Kaplan & Sadock’s Pocket Handbook of Clinical Psychiatry

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Psychotherapies

objects that elicit fear, patients and therapists prepare a graded list or hierar chy of anxiety-provoking scenes associated with a patient’s fears. The learned relaxation state and the anxiety-provoking scenes are systematically paired in treatment. Thus, the three steps are relaxation training, hierarchy construction, and desensitization of the stimulus. When this procedure is performed in real life instead of in the patient’s imagination, it is called graded exposure . Therapeutic-graded exposure Similar to systematic desensitization, except that relaxation training is not in volved and treatment is usually carried out in a real-life context. Exposure is graded according to a hierarchy. Patients afraid of cats, for example, might prog ress from looking at a picture of a cat to holding one. Flooding Flooding is a technique in which the patient is exposed immediately to the most anxiety-provoking stimulus (eg, the top of a tall building if they are afraid of heights) instead of being exposed gradually or systematically to a hierarchy of feared situations. If this technique is carried out in the imagination rather than in real life, it is called implosion . Flooding is thought to be an effective behavioral treatment of specific pho bias, provided the patient can tolerate the associated anxiety. A great deal of experimental work is being done with exposure to the feared situations using virtual reality. Beneficial effects have been reported with computer-generated virtual reality exposure of patients with height phobia, fear of flying, arachno phobia, and claustrophobia. Social skills training Most often used in patients with schizophrenia or psychotic disorders, this type of therapy improves social skills. Social dysfunction is normalized by teaching the patient how to accurately read or decode social inputs. Role-playing is used to decrease social anxiety and improve social and conversational skills. It is usu ally done in groups. Assertiveness training In assertiveness training, a variety of techniques, including role modeling, desen sitization, and positive reinforcement, are used to increase the patient’s assertive ness. To be assertive requires that people have confidence in their judgment and sufficient self-esteem to express their opinions. Social skills training augments patient assertiveness in specific situations, but it can transcend these scenarios and give patients greater confidence to attend to a variety of real-life tasks, such as food shopping, looking for work, interacting with other people, and overcom ing shyness. Participant modeling In participant modeling, patients learn a new behavior by imitation—primarily by observation—without having to perform the behavior until they feel ready.

Psychotherapies

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