Staff Voices - Developing an Effective In Vivo Hierarchy

Staff Voices - Developing an Effective In Vivo Hierarchy

Developing the in vivo hierarchy with a client is an important step in implementing effective Prolonged Exposure (PE) treatment, but it is often given less attention by novice therapists because the more anxiety provoking and dramatic aspects of the upcoming imaginal exposure draw the focus of both the therapist and the client. However, the in vivo exposures address important avoidances in the client’s real life that may not be addressed in imaginal exposure, and are instrumental in making it possible for the client to participate fully in his or her own life.

In addition, the initial in vivo exposure will be the client’s first experience with therapeutic exposure, and it is important to select an activity or situation that will be challenging enough to elicit anxiety, but not so challenging that the client feels compelled to discontinue the activity too early or avoid the activity altogether. A successful experience with the first in vivo exposure target will boost the client’s confidence and instill hope as they prepare to take on more challenging tasks including the imaginal exposure. This is important because progress in imaginal exposure can be slower and more distressing initially for some clients. The successfully completed in vivo exposure can provide an important counterpoint if the client is feeling temporarily more distressed in the initial imaginal exposure sessions.

Here are some tips for constructing an in vivo hierarchy that will help your client get the most benefit from in vivo exposure.

Collaborate with the client

It is important to thoroughly assess the types of situations that the client avoids and to understand, from the client’s point of view, why these situations are avoided. Some clients feel frustrated because the link between the traumatic event and situations they currently avoid is not apparent to them (e.g., can’t go to Wal Mart) so providing education about how trauma cues generalize can be very helpful.

Adopt a scientific approach and invite the client to contribute the needed information to construct in vivo targets that match core fears and test specific beliefs related to the traumatic experience. Solicit the client’s input at every step. It is important that the client feels in control over the selection of in vivo targets and the pacing of assignments, and it is actually the client who has the knowledge and experience to map his or her unique pattern of avoidance.

Systematically assess target areas

Target areas can include people, places, objects, sensations or activities. Though it is tempting to begin by simply listing obvious targets that have already been mentioned in earlier sessions, don’t forget to inquire about other types of avoidance. These include situations that are avoided because they seem dangerous, as well as those that trigger memories of the trauma and emotional distress. Triggers can include seemingly innocuous objects or sensations that were present in the environment at the time of the trauma such as clothing worn, background images, and smells or sounds that accompanied the traumatic event.

Flesh out the feared outcomes

For each item what is the feared outcome? Is it physical danger, distressing emotions, loss of control, or some other negative result? How likely is the feared outcome in the client’s view? How catastrophic? The more specifically you delineate feared outcomes prior to attempting exposures, the better able the client will be to recognize the absence of feared outcomes when the exposure is completed.

Identify Safety Behaviors

As you are generating potential targets ask whether there are circumstances under which the client is able to confront an avoided situation more easily. This will help you identify safety behaviors. Safety behaviors can be almost any means of varying conditions so that one feels less distressed. Sometimes the safety behavior is a hidden weapon, a trusted person who is present, or a particular way of being in the situation that feels safer or more controllable, for example, sitting near an exit or remaining on the edge of a crowd. Safety behaviors can also include behaviors that would not be considered unusual among the client’s peers, but have special significance because of the client’s distorted beliefs. These include things like carrying a water bottle to ward off dry mouth (a symptom of anxiety), carrying anti-anxiety medication “just in case”, and checking doors at night to make sure they are locked. They can even include special prayers, rituals or “superstitious” behaviors that ward off anxiety. In vivo exercises should be completed without the use of safety behaviors, so the client can experience the anxiety fully and learn that the safety behavior is not necessary.

Target and test core fears

Keep the client’s core fears in mind, and design tasks to target those particular outcomes, for example, a client that is fearful of a surprise attack while sitting in a crowded restaurant may fail to become anxious if the restaurant is filled with senior citizens, moms and children, or military personnel. The assignment needs to match the characteristics of the core fear, which might include strangers, men, and unfamiliar people and places. On the other hand, if the fear is related to being unable to protect other, more vulnerable individuals during an attack, the early bird special or the Saturday Chik Fil-a crowd may be an ideal in vivo target.

Be specific rather than general

As demonstrated in the above example, it is better to be specific rather than general in describing the in vivo targets. Items like “driving,” “loud noises,” or “walking at night” leave much room for interpretation, and make it difficult to predict the level of anxiety the client is likely to feel. Clients may not know how to implement the item once they are home resulting in an exposure exercise that is too easy or too difficult to be beneficial. Does he drive around post or on the highway? Does he choose times when traffic is high or when there are few other drivers on the road? The answers will depend on the core fears that trigger the avoidance in each situation. “Driving on the highway during rush hour,” “listening to helicopters take off and land,” and “walking on Main Street after dusk,” are more specific, more predictable, and more easily targeted and tested with in vivo exposure. By specifically outlining the details of the task ahead of time you make it more likely that the client will be able to confront anxiety productively and have access to the corrective information that will reduce distress in the long run.

