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What is Flooding Treatment for Anxiety?

Heather Lyons, Ph.D.

Back in the early 2000s, NBC introduced a competition/reality show called Fear Factor. The premise of the show was to challenge contestants to confront and overcome their worst fears and phobias. For example, someone who was claustrophobic or terrified of small spaces might be buried alive in a coffin. Contestants who were afraid of snakes, rats, or spiders would be locked in a glass box and forced to let the things crawl all over them.

The winner of the competition was the one who lasted the longest in their particular situation. The show was canceled in 2006, leaving the viewing audience wondering if contestants conquered their fears or if the show’s challenges exacerbated them.

Facing your fears

Despite the purely commercial, rather than therapeutic, intent of the show, forcing people to face their fears in order to overcome them is actually a highly effective treatment for phobias and fears. This psychotherapy technique is called exposure, and it has proven to be an effective treatment for individuals who have posttraumatic stress disorder (PTSD), panic disorder, obsessive-compulsive disorder (OCD), and other anxiety disorders. Exposure can help people overcome their fears and phobias stemming from these conditions.

Flooding is a specific technique of exposure therapy, which is a type of cognitive-behavioral therapy (CBT). The overall goal of exposure therapy, according to the American Psychiatric Association, is to “reduce a patient’s fear and decrease avoidance” of “a patient to their “feared objects, activities, or situations in a safe environment.”

There are many different approaches to exposure therapy, including systematic desensitization, which incorporates relaxation exercises as well as gradual exposure to the feared item or situation, and graded exposure, which tackles the person’s milder fears first before working on the more difficult tasks.

Rather than using a gradual approach to conquer a patient’s fears, the flooding technique of exposure therapy works on the most difficult or intense fear or phobia first, and therapy continues until it’s overcome. Patients aren’t allowed to remove themselves from the situation. The advantage of this approach is that it’s quick and usually effective.

Types of exposure therapy

Flooding, like the other exposure therapies, works on the basic principle of creating an environment or situation that helps people confront their fear in order to overcome it. However, therapists have a few options for delivering that fear or phobia to the patient based on the person’s specific situation and practical considerations like logistics.

For example, building a human-sized glass case or acquiring hundreds of rats (Fear Factor style) isn’t feasible for the typical exposure therapist. However, showing a person one rat in a small cage in an office setting with the guidance of a therapist can be an effective and practical method in flooding therapy. This form of treatment, which involves exposing a person to a real-life object or scenario, is called in vivo exposure.

In other situations, the most effective or practical method of exposing people to something they fear is to ask them to picture the thing or situation in their mind mentally. This strategy is known as imaginal exposure. Using the rat example, an imaginal exposure session would entail a clinician asking a person to imagine themselves surrounded by rats rather than exposing them to an actual live rodent.

Flooding usually employs either in vivo exposure or imaginal exposure methods of exposure therapy. A third option, virtual reality exposure, combines elements of in vivo and imaginal exposure to create a virtual simulation of a situation or object that looks real but actually is not.

The origins of flooding

The psychologist Thomas Stampfl first introduced the concept of flooding in 1967. Still, its origins are rooted in the exposure therapies and classical conditioning techniques developed by Ivan Pavlov and others in the early 1900s. Pavlov famously conditioned his dog to associate a ringing bell with food. Later, he broke this association using the same conditioning techniques.

Classical conditioning, flooding, and others operate on the premise that through continual exposure to a specific fear, a person will eventually see the situation or item as less fear-producing. This approach, in turn, replaces the fear response with a non-fear response. For example, in 1973, psychiatrist Joseph Wolpe helped a girl overcome her fear of cars by driving her around for several hours until she eventually realized that she was safe. After the experiment, she no longer associated cars with danger.

Stampfl’s technique, now known as flooding, “bombarded” patients with six to nine continuous hours of exposure until they lost their fear of those situations. His theory was that fear had a time limit, and a person would eventually have to relax, calm down, and mentally process the fact that the object of their anxiety, fear, or phobia won’t hurt them.

