Beliefs about safety behaviours in the prediction of safety behaviour use.

BACKGROUND: Safety behaviours are ubiquitous across anxiety disorders and are associated with the aetiology, maintenance and exacerbation of anxiety. Cognitive behavioural models posit that beliefs about safety behaviours directly influence their use. Therefore, beliefs about safety behaviours may be an important component in decreasing safety behaviour use. Unfortunately, little empirical research has evaluated this theorized relationship. AIMS: The present study aimed to examine the predictive relationship between beliefs about safety behaviours and safety behaviour use while controlling for anxiety severity. METHOD: Adults with clinically elevated levels of social anxiety (n = 145) and anxiety sensitivity (n = 109) completed an online survey that included established measures of safety behaviour use, quality of life, and anxiety severity. Participants also completed the Safety Behaviour Scale (SBS), a measure created for the current study which includes a transdiagnostic checklist of safety behaviours, as well as questions related to safety behaviour use and beliefs about safety behaviours. RESULTS: Within both the social anxiety and anxiety sensitivity groups, positive beliefs about safety behaviours predicted greater safety behaviour use, even when controlling for anxiety severity. Certain beliefs were particularly relevant in predicting safety behaviour use within each of the clinical analogue groups. CONCLUSIONS: Findings suggest that efforts to decrease safety behaviour use during anxiety treatment may benefit from identifying and modifying positive beliefs about safety behaviours.

Safety behaviors, experiential avoidance, and anxiety: A path analysis approach.

Avoidance has long been viewed as an etiological mechanism of anxiety disorders. Of more recent focus within this literature is the distinction between avoidance that is trait-based (experiential avoidance) versus contextual (safety behaviors). Whereas both experiential avoidance and safety behaviors have been studied within anxiety research, no known studies have evaluated the direct and indirect relationships of these forms of avoidance in predicting critical outcomes, particularly in conjunction with symptom severity. To address this gap, the current study assessed social anxiety and panic symptoms, experiential avoidance, use of preventive and restorative safety behaviors, and quality of life to determine the direct and indirect contributions of trait-based and contextual avoidance in predicting clinically relevant outcomes via path analysis. U.S. adults with elevated social anxiety or panic symptoms (n = 254) were recruited online. Results from path analysis showed that, across groups, the relationship between symptoms and quality of life was indirectly accounted for by use of preventive safety behaviors. Further, for participants with panic symptoms (but not for those with social anxiety symptoms), experiential avoidance predicted quality of life even after accounting for use of preventive safety behaviors. The results of this study indicate that trait-based and contextual avoidance contribute significantly to clinically relevant outcomes.

The effects of safety behavior availability versus utilization on inhibitory learning during exposure.

This study re-analyzes data from Sy and colleagues (2011; Behaviour Research and Therapy, 49, 305-314) comparing safety behavior availability (SBA) to safety behavior utilization (SBU) during exposure therapy for claustrophobic concerns. The present investigation assessed differential rates of inhibitory learning (i.e. change in danger expectancy and coping self-efficacy) between SBA and SBU before, during, and after a single-session treatment. Thirty-nine participants with marked claustrophobic fear completed six consecutive 5-minute exposure trials in a claustrophobia chamber. Participants in the SBA condition exhibited more interference with inhibitory learning relative to the SBU condition. Danger expectancy was significantly higher in the SBA group and decreased at a markedly slower rate across exposure trials relative to SBU. Coping self-efficacy was also significantly lower among participants in the SBA condition, although groups demonstrated similar rates of change across trials. Limitations, clinical implications, and future directions are discussed.

The Scarier the Better: Maximizing Exposure Therapy Outcomes for Spider Fear.

