Exposure In Vivo with and Without Presence of a Therapist: Does It Matter?

Chapter

Abstract

Cognitive-behavioral therapies (CBT) are well established as first line treatments for anxiety disorders. Particularly exposure is often discussed as a crucial intervention for promoting therapeutic change. A large number of studies suggests that exposure alone or in combination with other interventions is highly effective in reducing anxiety and anxiety-related avoidance across different anxiety disorders However, the questions of why they are so effective and by which mechanisms of action CBT works remain unclear. One issue that is rarely discussed in this context is the role of the therapist during exposure exercises. This chapter reviews evidence from studies providing data on the relevance of therapist presence during exposure, focussing on anxiety disorders and panic/agoraphobia in particular. In addition, findings from a large multicenter randomized clinical control study on the role of therapist-assisted exposure in vivo for patients with panic disorder and agoraphobia are presented, suggesting that therapists’ presence during in-vivo exposure yields faster results; however, if carefully prepared, self-directed exposure exercises might gain similar effects in the long run.

Keywords

Transportation Smit Agoraphobia Phobic Disorder 

References

  1. Al-Kubaisy, T., Marks, I. M., Logsdail, S., Marks, M. P., Lovell, K., Sundry, M., et al. (1992). Role of exposure homework in phobia reduction: a controlled study. Behavior Therapy, 23, 599–621.CrossRefGoogle Scholar
  2. Bandelow, B. (1997). Panik und Agoraphobie-Skala (PAS). Handanweisung. Göttingen: Hogrefe.Google Scholar
  3. Boschen, M. J., Neumann, D. L., & Waters, A. M. (2009). Relapse of successfully treated anxiety and fear: Theoretical issues and recommendations for clinical practice. Australian and New Zealand Journal of Psychiatry, 43, 89–100.PubMedCrossRefGoogle Scholar
  4. Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behaviour Research and Therapy, 23, 35–44.PubMedCrossRefGoogle Scholar
  5. Edelman, R. E., & Chambless, D. L. (1993). Compliance during sessions and homework in exposure-based treatment of agoraphobia. Behaviour Research and Therapy, 31, 767–773.PubMedCrossRefGoogle Scholar
  6. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.PubMedCrossRefGoogle Scholar
  7. Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). The impact of fear activation and anger on the efficacy of exposure treatment for post-traumatic stress disorder. Behavior Therapy, 26, 487–499.CrossRefGoogle Scholar
  8. Ghosh, A., & Marks, I. M. (1987). Self-treatment of agoraphobia by exposure. Behavior Therapy, 18, 3–16.CrossRefGoogle Scholar
  9. Ghosh, A., Marks, I. M., & Cart, A. C. (1988). Therapist contact and outcome of self-exposure treatment for phobias. British Journal of Psychiatry, 152, 234–238.PubMedCrossRefGoogle Scholar
  10. Gloster, A. T., Wittchen, H.-U., Einsle, F., Hofler, M., Lang, T., Helbig-Lang, S., et al. (2009). Mechanism of action in CBT (MAC): Methods of a multi-center randomized controlled trial in 369 patients with panic disorder and agoraphobia. European Archives of Psychiatry and Clinical Neuroscience, 259, 155–166.CrossRefGoogle Scholar
  11. Gloster, A. T., Wittchen, H.-U., Einsle, F., Lang, T., Helbig-Lang, S., Fydrich, T., et al. (2011). Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT. Journal of Consulting and Clinical Psychology, 79(3), 406–420.PubMedCrossRefGoogle Scholar
  12. Hellström, K., & Öst, L.-G. (1995). One-session therapist directed exposure vs two forms of manual directed self-exposure in the treatment of spider phobia. Behaviour Research and Therapy, 33, 959–965.PubMedCrossRefGoogle Scholar
  13. Hofmann, S. G., & Smits, A. J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632.PubMedCrossRefGoogle Scholar
  14. Holden, A. E., O’Brien, T., Barlow, D. H., Stetson, D., & Infantino, A. (1983). Self-help manual for agoraphobia: A preliminary report of effectiveness. Behavior Therapy, 14, 545–556.CrossRefGoogle Scholar
