Exposure Therapy for Anxiety, Second Edition: Principles and Practice - Softcover

Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H.

Softcover

ISBN 10: 1462539521 ISBN 13: 9781462539529

Publisher: Guilford Press, 2019

Synopsis

Now revised and expanded to include cutting-edge acceptance-based techniques and a new focus on inhibitory learning, this is the leading guide to therapeutic exposure, a crucial element of evidence-based psychological treatments for anxiety. The book helps the clinician gain skills and confidence for implementing exposure successfully and tailoring interventions to each client's needs, regardless of diagnosis. The theoretical and empirical bases of exposure are reviewed and specialized assessment and treatment planning techniques are described. User-friendly features include illustrative case examples, sample treatment plans, ideas for exercises targeting specific types of fears, and reproducible handouts and forms that can be downloaded and printed in a convenient 8½" x 11" size.

New to This Edition
*Chapter on acceptance and commitment therapy (ACT) techniques.
*Reflects a shift in the field toward inhibitory learning--helping clients learn to tolerate anxiety and uncertainty to maximize long-term outcomes.
*Chapter on uses of technology, such as computer-based therapy and virtual reality tools.
*Conceptual, empirical, and clinical advances woven throughout.

See also the related client recommendation, The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck.

About this title

About the Author

Jonathan S. Abramowitz, PhD, ABPP, is Professor of Psychology and Neuroscience, Research Professor of Psychiatry, and Director of the Anxiety and Stress Disorders Clinic at the University of North Carolina at Chapel Hill. Dr. Abramowitz conducts research on anxiety disorders and has published over 250 articles, book chapters, and books. He serves as Editor of the Journal of Obsessive–Compulsive and Related Disorders and is on the editorial boards of several other scientific journals. He is past president of the Association for Behavioral and Cognitive Therapies and serves on the scientific and clinical advisory board of the International OCD Foundation. Dr. Abramowitz is a recipient of the Outstanding Contributions to Research Award from the Mayo Clinic Department of Psychiatry and Psychology and the David Shakow Early Career Award for Distinguished Scientific Contributions to Clinical Psychology from Division 12 of the American Psychological Association. His books include Getting Over OCD, Second Edition, and The Stress Less Workbook (for general readers) and Exposure Therapy for Anxiety, Second Edition (for mental health professionals).

Brett J. Deacon, PhD, is a clinical psychologist in private practice in Wollongong, Australia, and Conjoint Associate Professor at the University of New South Wales. He has published approximately 100 research articles and book chapters, served as Editor of The Behavior Therapistand Associate Editor of the Journal of Cognitive Psychotherapy, and is an editorial board member of numerous scientific journals. Dr. Deacon’s research examines the dissemination, optimal delivery, and acceptability of exposure therapy for anxiety. He is the recipient of numerous teaching, research, and student mentorship awards from the University of Wyoming, as well as the Golden Anniversary Alumni Award from Northern Illinois University College of Liberal Arts and Sciences. Dr. Deacon presents workshops around the world on exposure therapy.

Stephen P. H. Whiteside, PhD, ABPP, is Professor of Psychology and Director of the Pediatric Anxiety Disorders Program at the Mayo Clinic in Rochester, Minnesota. His research focuses on improving access to evidence-based care for pediatric anxiety disorders and obsessive–compulsive disorder through the development of effective and efficient treatments facilitated by technology. Dr. Whiteside serves on the editorial board of the Journal of Anxiety Disorders and on the Education and Training Committee of the Minnesota Psychological Association. He has published over 60 scientific articles and is the codeveloper of the Mayo Clinic Anxiety Coach, a smartphone app that aids in the delivery of exposure.

Excerpt. © Reprinted by permission. All rights reserved.

Exposure Therapy for Anxiety

Principles and Practice

By Jonathan S. Abramowitz, Brett J. Deacon, Stephen P.H. Whiteside

The Guilford Press

Copyright © 2019 The Guilford Press
All rights reserved.

