In vivo flooding for anxiety disorders: Proposing its utility in the treatment posttraumatic stress disorder
Section snippets
Graded in vivo exposure versus in vivo flooding
Historically, exposure treatments for anxiety employed imaginal methods (Gelder et al., 1973, Hussain, 1971; Marks, Boulougouris, & Marset, 1971; Stampfl & Levis, 1967; Wolpe, 1958, Wolpe, 1961). Subsequent investigation compared the relative efficacy of imaginal versus real life exposure techniques for a range of anxiety conditions of varying levels of severity (e.g., Everaerd, Rijken, & Emmelkamp, 1973; Mathews et al., 1976). Overall the superiority of in vivo exposure techniques to imaginal
Treatments for posttraumatic stress disorder (PTSD)
Posttraumatic stress disorder is a traumatic stress response diagnosed following exposure to significant trauma such as physical and sexual assault, war or combat-related trauma, motor vehicle accidents and natural disasters (American Psychiatric Association, 1994). It is characterized by re-experiencing symptoms (e.g., nightmares, intrusive and distressing memories of the traumatic event), avoidance symptoms (e.g., avoiding situations that represent the trauma, not talking about the trauma,
Can in vivo flooding be used in the treatment of PTSD?
As emphasized by the above literature, when the separate effects of exposure has been examined in PTSD treatment studies it has been in reference to imaginal versus in vivo exposure, and has not examined in vivo exposure in its own right. Indeed, this has generally been the case with the anxiety field as a whole as discussed earlier in this review. For example, in reviewing the literature in the context of treating clinical fear, James (1986) examined whether in vivo flooding was superior to
The need for empirical investigation of in vivo flooding
What might be the advantages of in vivo flooding? Some literature suggests that in vivo flooding in the treatment of other anxiety disorders might have faster therapeutic effects than in vivo graded exposure (or for that matter, imaginal flooding) (Mannion & Levine, 1984), thus it is possible that such procedures could result in accelerated treatment outcome. Consistent with this notion, Yuksel et al. (1984) reported comparable treatment outcome in rapid and slow therapist-aided in vivo
The role of cognition (beliefs) in the treatment of PTSD
Although the present review has focused upon behavioral components of therapies for PTSD, this should not be taken to reflect that cognition is considered unimportant in the development and maintenance of the posttraumatic response. Indeed, in addition to the necessary component of fear activation and habituation in the treatment of posttraumatic stress, Foa and Kozak's (1986) ‘fear network’ model also requires that new, corrective information be introduced which is incompatible with the
Scientist-practitioner model
An additional reason for the study of in vivo flooding lies in the need to provide clinicians with practical yet empirical information regarding the efficacy (or non-efficacy) of varying therapeutic techniques. There is some preliminary evidence to suggest that imaginal or prolonged exposure, a validated treatment technique for PTSD (Foa, Keane, & Friedman, 2000) may not be used widely by therapists in the treatment of PTSD (Becker, Zayfert, & Anderson, 2004; Gillock, Zayfert, & Hayes, 2001).
Summary
In conclusion, studies need to examine the effectiveness (or lack of) of in vivo flooding in its own right. Saigh (1989) recommends that exposure treatments be dismantled to understand the active components. In vivo flooding needs to be compared with in vivo graded exposure, and finally, given the importance of cognitions in posttraumatic stress, the efficacy of in vivo flooding in conjunction with cognitive therapy techniques should also be investigated. Similarly, in line with recommendations
References (65)
- et al.
Comparison of flooding procedures in animals and man
Behaviour Research and Therapy
(1971) - et al.
A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD
Behaviour Research and Therapy
(2004) - et al.
Physiological response to combat memories and preliminary treatment outcome in Vietnam veteran PTSD patients treated with direct therapeutic exposure
Behavior Therapy
(1990) - et al.
Superiority of flooding (implosion) to desensitisation for reducing pathological fear
Behaviour Research and Therapy
(1971) - et al.
A cognitive model of posttraumatic stress disorder
Behaviour Research and Therapy
(2000) - et al.
Flooding in imagination vs. flooding in vivo: A comparison with agoraphobics
Behaviour Research and Therapy
(1975) - et al.
A comparison of ‘flooding’ and ‘successive approximation’ in the treatment of agoraphobia
Behaviour Research and Therapy
(1973) - et al.
The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder
Behavior Therapy
(1995) - et al.
The rapid treatment of a young man's balloon (noise) phobia using in vivo flooding
Journal of Behavior Therapy and Experimental Psychiatry
(1993) The effects of variable exposure in flooding therapy
Behavior Therapy
(1985)
The effects of flooding on reducing snake fear in rhesus monkeys: 6-month follow-up and further flooding
Behaviour Research and Therapy
Utility of the heart rate response as an index of emotional processing in a female rape victim with posttraumatic stress disorder
Cognitive and Behavioral Practice
The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation
Behaviour Research and Therapy
Relevant and irrelevant fear in flooding – a crossover study of phobic patients
Behavior Therapy
Successful flooding treatment of a noise phobia in an eleven-year-old
Journal of Behavior Therapy and Experimental Psychiatry
Diagnostic and statistical manual of mental disorders
Exposure and response prevention in the natural environment: A comparison with obsessive–compulsive patients
Behaviour Research and Therapy
Treatment of acute stress disorder: A comparison of cognitive behavior therapy and supportive counseling
Journal of Consulting and Clinical Psychology
Treating acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques
American Journal of Psychiatry
Temporally massed CS presentations generate more fear extinction than spaced presentations
Journal of Experimental Psychology: Animal Behavior Processes
Assessment and treatment of combat-related post-traumatic stress disorder in a medical center setting
Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse
Journal of Consulting and Clinical Psychology
The investigation of exposure and cognitive therapy: Comment on Tarrier et al. (1999)
Journal of Consulting and Clinical Psychology
Emotional processing of fear: Exposure to corrective information
Psychological Bulletin
A comparison of exposure therapy, stress innoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims
Journal of Consulting and Clinical Psychology
Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims
Journal of Consulting and Clinical Psychology
Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies
Treatment of post-traumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling
Journal of Consulting and Clinical Psychology
Does imaginal exposure exacerbate PTSD symptoms?
Journal of Consulting and Clinical Psychology
Specific and non-specific factors in behaviour therapy
British Journal of Psychiatry
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