Snake Phobia Behavioral (Exposure) Therapy

>>Narrator: Meet 22-year-old Mariam Dum from Venezuela, clinical psychologist, Lars-Göran Öst from Sweden, and Elf. He’s an American corn snake. This multinational threesome is working together. Mariam helps out when Elf gets tangled in Öst’s belt loops, and Öst helps Mariam put Elf around her neck. The picture looks simple enough, unless you go back in time, just three hours ago, as Mariam was preparing to meet Elf for the first time. >>Mariam: [Crying] >>Narrator: Mariam has a specific phobia– a fear of snakes. Other specific phobias include claustrophobia and a fear of flying and thunder. Mariam’s had almost no contact with snakes and doesn’t know why she’s afraid. >>Mariam: Since I remember myself, I remember being afraid of snakes. >>Narrator: She has trouble with movies. >>Mariam: I have to close my eyes, always. >>Narrator: At the zoo. >>Mariam: It’s impossible. >>Narrator: And it interferes with her life. >>Mariam: I have dreams of snakes. It’s horrible. I think I like [inaudible] without, and there’s snakes in some other things. >>Narrator: Mariam is a research technician here at Boston University’s Center for Anxiety and Related Disorders. Psychologist, David Barlow, is director of the center and a pioneer in exposure therapy. His research demonstrates the outstanding success that’s been achieved in treating phobias in a very brief time period. Just one week. Some psychologists at the center use virtual reality to gradually introduce a patient to a feared situation. But Öst bypasses all that. He treats specific phobias in just three hours. >>Barlow: What he’s done though, over the years, and he leads . . . in some way, he leads the world in this . . . is stripted . . strip the program down to its essence. >>Narrator: Barlow invited Öst from Sweden to demonstrate brief exposure therapy. >>Barlow: In the hopes that we will be better able to apply it here in the United States. >>Narrator: And Mariam has agreed to be treated in front of her colleagues. Exposure therapy requires that patients gain experience with the feared object. >>Barlow: Unless one is willing to experience one’s own negative emotions, and expose them as not dangerous and overwhelming or threatening, then they probably will not be able to overcome their anxiety and phobia. >>Narrator: But some say this intense exposure is cruel. >>Öst: I disagree completely, because everything we do in the treatment is decided by the patient. And it is within this time limit a very gradual approach. >>Barlow: There are surprisingly few people, given the suffering that they have endured, up until this point, who aren’t willing to take that plunge and see if they can overcome it. >>Öst: People have this idea that you suddenly pick out the animal and throw it in the lab toward the patient. That will never happen. >>Narrator: It’s teamwork. Öst interviews Mariam for 45 minutes, and then describes and prepares her for treatment in an additional 15 minutes. >>Öst: So I will challenge you to try things. But I will never force you to do anything that . . . >>Narrator: It’s critical to determine Mariam’s worst fear, what’s called her catastrophic belief. Her catastrophic belief is that if a snake is loose, and she can’t escape, she’ll have heart failure. >>Öst: How certain are you then, that you might die as a consequence of that interaction? >>Mariam: Maybe 70 percent. >>Öst: Seventy percent. Okay. >>Narrator: No one has ever died or become ill either with Öst’s or Barlow’s treatment. But Mariam believes her anxiety won’t diminish, and she’ll escape. >>Mariam: They can run away from the room. >>Öst: The strong belief in the catastrophe, that is what’s driving the avoidance behavior and the avoidance behavior is the direct maintaining factor for the phobia. >>Narrator: But if Mariam doesn’t escape, Öst predicts her anxiety . . . >>Öst: Will then gradually diminish as we go along in the treatment. >>Narrator: An important way there can be cognitive changes. >>Öst: To help you get new information about that catastrophic belief. >>Narrator: Öst does not prepare patients with relaxation or deep breathing. >>Öst: I don’t think it’s necessary at all. >>Barlow: What we discovered through systematic research evaluating this component, that patients receiving these skills, were trained in these skills, who then used them to cope with their anxiety or fear actually did not do as well. >>Narrator: Deep breathing masks anxiety and the patient doesn’t learn anxiety isn’t dangerous. Here is will be used only if Mariam hyperventilates. Just prior to exposure, she rates her anxiety on a scale of 0 to 100. >>Mariam: Seventy or 80. >>Narrator: Now, it’s time to go get the snake. Mariam’s anxiety sores. >>Öst: I can stand with my back towards you, if you want to. >>Mariam: Okay. [Crying] >>Öst: And then I can . . . >>Mariam: Wait. Can I close my eyes? >>Öst: And then I can gradually turn. >>Mariam: [Crying]. >>Öst: Standing here now with my back towards you. >>Narrator: Öst does that for two minutes. What is Mariam thinking? >>Mariam: It was horrible. I felt like I was going