ISBN: 978-1-4625-3952-9

Contents

I. The Fundamentals of Exposure Therapy, 1, 
1. Overview and History of Exposure Therapy for Anxiety, 3, 
2. How Well Does Exposure Therapy Work?, 19, 
3. The Nature and Treatment of Clinical Anxiety, 32, 
4. Treatment Planning I: Functional Assessment, 53, 
5. Treatment Planning II: Treatment Engagement and Exposure List Development, 79, 
6. Implementing Exposure Therapy, 106, 
II. Implementing Exposure Therapy for Specific Types of Fears, 133, 
7. Animal-Related Fears, 135, 
8. Environmental Fears, 151, 
9. Social Situations, 165, 
10. Unwanted Intrusive Thoughts, 183, 
11. Bodily Cues and Health Concerns, 215, 
12. Contamination, 237, 
13. Trauma-Focused Fear, 257, 
14. Blood-, Injection-, and Injury-Related Stimuli, 275, 
15. Incompleteness, Asymmetry, and "Not-Just-Right" Feelings, 289, 
III. Special Considerations in the Use of Exposure Techniques, 303, 
16. Exposure Therapy with Complex Cases, 305, 
17. Exposure Therapy with Children, 320, 
18. Involving Significant Others in Treatment, 337, 
19. Combining Exposure Therapy with Medication, 353, 
20. Maintaining Improvement after Treatment, 365, 
21. Using Technology to Implement Exposure Therapy, 375, 
22. Using Acceptance and Commitment Therapy with Exposure, 384, 
23. A Risk-Benefit Analysis of Exposure Therapy, 400, 
References, 415, 
Index, 443, 

CHAPTER 1

Overview and History of Exposure Therapy for Anxiety

The range of human fears is immeasurable. Whereas some people break out in a cold sweat at the thought of riding in an elevator or driving over a bridge, others fear animals (large or small, alive or dead), loss of control, speaking in front of others, or experiencing the sensations of physiological arousal. Still others are afraid of eternal damnation, "immoral" words and "unlucky" numbers, unwanted thoughts about sex or violence, or using public restrooms. There are even those who become immobilized at the sight of a clown, a cemetery, or their own navel.

In order to help people overcome such distressing and disabling anxiety, mental health professionals face the daunting task of selecting an effective treatment strategy from a dizzying array of available options. Some of these strategies are vigorously promoted as "cures" for a wide range of psychological (and medical) problems. Some are touted as short-term or "brief," whereas others ostensibly work over a longer period. Some are designed for individual therapy and others for group settings. Although proponents of most of these interventions claim that they are effective, convincing scientific evidence to support these claims is lacking in the majority of cases.

With so many possibilities, it is inevitable that many interventions that seem plausible are in the end ineffective or even harmful. Indeed, the treatment of anxiety has a long and colorful history dating back well past the fifth century B.C. Dimopoulos, Robinson, and Fountas (2008) recount instructive examples of "treatment" for panic attacks by "trephination," as described by contemporaries of Hippocrates. Essentially, "physicians" of the day — who had little knowledge of human anatomy — bored holes into the sufferer's skull, presumably to coax out from the brain the demons that were thought to cause "insanity." Although we may snicker at this practice now, variations of this approach have endured and are still in use in some parts of the world today. Practitioners used trephination because it "worked," by which we mean that it was occasionally followed by the cessation of panic attacks. However, one can achieve this same spontaneous remission of symptoms in about a third of panic sufferers without any intervention at all (Swobota, Amering, Windhaber, & Katschnig, 2001) — which has the added benefit of saving patients a hole in their head! Given the complexity and subtly of clinical fear and anxiety, it is no surprise that so many different treatments have been tried, and that so many have persisted despite a lack of evidence supporting their effectiveness.

