Exposure Therapy for Anxiety: Principles and Practice

528 Pages·2010·6.82 MB·English

by  Jonathan S. Abramowitz PhD

Exposure Therapy
for Anxiety
Principles and Practice
Jonathan S. Abramowitz
Brett J. Deacon
Stephen P. H. Whiteside
Copyright
© 2011 The Guilford Press
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© 2011 Epub Edition ISBN: 9781609180171
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Last digit is print number: 9 8 7 6 5 4 3 2 1
LIMITED PHOTOCOPY LICENSE
These materials are intended for use only by qualified mental health professionals.
The publisher grants to individual purchasers of this book nonassignable permission to reproduce all
materials for which photocopying permission is specifically granted in a footnote. This license is
limited to you, the individual purchaser, for personal use or use with individual clients. This license
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The authors have checked with sources believed to be reliable in their efforts to provide information that is
complete and generally in accord with the standards of practice that are accepted at the time of publication.
However, in view of the possibility of human error or changes in behavioral, mental health, or medical
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Library of Congress Cataloging-in-Publication Data
Abramowitz, Jonathan S.
Exposure therapy for anxiety: principles and practice / by Jonathan S. Abramowitz, Brett J. Deacon, and
Stephen P. H. Whiteside.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-60918-016-4 (hard cover: alk. paper)
1. Anxiety disorders—Treatment. 2. Exposure therapy. I. Deacon, Brett J. II. Whiteside, Stephen P. H.
III. Title.
[DNLM: 1. Anxiety Disorders—therapy. 2. Implosive Therapy—methods. WM 172]
RC531.A27 2011
616.85′22—dc22
2010037386
To the many patients we have treated
and therapists we have supervised; you have taught
us much about the nature and treatment of anxiety
To Stacy, Emily, and Miriam Abramowitz
with all my love
—J. S. A.
To my parents, Robert and Sharon Deacon,
with love and gratitude
–B. J. D.
To my wife, Catherine, and my parents, Jim and Mary;
thank you for all your patience and support
—S. P. H. W.
About the Authors
Jonathan S. Abramowitz, PhD, ABPP, is Professor and Associate Chair of the
Department of Psychology and Research Associate Professor in the Department
of Psychiatry at the University of North Carolina (UNC) at Chapel Hill. He is
also Director of the UNC Anxiety and Stress Disorders Clinic. Dr. Abramowitz
conducts research on anxiety disorders and has published 10 books and over 150
peer-reviewed research articles and book chapters. He currently serves as
Associate Editor of the journals Behaviour Research and Therapy and Journal of
Cognitive Psychotherapy and on the editorial boards of several other scientific
journals. He is a member of the board of directors of the Anxiety Disorders
Association of America and the Scientific Advisory Board of the International
OCD Foundation. Dr. Abramowitz received the Outstanding Contributions to
Research Award from the Mayo Clinic Department of Psychiatry and
Psychology in 2003 and the David Shakow Early Career Award for
Distinguished Scientific Contributions to Clinical Psychology from Division 12
of the American Psychological Association in 2004. He regularly presents
papers and workshops on anxiety disorders and their treatment at regional,
national, and international professional conferences.
Brett J. Deacon, PhD, is Associate Professor in the Department of Psychology
at the University of Wyoming and Director of the University of Wyoming
Anxiety Disorders Clinic in Laramie. Dr. Deacon has published over 50 peer-
reviewed research articles on the nature and treatment of anxiety disorders. He
serves on the editorial boards of numerous scientific journals and is a member of
the Clinical Advisory Board of the Anxiety Disorders Association of America.
He is the recipient of numerous teaching and research awards from the
University of Wyoming as well as the Northern Illinois University College of
Liberal Arts and Sciences Golden Anniversary Alumni Award in 2009. Dr.
Deacon regularly presents workshops on cognitive-behavioral therapy for
anxiety disorders at regional and national conferences.
Stephen P. H. Whiteside, PhD, ABPP, is Associate Professor of Psychology
and Director of the Child Anxiety Disorders Program at the Mayo Clinic in
Rochester, Minnesota. He conducts research on the assessment and treatment of
childhood anxiety disorders, including the use of neuroimaging to examine the
effects of cognitive behavioral therapy. He has received research funding from
the International OCD Foundation and has published 35 articles and book
chapters. 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.
Acknowledgments
T
his book reflects how we understand and treat clinical anxiety problems.
The conceptual model and intervention strategies elucidated herein are based on
a firm foundation of scientific literature that we are at once students of and
contributors to. We wish to thank all of those who have helped us learn from and
add to this knowledge, including the countless patients with whom we have
worked (some successfully and some unsuccessfully) and therapists we have
supervised, as well as the many outstanding teachers who have been
instrumental in our growth and learning. Several individuals who have served as
our teachers and mentors deserve specific mention: Edna Foa, Martin Franklin,
Arthur Houts, Paul Kettlewell, Michael Kozak, Don Lynam, and David
Valenteiner. We thank these individuals for their insights and hope they will see
their influence reflected in this book. We are also enormously fortunate to have
