Exposure Therapy for Anxiety Disorders, OCD, and PTSD PDF

Exposure Therapy for Anxiety Disorders,...

Exposure Therapy for Anxiety Disorders, 8 Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder Thea Gallagher, Psy.D. Elizabeth A. Hembree, Ph.D. Copyright © 2017. American Psychiatric Publishing. All rights reserved. Seth J. Gillihan, Ph.D., LLC Edna B. Foa, Ph.D. In this chapter, we describe a cognitive-behavioral approach that has pro­ duced a vast research literature in the past three decades about the efficacy of variants of exposure therapy for anxiety disorders, obsessive-compulsive 135 Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  136 The Art and Science of Brief Psychotherapies disorder (OCD), and posttraumatic stress disorder (PTSD). We limit our discussion to treatments that have amassed the strongest empirical support. We begin by reviewing what distinguishes cognitive-behavioral therapy (CBT) from other psychotherapies, followed by a brief review of CBT’s ef­ ficacy. We then present a general description of the cognitive-behavioral conceptualization of anxiety disorders, OCD, and PTSD. To this end, we discuss Foa and Kozak’s (1986) emotional processing theory, which ex­ plains the nature of pathological anxiety and the mechanisms of cogni­ tive-behavioral treatments that are involved in ameliorating pathological anxiety. Next, because thorough assessment is a crucial first step in expo­ sure-based interventions, we briefly review some of the evaluation tech­ niques commonly used by cognitive-behavioral therapists to construct a plan that addresses the patient’s core difficulties. Finally, we present de­ tailed descriptions of two exposure therapy programs that have been de­ veloped and extensively studied at the Center for the Treatment and Study of Anxiety (CTSA) at the University of Pennsylvania in Philadel­ phia: exposure and ritual prevention (Ex/RP) treatment, which is aimed at ameliorating OCD symptoms, and prolonged exposure treatment, which is aimed at reducing the severity of chronic PTSD. Each treatment is illustrated by a detailed case example. Throughout the chapter, we present clinical examples of the interventions we describe. In addition, several videos illustrate Dr. Foa’s prolonged exposure treatment of Lisa, a patient with PTSD secondary to rape (see www.appi.org/Dewan). View Video 15 Focus and Rationale (5:18) Copyright © 2017. American Psychiatric Publishing. All rights reserved. General Description of Cognitive-Behavioral Therapy CBT is notable for its empirical approach to developing psychosocial treat­ ments and evaluating their efficacy for a range of psychological problems. This spirit of empiricism has a strong influence on the tone that is set in CBT. Psychoeducation is an important component of CBT treatment pro­ grams. Patients are educated about the cognitive-behavioral approach to understanding and treating their specific problems and about the direct re­ lationship between the therapeutic techniques and the way in which the etiology and maintenance of the disorder are conceptualized. The goal of psychoeducation is twofold. First, patients are more likely to comply with the treatment requirements, such as homework exercises, Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 137 if they understand why they are being asked to do them. Second, our aim as therapists is to help our patients become experts of their own treat­ ment so that they will be able to continue applying what they have learned long after treatment has ended. Empowering patients to become experts in their own treatment likely plays a role in maintaining the long­ term benefits of CBT across a range of disorders (for a review of meta­ analyses, see Butler et al. 2006). View Video 16 Psychoeducation (3:43) The duration of CBT often differs from that of more traditional forms of psychotherapy. Traditional psychodynamic therapy is typically long term, with no set end point. In contrast, at the initiation of CBT for a tar­ get problem, clinicians base their estimate of how many sessions will be required on empirical studies and communicate this estimate to their pa­ tients. Some specific phobias can be treated effectively in a matter of hours; even severe cases of other anxiety disorders can be treated in fewer than 20 sessions. Significant gains are often made quite quickly in CBT because the treatments focus on a well-defined problem and are based on protocols that have been found efficacious for the target problem. Accordingly, cli­ nicians initiate a course of CBT knowing not only how the treatment as a whole will progress but also what each treatment session should entail. For example, as outlined later in the subsection “Ex/RP Treatment Pro­ Copyright © 2017. American Psychiatric Publishing. All rights reserved. gram for OCD,” the treatment program for OCD used at the CTSA typ­ ically consists of 17 sessions. It begins with 2 sessions of psychoeducation and gathering information relevant to the patient such as specific symp­ toms and history of the problem and progresses to 15 sessions of Ex/RP. Each Ex/RP session begins with a review of homework, is followed by in vivo and/or imaginal exposure, and closes with assignment of homework. Prolonged exposure for PTSD generally consists of 8–15 sessions and also begins with 2 sessions of psychoeducation and information gathering be­ fore introducing the exposure components. Another unique aspect of CBT is that little attention is dedicated to figuring out the origins of the patient’s problem. Some time is spent during psychoeducation discussing very generally why people might de­ velop a particular disorder, but this conversation is general to the disorder rather than specific to the patient. Patients in CBT often find the imme­ diate focus on the problems that disturb them at present quite reassuring. Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  138 The Art and Science of Brief Psychotherapies Many patients with anxiety disorders, OCD, or PTSD have had psycho­ dynamic, insight-oriented psychotherapy before seeking CBT treatment. They have learned that trying to figure out why they have a particular problem may help them better understand themselves but des not pro­ vide the relief that they are seeking—that is, a reduction in their symptom severity and an increased ability to function in daily life (see Video 15). As noted previously, cognitive-behavioral treatment programs focus on changing current behaviors, cognitions, and emotions and on how to maintain these changes over time. With this focus, CBT is a very active treatment. Once assessment, treatment planning, and psychoeducation have been accomplished, most sessions of CBT involve participation in active techniques, including exposure, cognitive restructuring, and role­ playing. There is very little unfocused talking and a lot of active doing. This active approach carries over to the time between sessions: an in­ tegral component of CBT is homework. Practicing skills between sessions increases patients’ proficiency with them and also promotes a sense of mastery and confidence. For exposure therapy (described later in this chapter), homework practice increases the likelihood that patients will habituate—that is, will experience a decrease in the anxiety that arises in feared but “safe” situations. It also provides patients with more opportu­ nities to have corrective learning experiences in their feared situations (e.g., “I rode the subway every day this week, and although I felt the symptoms of panic, I did not have a heart attack; in fact, I managed just fine”). In addition, homework exercises provide important opportunities for patients to learn that they can use their newly acquired skills in real­ life settings outside the therapist’s office and can manage their problem on their own (i.e., without the therapist). Finally, homework exercises Copyright © 2017. American Psychiatric Publishing. All rights reserved. provide patients with an opportunity to “be their own therapist,” a role in which they need to feel comfortable by the end of treatment. Given these important aspects of homework, it comes as no surprise that homework compliance is a good predictor of treatment outcome (for a review and meta-analysis, see Mausbach et al. 2010). View Video 17 Homework Review (1:46) View Video 18 Homework Assignment (2:24) Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 139 View Video 19 Graded Homework (2:44) The relationship between cognitive-behavioral therapist and patient is highly collaborative. The therapist has expertise and experience that may help the patient with his or her problems, but successful therapy requires the patient’s full participation in treatment planning and decision making. As in most forms of psychotherapy, a strong therapeutic alliance is critical (Horvath et al. 2011). The therapist begins to establish this alliance at the very first meeting by acknowledging the patient’s courage in entering treatment and supporting his or her desire to learn new ways to cope with problems. By providing education in the early sessions about the patient’s disorder and recommendations for treating it, the therapist communicates his or her understanding of the patient’s unique situation by including spe­ cific examples from the patient’s particular experience and symptoms. As treatment progresses, decision making about the frequency of sessions, tar­ get problems, and homework assignments is collaborative, with the thera­ pist making recommendations but taking into consideration the patient’s preferences and judgment. Another critically important component of CBT is the presentation of a clear and credible treatment rationale. The patient must understand and accept the rationale in order to follow the treatment plan both in and out of session. Incomplete treatment compliance often stems from the pa­ tient’s inadequate understanding or acceptance of the treatment ratio­ nale. To facilitate the patient’s acceptance of the rationale, the therapist Copyright © 2017. American Psychiatric Publishing. All rights reserved. usually describes the conceptual model underlying the treatment as clearly as possible, with the goal of helping the patient see that the treat­ ment makes sense and “fits” with the patient’s experience. The therapist makes clear why particular skills or specific therapy procedures will help the patient’s problems. The use of metaphors or analogies can be helpful in presenting a con­ vincing rationale by illustrating the treatment model. For example, in pro­ longed exposure therapy for PTSD, we sometimes liken the process of confronting and describing painful trauma memories to the process of eating and then digesting poisoned food. The person who eats poisoned food will suffer from such symptoms as nausea, stomachache, and fever; these symptoms will diminish once the food is