BACKGROUND: While exposure therapy effectively reduces anxiety associated with specific phobias, not all individuals respond to treatment and some will experience a return of fear after treatment ceases. AIMS: This study aimed to test the potential benefit of increasing the intensity of exposure therapy by adding an extra step that challenged uncontrollability (Step 15: allowing a spider to walk freely over one's body) to the standard fear hierarchy. METHOD: Fifty-one participants who had a severe fear of spiders completed two 60-min exposure sessions 1 week apart in a context that was either the same or different from the baseline and follow-up assessment context. Participants were categorized into groups based on the last hierarchy step they completed during treatment (Step 14 or fewer, or Step 15). RESULTS: Those who completed Step 15 had greater reductions in fear and beliefs about the probability of harm from baseline to post-treatment than those who completed fewer steps. Although completing Step 15 did not prevent fear from returning after a context change, it allowed people to maintain their ability to tolerate their fear, which earlier steps did not. Despite some fear returning after a context change, individuals who completed Step 15 tended to report greater reductions in fear from baseline to the follow-up assessment than participants who completed 14 or fewer steps. CONCLUSIONS: Overall, these results suggest that more intensive exposure that directly challenges harm beliefs may lead to greater changes in fear and fear beliefs than less intensive exposure.

Predictive Relationship Between Parental Beliefs and Accommodation of Pediatric Anxiety.

Behavior performed by parents to assist a youth in avoiding or alleviating anxiety, known as accommodation, is ubiquitous among pediatric anxiety disorders and strongly related to poor treatment outcome. According to cognitive-behavioral theory, the beliefs parents hold regarding accommodation should predict parental accommodating behavior. Unfortunately, little is known about the beliefs parents hold regarding accommodation, as there exists no validated measure of this construct. First, the psychometric properties were examined for the Parental Accommodation Scale (PAS), a novel measure of parental accommodating behavior frequency (PAS-Behavior scale) and parental beliefs about accommodation (PAS-Belief scale). Second, the relationship between parental beliefs about accommodation and accommodation frequency was examined. Results provide preliminary evidence of the internal consistency and convergent validity of the PAS. Stronger positive beliefs about accommodation significantly predicted accommodation frequency, even after controlling for youth anxiety severity. Specifically, beliefs that accommodation prevents youth from losing behavioral and emotional control significantly predicted accommodation frequency. Therefore, efforts to decrease accommodation in clinical settings should involve correcting maladaptive parental beliefs about accommodation, with a particular emphasis on beliefs regarding the necessity of accommodation in preventing a youth from losing behavioral and emotional control.

Targeting clinician concerns about exposure therapy: A pilot study comparing standard vs. enhanced training.

Owing to concerns about the safety and tolerability of exposure therapy, many clinicians deliver the treatment in an overly cautious manner, which may limit its effectiveness. Although didactic training in exposure reduces clinician concerns about the treatment to a moderate extent, improved training strategies are needed to minimize these concerns and improve exposure delivery. The present study compared the effectiveness of a standard (i.e., didactic) exposure therapy training model to an "enhanced" training paradigm encompassing strategies derived from social-cognitive theory on attitude change. Clinicians (N = 49) were assigned to one of the two training approaches. Relative to standard training, clinicians who received enhanced training showed: (a) significantly greater reductions in concerns about exposure from pre- to post-training, and (b) superior self-reported delivery of the treatment. Reduction in concerns during training mediated the effects of training condition on clinicians' self-reported exposure delivery. These findings underscore the importance of addressing clinician concerns about exposure therapy in training contexts.

Factors associated with practitioners' use of exposure therapy for childhood anxiety disorders.

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists.

Although client preferences are an integral component of evidence-based practice in psychology (American Psychological Association, 2006), relatively little research has examined what potential mental health consumers value in the psychotherapy they may receive. The present study was conducted to examine community members' preferences for the scientific and relational aspects of psychotherapy for different types of presenting problems, and how accurately therapists perceive these preferences. Community members (n = 200) were surveyed about the importance of scientific (e.g., demonstrated efficacy in clinical trials) and relational (e.g., therapist empathy) characteristics of psychotherapy both for anxiety disorders (e.g., obsessive-compulsive disorder) and disorder-nonspecific issues (e.g., relationship difficulties). Therapists (n = 199) completed the same survey and responded how they expected the average mental health consumer would. Results showed that although community members valued relational characteristics significantly more than scientific characteristics, the gap between these two was large for disorder-nonspecific issues (d = 1.24) but small for anxiety disorders (d = .27). Community members rated scientific credibility as important across problem types. Therapists significantly underestimated the importance of scientific characteristics to community members, particularly in the treatment of disorder-nonspecific issues (d = .74). Therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to community members. The implications of the present findings for understanding the nature of client preferences in evidence-based psychological practice are discussed.

