Miriam’s Treatment
Miriam is an imaginary person, but behavioral therapy is used by thousands of therapists with their clients every day. Review the following table to discover how Miriam’s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person’s course of therapy is unique.
| Therapy Sessions | Session Description |
|---|---|
| Miriam’s therapy: Preparation | Prior to starting progressive exposure, Miriam created her hierarchy of fears. She spent several session working on relaxation. She practiced relaxation at home several times a day until she and you, her therapist, agreed that she was ready to start treatment. |
| Miriam’s therapy: Exposure Session 1 |
The bottom (lowest anxiety) of Miriam’s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a 1 to 10 scale, Miriam said 1: No fear at all. Miriam brought two friends with her to the therapy session today. You had them sit in a comfortable part of your office, drinking tea and chatting for 15 minutes. Afterwards Miriam reported her fear level during the chat as a 1 on a ten-point scale: no fear. You then had her sit in a comfortable chair and think about giving a talk about the challenges of her job to a small, friendly audience. At the beginning of this task, she rated her anxiety as 3 on a 10-point scale. As she thought about it—with helpful suggestions from you—she also relaxed, using her relaxation training. After about 10 minutes, she reported her anxiety had dropped to 1, the lowest level of anxiety on your scale. You gave Miriam “homework”—to repeat this exercise twice a day until the next session. |
| Miriam’s therapy: Exposure Session 2 |
At the beginning of today’s session, you had Miriam repeat the task from the previous session of thinking about talking about her job to a small, friendly group. At the beginning she rated her fear at 2, but it dropped to 1 within a few minutes. Now you took Miriam to the next level. You had her imagine telling a large audience of company executives about some technical problem she was working on at her job. At the beginning, just thinking about doing this led to a fear level of 5. After 10 minutes, her fear level dropped to 2. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session. You gave Miriam homework again—to practice a similar situation at home. |
| Miriam’s therapy: Exposure Session 3 |
You started this situation with a new scenario similar to the one Miriam did in the last session and practiced at home. She was quickly able to drop her anxiety level to 1. You had a professional photography group create a video of someone very similar in appearance and manner to Miriam giving a talk in from of a small friendly audience on a topic similar to one Miriam might give. You asked her to watch this video and imagine herself in the place of the real speaker. She rated this a 6 on the anxiety scale. Over several repetitions, her rating dropped to 2. For homework, Miriam watched the video several times a day. You instructed her in ways to make the video seem MORE REAL, so she could really feel the anxiety of being in front of people. |
| Miriam’s therapy: Exposure Session 4 |
You have had Miriam arrange to give a talk NEXT SESSION to a small group of Miriam’s co-workers. You also had Miriam prepare the talk. Today you practiced the talk with her. At the start of the practice session, with only you there, Miriam rated her anxiety level at 9 out of 10. Over the course of the hour, her anxiety level dropped to 5. Her homework was to continue to practice the talk and to work on relaxation. |
| Miriam’s therapy: Exposure Session 5 | Today, Miriam gave the talk to the small group. Her anxiety rating before she went in front of them was 10. Except for a little stumbling at the start, the 20-minute presentation went well. Miriam reported an anxiety level of 4 after the talk. |
| …we’ll skip few sessions here, but you get the idea… | |
| Miriam’s therapy: Exposure Session 6 |
In this last session, you have arranged for Miriam to be the introductory speaker at a literacy tutoring volunteer organization nearby. Miriam has done a small amount of volunteer work with the organization, but she knows very little about it. With the help of the staff, she prepares a talk during the week before this session. The audience is composed of 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Miriam knows none of them and none of them has ever heard of her. Miriam’s introductory comments take about 15 minutes. She rates her anxiety level before going out at 8. After the talk, she rates her anxiety at 2. In fact, she said it was almost fun. |
| After Therapy | Miriam continues to see you for a few more sessions. You give her additional homework and you help her develop a plan that includes arranging to give professional presentations for her job and continuing to give talks at the literacy volunteer organization. Miriam reports that none of these ideas create an anxiety level above 3 when she thinks about doing them. |
You just learned about systematic desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let’s review a few points from systematic desensitization. In flooding therapy, you would skip the earliest situations described in systematic desensitization and you move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.
Flooding has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding that work for systematic desensitization:
- The person consciously works to replace anxiety and fear with relaxation.
- The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.
- Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.