digested. Prolonged expo­ sure helps the patient process and digest the traumatic memories, thereby bringing about reduction in PTSD symptoms. As therapy progresses, it is often useful to refer to compelling metaphors with the aim of reminding Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  140 The Art and Science of Brief Psychotherapies the patient why he or she might need to do something that is difficult such as confronting painful memories through imaginal exposure. In summary, CBT is empirically based, time limited, problem focused, present centered, active, collaborative, and rationale supported. Efficacy of Cognitive-Behavioral Therapy One of the biggest selling points for CBT among both therapists and pa­ tients is that on the whole, it is quite effective. A very large number of well-conducted studies have confirmed that CBT works for a wide range of disorders, including depression (Ashman et al. 2014; Coffman et al. 2007; Conradi et al. 2008; Lutz et al. 2016; Wiles et al. 2016), OCD (Foa et al. 2015; Simpson et al. 2008), PTSD (Foa et al. 2013; Nacasch et al. 2011), panic disorder (Landon and Barlow 2004; Teng et al. 2008), gen­ eralized anxiety disorder (Rosnick et al. 2016), specific phobia (Choy et al. 2007; Ollendick et al. 2009), social phobia (Clark et al. 2006; Heim­ berg et al. 1998), chronic low back pain (Castro et al. 2012; Glombiewski et al. 2010; Nakao et al. 2012), insomnia (Espie et al. 2012; Morin et al. 2006; Talbot et al. 2014), and many others. In general, the effect sizes for CBT treatments are quite large. For example, a meta-analysis of the effi­ cacy of prolonged exposure for PTSD revealed an effect size of Hedges’ g=1.07, indicating that 86% of patients treated with prolonged exposure fared better than individuals in control conditions (Powers et al. 2010). Similarly large effect sizes have been found for Ex/RP in the treatment of OCD; in a meta-analysis, Rosa-Alcázar et al. (2008) found an effect size of d=1.13 for Ex/RP, which means that the typical patient treated with Ex/RP had a better outcome than 87% of patients in the control treatment. Copyright © 2017. American Psychiatric Publishing. All rights reserved. Cognitive-behavioral therapies translate well into clinical practice out­ side of the relatively controlled environment of the randomized con­ trolled trial (RCT). A meta-analysis revealed a minuscule reduction in efficacy for these therapies when they were administered in community clinics and other non-RCT settings (Stewart and Chambless 2009), un­ derscoring the robustness of CBT interventions. The high efficacy of cognitive-behavioral treatments across anxiety disorders, OCD, and PTSD likely has to do with the commonalities across the disorders and the common therapy techniques. Anxiety disorders, OCD, and PTSD involve pathological fear in that objectively relatively safe stimuli are perceived as being dangerous. For example, a patient with OCD may believe that he has been contaminated by germs because he touched a doorknob in a restaurant and that unless he washes his hands thoroughly, he will cause illness to himself and all the people with whom he comes in direct or indirect contact. Similarly, a patient with PTSD re­ Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 141 lated to being raped 5 years earlier may fear that if she goes out by herself to meet friends in a restaurant after dark, she will be attacked and raped again. The common therapy techniques for both patients consist of ex­ posure (in vivo and/or imaginal) that reduces the patients’ pathological anxiety by providing them with experiences (during confrontation with their feared situations or objects) that disconfirm their unrealistic antici­ pated “disasters.” In the following section we present a model for understanding and treating the disorder-specific manifestations of pathological fear. Emotional Processing Theory Foa and Kozak (1985, 1986) integrated concepts from conditioning and extinction theory, cognitive therapy, and information processing. Their aim was to provide a theoretical framework for understanding the psy­ chopathology of anxiety disorders, OCD, and PTSD, and the mecha­ nisms underlying treatments for these disorders, with special emphasis on exposure therapy. Conceptualization of Anxiety Disorders, OCD, and PTSD According to Foa and Kozak’s (1986) emotional processing theory, fear is represented in memory as a cognitive structure that includes information about the fear stimuli and fear responses and their meaning. For example, a rape survivor with PTSD may have a fear structure that includes repre­ sentations of stimuli such as a dark parking garage at night and represen­ tations of responses such as heart beating fast and muscle tension. Of particular importance is the meaning of the parking garage as “dangerous” Copyright © 2017. American Psychiatric Publishing. All rights reserved. and the meaning of her heart beating fast and muscle tension as “I am afraid.” The representations of the stimuli, responses, and their meaning in the structure are related to each other such that a stimulus and/or re­ sponse in the environment that matches those represented in the fear structure will activate the entire structure. Thus, entering a dimly lighted parking garage will activate the representation of the dark parking garage, the meaning associated with that representation (“danger”), and the be­ havioral and physiological fear responses. Foa