1P. Neudeck and H.-U. Wittchen (eds.), Exposure Therapy: Rethinking the Model – Refi ning the Method, DOI 10.1007/978-1-4614-3342-2_1, © Springer Science+Business Media, LLC 2012

Dr. Peter Neudeck is a licensed psychotherapist specialized in cognitive-behavioral therapy. He has been working both in clinical and research positions and has estab-lished private practices for psychotherapy in Berlin and Cologne. He is also a lec-turer and supervisor for graduate and postgraduate CBT-psychotherapy programs across Germany. He recently received further professional development in CBASP and systemic therapy. His main research activities include psychobiology and psy-chotherapy of anxiety disorders in exposure based treatments. He has released numerous publications on exposure techniques in mental disorders.

P. Neudeck (*) Praxis für Verhaltenstherapie , Follerstr. 64 , D-50676 Köln/Cologne , Germany e-mail: peterneudeck@gmx.de

H.-U. Wittchen Institute of Clinical Psychology and Psychotherapy , Technische Universitaet Dresden , Chemnitzer Strasse 46 , 01187 Dresden , Germany e-mail: wittchen@psychologie.tu-dresden.de

Chapter 1 Introduction: Rethinking the Model - Re fi ning the Method

Peter Neudeck and Hans-Ulrich Wittchen

2 P. Neudeck and H.-U. Wittchen

Professor Hans-Ulrich Wittchen is director and CEO of the Institute of Clinical Psychology and Psychotherapy at the Technische Universitaet Dresden, including the Center of Clinical Epidemiology and Longitudinal Studies (CELOS) and the Psychotherapy Outpatient Center. He is and has been principal investigator and co-investigator of many national and international research programs and large-scale epidemiological studies. His work encompasses a wide range of etiological- pathogenetic, family-genetic, experimental, clinical, and epidemiological studies with a focus on prospective-longitudinal studies in addiction, anxiety, mood, and somatic disorders.

1.1 Why a Book on Exposure Therapy?

Exposure therapy is one of the most robust and most effective standard procedures among the behavioral psychotherapy variants. Initially frequently used as a stand-alone treatment particular for anxiety disorders, it is nowadays typically used in the context of a conceptually wider framework of cognitive-behavioral therapies (CBT) in a variety of formats and techniques. Over the past two decades and as a result of the increasing emphasis on cognitive factors, however, exposure therapy and its core principles have also become increasingly diffuse. Being usually embed-ded in complex CBT procedures, and frequently used interchangeably with the term cognitive-behavior therapy, principles and unique procedures of exposure therapy appear to be more and more confuse, particularly when conceptually important boundaries between cognitive, affective, and behavioral components in the process of intervention have become blurred. We feel that this development is threatening to the integrity of exposure therapy as a scienti fi cally based, highly effective psychological treatment approach. We also see the risk that the apparent lack of attention devoted to exposure therapy and its foundations might result in a deterioration of the effectiveness of behavioral psychotherapies.

31 Introduction: Rethinking the Model - Refi ning the Method

The main goal of this book is to stimulate the fi eld to shift attention toward reconsidering the scienti fi c basis of exposure therapy, consolidating the basic mod-els and principles by incorporating novel scienti fi c evidence and to start work into the core questions we need to address, namely “Why does exposure therapy work? Why does cognitive-behavior therapy work?” There have been signi fi cant develop-ments in recent years that further endorsed our motivation for this book: First, meth-ods of exposure therapy have been expanded to a wide range of disorders beyond the anxiety spectrum, including body dysmorphic disorder and hypochondriasis. Secondly, exposure techniques also play an important role in the so-called “third wave therapies” (ACT, Schema Therapy, CBASP). Thirdly, a tremendous amount of evidence has been accumulated regarding core aspects of exposure therapies such as ethics, control strategies, and the role of cognitive interventions. And fourth, new data have become available regarding the theoretical foundations and assumed mechanisms of action (i.e., habituation, extinction learning) of exposure therapy.

The aim of this book is to provide practitioners and scientists with a critical review of these developments by state-of-the-art contributions of several outstand-ing international experts. Given the huge amount of peer-reviewed experimental papers, fi ndings of randomized clinical trials, reviews, and meta-analyses on expo-sure therapy every year, it was important for us to provide a forum where different approaches (i.e., concerning dissemination in clinical practice, cognitive enhancers, and cognitive interventions, anxiety control strategies) are presented and critically discussed. Although exposure therapy has a long tradition among the behavioral approaches and is considered a “standard procedure,” there are many unresolved questions. This book provides an up-to-date appraisal of these issues from various perspectives and highlights the need to rethink the model of exposure therapy.

