Academic journal article Journal of Cognitive Psychotherapy

Incorporating the Judicious Use of Safety Behavior into Exposure-Based Treatments for Anxiety Disorders: A Study of Treatment Acceptability

Academic journal article Journal of Cognitive Psychotherapy

Incorporating the Judicious Use of Safety Behavior into Exposure-Based Treatments for Anxiety Disorders: A Study of Treatment Acceptability

Article excerpt

This analog study investigated treatment acceptability and preference as a function of safety behavior use (judicious vs. discouraged) and treatment rationale (cognitive vs. extinction). Thirty-two clinically anxious participants and 437 undergraduate students provided ratings of acceptability and adherence, as well as preference ranks for four written vignettes describing a course of cognitive-behavioral therapy (CBT) for fear or anxiety. Treatment descriptions promoting judicious safety behavior use received significantly higher acceptability and adherence ratings compared to those discouraging its use. Descriptions that presented a cognitively based rationale, compared to an extinction-based rationale, were also rated as both significantly more acceptable and easier to adhere to. The highest preference rank was for treatment that included judicious safety behavior use, conveyed via a cognitive rationale. A similar pattern of results was observed in both participant groups. These findings suggest that the judicious incorporation of safety behavior into CBT has the potential to reduce treatment refusal and dropout. Results are discussed in terms of their implications for cognitive-behavioral and exposure-based treatments.

Keywords: safety behavior; treatment acceptability; exposure; CBT; anxiety disorders; adherence

Exposure therapy, whether delivered alone or in combination with cognitively based techniques, has received substantial empirical support (Butler, Chapman, Forman, & Beck, 2006; Norton & Price, 2007; Olatunji, Cisler, & Deacon, 2010), and it is the psychosocial treatment of choice for anxious psychopathology (Chambless et al., 1998; Chambless & Ollendick, 2001). This treatment method aims to facilitate declines in the fear response and to promote corrective learning by requiring patients to engage in repeated and prolonged exposure to situations, sensations, and/or thoughts and images that elicit fear or anxiety (Barlow, 2002; Craske, 1999).

Despite the well-established efficacy of exposure-based treatments for anxiety disorders, not all patients benefit from exposure and a considerable number refuse treatment or drop out before treatment has been completed. Both a fear of confronting anxiety-provoking situations and an intolerance of distress have been identified as important factors in treatment acceptability (Emmelkamp & van den Hout, 1983; Maltby & Tolin, 2003, 2005), which has been defined as the degree to which an individual perceives treatment procedures for a specific clinical problem as appropriate, fair, reasonable, and unintrusive (Kazdin, 1980).

In a longitudinal investigation of the use of cognitive-behavioral therapy (CBT) by individuals being treated for obsessive-compulsive disorder (OCD), being too anxious or fearful to participate in CBT was endorsed as a reason for not initiating treatment or dropping out prematurely by 31% and 29% of participants, respectively (Mancebo, Eisen, Sibrava, Dyck, & Rasmussen, 2011). Fear of engaging in CBT was the main reason for not initiating treatment or dropping out for 20% and 21% of participants, respectively. Although data were not collected on specific aspects of CBT that were fear provoking, this study highlights the possibility that fear associated with certain CBT techniques, such as exposure and response prevention, can be an important barrier to treatment initiation and completion. Rates of refusal and dropout for exposure-based treatment range from 20% to 43% for OCD (Foa et al., 2005; Franklin & Foa, 1998; Stanley & Turner, 1995; Whittal, Thordarson, & McLean, 2005), 14% to 20% for posttraumatic stress disorder (PTSD; Hembree et al., 2003; Van Etten & Taylor, 1998), 7% to 31% for panic disorder (Cox, Endler, Lee, & Swinson, 1992), 0% to 45% for specific phobias (Choy, Fyer, & Lipsitz, 2007), and 0% to 27% for social phobia (Feske & Chambless, 1995).

Clinical researchers have investigated various methods of augmenting or modifying exposure- based treatments to improve their acceptability (e. …

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