and Kozak (1986) also specified the distinguishing features of nor­ mal and pathological fear structures. In the previous example, the rape sur­ vivor’s fear structure is normal if it is restricted to settings that are actually dangerous; in these circumstances, activation of the fear structure will lead to adaptive responses such as walking with a coworker or leaving the office while it is still light. In contrast, the fear structure is pathological if it is ac­ tivated by safe stimuli, such as well-lighted parking garages with many peo­ Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  142 The Art and Science of Brief Psychotherapies ple around. In other words, the pathological fear structure results in overgeneralization when safe situations that are somewhat similar to the dangerous situation are perceived as dangerous. Pathological fear structures also comprise excessive response elements (e.g., hypervigilance). Consider the example of a man who is bitten by a stray dog one day and subsequently develops a fear of all dogs. The sight of a dog walking down the street reminds him of the dog that bit him, and he immediately associates this unfamiliar dog with danger. This association triggers ex­ treme fear in the man. His heart rate and respiration accelerate rapidly, his muscles tense and his body trembles, and he breaks out in a sweat. He im­ mediately runs to the nearest building (avoiding safe, harmless stimuli), not leaving until he is sure that the dog is gone. This man has a hard time believing that this particular dog is friendly and safe and has never bitten anyone, despite repeated reassurance. This scenario is repeated every time the man encounters a dog, even at a distance. The fear of dogs may become so strong and pervasive that he ends up never leaving his home. The avoidance behavior causes so much interference in the man’s life that he finally seeks treatment for his phobia. Conceptualization of Treatment as Modifying Pathological Fear Structures How can the clinician help the patient to decrease pathological fear? Foa and Kozak (1986) proposed that in order for treatment to successfully re­ duce a pathological fear, treatment must 1) activate the fear structure and 2) provide new information that is incompatible with the existing patho­ logical elements so that they can be corrected. Exposure therapy has Copyright © 2017. American Psychiatric Publishing. All rights reserved. proven to be a very effective means of accomplishing both of these ob­ jectives. Exposure procedures activate the fear structure by helping the person confront, in real life or in imagination, his or her feared situation or object. This confrontation provides an opportunity for corrective in­ formation (i.e., new learning) to be integrated into the memory of this sit­ uation, thus lessening the fear associated with it. For example, if the man with the dog phobia repeatedly approaches and pets dogs that wag their tails and do not bite him, then he will learn that most dogs are safe. This modification in the meaning of a dog from a “vicious, dangerous” to a “safe, friendly” animal is the essence of emotional processing, which un­ derlies the reduction in pathological fear. Successful outcomes require tailoring the CBT interventions to the specific target disorder, which requires understanding the underlying fear structure of the disorder. Although each patient with an anxiety disorder may have a somewhat distinctive presentation, specific disorders tend to Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 143 have signature fear structures. Panic disorder, for example, features strong associations between fear responses (e.g., heart beating fast) and meaning of danger. The typical patient with panic disorder experiences physiolog­ ical symptoms such as a pounding heart (response) in specific situations such as driving on an expressway (stimulus) and fears that he is dying of a heart attack (heart pounding means “heart attack”). As such, the fear structure in panic disorder involves strong associations between response and meaning elements. Therefore, effective treatment will involve expos­ ing the patient to the fear response by deliberately bringing on that re­ sponse (e.g., by jogging in place; see the subsection “Interoceptive Exposure”). In the absence of the anticipated harm (e.g., heart attack), the pathological meaning of the fear response is modified. In contrast, patients with specific phobias are generally not afraid of their own fear response; rather, their fear is associated with a relatively safe stimulus such as flying on an airplane. Therefore, treatment of spe­ cific phobia focuses on exposure to the feared, but safe, stimulus in order to modify the pathological association between the stimulus and the meaning of danger. In OCD the patient’s fear structure tends to involve two sets of pow­ erful associations. First, patients associate relatively harmless stimuli with grave danger. A classic OCD presentation involves the belief that touch­ ing something that is relatively safe is in fact dangerous. For example, the patient might fear that touching a public toilet seat with a bare hand means that he or she will contract a sexually transmitted disease. In this case, the patient’s erroneous association in the fear structure is between stimulus and meaning elements. Second, patients experience excessive fear in response to these meaning elements, resulting