1.2 The Challenges

A core challenge in exposure therapy and CBT alike refers to the unresolved ques-tion, why these therapies work and what are the basic mechanisms of action involved. When we examine highly effective traditional treatment packages like the Panic Control Treatment (PCT) or the Mastery of Your Panic Treatment for anxiety disor-ders as an example, the dilemma is evident. These packages contain so many ele-ments that it seems a daunting task to fi nd out what actually contributes to successful treatment. The PCT treatment for example combines education, cognitive interven-tions, relaxation, controlled breathing procedures, and exposure techniques, usually delivered in 11 or 12 weekly sessions. Two techniques are used to change maladap-tive fear and anxiety behaviors in particular: The exposure to internal cues (intero-ceptive exposure) and the exposure to external cues (situational exposure). As Hofmann and Spiegel ( 1999 ) pointed out, PCT does not include systematic in situ exposure; for patients with signi fi cant situational avoidance a supplement was, however, developed later on. One might ask a whole series of questions, such as: What are the ingredients or core elements of exposure therapy in such complex packages?

4 P. Neudeck and H.-U. Wittchen

What exactly is exposed, how and when? What are the assumed and essential mechanisms of action during in-situ exposure and what makes the difference to interoceptive exposure?

When considering mechanisms of action more closely, it seems to be evident that there are likely many core candidates that we need to look at; and the list of poten-tially relevant explanatory concepts and models is quite long: From the historically relevant concept of reciprocal inhibition as the working mechanism of systematic desensitization, over Mowrers Two-Factor Theory of Fear Acquisition, Lang’s Bioinformational Theory, Rachman’s Emotional Processing Theory, Foa and Kozak’s Emotional Processing Model, the Cognitive Approach of Perceived Control and Self-Ef fi cacy to more recent neural networking and connectionists models (Tyron, 2005 ) . Each of these theoretical approaches makes contributions to explain changes according to exposure procedures, although the theoretical frameworks of these explanations considerably differ to a substantial amount. It should be noted, however, that most of these models also add more or less to the effects of cognitive interventions in CBT. Thus, these models are not speci fi c and fail to give us a con-sistent and solid clari fi cation of why exposure therapy works within and outside the context of CBT.

1.3 Purple Hat Therapy

Rosen and Davison ( 2003 ) illustrated their listing of empirical supported treatments with an intervention called “Purple Hat Therapy” (PHT). Therein, the patient is asked to wear a purple hat while exposed to a feared stimulus. PHT is more effective then the control treatment due to exposure to the feared situation. The founders and future trainers of the Purple Hat “Therapy”, however, will most likely attribute the effec-tiveness to the purple hat the patient wears during the exposure sessions. Hereafter, special trainings and courses in the PHT and a series of papers about PHT are most likely to be published. Thinking and speculating further, one might assume that the basic mechanism of action of exposure therapy is change of the patients’ cognitions. In consequence, the main ingredient of exposure therapy would be that the therapist focuses on the problem-solving skills of the patient, while exposing him to an avoided stimulus. From this context, one might ask: What is the Purple Hat then?

When looking into clinical studies on the effectiveness of exposure therapy in the last decade, methodological problems are evident stressing this issue of the “Purple Hat.” For example, Paunovic and Öst ( 2001 ) designed a trial to investigate the com-parative effectiveness of exposure therapy and CBT in the treatment of posttrau-matic stress disorder and found no differences between the treatments on any measure. In the method section of their paper, the procedure of exposure was described as a graduated confrontation “with anxiety-provoking trauma-related images and situations with the help of the therapist” (p. 1188 ). No information is, however, provided about the rationale and context of the procedure. No patient will agree to expose himself/herself to feared stimuli without any prior instruction or the

51 Introduction: Rethinking the Model - Refi ning the Method

provision of knowledge about the purpose of such a procedure. So is the Purple Hat hiding here? In fact, the CBT procedure in this study was to identify intrusive thoughts and catastrophic interpretations at the fi rst step. The second step was then to recog-nize faulty thinking and to challenge catastrophic thoughts, followed disputing the thoughts and generating non-catastrophic alternatives (step 3). The fi nal step was to proof the validity of the patient’s hypothesis, with “behavioral experiments.” After six sessions, the “exposure therapy” started and ran parallel to the cognitive therapy. The authors write: “Exposure was conducted similarly as described above. The main difference was that there was less time for exposure because cognitive interventions and controlled breathing were also included.” (p. 1189).