This somewhat unruly state of the field demands not only that treatments prove their muster in carefully conducted research trials, but also that we gain knowledge about the process by which they produce their outcomes. Accomplishing this task requires demarcating potentially useful and valid principles of therapeutic change. Several candidates common to most, if not all, psychological treatments for clinical fear and anxiety include the therapeutic relationship, the milieu in which the patient is treated, and the patient's (and therapist's) expectations of improvement (Frank, 1989). Yet another common principle of change — that with which we concern ourselves in this book — derives from the observation that alterations in thoughts, feelings, and behavior appear to occur following a strong emotional response to material presented within the context of therapy. Psychoanalytically oriented therapists, for example, confront patients with information about so-called unconscious conflicts and unacceptable wishes through free association and the interpretation of dreams (Freud, 1949/1989). Likewise, Gestalt therapists use imagery, role enactment, and group interactions to coax the patient into confronting information that has been avoided (Perls, 1969). In this volume, we focus on a cognitive-behavioral oriented approach — namely, exposure therapy — that involves a more direct and systematic sort of encounter with feared stimuli.

Exposure therapy refers to the process of helping a patient approach and engage with anxiety-provoking stimuli that objectively pose no more than everyday risk without the use of anxiety-reduction "coping" skills. Anxiety-evoking stimuli can be alive (e.g., snakes, clowns), inanimate (e.g., balloons, toilets), situational (e.g., funeral homes, bridges), cognitive (e.g., ideas of committing heinous acts, memories of a traumatic event), or physiological (e.g., racing heart, dizziness). Engagement with the objectively safe (or "low-risk") fear-eliciting stimulus typically precipitates a response ranging from mild apprehension to intense panic, the basis for which is the patient's exaggerated expectation of danger. It is thought that learning of one form or another takes place when a person repeatedly confronts a feared stimulus (e.g., a dog) in the absence of the expected feared consequence (e.g., the dog does not bite). Although debate continues regarding what exactly happens in the mind and brain during therapeutic exposure, a new behavioral repertoire seems to be cultivated and strengthened each time an individual effectively handles a previously feared situation without relying on safety cues or strategies for reducing the anxiety. Before we discuss the implementation of exposure therapy, however, let us explore the concept of anxiety and the history of exposure therapy.

ANXIETY: NORMAL AND ABNORMAL

Although a complete definition of anxiety is outside the scope of the present volume (entire books have been written on the subject; e.g., Barlow, 2002), anxiety is, broadly speaking, an organism's response to the perception of threat. This implies that actual threat need not be present in order to experience anxiety. The reader will surely recall instances of his or her own intense fear and apprehension that turned out to be baseless. Similarly, it is possible to actually be in danger, yet not become anxious because the threat is not perceived. We have probably all had experiences in which it was only later that we realized how potentially dangerous a particular situation was. Either way, everyone is familiar with the psychological experience of feeling threatened, whether we label it as anxiety, apprehension, fear, panic, worry, stress, or something else. Moreover, we are all familiar with the physiological arousal that accompanies this emotion.

Normal Anxiety

At a neurophysiological level, the anxiety (fear) response appears to be implemented in various brain structures, including the visual thalamus, visual cortex, and the amygdala (we note, however, that precisely how anxiety manifests in the brain is not completely understood). The brain stimulates the release of adrenaline from the adrenal glands, which activates the sympathetic nervous system and initiates the body's "fight-or-flight response." This response is the body's built-in way of priming the organism for reacting to a perceived threat by attacking (fighting for one's life) or running (fleeing to safety).

The fight-or-flight response occurs simultaneously on three levels. First, at a physiological level, the body prepares for physical exertion by enriching the blood with oxygen, which is converted to energy for use by the body's muscles. This change involves abrupt and noticeable increases in the intensity of the heart rate and depth of breathing. In addition, feelings of nausea are also common since digestion is not typically involved in fleeing or fighting for ones' life, and thus resources are diverted away from the digestive system to other areas of the body. Second, at a cognitive level, there is an automatic shift in attention toward the perceived threat (and ways to seek safety from it), so that it might seem difficult to concentrate on any extraneous matters. This focus serves as a constant reminder of the potential for harm and allows for early detection of threats and means of escaping them. Finally, at a behavioral level, the individual is compelled to take actions that are geared toward fighting, avoiding, or escaping the feared stimulus, such as by running away, thereby increasing the odds of survival.

