Training with tarantulas: A randomized feasibility and acceptability study using experiential learning to enhance exposure therapy training

BackgroundAlthough exposure is a key evidence-based intervention for anxiety, it is infrequently used in clinical settings. This study employed a novel training strategy, experiential learning, to improve exposure implementation. This study aimed to assess the feasibility and acceptability of experiential training and preliminary training effectiveness.MethodsParticipants were 28 therapists who were randomized to (a) training-as-usual or (b) experiential training (training-as-usual plus a one-session treatment for fear of spiders). Workshops lasted one day and were followed by three months of weekly consultation.ResultsExperiential training was viewed as feasible and acceptable. Participants, including those who were fearful of spiders, had a positive response to the training and reported it to be useful. There was a significant increase in the number of exposures used by therapists receiving experiential training compared to training-as-usual at 1-month follow-up.ConclusionsA one-day training resulted in significant improvements in knowledge, attitudes toward exposure, and self-efficacy in using exposure. Preliminary findings suggest that experiential training resulted in greater use of exposure post-training compared to training-as-usual. Results provide evidence for the feasibility and acceptability of experiential training as a strategy to increase the use of evidence-based interventions.     

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.     

The impact of social skills training for social anxiety disorder: A randomized controlled trial

ObjectiveSocial anxiety disorder (SAD) impacts social, occupational and academic functioning. Although many interventions report change in social distress, improvement in social behavior remains under-addressed. This investigation examined the additive impact of social skills training (SST) for the treatment of SAD.MethodUsing a sample of 106 adults who endorsed SAD across numerous social settings, participants were randomized to exposure therapy (imaginal and in vivo) alone, a combination of SST and exposure therapy known as Social Effectiveness Therapy (SET), or a wait list control. The assessment strategy included self-report measures, blinded clinical ratings and blinded assessment of social behavior.ResultsBoth interventions significantly reduced distress in comparison to the wait list control and at post-treatment, 67% of patients treated with SET and 54% of patients treated with exposure therapy alone no longer met diagnostic criteria for SAD, a difference that was not statistically significant. When compared to exposure therapy alone, SET produced superior outcomes (p < .05) on measures of social skill and general clinical status. In addition to statistical significance, participants treated with SET or exposure reported clinically significant decreases on two measures of self-reported social anxiety and several measures of observed social behavior (all ps < .05).ConclusionsBoth interventions produced efficacious treatment outcome, although SET may provide additional benefit on measures of social distress and social behavior.     

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial

AimTo compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.MethodsParticipants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.ResultsParticipants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.ConclusionsInternet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.     

360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial

Public speaking anxiety (PSA) is a prevalent condition which is highly interrelated with social anxiety. PSA can be effectively treated with exposure therapy. Virtual reality exposure therapy (VRET) is increasingly being explored as a novel and cost-effective mode of treatment. No previous randomized controlled trial has examined whether stand-alone 360° video VRET is an effective intervention for treating PSA and interrelated disorder relevant fears. Further, studies have not explored whether 360° video content influences VRET outcomes. Participants with high PSA (n = 51) were randomly allocated to: 360° video VRET incorporating stimuli of audiences (360°Audience) (n = 17), 360° video VRET incorporating stimuli of empty rooms (360°Empty) (n = 16) and no treatment control (n = 18). Outcomes were measured over five time-points. Mixed ANOVA revealed a significant interaction between time and intervention group for PSA, social anxiety and fear of negative evaluation (FNE). Within-group analysis demonstrated there was a significant pre-intervention to post-intervention reduction across measures for both 360° video VRET groups: PSA 360°Audience ($\eta$ _p² = .90, p<.001), 360°Empty ($\eta$ _p² = .71, p < .001); social anxiety 360°Audience ($\eta$ _p² = .49, p=.002), 360°Empty ($\eta$ _p² = .39, p = .009); FNE 360°Audience ($\eta$ _p² = .59, p<.001), 360°Empty ($\eta$ _p² = .43, p = .006). Active intervention participants showed significant improvement from pre-intervention to 10-week follow-up on all measures. Findings illustrate that 360° video VRET is an efficacious way to significantly reduce PSA, social anxiety and FNE.     