to leave the room. and that it was, you know, stronger than me. >>Narrator: And what was Öst thinking about her reaction? >>Öst: It’s maybe not the strongest I’ve seen, but up there among the 25 percent strongest. >>Narrator: But he knows that initial anxiety is not the best predictor of success. It’s a motivation to succeed. She lets him turn around after three minutes. >>Mariam: Okay. I’m going to close my eyes. Okay? But don’t count. >> Öst: No. [Mariam Crying] >>Öst: You’re doing good. Elf’s tried to watch it. It’s in my hands. [Mariam continues crying] >>Narrator: She looks for the first time. >>Öst: That’s the only way you are going to get new knowledge. >>Mariam: Okay [Crying] >>Öst: It’s completely peaceful. >>Narrator: She stands and smiles as her anxiety level comes down. >>Mariam: Fifty. >>Narrator: She’s learning. >>Öst: But if you stay exposed to the situation long enough, you see that the anxiety level goes down. >>Narrator: She lets him enter after eight minutes. She realizes that her catastrophic belief can’t occur unless Öst releases the snake. >>Öst: I’m not doing that. >>Narrator: After 15 minutes, Öst sits down. Some anxiety returns. >> Öst: Try to breathe slowly and calmly and with your stomach. >>Narrator: She calms down. >>Öst: So what about a name for it? [Mariam and Öst laugh] >>Öst: And where are you going? >>Mariam: I’m going to move here. >> Öst: Okay. What do you think it feels like? >>Mariam: This is a . . . it’s a nice snake. >>Narrator: Her anxiety is down. >>Öst: Perfect. Great. You’re sitting about, what is this? Three meters away? >>Narrator: She decides to approach. >>Mariam: Okay. I’m going to approach you. I’m going to approach you. >>Öst: Yeah? Good. >>Mariam: But hold it [Chuckles]. >>Öst: Yeah? >>Narrator: What psychological principles might account for the improvement so far? >>Öst: It might be that you have a happy situation going on which leads to extinction of the anxiety reaction. You could say that the confidence is increasing. specific [inaudible] ideas come in to play here from a committed point-of-view. I think what is happening here is that the patient is, with the help of the therapist, accepting to take in new information. >>Narrator: There is also positive reinforcement in modeling. What’s Öst’s assessment so far? >>Öst: Deep in my mind, I know it’s going to work. That means that I don’t have to be impatient. I can be calm. >>Narrator: Certainly his research supports his confidence. Across several types of specific phobias, even with children, Öst’s research shows over 80 percent improvement compared with controlled groups, and the results are maintained at a one-year followup. >>Barlow: Well, the research is actually very, very strong. I’m going to say, surprisingly strong, when you consider the kind of traumatic nature of the intense approach. >>Narrator: It’s close to one hour now, and she decides to name the snake. >>Mariam: Maybe Elf. >>Öst: Elf! >>Mariam: Yeah. >> Öst: Okay. Elf. That’s a nice name. What would it feel like touching it? >>Mariam: I’m thinking about it. >>Öst: Yeah? >>Narrator: After an hour, she touches Elf. >>Öst: Good. Did you touch it? >>Mariam: A little bit. >>Öst: A little bit. Yeah. >>Mariam: I can’t believe I’m touching a snake. >>Öst: You are touching the snake. >>Narrator: Progress is very uneven throughout the afternoon, but it provides an opportunity to challenge the catastrophic belief. [Mariam crying] >>Öst: No. And you died. >>Mariam: No. >> Öst: Nooo. You survived! Great! >>Narrator: Elf is placed on Mariam’s lap. But again, progress is uneven. Elf’s on her lap now alone. >>Mariam: One more time. >>Öst: One more time? >>Narrator: And finally, it’s time to test Mariam’s catastrophic belief, but Elf’s more interested in the radiator and warmth. >>Öst: The snake, it didn’t do a lot of things that she predicted it would do. >>Narrator: What about Mariam’s catastrophic belief? >>Öst: Is it down to 0? >>Mariam: Yes. >>Öst: Good. >>Narrator: Now, it’s time to pose. >>Mariam: A picture. [Laughter] >>Narrator: And then, help untangle Elf. As for her anxiety . . . >>Mariam: Yeah. And at the end, when I was helping him, with the . . . It was zero. That impressed me, the last part, really, that I was able to do that. >>Narrator: There was time for some celebration and congratulations. >>Barlow: Did you really think you could deal with it this way? >>Mariam: No. >>Narrator: And reflect on implications for treatment. >>Barlow: We have no reason to believe that the three-hour program would be any less effective than the one-week program. So then it becomes an issue of, you know, what would the patient choose? There are many patients who really don’t have the time to take a week out of their lives. >>Narrator: The recommendation is that Mariam engage in maintenance, watch nature films, go to the park and the zoo. >>Mariam: If I see a snake on the street, at least I’m going to be able to see it and walk and not see it and run. >>Narrator: And two months after treatment, we spoke with Mariam by phone. [Mariam speaking]

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