in avoidance of the Copyright © 2017. American Psychiatric Publishing. All rights reserved. stimulus and/or ritualizing to neutralize the feared consequences associ­ ated with the stimulus. This aspect of the fear structure represents an as­ sociation between meaning elements and responses. The pattern of associations between stimulus, response, and meaning elements of the fear structure in OCD accounts for why effective treatment for this dis­ order requires both exposure to feared stimuli and prevention of the rit­ uals (responses). Effective treatment of anxiety disorders, OCD, and PTSD may require modification of the exposure intervention in order to bring about discon­ firmation of the erroneous elements in the patient’s fear structure. Social phobia is a good example. Usual in vivo exposure is often insufficient to adequately reduce the social fear because the absence of social rejection during in vivo exposure does not disconfirm the patient’s belief that he or she is socially awkward and inadequate. It is common for individuals with social phobia to assume that the absence of overt rejection or criticism by Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  144 The Art and Science of Brief Psychotherapies another person is due to a general social norm that advises restraint in ex­ pressing direct criticism and that the other person actually still feels crit­ ical toward them. Therefore, CBT for social phobia often incorporates video feedback in which patients make explicit predictions about how they will perform during a videotaped social task such as having a one-on­ one conversation with a confederate. In most cases, after watching the video, patients will rate their behavior much more favorably than they had predicted. Thus, modification of the exposure by introducing video feedback facilitates the patient’s ability to incorporate the corrective in­ formation that disconfirms his or her inaccurate association between the stimulus (the other person’s behavior) and meaning (“criticism”), thereby modifying the pathological fear structure. PTSD likewise requires tailoring of the exposure to bring about the necessary changes in the pathological fear structure. As discussed earlier in the example of the rape survivor, patients with PTSD generally have a wide array of dysfunctional associations between stimulus, response, and meaning elements of the fear structure. In addition to the excessive fear responses to trauma-related stimuli and the erroneous associations be­ tween stimulus (parking garage) and meaning (danger) elements and be­ tween response (“I froze”) and meaning (“I am incompetent”) elements, the trauma memory is fragmented in individuals with PTSD. In addition, PTSD sufferers do not differentiate sufficiently between thinking about the trauma and being traumatized again. Repeated revisiting of the trauma memory (imaginal exposure) helps patients organize the trau­ matic memory and gain new perspectives about it, promotes differentia­ tion between thinking about the trauma and being in the trauma again, strengthens discrimination between the traumatic experience and similar Copyright © 2017. American Psychiatric Publishing. All rights reserved. situations (disconfirming the perception that the world is entirely dan­ gerous), and disconfirms patients’ perception that they are unable to cope with stress (being incompetent). Cognitive-Behavioral Assessment Conducting a thorough assessment and establishing an accurate diagnosis and understanding of the patient’s fear structure are an essential first step in treatment planning. Jumping into treatment without first having a very clear sense of the patient’s problems can be frustrating for both patient and therapist and can even be detrimental to treatment outcome. The process of assessment and diagnosis is best accomplished with a clinical interview. Although some clinicians prefer to use an unstructured inter­ view format, structured clinical interviews (e.g., Structured Clinical In­ terview for DSM-5; First et al. 2016) are useful tools. Structured Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 145 interviews that are disorder specific, including the Yale-Brown Obsessive Compulsive Scale (Goodman et al. 1989) and the PTSD Symptom Scale—Interview for DSM-5 (Foa et al. 2015), are commonly used. These focused interviews are very helpful for treatment planning and for track­ ing changes in disorder-specific symptoms over the course of treatment. Self-report measures (e.g., quality of life, difficulties with anger), which can provide useful information in addition to the clinical interview, serve as another way to track progress over time. Harrington and Antony (2009) edited an excellent volume aimed at helping clinicians to select empirically based assessment measures for anxiety disorders. Regardless of the specific tools used, the goals are the same: to identify the primary problem that should be the focus of treatment and to assess other factors that might be relevant to treatment. A diagnosis rarely can be made solely on the basis of the patient’s simple description of a pre­ senting problem. For example, consider a patient who presents with a fear of flying. Knowing only this information does not establish a diagnosis or a treatment plan. The patient might fear being in an airplane crash, sug­ gesting the presence of a specific phobia of flying. The patient might ac­ tually have been on an airplane