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ScienceDirectCognitive and Behavioral Practice 20 (2013) 445–454

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Collaborative Empiricism: A Cognitive Response to Exposure Reluctanceand Low Distress Tolerance

David A. Clark, University of New Brunswick

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Even though behavioral interventions such as exposure and behavioral activation play a critical role in the effectiveness of CBT foranxiety and depression, many treatment seekers may be reluctant to confront avoided situations and negative emotional states. In thispaper a cognitive approach to reluctance to engage in exposure or accept feelings of distress is presented. Several representativemaladaptive schemas of exposure and distress tolerance are considered and a refined cognitive therapy approach to the therapeuticalliance based on Tee and Kazantzis’ (2011) self-determination conceptualization of collaborative empiricism (CE) is discussed.Cognitive strategies that specifically address reluctance to engage in exposure or to confront negative feelings are considered in thecontext of improved therapist-client collaboration and the promotion of client internal attributions for behavioral change. A caseexample of enhanced CE for dealing with exposure reluctance is presented and several issues are proposed that could advance researchand understanding of the mechanisms of change involved in client acceptance of behavioral exercises.

C OGNITIVE behavioral therapies (CBT) are well-recognized, empirically supported psychological

treatments for major depression and the primaryanxiety disorders (American Psychiatric Association,2006; Chambless & Ollendick, 2001; National Instituteof Clinical Excellence [NICE], 2004a, 2004b). Theireffectiveness has been demonstrated in numerousoutcome studies (see Epp, Dobson, & Cottraux, 2009,for review), with large effect sizes reported in a varietyof meta-analyses (Butler, Chapman, Forman & Beck,2006; Chambless & Peterman, 2004; Gould, Safren,Washington, & Otto, 2004). Behavioral exercises in theform of exposure and response prevention, behavioralactivation, and empirical hypothesis-testing are key thera-peutic ingredients that significantly contribute to theeffectiveness of CBT (Simpson et al., 2011; see also reviewsby Clark & Beck, 2010; Dobson & Dobson, 2009; Hollon &Dimidjian, 2009). These intervention strategies are criticallyimportant therapeutic tools for modifying the maladaptivecognitions, interpretations and beliefs considered responsi-ble for the persistence of anxiety and depression. In fact,Gunter and Whittal (2010) noted that CBT may be uniquein requiring clients to intentionally face situations they

ords: collaborative empiricism; exposure; cognitive therapy;itive behavior therapy; noncompliance

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deliberately avoid, in large part because these situationsactivate high levels of subjective anxiety or distress. Therationale behind such interventions is that repeatedexposure to avoided situations or unwanted negativeemotions not only provides disconfirming informationthat is critical for changingmaladaptive thoughts and beliefsbut evidence that negative emotion can be tolerated andallowed to decline naturally.

Two problems have emerged with the use of behavioralinterventions in CBT. First, clients with anxiety may bereluctant, or even refuse, to engage in exposure to theirfeared and avoided situations. Often anxious individualsbegin treatment with reservations about the therapy process(Dozois,Westra, Collins, Fung,&Garry, 2004). For example,Kozak, Liebowitz, and Foa (2000) reported that 30% ofindividuals with obsessive-compulsive disorder (OCD)referred to their clinic refused treatment. In a randomizedcontrolled trial of treatment for OCD involving exposureand response prevention (ERP) versus clomipramine, ortheir combination, 8 individuals (22%) allocated to ERPalone withdrew after learning of their treatment assignment(Foa et al., 2005). Other OCD researchers have alsoreported a significant percentage of individuals who fail tocomplete treatment (Aderka et al., 2011). However, thereare many reasons why an individual might refuse treatmentassignment in a randomized controlled trial, includingrefusal to take medication (Huppert, Franklin, Foa, &Davidson, 2003). Furthermore, there is no evidence thatexposure therapies for PTSD, for example, have a higherdropout rate than non-exposure therapies (Hembree et al.,

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2003). Nevertheless, most practitioners have experiencedclients with varying levels of reluctance to fully commit toexposure-based assignments in treatment of anxiety thatmight lead tooutright treatment refusal or dropout, ormoresubtly as homework noncompliance. As previously noted,some level of homework noncompliance may be the rulerather than the exception in CBT (Kazantzis, Lampropou-los, & Deane, 2005).

