Exposure treatment Health Article

Recent innovations in exposure treatment

VIRTUAL REALITY EXPOSURE TREATMENT. Virtual reality is a technique that allows a person to participate actively in a computer-generated (or virtual) scenario or environment. The participant has the sense of being present in the virtual environment. Virtual reality uses a device mounted on the participant's head that shows computer graphics and visual displays in real time, and tracks the person's body movements. Some forms of virtual reality also allow participants to hold a second device in their hands that enables them to interact more fully with the virtual environment, such as opening a car door.

Virtual reality has been proposed as a new way of conducting exposure therapy because it can provide a sense of being present in a feared situation. Virtual reality exposure may be useful for treating such phobias as fear of heights, flying, or driving, as well as for treating PTSD. This method appears to have several advantages over standard exposure therapy. First, virtual reality may offer patients a greater sense of control because they can instantly turn the device on and off or change its level of intensity. Second, virtual reality would protect patients from harm or social embarrassment during their practice sessions. Third, it could be implemented regardless of the patient's ability to imagine or to remain with prolonged imaginal exposure. These proposed advantages of virtual reality over standard exposure therapy have yet to be tested, however.

Some studies have been conducted using virtual reality in the treatment of patients with fear of heights and fear of flying, and in a sample of Vietnam veterans diagnosed with PTSD. These studies of virtual reality exposure therapy have limitations in terms of study design and small sample size, but their positive results suggest that virtual reality exposure therapy deserves further investigation.

CUE EXPOSURE TREATMENT FOR ALCOHOL DEPENDENCE. Cue exposure is a relatively new approach to treating substance-related disorders. It is designed to recreate real-life situations in a safe therapeutic environment that expose patients repeatedly to alcohol-related cues, such as the sight or smell of alcohol. It is thought that this repeated exposure to cues, plus prevention of the usual response (drinking alcohol) will reduce and possibly eliminate urges experienced in reaction to the cues.

Persons diagnosed with alcohol dependence face a number of alcohol-related cues in their environment, including moods associated with previous drinking patterns; people, places, times, and objects associated with the pleasurable effects of alcohol; and the sight or smell of alcoholic beverages. Exposure to these cues increases the patient's risk of relapse, because the cues can interfere with a person's use of coping skills to resist the urge to drink. The purpose of cue exposure is to teach patients coping skills for responding to these urges. It is thought that a person who practices coping skills in the presence of cues will find the coping skills strengthened, along with the conviction that he or she can respond effectively when confronted by similar cues in real-life situations.

There are various approaches to cue exposure. The choice of cues is usually based on treatment philosophy and goals, which may require abstinence from alcohol or permit moderate drinking. In abstinence-only programs, patients may be exposed to actual alcohol cues and/or imagined high-risk situations. This imaginal exposure is useful for dealing with cues and circumstances that cannot be reproduced in treatment settings, such as fights. Patients learn and practice urge-specific coping skills. While a patient may learn to cope successfully with one cue (such as the smell of alcohol), the urge to drink may reappear in response to another cue, such as seeing a friend with whom they used to go to bars. The patient would then learn how to manage this particular cue. This program may take six to eight individual or group sessions and may occur on an inpatient or outpatient basis. Often patients remain in the treatment setting for several hours after the exposure to ensure that any lasting urges are safely managed with the therapist's help.

More specifically, cue exposure focuses on the aspect of alcohol consumption that produces the strongest urge. The patient would report each change in their level of urgency, using a scale of zero to ten that resembles the SUDS scale. The urge to drink usually peaks after one to five minutes. When the desire for a drink arises, the patient is instructed to focus on the cue to see what happens to their desire. In most cases the urge subsides within 15 minutes, which is often different from what the patient expected. In later sessions, the patient is instructed when the urge peaks to imagine using the coping skills that he or she was recently taught. The patient may also be instructed to imagine being in high-risk situations and using the coping skills. Some examples of these coping skills include telling oneself that the urge will go away; picturing the negative consequences of drinking alcohol; and thinking of the positive consequences of staying sober.

Although there has been little research on cue exposure, available studies show positive outcomes in terms of decreasing the patients' consumption of alcohol. There have been, however, few outcome studies comparing cue exposure treatment to other treatment approaches. It may be hard to separate the benefits due to exposure from the benefits due to coping skills training. In any event, cue exposure treatment is a promising approach that deserves further study to determine if either component alone is sufficient or if a combination of the two is more effective.