the situation until their anxiety drops by 50% from the start of the exercise rating. They should complete the duration on the diary at the end of the exercise, once it is known how long this took. This is a measure of progress towards habituation and highlights any instances where it has not come down as quickly as expected, or may have come own too quickly, suggesting a problem with the way the exercise has been carried out.
Repeated: The third condition is that each step of the hierarchy needs to be repeated until it
no longer triggers a high level of fear. 4-5 exercises of exposure a week on average is needed to achieve over learning of the conditioned response. Some weeks the patient will need to a mix of steps if they habituate to one mid way through before their next session. They repeat each step of the hierarchy as an exercise until your anxiety drops to 40% or less before and at the start of the exercise at least once. Then habituation to that step has taken place and they can move to the next exercise. Remember each step will produce an increased level of fear as they work up the hierarchy and take more time to drop, although it often gets easier than predicted.
Without distraction: The final condition is that they need to be aware of any internal or external
distractions, even subtle things that can distract them while doing the exercise. These must be discussed with the patient and a clear rationale given for how they must experience the anxiety without any safety behaviours or anything to bring anxiety down artificially, including subtle internal and external avoidances.
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© Marie Chellingsworth (2020). The CBT Resource.
The importance of homework
Change method homework is the focus of CBT, with the sessions to guide and support use of the techniques between sessions. Change methods are needed from the first session for the correct dose of the intervention to be possible and get recovery rates up. A change method from the first session has been shown to be a strong factor in patient engagement and reliable improvement in IAPT (Ewbank et al, 2019). As Laidlaw, (2015) states homework is not an optional extra to be used as and when it suits, but must form the start and end of every session. Research tells us that patients who are compliant with homework get the best outcomes (Coon & Gallagher-Thompson, 2002; Kazantzis et al., 2005) and that reviewing homework on the part of the practitioner increases patient compliance (Tompkins, 2002). Unlike high intensity CBT approaches, where the session time is longer and somewhat more flexible; due to the time and evidence of Low Intensity CBT and the way in which it brings about change, the focus should always be on the change method tasks that the patient does between sessions. Effective Low Intensity CBT © Marie Chellingsworth (2020). The CBT Resource.
treatment sessions, whether delivered on the telephone or face to face should always use a Plan It, Do It and Review it cycle structure. This means the focus of the first treatment session should be on making an effective plan for the change method inter-session task that the patient is to carry out between your sessions. Whether you use the term homework or inter-session task is entirely down to you and what your patient would prefer. Some patients with negative experiences of school may prefer the latter. Any potential internal things that may get in the way of their plan (things within them like confidence or understanding for example) or external things (like neighbours popping round or a friend calling on the telephone) that are outside of their control should be considered and problem solved in advance when homework setting, not resolved after the event, to maximise the potential of the patient carrying it out and having a good experience of the task. The homework plan on the diary for completion in the following week should be routinely checked off against the 4 essential conditions at the end of the session to reinforce their importance.
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