Pollard (2007) offered a number of recommendationsfor addressing the maladaptive beliefs and expectationsthat might interfere in an OCD client's readiness toengage in exposure. Clearly, beliefs that one willexperience extreme levels of anxiety or some dreadednegative consequence (e.g., heart attack, humiliation,contamination, etc.) if exposed to a feared situationcould lead to noncompliance with the behavioral exercise(Abramowitz, Deacon, & Whiteside, 2011). In treatmentof depression, individuals might be reluctant to engage inmastery and pleasure exercises, or other forms ofbehavioral activation, because of low expectations ofbenefit and/or high levels of hopelessness. In addition,one might expect that individuals with low tolerance fornegative emotions, such as anxiety or even sadness, wouldbe more reluctant to commit to any therapy that involvesactivation of a negative affect state (see Zvolensky, Leyro,Bernstein, & Vujanovic, 2011). In sum, a significantnumber of individuals seeking CBT for an emotionaldisorder may be reluctant to engage in exposure andother behavioral exercises because they do not want torisk experiencing more intense and persistent subjectivedistress. However, the extent of this problem is difficult todetermine because there are no empirical data on reasonsfor treatment refusal or dropout in naturalistic clinicalsettings.

A second problem evident in CBT practice is that manyclinicians, even those who adhere to a CBT orientation,do not routinely employ evidence-based interventions intheir practice (Becker, Zayfert, & Anderson, 2004; Waller,2009). A Web-based survey of 2,200 North Americanpsychotherapists found that assigning homework orbehavioral tasks outside of therapy sessions is a commontherapeutic practice but use of in vivo or imaginalexposure was used frequently by only 12% of the sample(Cook et al., 2010). Gunter and Whittal (2010) discusswhether practitioners are reluctant to use exposurebecause of fear that it may harm the client. If the clientis also reluctant to engage in exposure to avoidedsituations and negative emotions, this could feed intothe clinician's own misgivings and result in a decision toexclude one of the most effective therapeutic interven-tions for treatment of anxiety and possibly depression.

Negative attitudes of clients and therapists alike towardthe utilization of exposure interventions represents asignificant threat to improved community access to and

availability of highly effective CBT for anxiety anddepression. It is quite possible that greater attention tothe critical aspects of the therapeutic relationship mightimprove acceptance of the behavioral components ofCBT. Various clinical researchers have argued that a morefocused, or nuanced, approach to the therapeutic alliancemight improve client engagement in therapy (J. Beck,2005; Leahy, 2001; Waller, 2009; see Safran & Muran,2006, for contrary viewpoint). More recently, collabora-tive empiricism (CE), a key feature of the therapeuticrelationship expounded in CBT, has been conceptualizedas a significant contributor to treatment outcome(Kuyken, Padesky & Dudley, 2009; Tee & Kazantzis,2011). In light of these discussions, this paper willexamine whether the more elaborated understanding ofCE offered by Tee and Kazantzis might be used toimprove client readiness for exposure to avoided situa-tions and increase tolerance for negative emotions. Ibegin by identifying several primary maladaptive beliefsthat characterize exposure reluctance and low distresstolerance. I then discuss how Tee and Kazantzis’ self--determination conceptualization of CE might be the basisfor tackling the maladaptive beliefs about exposure andnegative emotion that undermine engagement in thetherapy process. A case illustration is presented thatexemplifies how CE could address exposure reluctanceand low distress tolerance (DT). Finally, the paperconcludes with several questions for future research thatcould elucidate the mechanisms of change involved inpromoting client engagement in exposure.

Maladaptive Beliefs About Exposure

The topic of client resistance or noncompliance withbehaviorally based assignments is often discussed in CBTtreatment manuals, with a variety of client characteristicsand therapy process variables proposed as having asignificant impact on client readiness for change (e.g.,Abramowitz et al., 2011; Beck, Rush, Shaw, & Emery, 1979;Clark & Beck, 2010; Dobson & Dobson, 2009). Maladap-tive beliefs about exposure and their anticipated negativeconsequences are often considered contributing factorsto treatment resistance, but there is no consensus onwhich beliefs might be central to a person's reluctance toengage in exposure to avoided situations. Moreover, thereare no published empirical studies or validated self-reportmeasures of maladaptive beliefs about exposure. Basedon clinical experience and discussions in the clinicalliterature, Table 1 presents six beliefs about exposure thatmight reduce willingness to engage in situational expo-sure.

The maladaptive beliefs listed in Table 1 are notintended to be exhaustive but rather serve as examples ofthe types of beliefs that could result in client reluctance toengage in exposure. Moreover, the belief labels found in

Table 1Six Maladaptive Beliefs About Behavioral Exposure

Belief Type Example

Anxiety Intolerance “I will become so anxious I won't be ableto stand it.”“I'll have a panic attack.”“I'll be totally overwhelmed with theanxiety.”“I just hate feeling anxious; it's the worsefeeling in the world.”