that made an emergency landing because of engine failure and might have since been experiencing nightmares and flashbacks. This history would be more suggestive of a diagnosis of PTSD. Or the patient might fear having a panic attack while on an airplane and be uncomfortable with the idea of not being able to leave the situation if a panic attack were to occur. This patient most likely would have panic disorder. These distinctions are important because although CBT for anx­ iety disorders, OCD, and PTSD shares common features, the treatment approach for each of these manifestations of fear of flying would be quite Copyright © 2017. American Psychiatric Publishing. All rights reserved. different. Understanding the underlying fear structure guides the selec­ tion of the appropriate treatment program. It is also important to obtain a full description of the characteristics of feared situations. Typically, subtle variables influence the clinical presenta­ tion. For example, a patient with panic disorder who fears flying (among other situations) might be fine on a 1-hour airplane ride. Longer flights, however, could be a problem. Similarly, this patient might feel confident flying with a companion but be very frightened of flying alone. Assessing the overt avoidance practiced by the patient (e.g., not taking long flights and not flying alone) and more subtle avoidance (e.g., having a few drinks before getting on the airplane) is very important for the process of treat­ ment planning. Patients are often amazed when clinicians ask questions about these subtle nuances. This quickly conveys the therapist’s under­ standing of the patient’s disorder and particular symptoms, thereby making the patient feel understood and enhancing the therapeutic alliance. Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  146 The Art and Science of Brief Psychotherapies In the process of assessment, therapists also ask patients about other problems or difficulties they might be experiencing. Comorbidity is com­ mon with many disorders, and although treatment focuses on one disor­ der at a time, clinicians should be aware of the bigger picture. Additional diagnoses may play a role in the maintenance of a primary disorder (e.g., a person with social anxiety who abuses alcohol as a means of alleviating anxiety in social situations) and also can influence the targets and progress of therapy. For example, a person with PTSD and very severe depression accompanied by suicidal ideation may benefit from treatment aimed at amelioration of depression before focusing on the PTSD. Cognitive-behavioral therapists also assess the patient’s general func­ tioning and how it has been affected by the presenting problem. Import­ ant areas to assess include occupational or educational and social functioning. This assessment serves as a useful metric for the severity of the disorder and helps in the process of establishing rapport by looking at the whole person rather than focusing only on symptoms. Furthermore, knowing what the patient hopes to gain from a decrease in symptoms can be helpful later in treatment when he or she is faced with challenging tasks in therapy. For example, when it is extremely difficult for patients with OCD to give up rituals, it can be very motivating to remind them of how their lives will improve when their symptoms decrease and interfere less with their daily functioning (e.g., returning to work, having more time to spend with family). Although behavioral tests are not essential, they can be useful. During clinical interviews and when completing self-report measures, many pa­ tients have difficulty reporting the thoughts, behaviors, and feelings that they experience when they are faced with the feared object or situation. Copyright © 2017. American Psychiatric Publishing. All rights reserved. Other patients avoid the feared object or situation to such an extent that they may not have a clear recollection of how they reacted in the past when confronted with these feared stimuli. In these instances, having pa­ tients undergo a behavioral test in the presence of the assessing clinician can provide valuable information for diagnosis and treatment planning. Behavioral tests often involve having patients engage in a feared behav­ ior, such as asking a patient with a fear of public speaking to give a speech in front of several strangers. Role-playing a social interaction with a pa­ tient can give the assessor a good sense of the patient’s strengths and weaknesses in social skills or assertive behavior. Behavioral tests also can involve assessing how far a patient can progress through a series of actions leading up to a feared behavior. For instance, a person with agoraphobia who no longer goes to work may be asked to progress as far along his or her route to work as possible (e.g., leaving the house, getting in the car, driving through traffic, arriving at the office). The major variable of in­ Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 147 terest in this type of behavioral test is how far along the fear hierarchy the patient can progress; this test also can serve as a good measure of treat­ ment outcome. Being observant of subtleties in behavior can help formulate a clearer case conceptualization. Patients with OCD may arrive at sessions very late because they were held up at home with their rituals, or compulsions may be evident right in the session. For example, a patient whose