Biological or psychological? Effects of eating disorder psychoeducation on self-blame and recovery expectations among symptomatic individuals.

Recent years have witnessed increasing popularity and promotion of biological influences (e.g., genetics) in eating disorder (ED) development. Although research suggests biological models of EDs reduce blame-oriented stigma in the general public, their effect on symptomatic individuals' attitudes toward themselves, treatment, and their prognosis has not been studied. Additionally, little is known about how other credible forms of conceptualizing ED development (e.g., cognitive-behavioral) affect individuals with disordered eating. Accordingly, the present study assessed the effects of three different forms of psychoeducation about ED development (biology-only, malleability of biology, cognitive-behavioral) among a sample high in ED symptoms. Participants (N = 216) viewed an audiovisual presentation describing ED development from one of the three perspectives before completing measures of self-blame for symptoms, prognostic expectations, self-efficacy in recovering, and attitudes toward a description of cognitive-behavioral therapy. There were no significant differences between conditions in self-blame. Relative to biology-only, the psychoeducational messages emphasizing malleable biology and cognitive-behavioral factors produced more prognostic optimism and self-efficacy in recovering. Perceived credibility of cognitive-behavioral therapy and expectations for its efficacy were highest in the cognitive-behavioral psychoeducation condition. Implications for efforts to educate the public and treatment-seeking individuals about the nature of EDs are discussed.

The credibility of exposure therapy: Does the theoretical rationale matter?

OBJECTIVE: Little is understood about how the public perceives exposure-based therapy (ET) for treating anxiety and trauma-related disorders or how ET rationales affect treatment credibility. Distinct approaches to framing ET are practiced, including those emphasized in traditional cognitive behavioral therapy, acceptance and commitment therapy, and the more recent inhibitory learning model. However, their relative effect on ET's credibility remains unknown. METHOD: A final sample of 964 U.S. adults provided baseline views of ET. Participants rated ET treatment credibility following a simple ET definition (pre-rationale) and following randomization to rationale modules addressing ET goals, fear, and cognitive strategies from distinct theoretical perspectives (post-rationale). Baseline ET views, symptoms, and sociodemographic characteristics were examined as putative moderators and predictors. RESULTS: At baseline, the majority had never heard of ET. From pre- to post-rationale, ET treatment credibility significantly increased but the rationales' theoretical perspective had little impact. More negative baseline ET views, specific ethnic/racial minority group status, and lower education moderated or predicted greater increases in treatment credibility following the rationale. CONCLUSIONS: ET remains relatively unknown as a treatment for anxiety or trauma, supporting the need for direct-to-consumer marketing. Diverse theory-driven rationales similarly increased ET credibility, particularly among those less likely to use ET.

Interoceptive exposure exercises for social anxiety.

Individuals with social anxiety disorder (SAD) commonly experience panic attacks and evidence increased anxiety sensitivity (AS) specific to noticeable anxiety sensations. Interoceptive exposure (IE) is an effective treatment for reducing AS, but few IE tasks target fears of blushing, sweating, or trembling, which are incorporated within AS social concerns and especially feared by individuals with SAD. The primary study aims were trifold: (1) identify novel IE tasks that produce blushing, sweating, and/or trembling; (2) assess the intensity of sensations and anxiety produced by a series of novel and validated IE tasks; and (3) evaluate the incremental validity of combining an IE task and a speech task. Individuals (N = 55) with heightened fear of noticeably blushing, sweating, and/or trembling completed a control task and 8 IE tasks (e.g., hot sauce, hyperventilation). All tasks produced greater intensity of anxiety and sensations compared to the control task (ps < .001; range of η(p)(2) = .20-.50). Responses to the combination of an IE task and social task compared to a social task alone did not differ significantly. Future directions for research and clinical implications of the findings are discussed.

Developing scales measuring disorder-specific intolerance of uncertainty (DSIU): a new perspective on transdiagnostic.