Negative EffectsExpectancy

“Confronting the fear will only make meworse.”“I've been doing so well lately; this willonly wreck it.”“What if this causes a relapse and I actuallyfeel worse?”

CatastrophicConsequence

“What if the exposure triggers a heartattack, suffocation or other medicalcatastrophe because of the overwhelmingstress and anxiety?”“What if I end up humiliating myself in frontof others?”“What if I get stuck in a compulsive ritualbecause of my fears?”

Loss of Control “I can't stand feeling out of control.”“What if something unexpected happensduring exposure?”“I need to be able to remain calm and incontrol.”“I need to be certain that everything willbe fine.”“I need to learn to control the anxiety.”

False TreatmentExpectations

“I've already exposed myself to anxioussituations and it doesn't work.”“I don't believe generating anxiety is theway to reduce it.”“I've tried to face my fears in the past andcouldn't do it.”“I want to experience as little anxiety aspossible.”

Safety-Cue Effects “I can't stand to be alone.”“I need a friend/family member in order toget through this.”“I need to be certain help is immediatelyavailable if I experience problems.”“I need to be able to calm myself downquickly if I get too anxious.”

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Table 1 have heuristic value introduced to denote themajor emphasis of certain beliefs and are not meant tosignify distinct, mutually exclusive categories. Alone or incombination, these maladaptive exposure beliefs could beexpected to undermine the therapist's attempt toincorporate exposure as a key component of treatment.In a recent American Psychological Association Division12 survey of practitioners’ experience in using CBT for

treating panic disorder, inability to work independentlybetween sessions (i.e., homework noncompliance),unwillingness to give up safety behaviors, and fear ofexposure and associated emotional reactions were amongthe more common reasons cited for limited symptomreduction (APA, Division 12, 2010). In addition, cliniciansjudged a weak therapeutic alliance and client beliefs thatthey can be free of anxiety or engage in exposure withoutexperiencing panic or anxiety as additional factors that canlimit treatment success. Although these survey findingsrepresent practitioners’ open-ended view of the barriers toimplementing effective CBT for panic, they are consistentwithmy contention thatmaladaptive beliefs about exposurewill limit treatment effectiveness by mediating non-compliance with exposure assignments.

Maladaptive Beliefs About DT

Simons and Gaher (2005) first defined DT as the “…capacity to experience and withstand negative psycholog-ical states” (p. 83). It consists of an evaluation andexpectation of the acceptability, tolerability, disruption,and regulation of negative emotion. The authors indicatethat low DT individuals will experience distress as un-bearable, unacceptable, and all-consuming, so they arestrongly motivated to avoid anything that triggers negativeemotions or will pursue rapid means to alleviate adistressing state. It is immediately clear that low DT mightbe a highly relevant individual difference variable involvedin nonadherence to behavioral exposure. DT is related to anumber of other personality constructs, such as experien-tial avoidance, emotional suppression, disengaged coping,emotional dysregulation, anxiety sensitivity, persistence,and perseveration (see Zvolensky et al., 2011).

In the context of anxiety, DT has been viewed ashierarchically linked to anxiety sensitivity (Schmidt,Mitchell, Keough, & Riccardi, 2011), with the formerreferring to the tolerability to emotions generally, and thelatter to the specific emotion of fear and its sensations. Intheir review Schmidt et al. (2011) concluded that low DTmight be a risk factor for anxiety psychopathology and itmay also amplify anxiety in those with clinical disorders.Moreover, low DT has been implicated in majordepression as the tendency to consider negative emotionslike sadness as threatening and to believe one is unable tocope with negative emotional situations. This is associatedwith an unwillingness to experience or accept negativeemotion (Clen, Mennin, & Fresco, 2011). Clen andcolleagues discussed the relevance of low DT to otheremotion dysregulation concepts found in depression, suchas depressive rumination, emotional suppression, andbehavioral avoidance. Although research is preliminary,the authors speculate that low DT might explain whyindividuals with major depression might have a greater

Table 2Five Maladaptive Beliefs About Exposure to Negative Emotion

Belief Type Example

Intolerance ofNegative Emotion

“I can't stand feeling upset or distressed.”“It's important not to let myself get upset.”“I'll get overwhelmed and won't be ableto function all day if I get upset.”“Nothing is worse than feeling upset ordistressed about something.”

EmotionSuppression

“It's important not to show your emotionsto others.”“People will think you are weak andvulnerable if you appear emotional.”“People will take advantage of you ifappear upset.”“It's important not to let people knowhow you feel.”

⁎EmotionalOvercontrol

“I need to maintain strict control overmy emotions.”“Something bad will happen to me if Ilose control over my emotions.”“I need to learn to control my emotionsbetter.”