primary ritual was making things “come out even” was quite distressed in her first exposure session to have only one exposure planned by the therapist for that session. Her compulsion compelled her to insist on doing two of the exposures on her hierarchy. Another patient automatically straightened sheets of paper on the therapist’s desk that were off center; another had the obsessive fear that if she did not complete the treatment program “perfectly,” she would make no progress. Exposure Therapy Interventions In this section, we describe the interventions that cognitive-behavioral therapists frequently use in the treatment of pathological anxiety. As noted in the subsection “Conceptualization of Treatment as Modi­ fying Pathological Fear Structures,” a pathological fear structure can be modified by activating the fear structure and providing information that is incompatible with the pathological elements of the fear structure. Therefore, in exposure treatments for anxiety, patients are encouraged to confront the feared and avoided situations or objects in two main ways in order to activate their fear structure: 1) in vivo exposure, which entails sys­ tematic and gradual confrontation with objects, situations, places, or ac­ Copyright © 2017. American Psychiatric Publishing. All rights reserved. tivities that trigger fear and urges to avoid, and 2) imaginal exposure, which requires the patient to vividly imagine the feared situation and its consequences and to not avoid or escape the resulting anxiety. In Vivo Exposure In vivo exposure refers to real-life confrontation with feared stimuli. The first step in implementing in vivo exposure is to create an exposure hier­ archy. The patient and the therapist work together to generate a list of sit­ uations or activities that the patient either endures with great discomfort or avoids completely. Once the list is generated, patients are asked to as­ sign each item a Subjective Units of Distress Scale (SUDS) rating ranging from 0 to 100 as a means of hierarchically ordering the items. A SUDS level of 0 indicates no distress or anxiety at all (e.g., “sitting on the beach last summer”), whereas a SUDS level of 100 indicates the most distressed a person has ever been (e.g., “when I was attacked and thought I was go­ Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  148 The Art and Science of Brief Psychotherapies ing to die”). A SUDS level of 50 represents a moderate degree of distress. A well-constructed hierarchy includes a range of items spanning from ones that generate moderate anxiety to those that generate the most anx­ iety a patient can imagine (see Table 8–1). In general, it is best to confront the items in a systematic way, beginning with items that have been assigned moderate SUDS ratings and working up through the list to more feared items. This approach allows patients to gain confidence and self-efficacy through early success experiences and is also more palatable to patients than starting exposure exercises with the most anxiety-provoking items on the hierarchy. When possible, it is advantageous to do the first exposure during a treatment session so that the therapist can demonstrate the process of ex­ posure, troubleshoot any obstacles that arise, and lend support for this challenging task. In-session exposures are not limited to the clinician’s of­ fice but rather take place where the anxiety “lives.” For example, if a pa­ tient fears being contaminated in public places, a good early exposure would be to have him touch doorknobs and telephones in the therapist’s clinic. However, treatment will be most effective if it is later held in places such as train stations and supermarkets to promote disconfirmation of the patient’s feared consequences. It is also essential that patients begin to do exposures on their own between sessions from the start of therapy. Some patients discount success experiences that occur during in-session expo­ sures. In the case of social phobia, patients may credit success experiences to the benevolence of the therapist or others involved in the exposure. In other anxiety disorders (e.g., panic disorder) or OCD, clinicians serve as safety cues, and it is important for patients to see that they can confront their feared situations on their own and effectively manage their anxiety. Copyright © 2017. American Psychiatric Publishing. All rights reserved. Duration of exposure to feared situations is an important factor. Exposure should last long enough for patients to realize that their feared consequences do not occur and that anxiety does not last forever but rather habituates. As such, when exposure is conducted during the session, the session should rarely be shorter than an hour. If habituation does not occur during the ses­ sion, the therapist may instruct the patient to continue with the exposure ex­ ercises in the clinic on his or her own and also as part of homework. Exposures that are by nature very short in duration (e.g., asking a stranger a question) should be repeated a number of times in a row. For example, if a patient with social phobia fears greeting people (a behavior that takes just a few seconds), he or she can be instructed to go to the mall and greet the clerk in every store. For additional guidelines on how to conduct effective expo­ sures, readers are referred to Antony and Swinson 2000, p. 199). Flexibility and creativity on the part of the clinician are necessary when