  15. Ito, L. M., De Araujo, L. A., Tess, V. L. C., de Barros-Neto, T. P., Ahsbar, F. R., & Marks, I. (2001). Self-exposure therapy for panic disorder with agoraphobia - Randomised controlled study of external v. interoceptive self-exposure. British Journal of Psychiatry, 178, 331–336.PubMedCrossRefGoogle Scholar
  16. Jannoun, L., Munby, M., Catalan, J., & Gelder, M. (1980). A home-based treatment program for agoraphobia: Replication and controlled evaluation. Behavior Therapy, 11, 294–305.CrossRefGoogle Scholar
  17. Lang, T., Helbig-Lang, S., Westphal, D., Gloster, A. T., & Wittchen, H.-U. (2012). Expositionsbasierte, manualisierte Behandlung der Panikstörung und Agoraphobie. Göttingen: Hogrefe.Google Scholar
  18. Mathews, A. M., Teasdale, J., Munby, M., Johnston, D., & Shaw, P. (1977). A home-based treatment program for agoraphobia. Behavior Therapy, 8, 915–924.CrossRefGoogle Scholar
  19. Mavissakalian, M., & Michelson, L. (1983). Self-directed in vivo exposure practice in behavioural and pharmacological treatments of agoraphobia. Behavior Therapy, 14, 506–519.CrossRefGoogle Scholar
  20. McDonald, R., Sartory, 0., Grey, J., Cobb, J. P., Stern, R., & Marks, I. M. (1979). The effect of self-exposure instruction on agoraphobic outpatients. Behaviour Research and Therapy, 17, 83–85.CrossRefGoogle Scholar
  21. McNamee, G., O’Sullivan, G., Lelliott, P., & Marks, I. M. (1989). Telephone-guided treatment for household agoraphobics with panic disorder: Exposure vs. relaxation. Behavior Therapy, 20, 491–497.CrossRefGoogle Scholar
  22. Michelson, L. K., Marchione, K. E., Greenwald, M., Testa, S., & Marchione, N. J. (1996). A comparative outcome and follow-up investigation of panic disorder with agoraphobia: The relative and combined efficacy of cognitive therapy, relaxation training, and therapist-assisted exposure. Journal of Anxiety Disorders, 10, 297–330.CrossRefGoogle Scholar
  23. Michelson, L., Mavissakalian, M., Marchione, K., Dancu, C., & Greenwald, M. (1986). The role fo self-directed in vivo exposure in cognitive, behavioral, and psychophysiological treatments of agoraphobia. Behavior Therapy, 17, 91–108.CrossRefGoogle Scholar
  24. Mineka, S., Mystkowski, J. L., Hladek, D., & Rodriguez, B. I. (1999). The effects of changing contexts on return of fear following exposure therapy for spider fear. Journal of Consulting and Clinical Psychology, 67, 599–604.PubMedCrossRefGoogle Scholar
  25. Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive-behavioral therapy for anxiety disorders: A review of meta-analytic findings. Psychiatric Clinics of North America, 33, 557–577.PubMedCrossRefGoogle Scholar
  26. Öst, L.-G., Salkovskis, P. M., & Hellström, K. (1991). One-session therapist-directed exposure vs. self-exposure in the treatment of spider phobia. Behavior Therapy, 22, 407–422.CrossRefGoogle Scholar
  27. Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 635–641.PubMedCrossRefGoogle Scholar
  28. Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis. Clinical Psychology Review, 30, 37–50.PubMedCrossRefGoogle Scholar
  29. Schneider, A. J., Mataix-Cols, D., Marks, I. M., & Bachofen, M. (2005). Internet-guided self-help with or without exposure therapy for phobic and panic disorders. Psychotherapy and Psychosomatics, 74, 154–164.PubMedCrossRefGoogle Scholar
  30. Van Minnen, A., & Hagenaars, M. (2002). Fear activation and habituation patterns as early process predictors of response to prolonged exposure treatment in PTSD. Journal of Trauma and Stress, 15, 359–367.CrossRefGoogle Scholar
  31. Woody, S. R., & Ollendick, T. H. (2006). Technique factors in treating anxiety disorders. In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 167–186). New York: Oxford University Press.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Christoph Dornier Foundation for Clinical PsychologyBremenGermany
  2. 2.Department of Clinical Psychology and PsychotherapyUniversity HamburgHamburgGermany

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