⁎Unacceptability,Nonacceptance

“I can't allow myself to feel certainemotions like shame or guilt.”“If I feel these emotions, it must beentirely my fault.”“I can't admit to having certain feelings.”“It's unbearable to feel an unacceptableemotion.”

⁎Rationality “Emotions can be controlled throughreason and understanding.”“Our feelings should always make sense.”“There is always a good reason why wefeel a certain way.”“It is better to be rational and logicalrather than emotional.”

⁎ Derived from Leahy (2002).

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tendency to rely on maladaptive emotion-regulation strate-gies like depressive rumination or emotional suppression.

Although a specific cognitive conceptualization of DThas not been proposed, the 16-item Distress ToleranceScale (DTS) developed by Simons and Gaher (2005) wasintended to measure “… beliefs about feeling distressed orupset” (p. 99). However, many of the items ask respondentsabout their experienceof distress, so theDTS is not a “pure”belief measure. Nevertheless, those scoring high on themeasure would be expected to hold maladaptive beliefsabout the experience of distress. Moreover, Leahy (2002)proposed a model of emotional schemas to explain howindividuals interpret their emotions and select certainemotion-regulation strategies. He argued that preexistingemotional schemas, or the plans, concepts and strategiesactivated in response to emotion-relevant cues, areinvolved in the pathogenesis of anxious and depressivedisorders (Leahy, 2010). In his model Leahy (2002)proposed 14 dimensions of emotional schemas, manyinvolving evaluations and beliefs about emotions, that areparticularly relevant to the present discussion. Table 2presents five types of maladaptive beliefs about negativeemotion, in part derived from Leahy's model as well asthe emerging research on DT.

As before, the maladaptive beliefs about experiencingnegative emotional states are examples of the faultythinking that may underlie low DT. Beliefs about theintolerance of feeling anxious, sad, or angry would be atthe heart of low DT. Schemas about the need to exercisestrict control over negative emotions and to suppress orinhibit emotional expression will result in the use ofdysfunctional emotion-regulation strategies. There isemerging evidence that emotional suppression willincrease negative emotion in both clinical and nonclinicalsamples (Campbell-Sills, Barlow, Brown, & Hofmann,2006) and is associated with lower well-being moregenerally (Gross & John, 2003). The last two maladaptivebeliefs of low DT, unacceptability and rationality, arederived from Leahy's (2002) emotional schema model.He argues that individuals who refuse to allow themselvesto have certain feelings, such as anxiety, shame, or guilt,will struggle more with these emotions than individualswho are more accepting of their negative feelings. As well,Leahy argues that an overemphasis on rationality and logicmay inhibit emotional expression and self-understandingof emotional experience. It is readily apparent how thesemaladaptive beliefs about negative emotionmight underlielow DT and contribute to the avoidance of any experience,such as exposure, that might involve the activation of anegative emotional state.

Schematic Change Through CE

In the previous discussion I have listed a number ofmaladaptive beliefs about negative emotional states and

behavioral exposure that might cause an anxious ordepressed client to be reluctant to engage in any behavioralassignments involving a negative emotional experience. Theidentification and modification of these treatment-resistantschemas should be incorporated into the case formulationand become a central goal in the CBT treatment plan if theclinician notices the emergence of treatment-interferingbehavior. Given the cost in therapist time, shiftingthe therapeutic agenda to treatment-resistant schemasshould only be considered when noting early signs oftreatment-interfering behavior, such as partly completedhomework. Also, a reluctant client who is not fullycommitted to the therapy process might find a discussionof their noncompliance quite threatening, even accusa-tory. There is a high risk that clients will terminatetreatment once the therapist turns the spotlight on the

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cognitive basis of their refusal to engage in behavioralexposure to avoided situations and negative emotion.The therapist's style in approaching this sensitive topicwill be crucial to treatment success. I believe a greateremphasis on CE can facilitate dealing with resistantclients who avoid exposure.

The term “treatment alliance” is a summary term thatrefers to various interpersonal processes involving thetherapist and patient that are thought to influencetreatment outcome (Elvins & Green, 2008). Meta-analyticstudies have found a modest but consistent associationbetween positive therapeutic alliance and better treatmentoutcome (Horvath & Symonds, 1991; Martin, Garske, &Davis, 2000). However, less is known about the actualcomponents of the therapeutic alliance responsible for itseffects on treatment (see Flückiger, Del Re, Wampold,Symonds, & Horvath, 2012). Bordin (1979) proposed thatthe therapeutic alliance consists of three components:goals, tasks, and bond. Goals and tasks refer to therapist--client agreement on treatment goals and the tasks orstrategies necessary to achieve these goals. Bond refers tothe degree of trust, respect, and liking between therapistand client. More recent studies indicate that goals and taskagreement may be more directly related to outcome thanbond, or quality of the therapist-client relationship (Taber,Leibert, & Agaskar, 2011; Webb, DeReubeis, Shelton,Hollon, & Dimidjian, 2011).