setting up exposures. A patient who has a fear of public speaking can Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 149 Table 8–1. Sample hierarchy for specific phobia of dogs Item SUDS rating Look at Dogs Illustrated magazine 30 Watch movie about wild dogs 35 Go to mall and look at dogs through front plate-glass window 50 of pet store Sit in therapist’s office with small dog (on leash) 55 Pet small dog with therapist holding leash 60 Sit on floor of office with dog walking freely around office 65 Refrain from crossing to other side of street when people walk 65 by with dogs on leashes Go to pet store where people walk around with their pets on 75 leashes Go to pet store and ask to pet and hold specific dogs 80 Visit friend who has large, rambunctious dog who likes to 85 jump on people Go to dog park in city where dogs have to be on leashes 90 Go to dog park in city where dogs can run freely 100 Note. SUDS=Subjective Units of Distress Scale. practice an impromptu speech in front of the therapist and office staff. Role-plays can be set up in which patients practice asking people out on dates, having casual conversations, or going for a job interview. Therapists also can accompany patients with social phobia as they return an item of clothing to a store or attend a public event, such as a book reading, where Copyright © 2017. American Psychiatric Publishing. All rights reserved. they can ask questions in front of strangers. In Vivo Exposure for Treatment of Panic Disorder Imaginal exposure is rarely used in the treatment of panic disorder. Situ­ ations feared by patients with panic disorder typically are readily avail­ able. People with panic disorder frequently fear enclosed places, so even sitting in the clinician’s small office with the door closed can be a useful exposure. Other common exposures include riding the elevator, standing in long lines, riding the subway, driving on one-way streets during rush hour, and going to crowded supermarkets. Some patients with panic disorder have difficulty transitioning from in-session exposures in the presence of the “safe” therapist to doing un­ accompanied homework. In such cases, it can be helpful to add interme­ diate steps to the hierarchy. For example, the therapist and patient can go to a large mall together and separate for increasingly longer time periods. Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  150 The Art and Science of Brief Psychotherapies Similarly, patients sometimes do exposure homework accompanied by a friend or family member, which can be helpful early in treatment; such safety nets are gradually phased out as treatment continues. In Vivo Exposure for Treatment of Social Phobia As with panic disorder, in vivo exposure for social phobia is conducted both accompanied by the therapist during sessions and as between-session homework. The use of confederates may be helpful in designing expo­ sures during sessions, which can range from a one-on-one conversation to a presentation in front of a small group. Patients with social phobia often rely on safety behaviors during social interactions—for example, asking a lot of questions or trying to stay very still so they do not look “awkward”— that they believe will prevent their feared consequences from happening (see McManus et al. 2010). Paradoxically, these behaviors often produce the outcome that the pa­ tients are trying to prevent. For example, the patient staying still for a long period of time draws attention to this odd behavior rather than creating the desired outcome of not drawing attention to the patient. Therefore, patients should be encouraged to participate in a social exchange with and without their safety behaviors and to report the degree to which their feared disaster comes true. Most patients with social phobia report, much to their surprise, that they actually perform better when dropping their safety behaviors. As mentioned in the subsection “Conceptualization of Treatment as Modifying Pathological Fear Structures,” the use of video feedback can provide particularly compelling evidence that disconfirms patients’ expectations and modifies their pathological fear structure. For instance, patients can see for themselves that attempts to “stay very still” Copyright © 2017. American Psychiatric Publishing. All rights reserved. in fact make them appear more rather than less awkward. Once patients have learned the concept of dropping safety behaviors, they make plans with the therapist to continue the exposure exercises be­ tween therapy sessions. The specific exposure exercises will be tailored to the domains in which the patient struggles and will progress up the hier­ archy. For example, a patient who fears speaking in class may first make rehearsed statements and then progress up his hierarchy to making com­ ments without first rehearsing. Similarly, a patient who is afraid of speak­ ing with her professors may first ask a question at the end of class and later visit the professor during office hours. In Vivo Exposure for Treatment of OCD In vivo exposure is an essential component of treatment for most patients with OCD. Specific to OCD is the use of exposure combined with pre­ Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2017). The art and science of brief psychotherapies : An illustrated guide. American Psychiatric Publishing. Created from monash on 2024-11-03 00:33:19.  Exposure Therapy for Anxiety Disorders, OCD, and PTSD 151