Intolerance of uncertainty (IU) is a construct of growing prominence in literature on anxiety disorders and major depressive disorder. Existing measures of IU do not define the uncertainty that respondents perceive as distressing. To address this limitation, we developed eight scales measuring disorder-specific intolerance of uncertainty (DSIU) relating to various anxiety disorders and major depressive disorder. We used exploratory factor analysis and item characteristic curves in two large undergraduate samples (Ns=627 and 628) to derive eight three-item DSIU scales (24 items total) that exhibited excellent psychometric properties. Confirmatory factor analysis supported the factor structures of the scales and the transdiagnostic nature of IU. Each scale predicted unique variance in its respective symptom measure beyond a traditional measure of IU. DSIU represents a theoretically proximal and causal intermediary between known vulnerability factors and disorder symptomatology. The DSIU scales can be used to advance theories of psychopathology and inform case conceptualization and treatment planning.

The OCD Project: Educational or Sensational?

Ninety-two young adults were randomly assigned to watch two episodes of The OCD Project, a reality television program depicting the treatment of obsessive-compulsive disorder using exposure therapy, or two episodes of another reality television program (Big Brother). Participants in The OCD Project condition (n = 35) endorsed significantly fewer negative beliefs about exposure therapy than participants in the Big Brother condition (n = 42). Participants' obsessive-compulsive disorder symptoms did not moderate the beneficial effects of watching The OCD Project These results provide preliminary evidence that reality television programs can have a modest psychoeducational benefit and might be used to change attitudes about mental health problems and their treatment.

Effects of a chemical imbalance causal explanation on individuals' perceptions of their depressive symptoms.

Although the chemical imbalance theory is the dominant causal explanation of depression in the United States, little is known about the effects of this explanation on depressed individuals. This experiment examined the impact of chemical imbalance test feedback on perceptions of stigma, prognosis, negative mood regulation expectancies, and treatment credibility and expectancy. Participants endorsing a past or current depressive episode received results of a bogus but credible biological test demonstrating their depressive symptoms to be caused, or not caused, by a chemical imbalance in the brain. Results showed that chemical imbalance test feedback failed to reduce self-blame, elicited worse prognostic pessimism and negative mood regulation expectancies, and led participants to view pharmacotherapy as more credible and effective than psychotherapy. The present findings add to a growing literature highlighting the unhelpful and potentially iatrogenic effects of attributing depressive symptoms to a chemical imbalance. Clinical and societal implications of these findings are discussed.

The relevance of analogue studies for understanding obsessions and compulsions.

Analogue samples are often used to study obsessive-compulsive (OC) symptoms and related phenomena. This approach is based on the hypothesis that results derived from such samples are relevant to understanding OC symptoms in individuals with a diagnosis of obsessive-compulsive disorder (OCD). Two decades ago, Gibbs (1996) reviewed the available literature and found initial support for this hypothesis. Since then there have been many important advances addressing this issue. The purpose of the present review was to synthesize various lines of research examining the assumptions of using analogue samples to draw inferences about people with OCD. We reviewed research on the prevalence of OC symptoms in non-clinical populations, the dimensional (vs. categorical) nature of these symptoms, phenomenology, etiology, and studies on developmental and maintenance factors in clinical and analogue samples. We also considered the relevance of analogue samples in OCD treatment research. The available evidence suggests research with analogue samples is highly relevant for understanding OC symptoms. Guidelines for the appropriate use of analogue designs and samples are suggested.

Why do clinicians exclude anxious clients from exposure therapy?

Despite research demonstrating the effectiveness of exposure therapy for pathological anxiety, this treatment is underutilized by clinicians. Anecdotal evidence and clinical experience suggest that therapists who possess reservations about exposure therapy tend to exclude clients from this treatment based on client characteristics believed to predict worse response. When exceptions are made based on characteristics that do not reliably predict poor outcomes, clients face the opportunity cost associated with investment in less effective treatments. The present investigation assessed therapists' likelihood of excluding clients from exposure due to different client and therapist characteristics. Exposure therapists (N = 182) completed an online survey that included the Therapist Beliefs about Exposure Scale, Anxiety Sensitivity Index-3, and the Broken Leg Exception Scale (BLES), a novel measure assessing the likelihood of excluding clients from exposure based on 25 different client characteristics. The BLES demonstrated good psychometric properties. Client characteristics most likely to result in exclusion from exposure therapy were comorbid psychosis, emotional fragility, and reluctance to participate in exposure. Greater likelihood of excluding clients from exposure was associated with higher therapist anxiety sensitivity and endorsement of negative beliefs about exposure therapy. Clinical and training implications of these findings are discussed.