The fight-or-flight response is critical to the survival of humankind (and most other species in the animal kingdom). Just imagine what would happen if you were crossing a busy street in a large city — cars bearing down on you — and you felt absolutely no stress or anxiety. Most of us can recall a time when spontaneous actions motivated by the fight-or-flight response probably saved our life, or at least helped us avoid serious injury. As more than one author has put it, "in times of danger, anxiety can be a person's best friend" (e.g., Rosqvist, 2005, p. 1).

Abnormal Anxiety

Unfortunately, sometimes the fight-or-flight response is the kind of "friend" that relieves us of the need for enemies. This happens when anxiety occurs in the absence of danger or when it is out of proportion relative to the actual threat. In these situations, such as having to speak in front of others, having your body prepared to run for safety probably won't keep you safe, but may make you sweaty or cause you to stutter due to increased muscle tension. Such excessive anxiety — stemming from the misperception of a safe situation as dangerous — appears to form the basis of most clinical anxiety problems (i.e., anxiety disorders; Barlow, 2002; Beck, Emery, & Greenberg, 1985). In such instances, the fight-or-flight response is triggered unnecessarily and may even worsen the situation by leading to more negative thoughts, such as "Everyone will notice my anxiety and think I'm incompetent." This sort of emotional reasoning bias serves to increase the perception of threat (Arntz, Rauner, & van den Hout, 1995) and maintain physiological responding, thereby creating a vicious cycle in which the perception of threat leads to anxious responding, which leads to more threat perception, and so on.

Another unfortunate consequence of habitually misperceiving objectively safe stimuli as dangerous is the development of strategies for avoiding these fear cues. These strategies may include "passive avoidance," such as a student with social anxiety refraining from raising her hand in class because she fears that her peers will laugh at her if she gives an incorrect answer. Other feared stimuli, including germs and traumatic memories, cannot be completely avoided. In such instances, the anxious individual will often develop strategies that serve as an "escape" from the feelings of anxiety that accompany exposure to these triggers (Barlow, 2002). Such "active avoidance" strategies include compulsive washing and cleaning to prevent illness after handling money and remaining close to a "safe person" for protection in a currently safe circumstance reminiscent of a previous traumatic event. By minimizing exposure to stimuli associated with clinical (unrealistic) anxiety, regardless of the form of avoidance, the person never has the opportunity to learn that such stimuli really are objectively safe (i.e., low risk; Clark, 1999). That is, the person cannot correct his or her misperception of the fear trigger, and he or she goes on believing (erroneously) that it is dangerous.

Not only do efforts to escape and avoid perceived threats prevent clinical anxiety from self-correcting over time, they may actually worsen the very problems they are intended to alleviate. Accordingly, much of the devastating effects of clinical anxiety result from the extreme lengths to which people go in trying to keep themselves safe by avoiding and escaping from (largely nonthreatening) fear cues. For example, we know of one man with a fear of AIDS who couldn't leave his bedroom for 5 years after someone with HIV had visited his home. A woman drove 45 miles out of her way to work each day to avoid having to cross a certain bridge. Another woman relocated from the West Coast of the United States to Rochester, Minnesota, just so she could be near the Mayo Clinic in case she suffered the extremely unlikely medical emergency she was anticipating. Although medically healthy, this individual restricted herself to traveling no more than a few miles from the clinic, and at all times carried with her various medical devices, self-test kits, and medicines. More detailed information regarding the development and maintenance of abnormal anxiety is presented in Chapter 3.