The original treatment manual for cognitive therapy ofdepression delineated three components of the “therapeu-tic alliance” that are critical for treatment success (Beck etal., 1979): (a) therapist characteristics of warmth, accurateempathy, and genuineness; (b) the building of trust andrapport in the therapeutic interaction; and (c) therapeuticcollaboration in the form of therapist and client agreementon various experiential exercises conducted betweensessions in order to gather evidence that invalidatesdepressogenic thoughts and beliefs. In cognitive therapy,exposure exercises are frequently employed in treatment ofanxiety disorders to evaluate anxiogenic thinking patterns,but the assignments are always developed as a shared,collaborative effort between therapist and client (Beck &Emery, 1985; Clark & Beck, 2010).

More recently attempts have been made to clarify thenature of the collaborative relationship in cognitivetherapy, or what has been termed collaborative empiri-cism (CE). In their elaboration on case conceptualization,Kuyken, Padesky, and Dudley (2008) delineated twoaspects of CE. Collaboration involves the therapist andclient sharing their respective expertise in order todescribe, explain, and help resolve the client's presentingproblems. Empiricism is using a CBT model to concep-tualize and then utilize an empirical approach based onobservation, evaluation of experience, and learning. Theauthors argue that CE is a critical process in developing

the cognitive case conceptualization. In their subsequentbook on case conceptualization, Kuyken and colleagues(2009) noted that therapists employing CE will makefrequent checks on the client's understanding, negotiatechanges in the session agenda, collaborate on the designof homework assignments, and ask for the client's opinionon choice of treatment goals and direction.

Tee and Kazantzis (2011) proposed that self-determination theory (SDT) might provide a conceptualframework for understanding the therapeutic benefits ofCE. SDT states that individuals who aremore autonomouslyengaged in therapy, that is, individuals who internallyattribute treatment gains to their own efforts, are morelikely to integrate learning and behavior change, whichthen leads to more positive outcomes (Ryan & Deci, 2008).Ryan and Deci argue that an external locus of causality willbe associated with unstable treatment outcomes becausethe client will experience conflict about the change process.Based on this formulation, Tee and Kazantzis argued thatkey elements of CE, such as shared decisionmaking, sharedformulation, negotiation of treatment goals, and mutualresponsibility for task assignment, will increase clientinvolvement and a more autonomous self-attribution forbehavioral change. Thus, more consistent and efficacioustreatment outcome should be associated with high CE caseformulation and treatment.

Based on these considerations, how could a greateremphasis on CE reduce client reluctance to engage inexposure to avoided situations and negative emotions?How might CE be utilized to increase the probability ofautonomous self-attribution for symptom reduction frombehavioral exposure assignments? The following are somesteps the therapist can take to fine-tune CE in order toincrease internal self-attribution and greater acceptanceof exposure intervention.

1. Inquire about client beliefs concerning symptom change.Often clients begin therapy with preexisting beliefsabout effective or ineffective approaches to symptomreduction. These beliefs may be based on priortreatment experiences or information obtained fromother sources like the Internet. For example, theymay believe that anxiety or depression is a “brainchemical imbalance” and can only be treated withmedication, or that one must learn perfect controlover emotions by using various calming strategies.Clients might believe that symptom relief can only beobtained by eliminating stress or conflicts in their life,or that an unknown cause in one's childhoodmust bediscovered. These beliefs would conflict with a CBTperspective on emotional disorders and could lead toresistance to engage in exposure. Their identificationand correction early in therapymight be essential fortreatment progress.

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2. Identify, evaluate, and modify maladaptive exposurebeliefs. It is important that the therapist inquireabout beliefs and expectations the client might haveabout exposure to avoided situations (see Table 1).Most people have had some personal experience ofconfronting an undesirable situation. Probing forsuch examples will help discover any negativebeliefs the client may hold about engaging inexposure. As well, question clients about any storiesor other information they may have heard aboutexposure that could result in negative expectations.It is important to have a good understanding ofclients’ attitudes about exposure before assigningexposure tasks. It is probably more advantageous todeal with resistance before it becomes homeworknoncompliance than after the client refuses toengage in an exposure exercise.