So what were the ingredients of the cognitive therapy arm in this study? Problem solving, behavioral experiments, disputing, exposure, and breathing control. In comparison, the ingredients of the exposure therapy condition were imagined and in-vivo exposure.

And what were the active ingredients in the two treatment conditions? Did cog-nitive therapy work through the problem-solving technique or through the behav-ioral experiments, etc? Did exposure work through controlled breathing? And furthermore: Do behavioral experiments work because they induce a change of beliefs or through exposure?

Hard to say—isn’t it? Let us take another example: Investigating the effects of CBT compared with traditional behavior therapy, namely exposure and response pre-vention (ERP) in group psychotherapy for obsessive–compulsive disorder, McLean et al. ( 2001 ) described the CBT condition as follows: “Behavioral experiments had similar features to ERP; however, the function was different. In ERP, the purpose of repeated exposure was habituation. Behavioral experiments that were completed in the CBT condition were always done to test an appraisal.” (p. 210). One might argue that the difference between the conditions was the introduction; so the core compo-nent in both treatments was “exposure.” The examples above are representative of methodological problems we fi nd in many clinical treatment studies.

A third example: A recent review of behavioral experiments vs. exposure alone in the treatment of anxiety disorders (McMillan & Lee, 2010 ) comprised 14 clinical trials. The authors state that they “found fi rst evidence, that setting up exposure as a cognitive test may be more effective than exposure in which this does not occur” (p. 474). A notable limitation of the studies reviewed was that the duration of the exposure itself was very short (i.e., 5 min, Kim, 2005 ; Wells et al., 1995 ) . Only two of the 14 studies used a single duration of more than 30 min for each exposure ses-sion (which sounds more reasonable and state of the art to us). The authors con-cluded: “There is a need for studies using brief interventions in which differences are limited to the use of exposure as a cognitive test vs. exposure in which that cognitive component is absent, and in which the duration of exposure is substantially longer than that used in the majority of studies reviewed here.” (McMillan & Lee, 2010 ; p. 475). Furthermore, they suggested variables which need to be changed and tested in future studies, such as the content of the cognitive rationale, or the presence and absence of the therapist and his role for modifying the situation. The authors inter-preted their fi ndings as being contrary to Langmore and Worrell’s review (Langmore

6 P. Neudeck and H.-U. Wittchen

& Worell, 2007 ) , who concluded that there is no need to challenge thoughts in CBT. McGillan and Lee suggested that exposure might be more effective when there is a challenge in cognitions such as in behavioral experiments.

So here we stand-alone and nude regarding behavioral experiments. How can a method “A” be more effective when adding an ingredient of method “B,” albeit not knowing through what method “B” works? And by the way, how do behavioral experiments work if anything: through a change of cognitions or exposure or in some way by both?

Is there a way forward to solve the puzzle and to speci fi cally identify the active ingredients of exposure therapy as well as their role in CBT? One, though imperfect way, has been recently exempli fi ed by a German multicenter study: “Psychological Treatment for Panic Disorder with Agoraphobia: A Randomized Controlled Trial to Examine the Role of Therapist-Guided Exposure in situ in CBT” (Gloster et al., 2011 ; also see Lang & Helbig-Lang in this book). In this study, two identical treat-ment packages were compared and only one variable differed between them, namely the absence or presence of the therapist. The introduction of the rational, the fre-quency of exposure etc was completely equal in both treatment conditions. However, we are aware of putative limits of randomized clinical trials. Albeit thoughtfully developed, they are not really suitable to capture the true complexity of the problem. But at least it is a very fi rst start. Clearly we need to think about novel designs and approaches beyond the traditional study designs, in order to be able to collect data and to develop more speci fi c hypotheses regarding the basic elements, ingredients, and mechanisms of exposure therapy.

This immediately brings up the question how to conceptualize and de fi ne expo-sure therapy. For this book, we suggest the following working de fi nition for expo-sure: “Exposure is a component of a treatment package in which the patient is educated about the disorder, prepared and provided with a rationale of the thera-peutic change, and exposed to avoided and feared external and internal stimuli.”

The treatment package can be purely behavioral, cognitive–behavioral, rational–emotive, dialectic–behavioral, systemic or interpersonal. Given the conceptual problems discussed above, it makes no sense in our perspective to compare “CBT treatment packages” against “exposure packages.” It is like testing apples and oranges. We strongly recommend testing the components of the treatment packages irrespective of their label.

