Exposure Therapy for Anxiety: Principles and Practice

511 Pages·2012·6.72 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
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The publisher grants to individual purchasers of this book nonassignable permission to
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The authors have checked with sources believed to be reliable in their efforts to provide
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changes in behavioral, mental health, or medical sciences, neither the authors, nor the editor and
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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-