3. Identify, evaluate, and modify negative beliefs aboutdistress. The therapist should assess the client'sbeliefs about experiencing moderate distress beforeassigning an exposure exercise (see Table 2).Depending on the degree of DT, the therapistmay have to first strengthen emotion-focusedcoping strategies such as relaxation training orcontrolled breathing before initiating systematicexposure. Of course, care must be taken whenutilizing any relaxation strategies because clientscould turn them into maladaptive avoidant strate-gies to escape undesired negative emotion. Anempirical hypothesis-testing approach can be usedin which between-session homework provides cli-ents with experiences that demonstrate they cantolerate more distress than they originally expected.

4. Personalize and normalize exposure experiences. Individ-uals with emotional disorders often believe they areweak and unable to cope with negative emotion.They often forget, or at least downplay, times whenthey successfully coped with anxiety or evensadness. It is important that the therapist explorewith the client times of “normalized” anxiety,sadness, anger, or frustration. The objective is togather past evidence that refutes clients’ belief theycannot tolerate distress or are unable to cope withmoderate anxiety or other negative emotions.Often these discussions are an important discoveryfor clients and a source of great encouragementthat they can confront their fears through exposure.

5. Utilize graduated, negotiated, and hypothesis-testingexposure. Most exposure should be conducted in agraduated fashion, beginning with less distressingsituations and then progressing to more anxiety--provoking scenarios (Abramowitz et al., 2011; Antony& Swinson, 2000; Clark & Beck, 2010). Collaborationwith the client will be a critical feature of the

therapeutic interaction when discussing exposureassignments. The client should be directly involved inoutlining the parameters of the assignment. This willencourage greater responsibility and autonomousattribution for completing the exposure.

6. Integrate and consolidate behavioral outcomes. It iscritical that therapists review with clients theirbetween-session experiences with exposure assign-ments (Nelson, Castonguay & Barwick, 2007; Rouf,Fennell, Westbrook, Cooper, & Bennett-Levy, 2004).Positive behavioral outcomes should be emphasizedas providing disconfirming evidence against theclient's maladaptive beliefs about exposure or toler-ance of negative emotion. At the same time, anyfailures with exposure or behavioral activation shouldbe thoroughly explored using guided discovery andSocratic questioning in order to identify problemswith the assignment. In a highly collaborativemanner, the therapist problem-solves with the clientwhat changes in the exposure task could be made inorder to improve its therapeutic outcome. Wheneverthe client achieves a positive result with an initialexposure task or its subsequent refinement, thetherapist collaboratively attributes the experience tothe client's own efforts in order to reinforce anautonomous attribution for behavioral change. Byspending session time reviewing the outcome ofexposure assignments, the CBT therapist is integrat-ing the behavioral assignment into the therapeuticprocess and consolidating what the client has learnedfrom these critical experiences.

7. Reinforce an autonomous attribution for behavioralchange. Based on the previous discussion of SDT,the therapist seeks out opportunities to attributetreatment gains to the client's own efforts. This canbe done by viewing the therapist's role as facilitatoror consultant rather than healer. The therapist canalso review the trajectory of change, noting thattherapeutic gains were made after the clientengaged in behavioral exercises. The therapist canalso discuss how changes in the client's thinking ledto behavioral changes and subsequent reductions inanxiety or depression. At the very least, the therapistshould be vigilant for any client external attribu-tions of change that might undermine treatmentgains, and collaboratively address this misattributionin order to encouragemore autonomous attributionsfor the therapeutic process.

Case Illustration

The following case illustrates how a collaborativeapproach can be used to deal with a client reluctant toengage in exposure because she might experiencesignificant distress. In this example (a) maladaptive beliefs

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about exposure are identified and evaluated, (b) anexample of adaptive coping with “normal anxiety” isobtained, (c) treatment progress is attributed to the client'sefforts, and (d) a more gradual exposure assignment isnegotiated. Throughout the therapist repeatedly attributestreatment progress to the client's personal efforts andresources, thereby reinforcing an autonomous attributionfor behavioral change.

Mary is a 27-year-old clerical worker with a 10-yearhistory of OCD.Her primary obsession is a fear of chemicalcontamination on her hands and she washes her handsdozens of times daily. Whenever she has tomake a decision,even about trivial actions like getting out of bed or startingthe car in the morning, she doubts whether she is doing itcorrectly. This doubt then triggers fear that her handsmight be contaminated. Quickly her fear and anxietymount, and are only relieved if she thoroughly scrubs herhands. This scenario plays itself out many times during theday. Mary had unsuccessfully tried numerous medications,with the current regimen providing onlymodest relief fromanxiety. Her obsessions and compulsions persisted despitevarious psychotherapeutic attempts and at least twohospitalizations. Mary contacted my private practice,desperate for some relief from an OCD condition thatwas greatly interfering in her work, quality of life, and herimminent plans for marriage. However, Mary had to travelconsiderable distance to attend therapy sessions and herhealth insurance only covered 10 sessions annually. Maryexpressed interest in whether a brief, intensive course oftreatment might be viable.