DSM-5 Diagnoses Characterized by Anxiety

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) assumes a categorical stance and defines psychiatric disorders on the basis of observable signs and "symptoms." These diagnoses are intended to inform the clinician about the likely course of the problem and what treatments would be appropriate. The fifth edition of the DSM includes a number of conditions characterized by anxiety, as listed in Table 1.1. Although treatment manuals have been developed and evaluated for most of these conditions, the DSM diagnostic approach has a number of limitations that encumber its use for treatment planning. To begin with, the categorical delineation of the DSM system cannot fully capture the breadth and depth of human emotional experience. As far as anxiety-related disorders are concerned, the various DSM diagnostic labels merely reflect topographical (and largely superficial) differences among problems that have essentially the same fundamental psychological mechanism (e.g., Abramowitz & Deacon, 2005). That is, the disorders listed in Table 1.1 can all be conceptualized using the framework outlined above in which relatively safe stimuli are misperceived as dangerous, leading to unnecessary anxiety and what amount to unwarranted avoidance or escape behaviors that perpetuate the problem. Each diagnostic entity, however, has a somewhat unique set of fear cues, ways in which these cues are misperceived, and maladaptive coping responses. Table 1.2 shows these phenomena across the anxiety-related disorders in DSM-5.

The DSM also makes an arbitrary distinction regarding the level of severity that constitutes an anxiety (or anxiety-related) disorder (Widiger & Miller, 2008). In this system anxiety disorders are treated like medical diseases, such as cancer, which you either have or (preferably) do not. However, as can be seen from the discussion of normal and abnormal anxiety, fears and worries are more like blood pressure; everyone has it, but having too high (as well as too low) levels can be problematic. A categorically based diagnostic system does not provide treatment recommendations for individuals whose symptoms do not fall into a specific category or who have subthreshold symptoms.

Accordingly, we espouse an alternative approach to diagnosis in which a mental disorder is viewed as a "dyscontrolled organismic impairment in psychological functioning" that falls along a continuum of severity (Widiger & Miller, 2008). In other words, some psychological mechanism within the individual, such as how he or she is responding to certain fear cues, is not functioning optimally. This operationalization is compatible with the view that effective psychological therapies don't treat "disorders" as much as they change (or reverse) maladaptive psychological mechanisms that characterize these problems (Abramowitz & Blakey, in press-a). As the reader will find, we approach exposure therapy as targeting key processes underlying the persistence of clinical anxiety rather than a treatment for a specific "disorder" (see Chapter 3).

Although exposure therapy must be modified depending on the particular fear trigger (see the chapters in Part II), this is not the same as using a different treatment or treatment manual for each different anxiety-related disorder. As we argue in this book, the same basic principles of exposure therapy can be applied to any patient's anxiety problem, regardless of which DSM diagnostic category best describes it. This transdiagnostic approach frees the therapist from the arduous task of learning to use a bookshelf full of treatment manuals for all the anxiety-related DSM disorders, and instead emphasizes understanding and treating the common psychological mechanisms that underlie the maintenance of anxiety-related problems in general.

Etiology versus Maintenance

The reader will also note that exposure therapy and its conceptual framework for understanding clinical anxiety are focused on the psychological processes that maintain the problem, rather than those that might lead to its development or etiology. One reason for this is that whereas the maintenance factors in anxiety are well understood based on careful clinical observation and empirical research (e.g., Clark, 1999), we understand much less about the factors that dictate why some people are more vulnerable to developing such problems than are others. Mineka and Zinbarg (2006) have proposed a comprehensive etiological model of anxiety disorders that incorporates early learning experiences, the occurrence and context of stressful events, and genetic or temperamental vulnerability. In other words, the tendency to respond in excessively fearful ways — on physiological, emotional, and behavioral levels — appears to be mediated by both environmental and biological variables.

(Continues...)

Excerpted from Exposure Therapy for Anxiety by Jonathan S. Abramowitz, Brett J. Deacon, Stephen P.H. Whiteside. Copyright © 2019 The Guilford Press. Excerpted by permission of The Guilford Press.
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Edition details

• Publisher: Guilford Press
• Publication date: 2019
• Language: English
• ISBN 10: 1462539521
• ISBN 13: 9781462539529
• Binding: Paperback
• Edition number: 2
• Number of pages: 459