Theory-based training strategies for modifying practitioner concerns about exposure therapy.

Despite the well-established efficacy of exposure therapy in the treatment of pathological anxiety, many therapists believe this treatment carries an unacceptably high risk for harm, is intolerable for patients, and poses a number of ethical quandaries. These beliefs have been shown to account for two related problems: (a) underutilization of exposure therapy, and (b) overly cautious and suboptimal delivery the treatment, which likely attenuates treatment outcomes. At present, there is little guidance for those who train exposure therapists to address these concerns. This article reviews therapist negative beliefs about exposure therapy and discusses their modification based on findings from social and cognitive psychology pertinent to belief change, including dual-processing in reasoning, the need for cognition and affect, and attitude inoculation. A number of strategies are offered for augmenting training in exposure therapy in order to promote positive beliefs about the treatment. These strategies involve: (a) therapists engaging in simulated exposure therapy exercises and presenting arguments in defense of exposure's safety, tolerability, and ethicality, and (b) training therapists using emotion-based appeals (e.g., case examples) to supplement research findings. Directions for future research on practitioner concerns about exposure therapy are discussed.

Dissemination of empirically supported treatments for anxiety disorders: introduction to the special issue.

UNLABELLED: Effective exposure therapies for anxiety disorders have been available for half a century. Over that time we have made great strides increasing the potency of these powerful methods. Yet, most of us in practice still have a conversation like the following with our new patients: Therapist: "So what treatments have you had for your anxiety symptoms to date?" PATIENT: "I have seen numerous therapists over the last 10 years." Therapist: "Great, so what did you do?" PATIENT: "We talked about things. And I learned relaxation and breathing techniques." Therapist: "Did a therapist ever help you face your fears?" PATIENT: "What do you mean?" Therapist: "I mean did you directly confront feared situations, perhaps with your therapist outside the office?" PATIENT: "No, why, is that important?" This oft-repeated conversation highlights the disconnect between the well-established efficacy of exposure-based treatments for pathological anxiety and their inaccessibility to most anxious clients. This failure to successfully disseminate exposure-based empirically supported treatments is the motivation for this special issue. The articles that follow consider the causes of this dissemination failure, highlight areas of success, and offer constructive remedies for addressing this important public health problem.

Exposure therapy for emetophobia: a case study with three-year follow-up.

Emetophobia, also referred to as a specific phobia of vomiting, is a largely under-researched and poorly understood disorder with prevalence estimates of ranging between 1.7 and 3.1% for men and 6 and 7% for women (Hunter & Antony, 2009; Philips, 1985). The current case study, therefore, sought to methodically apply exposure-based behavioral treatment to the treatment of a 26 year-old, Hispanic, female suffering from emetophobia. Although not as powerful as a randomized design, this description may still add to the existing emetophobia literature through the illustration of adaptation of published behavioral treatments for other specific phobias. The case presented was successful in terms of outcome, and includes a three-year follow up wherein treatment gains were measurably maintained.

Assessing therapist reservations about exposure therapy for anxiety disorders: the Therapist Beliefs about Exposure Scale.

Exposure therapy is underutilized in the treatment of pathological anxiety and is often delivered in a suboptimal manner. Negative beliefs about exposure appear common among therapists and may pose a barrier to its dissemination. To permit reliable and valid assessment of such beliefs, we constructed the 21-item Therapist Beliefs about Exposure Scale (TBES) and examined its reliability and validity in three samples of practicing clinicians. The TBES demonstrated a clear single-factor structure, excellent internal consistency (αs=.90-.96), and exceptionally high six-month test-retest reliability (r=.89). Negative beliefs about exposure therapy were associated with therapist demographic characteristics, negative reactions to a series of exposure therapy case vignettes, and the cautious delivery of exposure therapy in the treatment of a hypothetical client with obsessive-compulsive disorder. Lastly, TBES scores decreased markedly following a didactic workshop on exposure therapy. The present findings support the reliability and validity of the TBES.