The first three sessions focused on a diagnostic andsymptom assessment, and culminated in a cognitive caseconceptualization, which is a description and explanation ofthe client's presenting problems based on a cognitivebehavioral formulation (Kuyken et al., 2008). Mary'sprimary Axis I diagnosis was OCD with a comorbid majordepression that was secondary to her long struggle with afear of contamination. After collaboratively setting treat-ment goals and discussing the treatment rationale formeeting these goals, an exposure hierarchy was con-structed. The cognitive model of obsessions was discussedand illustrated with various examples from Mary's dailyexperiencewithOCD.Given the limited number of sessionsavailable for treatment, it was decided to introduce a fairlyambitious exposure assignment at the sixth session. Aftermaking some initial progress, treatment hit an impasse withMary reluctant to advance further in the exposurehierarchyand expressing discouragement with the pace of change. Inthe next session the therapist shifted the agenda to addressMary's beliefs about exposure and anxiety in order to dealwith treatment-interfering behavior.

THERAPIST: Mary, you have been doing really well inconfronting some of the minor things in your life

that trigger the contamination fear. How do youfeel about your progress?

MARY: Well, I'm quite pleased but I don't think I'vemade much progress. I have a long way to go andwe have only four sessions left.

THERAPIST: I understand your concern, but thatdoesn't eliminate the fact that you've been doingexposure and making yourself uncomfortable.What do you now think about what you told mewhen we first started meeting—that you can't standfeeling anxious?

MARY: True, I guess I am a little tougher than Ithought but I haven't touched the really big stuffthat makes me very anxious.

THERAPIST: What are you afraid would happen if youexposed yourself to something that caused significantanxiety, let's say, using a household cleanser?

MARY: I could never do that; I'm sure I wouldbecome intensely anxious, may be even have apanic attack. I'd have to keep washing and washinguntil my hands were sore and bleeding. Somethinglike this would set me back weeks if not months. I'dhave to take time off work and probably end upalone in my apartment, afraid to touch anything.

THERAPIST: That sounds very dire indeed. Hasanything like that ever happened to you in the past?

MARY:No, not exactly. But I'm scared it couldhappen tome. I'm afraid to push myself too far in case I crack.

THERAPIST: Okay, I understand. It sounds like you'venever “cracked” but you imagine that you couldcrack and that really scares you. “Cracking up”sounds like a real personal catastrophe. In this typeof therapy we often refer to such thinking as“catastrophizing.” Is that what you are doing here,Mary, catastrophizing?

MARY: I suppose I am. True, I've never cracked, butwho wants to take the chance?

THERAPIST: Well, do you see any negative conse-quences for you of having this fear of cracking up

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or losing control, that is, your fear of becomingintensely anxious?

MARY: I guess it is probably preventing me fromdoing lots of things, and you mentioned before thatthis type of thinking might be fueling my OCD.

THERAPIST: Good points. Was there anything in yourlife that you used to be afraid to do but you forcedyourself to face the fear, endure the anxiety, andconquer your avoidance?

MARY: When I first started dating Ted (Mary'sfiancé) he was an avid downhill skier. I never skiedin my life and was terrified when I first tried. I wassure I would fall and break a leg. But I took skilessons, started on the bunny hill, and graduallyworked my way up so that now we ski the blue runstogether. I realized I had to get over my fear ofskiing if I had any chance of a relationship withTed.

THERAPIST: It sounds like you used a lot of the samestrategies to overcome your fear of skiing that weuse in this therapy to overcome obsessional fears.Even though you were very afraid to ski andcatastrophized the whole experience (“I'll fall andbreak a leg”), nevertheless you started out slow,repeatedly exposed yourself to skiing, endured theanxiety, and then conquered your fear. What'samazing is that you did this without therapy ormedication; you did it on your own.

MARY: I guess I did. I never thought of it that way.I've always thought of myself as emotionally weak,unable to deal with distress or upset.

THERAPIST: Remember that bank TV commercial,“you're richer than you think.” In this case wecould say “you're stronger than you think.” I amwondering if you would take that inner strengthand try considering something with me in thesession right now. I would like to get some liquidsoap and put it on your hands. Could you rub thesoap over your hands so your hands feel a littlesticky? Then could you imagine that your handsare contaminated with chemicals? Do you thinkyou could do that?