Therefore a standard of components used in such treatment packages is abso-lutely mandatory. We hypothesize at least the following components to be absolutely necessary:

Psychoeducation about the disorder – A patient model of history and maintenance of the disorder – A cue hierarchy – A well-described model of how and what kind of rational is provided – Finally a list of the feared consequences and the avoidance behavior –

For the exposure procedure we further need commonly agreed standards of what constitutes exposure, what the therapists is allowed to do (and what not), as well as

71 Introduction: Rethinking the Model - Refi ning the Method

standards and quality-assured principles of adequate duration, frequency, and appli-cation of exposure techniques. Exposure techniques include:

In-vivo (in-situ) exposure: gradually or massed – Interoceptive exposure: primary or secondary – Imaginary exposure: primary, secondary, and preliminary –

What about behavioral experiments then? To give a simple answer: a behavioral experiment is not an exposure technique. Studies comparing exposure techniques with behavioral experiments show that there are simply too many confounders, such as the speci fi c instructions to patients, duration, and purpose of exposure or the incorporation of cognitive elements. Because of these many confounders, it is highly questionable whether behavioral experiments could be labeled with suf fi cient integ-rity as a form of exposure. Hence, it makes little sense to compare these techniques to each other, but it is of great importance to study them in isolation and separately in order to answer questions like: What works in behavioral experiments and why? Again, it is important to compare different behavioral experiments against each other, instead of comparisons of behavioral experiments with exposure techniques.

Some of the questions raised seem to be very academic, and several seem to move in circles. Past research, for example, was unable to determine what comes fi rst, the cognitive change or the physiological habituation; similarly, studies were also unable to answer the question of what might be the main effect. Maybe it is more important in the future to search for the most effective variant of exposure than to invest to no avail in the search for the “blue fl ower.” For clinical practitioners, it is obvious that a patient habituates during an exposure session and it is no surprise that the patient has changed some of his automatic thoughts or maladaptive apprais-als after two or three exposure sessions. In their book “Exposure Therapy for Anxiety” (Abramovitz, Deacon, & Whiteside, 2010 ) the authors write: “Speci fi cally therapists are understandably reticent to adopt a treatment plan that deliberately (if only temporally) increases a patient’s already distressing anxiety. Consequently, a therapist would only select this treatment if she believed that it was the best method for helping their patients in the long run.” For practitioners, it is more important to get information about what in fact helps the patients. Should they spend a lot of time on explaining the rationale or is there just a little effect? Should they allow anxiety-control strategies such as distraction, or does this reduce the effectiveness? Taking this into account, future investigations on exposure need to search for the important elements of the treatment. In this book, you will hopefully fi nd some of the elements we expect to be con fi rmed as indispensable for successful exposure.

References

Abramovitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2010). Exposure therapy for anxiety: Principles and practice . New York: Guilford.

Gloster, A. T., Wittchen, H.-U., Einsle, F., Lang, T., Helbig-Lang, S., & Fydrich, T. (2011). Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to

8 P. Neudeck and H.-U. Wittchen

examine the role of therapist-guided exposure in situ in CBT. Journal of Consulting and Clinical Psychology, 79 (3), 406–420.

Hofmann, S. G., & Spiegel, D. A. (1999). Panic control treatment and its applications. Journal of Psychotherapy Practice and Research, 8 (1), 3–11.

Kim, E.-J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders, 19 (1), 69–86.

Langmore, R. J., & Worell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27 , 173–187.

McLean, P. D., Whittal, M. L., Thordarson, D. S., Taylor, S., Söchting, I., Koch, W. J., et al. (2001). Cognitive versus behavior therapy in the group treatment of obsessive compulsive disorder. Journal of Consulting and Clinical Psychology, 69 (2), 205–214.

McMillan, D., & Lee, R. (2010). A systematic review of behavioral experiments vs. exposure alone in the treatment of anxiety disorders: A case of exposure while wearing the emperor’s new clothes? Clinical Psychology Review, 330 (5), 467–478.

Paunovic, N., & Öst, L. G. (2001). Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behaviour Research and Therapy, 39 , 1183–1197.

Rosen, G. M., & Davison, G. C. (2003). Psychology should list empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages. Behavior Modi fi cation, 27 (3), 300–312.

Tyron, W. W. (2005). Possible mechanisms for why desensitization and exposure therapy work. Clinical Psychology Review, 25 , 67–95.

Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26 (1), 153–161.