What is implosion in behavior therapy?

Introduction

Implosion, along with in vivo and imaginal flooding, is categorized as a prolonged/intense exposure therapy. It is used in the treatment of fears, phobias, anxiety disorders, and negative emotional reactions such as anger. The therapist asks the client to imagine exaggerated, horrifying scenes that are constructed from the client’s report of stimuli that evoke fear or anxiety, supplemented by the therapist’s list of hypothesized cues. The therapist helps the client maintain a high level of fear or anxiety regarding these scenes until the anxiety response spontaneously subsides (implodes).

There are two types of hypothesized cues. One type consists of stimuli not reported by the client but inferred by the therapist to be related to the client-reported cues. The other type consists of cues that are identified by the therapist based on psychoanalytic theory. The therapist validates these hypothesized cues by observing the client for emotional responses, such as sweating, restlessness, facial flushing, or negative comments, during their presentation. Hypothesized cues that do not elicit signs or reports of discomfort are discarded by the therapist. Cues that elicit strong emotional responses are expanded and repeated. Hypothesized cues are considered to be more potent than client-reported cues because of their presumed greater proximity to the original traumatic episode.

During therapy, the client is instructed to “lose” him- or herself in the scenes described by the therapist, which are embellished with graphic and sometimes surreal imagery. For example, a snake-phobic subject might be asked to imagine being stalked and swallowed by a monster snake or having millions of tiny snakes slithering up his or her nose and into the mouth and ears. The therapist also probes for evidence of unresolved inner conflicts, such as anxiety about sex, through interviews with the client about childhood experiences and relationships. Relevant themes, as suggested by psychoanalytic theory, are incorporated into new scenes for the client to visualize and act out. Scene presentation is also dynamic, with material evolving on the basis of client feedback. For example, a client who was being treated for impotence spontaneously recalled an episode when his first-grade teacher ridiculed him for not being able to write the number six in front of the class. This memory was incorporated into a subsequent implosion session by the therapist.

The supposition underlying implosion therapy is that continuous and inescapable exposure to a stimulus that elicits fear or anxiety in the absence of reinforcement or negative consequences will eventually weaken the anxiety-eliciting power of the stimulus. This principle derives from classical studies of Pavlovian fear conditioning in which a neutral stimulus (conditioned stimulus) that predicts an aversive stimulus (unconditioned stimulus) acquires the ability to elicit a conditioned fear response. This learned fear response can be extinguished by subsequently presenting the conditioned stimulus without the unconditioned stimulus. Subsequent research has shown that extinction involves new learning rather than unlearning and that this new learning is specific to the extinction context. Psychologist Mark E. Bouton, a pioneer of the view that Pavlovian extinction is context dependent, has discussed its implications for exposure-based therapies in general.

Intense/prolonged exposure therapy is rapid and advantageous for clients who want immediate relief. Ethical considerations have been raised about the extreme level of discomfort that clients experience when undergoing implosion or flooding and the possibility that treatment may exacerbate a client’s anxiety. Clients may have to imagine a disturbing scene for more than an hour and rehearse the scenes outside of the therapeutic setting. A 1980 survey of exposure therapists, however, revealed serious negative side effects in only 9 of 3,493 clients (0.26 percent).

History and Evaluation of Implosion

Implosion was developed by the psychologist Thomas G. Stampfl in 1957 and outlined in a series of papers coauthored with psychologist Donald J. Levis from 1966 to 1969. Freudian psychodynamic concepts guide identification of hypothesized anxiety-eliciting stimuli; principles of Pavlovian and instrumental conditioning are invoked to explain acquisition, maintenance, and extinction of anxiety reactions. Stampfl and his colleagues claimed high success rates using this unique integrated approach and reported marked changes in symptomatology within one to fifteen one-hour sessions. Despite such reports, growth in the use of implosion was slow, a situation that psychologist Robert H. Shipley blamed on uncertainty about the technique and concern about its potential for worsening a client’s condition.

A 1973 review by psychologist Kenneth P. Morganstern was highly critical of exposure-therapy research. Case studies did not control for spontaneous remission of symptoms. Laboratory (analogue) studies tended to use mildly phobic subjects with little potential relevance to clinical populations. Moreover, experimental confounds made it impossible to draw any firm conclusions about the relative efficacy of implosion, flooding, and systematic desensitization. While exposure therapy has since gained widespread acceptance, the distinction between implosion and flooding is often blurred, and the terms are frequently used synonymously to refer to prolonged/intense exposure to anxiety-eliciting stimuli.

Exposure Therapy

Exposure therapies have gained recognition as efficient and effective treatments for post-traumatic stress disorders (PTSD). A 1998 study reported that eighteen of twenty-four infants were successfully treated with flooding for post-traumatic feeding disorders and that treatment prognosis correlated with four behavioral measures, including passive refusal to swallow food and not chewing/sucking/moving food placed in the mouth for more than five seconds. Success has also been reported for treating veterans with combat trauma and victims of physical and sexual assault.

Advances in technology have allowed therapists to use
virtual reality or computer-simulated exposure to replace in vivo exposure, which is not always practical, affordable, or safe. A 2007 review reported positive results of virtual reality exposure for combat veterans and a victim of the September 11, 2001, terrorist attacks. Whether this approach will come to replace implosion or imaginal flooding will depend on the outcome of studies using well-controlled, robust randomized trials with clinically identified populations and long-term follow-ups.

Bibliography

Abramowitz, Jonathan S., Brett J. Deacon, and Stephen P. H. Whiteside. Exposure Therapy for Anxiety: Principles and Practice. New York: Guilford, 2011. Print.

Bouton, Mark E. “Context and Ambiguity in the Extinction of Emotional Learning: Implications for Exposure Therapy.” Behaviour Research and Therapy 26.2 (1988): 137–49. Print.

Gregg, Lynsey, and Nicholas Tarrier. “Virtual Reality in Mental Health.” Social Psychiatry & Psychiatric Epidemiology 42.5 (2007): 343–54. Print.

Morganstern, Kenneth P. “Implosive Therapy and Flooding Procedures: A Critical Review.” Psychological Bulletin 79.5 (1973): 318–34. Print.

Neudeck, Peter, and Hans-Ulrich Wittchen, eds. Exposure Therapy: Rethinking the Model—Refining the Method. New York: Springer, 2012. Print.

Shipley, Robert H. “Implosive Therapy: The Technique.” Psychotherapy: Theory, Research, and Practice 16.2 (1979): 140–47. Print.

Sisemore, Timothy A. The Clinician's Guide to Exposure Therapies for Anxiety Spectrum Disorders: Integrating Techniques and Applications from CBT, DBT, and ACT. Oakland: New Harbinger, 2012. Print.

Spiegler, Michael D., and David C. Guevremont. Contemporary Behavior Therapy. 5th ed. Belmont: Wadsworth, 2010. Print.