an outstanding network of collaborative relationships with fine clinicians and
scholars in the field of anxiety disorders. We are especially grateful to Julie
Dammann, Sarah Kalsy, Dean McKay, Bunmi Olatunji, Brad Riemann, Steven
Taylor, Mike Tiede, and David Tolin, who have helped us refine our thinking
about the concepts and techniques discussed in this book. And, most of all, we
would like to thank our families, who have been very patient with us while we
labored over this project. We hope you are as proud of us as we are of you.
Preface
O
ver the last 30 years, empirically supported treatment manuals for specific
anxiety disorders have become extremely popular. Although these manuals serve
an important purpose, they are sometimes criticized as being written with an
assumption that “one size fits all,” that every patient with a particular anxiety
disorder has similar “classic” symptoms, and that every patient with a given
problem requires (and will respond to) the same treatment procedures, delivered
according to the same schedule. Finally, disorder-focused manuals sometimes
assume that patients with one anxiety disorder do not have symptoms of other
anxiety disorders or that all patients will fit neatly into our diagnostic boxes.
Research and clinical experience, however, question all of these assumptions.
Thus, while treatment manuals are critical for conducting research to establish
whether a therapy is effective (which involves the use of homogeneous patient
samples), manuals for particular disorders may be of less value for clinicians in
typical mental health settings, where anxiety symptoms are often manifested in
diverse and complex forms (e.g., many people with social phobia also have
panic attacks and abuse alcohol or drugs).
A cursory inspection of treatment manuals for various anxiety disorders,
however, reveals that despite some variability, the centerpiece of each manual is
essentially the same technique, therapeutic exposure, which involves helping the
patient confront his or her fears. Repeated and prolonged confrontation with
situations and stimuli that are associated with excessive fear weakens clinical
anxiety, because it teaches the person that such situations and stimuli are not as
dangerous as was previously thought and that anxiety and fear themselves are
not harmful. Accordingly, the main difference across the disorder-specific
treatment manuals is the way in which exposure must be engineered to help the
individual confront the feared situations, stimuli, contexts, and cues that are
characteristic of each anxiety disorder. Manuals for treating social phobia, for
example, discuss how best the clinician can arrange for individuals with this
disorder to confront social performance or evaluative situations. Manuals for
treating obsessive–compulsive disorder help the clinician arrange patients’
exposure to items or places that provoke obsessional fear, such as knives,
bathrooms, or cemeteries, outside the context of any reassurance-seeking
compulsive rituals.
With this brief overview in mind, our aim in writing Exposure Therapy for
Anxiety: Principles and Practice was to put under one cover a comprehensive
and practical guide to using exposure therapy for the treatment of a wide range
of anxiety problems. Because of its broad scope and relevance to clinical and
research activity, this book will appeal to practicing clinicians, researchers, and
students. An important recurring theme is that exposure is an effective (i.e.,
empirically supported or “evidence-based”) treatment method for overcoming
excessive (clinical) fear and anxiety regardless of the patient’s diagnostic
category or status. Instead of focusing on implementing exposure for different
anxiety disorders, we focus on how clinicians can use the principles of exposure
therapy to help patients overcome different types of fears that may occur in one
or more anxiety disorders or even among individuals not meeting formal
diagnostic criteria.
The successful application of exposure therapy requires a mastery of multiple
skills. Sometimes, exposure is relatively straightforward to implement, such as
in the treatment of many animal phobias. At other times, it is fraught with
conceptual challenges, as in the treatment of obsessional fears about going to
hell, getting cancer 40 years in the future, and hitting pedestrians with one’s car.
Treating trauma survivors (i.e., patients with posttraumatic stress disorder), who
experience fear when they remember or encounter reminders of horrific events,
presents additional practical challenges. Regardless, clinicians need to be able to
convey confidence and engage patients in an emotionally demanding treatment.
To this end, we share our extensive knowledge and clinical expertise with
exposure-based therapy to provide the reader with a resource for planning and
conducting challenging exposures. This book will increase the reader’s
confidence in exposure through user-friendly reviews of the history and science
behind exposure, through easy-to-follow guides to assessing anxiety symptoms,
and through setting up and conducting the therapy itself. Its copious case
examples and ideas for exposure exercises further enhance readers’ ability to
design their own exposures for even the most unique of patients.
We have divided the book into three parts. Part I comprises six chapters
covering topics that are fundamental to the practice of exposure therapy. Chapter
1 provides a definition and historical perspective on exposure, and Chapter 2
reviews the research attesting to its efficacy for anxiety-related problems.
Chapter 3 provides the conceptual basis for the use of exposure therapy and