Flooding for PTSD patients

Flooding and other methods of exposure therapy have proven particularly helpful for people with posttraumatic stress disorder. These methods are endorsed by the United States Department of Veterans Affairs (VA) and the American Psychiatric Association (APA) as a treatment for PTSD symptoms.

PTSD is a mental health condition that occurs following a traumatic event or prolonged traumatic experience. Many people associate PTSD with veterans returning from combat, but anyone involved in a traumatic event like physical assault, a childhood physical or sexual abuse, a violent crime, or an accident can be diagnosed with posttraumatic stress disorder.

PTSD symptoms include unwanted thoughts, feelings of hopelessness, depression, hypervigilance, and disturbing nightmares. Likewise, individuals with PTSD will develop patterns of avoidance to escape thoughts, feelings, items, and behaviors that remind them of the traumatic event. For instance, soldiers may avoid news coverage of wars or conflicts, or a survivor of a sexual assault may go out of their way to avoid the location of the crime.

Physically avoiding reminders of a traumatic event is referred to as behavioral avoidance. Emotional avoidance occurs when a person psychologically redirects their thoughts away from a trauma memory by focusing on something else. The problem with avoidance is that the person never learns to overcome their fear or phobia, so the traumatic memory never goes away, and long-term avoidance negatively impacts a person’s quality of life.

Flooding therapy for patients with PTSD usually uses imaginal exposure methods rather than in vivo. The violent and graphic nature of most patients’ traumatic experiences is often too dangerous or impractical to safely or feasibly replicate. With imaginal exposure, though, a licensed mental health clinician can guide a person through imagining and replaying their fears or phobias that stem from a traumatic event. Eventually, the person will learn to better manage their reactions to trauma memories, triggers, and flashbacks.

Flooding for anxiety disorder or panic disorder

Depending on a person’s particular type of anxiety disorder, different flooding techniques can often help them to overcome their fear or phobia. For example, a person suffering from a fear of social situations (social anxiety) might be treated by attending a party or reception, perhaps with their mental health clinician by their side. Social anxiety is characterized by a fear of being ridiculed or judged by other people in a social situation. By diving in and exposing themselves to other people within a social situation for a period of time, the person can learn that their fears are unfounded, and no one is judging or ridiculing them.

Flooding treatment for a person who has a panic disorder would be similarly executed. The therapist would determine which situations induce the greatest sense of impending doom, danger, or death for the patient and use imaginal exposure or in vivo exposure methods to help the patient picture or physically face those fears in order to overcome them.

Flooding for OCD patients

A person with obsessive-compulsive disorder performs ritualistic or repetitive behaviors that usually stem from an underlying fear. OCD patients may fear germs or dirt, losing things they may later need, disorder, imperfection, or a combination, and develop behaviors as a form of avoidance of these fears.

Flooding works for those with OCD because it helps them realize their fears are unfounded, ending their accompanying repetitive or ritualistic behaviors. Another exposure therapy, exposure and response prevention (ERP), can also be an effective treatment for OCD. With ERP, a mental health clinician will provoke the person’s obsession and ask them not to engage their usual ritualistic compulsion response, thus weakening the link between obsession and compulsion.

Where to find a flooding therapist

Flooding is not a technique to be used with every patient suffering from PTSD, OCD, or a panic or anxiety disorder. Also, some mental health professionals do not employ flooding or other exposure techniques in their therapy practices.

To find a therapist who practices flooding and exposure therapy, check out With Therapy’s unique matchmaking tool. In addition to particular areas of expertise, With Therapy can help you find a therapist who matches your preferred gender, race, sexual orientation, education, background, or other desired criteria. Once you identify your ideal therapist, you can schedule an appointment directly through the With Therapy site.

Facing your fears can be a scary proposition, but with a great therapist and proven techniques, you can improve your quality of life and overcome the things or situations that scare you the most

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