Target multiple contexts

Once you have specified the details that need to be present to activate the client’s core fear(s), consider assigning the task in different contexts. A successful experience in one context can be attributed to luck or special circumstances, but it is harder to discount success that takes place in multiple contexts, where the only variables held constant are the presence of the client and their fear. Facing crowds for example, can be experienced at the ticket booth for a popular movie, the DMV, Walmart on a Sunday, a high school sporting event, and a popular nightclub. The client can be with someone or alone, tired or well rested, in uniform or civilian clothes, and the setting can be familiar or unfamiliar. Conducting exposure tasks across multiple contexts helps to generalize and strengthen new learning.

Vary the degree of distress

An effective hierarchy must include targets that elicit a wide range of distress as measured by SUDs ratings. Often, however, the client is able to identify a few high distress situations that he or she avoids, but is unable to identify situations eliciting moderate or low levels of anxiety. You can essentially break down each high distress item into several items with varying degrees of distress by manipulating how the client confronts the target. There are several dimensions that can be manipulated in this way including the intensity or “realness” of the stimulus, the distance from which the stimulus is confronted, and the duration of the confrontation.

For example, clients with PTSD may become extremely distressed when they are in the presence of someone who appears similar to an assailant or aggressor involved in the trauma. The intensity of the experience can be reduced by viewing photos or videos, listening to sound recordings, watching people from a distance and engaging in short, structured meetings to gradually increase the level of distress while building competence. Only after the client has successfully habituated to these experiences and begun to challenge the distorted beliefs that maintain the anxiety, would he or she be asked to interact with real people in a less structured and more anxiety-provoking situation.

Another way to break down a high distress situation is to use safety behaviors strategically in the beginning and gradually withdraw or dilute the safety behavior as the client progresses. For example, a client who only goes out when accompanied by a spouse can begin to withdraw the spouse’s participation by allowing the spouse to wait in the car or asking the spouse to drop the client off and return at a designated time. Cell phone contact from a distance can provide an intermediate step as well. Eventually the client will be assigned to go alone, with no assistance from the spouse, but the gradual approach will have made the likelihood of success much greater.

Define acceptable risks

One of the biggest concerns voiced in workshops and consultation sessions is the question of risk. Though most in vivo exposure targets involve every day activities that carry a low risk of negative outcomes, all behaviors carry some amount of risk. Deciding what is an acceptable level of risk should take into account the behaviors of the general population as well as those of the client’s specific peer group.

“Do most people engage in the behavior on a regular basis without negative outcomes?”

For example, is it safe to ask a female client to walk down the street alone at night?  For most people the answer would depend on the street and time of night. In some areas walking alone at night would not be considered unusual or risky behavior for women. In other areas this behavior would be highly unusual and considered dangerous and unacceptable.

“Do most members of the client’s peer group engage in the behavior on a regular basis without negative outcomes? “

“Alternatively, is the level of risk deemed acceptable among the client’s peers?”

Consider another example. Is it safe to ask a client to resume hand-to-hand combat training with his or her unit? This assignment would be considered risky relative to the behavior of the general public, but is typical and expected behavior for military service members. Though the risk of injury is higher than for some other activities, if the client’s goals include returning to duty and continuing military service, the level of risk may be acceptable to the client.

Even when risk is relatively low, negative outcomes can occur. It is important to acknowledge these risks to the client and discuss the relative risks that we each face on a day-to-day basis as we drive our cars, walk down streets, and live in our respective environments. It is ultimately the client’s responsibility to weigh the possible risks against the potential gains.

Target meaningful change

Once you have identified a number of targets for possible inclusion, give priority to those items that will make a meaningful impact on the client’s life. Will reducing anxiety associated with the target improve functioning at home or at work? Will it improve mobility or make family life more satisfying? These added incentives will help the client persevere when the task is difficult, and will provide immediate reinforcement with each success. Items that seem arbitrary or less relevant to the client’s goals will engender less enthusiasm and cooperation, and they might not be necessary if the client is unlikely to face the target in real life.

After addressing higher priority items, you may still include items that have a smaller or more limited impact. For example, it was important for a sexual assault survivor to habituate to the smell of alcohol even though she didn’t drink and didn’t associate with people who consumed alcohol. However, on the few occasions she was confronted with the smell she became extremely nauseous and anxious. Since she couldn’t control whether or not she might be surprised by the smell in the future it made sense to habituate to the smell as part of her treatment.

Be flexible

Finally, learn to view the in vivo hierarchy as a process guide and not an iron clad contract. As treatment progresses new targets may become more salient, SUDs ratings may need to be adjusted, and new targets prioritized. Don’t be afraid to revise the hierarchy if it is not serving the client’s needs. Also remember that a hierarchy does not need to be perfect or reflect all of the above points to be helpful. Exposure exercises may and will go wrong but the client (and you!) will survive. Often an exposure exercise that the client views as a “total failure” will contain successful elements and provide an opportunity for you to reinforce effort, commitment to treatment and flexibility when things don’t go as planned. Just as we encourage our clients to approach rather than avoid, so can we face the in vivo hierarchy and gain competence and mastery.

Do you have questions about a hierarchy you are developing?

Do you have helpful tips or suggestions for your colleagues across the globe? Make a comment! Join a consultation call! We love to talk about this stuff!

Have you struggled to salvage an exposure exercise that didn’t go as planned?

Look for future blog entry about debriefing the client (and yourself) and extracting the nuggets of gold from the rubble.