The ‘Fears Conquered’ with exposure and habituation

The ‘Fears conquered with exposure and habituation’ protocol

The protocol should be delivered by a trained practitioner, supporting the ‘Fears Conquered’ selfhelp material, which has been tested to conform to good practice guidelines in self-help and have a suitable reading age. In line with NICE guidelines treatment for panic and agoraphobia should be exposure and habituation, integrated with use of an appropriate task based self-help material, with support session number dependant upon patient response and engagement to treatment homework (the treatment dose). Each session lasting 20-30 minutes for the homework review and subsequent weeks homework planning (subject to local variation for additional content needed in sessions). This should be delivered in weekly sessions, phased out as required as treatment progresses towards discharge. The protocol should end with relapse management using the relevant pages within the material. The change methods and scaffolding components of the protocol are:

Change Method/

Scaffolding

Technique Explaining the fear response and maintenance cycle Target Duration/Dose

A scaffolding technique to give the patient information about the adrenalin response, symptoms and how the body can learn to fear these symptoms and a cycle of panic, avoidance, escape and safety seeking can take hold, how exposure and habituation helps to break this cycle by helping the body to over-learn it does not need to produce fear on response to these triggers. A one off psycho-eduction task. At end of assessment/first treatment session depending on time available. This should be physiological in nature explaining the purpose of the symptoms of arousal, focused on accurately explaining the fear response and misinterpretation by the body of these symptoms relevant to the individual patient presentation, how the body has learnt to treat these normal physical symptoms inside of arousal and at other times as a sign of threat should be included, with normalisation of key individual patient symptoms of concern. It should be discussed how avoidance and safety seeking serves to maintain the disorder in a vicious cycle, but this learning can be reversed through the treatment. This should be reinforced through the reading in the patient self-help material.

Hierarchy creation A scaffolding task to help patients to build a hierarchy of increasing levels of fear triggers: avoided situations and physical sensations. Enables exposure and habituation to be planned in a graded way that feels manageable whilst having enough symptoms for habituation to take place. A brief exercise carried out as part of a session with the patient, with some activities in each level of difficulty added and either finished in the session or as homework if incomplete (alongside planning change method homework for completion after session 1, so the hierarchy requires an exercise in the easier section that produces enough fear to be effective (50-60%) to ensure this is possible). Ideally no safety behaviours are included on the hierarchy when completing it. Any steps with a safety behaviour included initially to make treatment possible, e.g. going out with someone, must still produce the required level of fear to be a suitable homework exercise and the same activity without the safety behaviour must be added to the hierarchy at a higher step to ensure it is dropped during treatment. The hierarchy should not include use of benzodiazepines or other prescribed or over the counter medicines or remedies that reduce affect and block habituation. Any such medication should always be discussed with a supervisor and the prescriber to see if a withdrawal programme is required prior to treatment taking place to.

Exposure and habituation exercises

Each week, the change method of exposure and habituation exercises to be completed over the following 7 days should be planned. These activities must be checked against the essential conditions as part of the planning process to ensure the patient is adhering to the conditions and has a working knowledge of how they operationalise. Homework each week should be drawn out on a blank graph to measure the habituation curve and give a visual illustration to the patient. Any difficulties or barriers should be problem solved. Weekly exposure and habituation exercises should take place. An average of 4-5 exercises should take place each week. Initially, as it is unknown how long it will take for anxiety to drop by 50% for each individual (usually somewhere between 20-120 minutes) from the start of the exercise rating, sufficient time needs to be set aside by the patient in the first week at the top end of the possible amount of time it could take e.g. 5 exercises spread across the week x 20120 minutes each time = a time commitment of somewhere between 1 hour and 40 minutes to minutes to 10 hours in the first week. After the first exercises the time of each subsequent exposure should decrease, but its important the patient leaves enough time aside for 4-5 weekly repetitions and has enough time after the exercise for affect to reduce back to baseline. Each time they step up the hierarchy they should be reminded that the time may increase again for the first time they carry out that exercise. It is also important that the patient knows how and when to step up the hierarchy independently, and that repetitions of exercises are not carried out unnecessarily once a step has been habituated to, while waiting for a review session

Relapse management

A short exercise to target early warning signs of relapse, normalise mood fluctuations and anxiety as a helpful response to keep us safe, to help the patient to consolidate learning of the change method to assist if they need them it the future. Used at the end of treatment, the patients learning of early warning signs of routine disruption, autonomic, cognitive and behavioural changes as well as reinforcing the change methods and learning from treatment.