MARY: No, I don't think so. That sounds reallyterrifying to me. I think that's asking too much.

THERAPIST: Okay, well can we at least talk about yourmisgivings.What are you concernedmight happen? Isthere some part of this exercise that scares you most?

MARY: I think I would be okay with the soap but I'mafraid to imagine that my hands are contaminated.I have a really active imagination; I can imaginethings so vividly I become convinced they are real. Icould end up with a panic attack and have to washrepeatedly.

THERAPIST: What I hear you saying is that you arethinking you might get stuck in an obsessional fearby imagining that your hands are contaminated.Has that ever happened to you?

MARY: Not exactly in the way you are talking. But Irealize each time that I fear contamination I am notactually contaminated; it's the thought of beingcontaminated that scares me.

THERAPIST: Sure, so it sounds like your concern withthe exercise is that by purposefully, intentionallybringing on the contamination fear, you'll beoverwhelmed with anxiety.

MARY: Exactly!

THERAPIST: Well, could we talk about what we mightdo if that happened? Let's say for the moment youimagined being contaminated and experiencedunbearable fear. What could you do to deal withthe anxiety?

MARY: I suppose I could take an Ativan; I carry themwith me all the time. But you wouldn't approve ofthat. What could you do to help me?

THERAPIST: We could try some deep breathing orother types of relaxation. I could also do somecoping imagery work with you. We could also stopthe exposure at any time and you could wash yourhands. Given we have such an extensive back-upplan, would you like to try this exercise?

MARY: I don't know. I'm really scared.

THERAPIST: I understand. Would you considermaking some changes in the exercise that wouldhelp you do it? How far do you think you could go?

453Collaborative Empiricism and Exposure

MARY: What if I took a marker, put a dot on myhand, and imagined it was dirt? Maybe if I was okaywith that, I could then imagine it was a chemical.

THERAPIST: That sounds fine tome. This will be a goodtest of your belief that even imagining contaminationwill cause you unbearable anxiety. However, you aretaking a more gradual approach to confronting yourfear, maybe like starting on the bunny hill when youlearned to ski. We'll eventually get to the same goal,although it may take a little longer and youmay needa couple of extra sessions. Is that okay with you?

MARY: Yes, I think I prefer that we work at a slowerpace.

THERAPIST: Great! Let's get started.

Conclusion

It is widely recognized that behavioral exercises such asexposure andbehavioral activation are critical ingredients ofchange in CBT for anxiety and depression (Clark & Beck,2010; Dobson & Dobson, 2009). Nevertheless, behavioralassignments such as exposure are often omitted by CBTpractitioners because of client refusal, possibly related to lowdistress tolerance. It was proposed that certain maladaptivebeliefs about exposure and the experience of negativeemotions might underlie client reluctance to engage inexposure-based therapy. Several potential maladaptivebeliefs were proposed and a therapeutic style based onenhanced CE was presented as a response to exposurereluctance. Several therapeutic strategies were suggested forrefining the CE approach to exposure reluctance and forimproving clients’ autonomous attribution for change (Tee& Kazantzis, 2011). A case example was presented thatillustrates the use of CE to address exposure reluctance.

Empirical research is needed on a number of keytreatment process issues concerning the role of CE infacilitating the uptake and effectiveness of exposure-basedinterventions. Research could focus on specifying thedevelopment and function of maladaptive beliefs thatcharacterize resistance to exposure and low distresstolerance. Psychotherapy process studies could examinewhether correction of these maladaptive beliefs results ingreater willingness to engage in exposure and betteracceptance of negative emotion, and whether this, in turn,contributes to improved treatment outcome. Another keyissue concerns whether a greater focus on CE actuallyimproves homework compliance that involves exposure tonegative emotions and avoided situations. What features ofCE are responsible for the improved compliance rates and

can therapists be trained inusing anenhanced formofCE toimprove client engagement in exposure? Another criticalquestion, within the context of the current proposal, iswhether a greater emphasis on collaboration and experien-tial behavioral exercises actually increases clients’ autono-mous attributions for behavioral change and whether theseattributions actually improve treatment outcome. Whilemany questions remain about the role of CE in addressingresistance to exposure, there can be little doubt that a moreempathic, collaborative, understanding, and empiricallygrounded therapeutic style stands the best chance of dealingwith client reluctance to confront avoided situations andtolerate negative emotional experiences.

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Address correspondence to David A. Clark, Ph.D., Department ofPsychology, University of New Brunswick, PO Box 4400, Fredericton,New Brunswick, Canada E3B 5A3; e-mail: clark@unb.ca.

Received: February 6, 2012Accepted: June 14, 2012Available online 3 July 2012