Motivational Interviewing to prevent dropout from an education and employment program for young adults: A randomized controlled trial

This study tested the efficacy of Motivational Interviewing for improving retention at a “second chance” program in the United States for unemployed young adults who had not graduated high school (ages 18–24; 60% male). We investigated how Motivational Interviewing effects might be mediated by change talk (i.e., arguments for change) and moderated by preference for consistency (PFC). Participants (N = 100) were randomly assigned to (1) Motivational Interviewing designed to elicit change talk, (2) placebo counseling designed not to elicit change talk, or (3) no additional treatment. Motivational Interviewing sessions increased change talk, but did not increase program retention or diploma earning. PFC was a significant moderator of Motivational Interviewing's impact on program retention; Motivational Interviewing was most effective at increasing 8 week retention for high PFC participants, and least effective for low PFC participants. These results suggest that Motivational Interviewing could be a useful tool for improving retention in education and employment programs, but clinicians should be attentive to how participant characteristics might enhance or diminish Motivational Interviewing effects.     

Mirror therapy and treadmill training for patients with chronic stroke: a pilot randomized controlled trial

Background: Previous lower-limb mirror therapy research has focused on non-weight bearing interventions.

Objectives: The primary aim of this study was to investigate the effect and feasibility of a combination of mirror therapy and treadmill training on post-stroke lower-limb recovery compared to a placebo intervention.

Methods: All patients (N = 30) walked on a treadmill for 30 min per day, 3 days per week, for 4 weeks. The mirror therapy and treadmill training group (n = 15) walked on the treadmill while viewing a reflection of their non-paretic limb in a mirror positioned in their mid-sagittal plane. The placebo group (n = 15) received no mirror visual feedback due to an altered mirror position. Primary outcome measures: Ten Metre Walk Test (10MWT) and Six Minute Walk Test (6MWT). Secondary outcome measures: Modified Ashworth Scale (MAS) and Fugl-Meyer Assessment-Lower Extremity (FMA-LE). Feasibility was appraised by examining participant compliance and any adverse events.

Results: No significant between group differences were demonstrated for the 10MWT, 6MWT or FMA-LE at post-training or 3-month follow-up assessment. A significant between group difference on the MAS was demonstrated in the reduction of ankle dorsiflexion muscle tone (p = 0.006) and ankle plantarflexion muscle tone (p = 0.01) in the mirror therapy group compared to the placebo group at post-training assessment but not at 3-month follow-up.

Conclusion: Our study reveals that in our group of patients with chronic stroke, mirror therapy combined with treadmill training facilitated significant reductions in ankle muscle tone (p < 0.05) compared to a placebo intervention.     

Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial

Seventy-six individuals with a principal diagnosis of generalized anxiety disorder (GAD) were randomly assigned to receive either an MI pretreatment or no pretreatment (NPT), prior to receiving CBT. Significant group differences favoring the MI-CBT group were observed on the hallmark GAD symptom of worry and on therapist-rated homework compliance, which mediated the impact of treatment group on worry reduction. Adding MI pretreatment to CBT was specifically and substantively beneficial for individuals with high worry severity at baseline. There was evidence of relapse at 6-month follow-up for high severity individuals who received MI-CBT, but significant moderator effects favoring the high severity MI-CBT group were again apparent at 12-months post-treatment. Pending replication in a more controlled test, these findings suggest that MI may be a promising adjunct to CBT for GAD for those of high severity, a group which has been less responsive to CBT in past research.     

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.     

Brief imaginal exposure exercises for social anxiety disorder: A randomized controlled trial of a self-help momentary intervention app

IntroductionEmerging technological interventions for psychological disorders are being developed continually. Offering imaginal exposure exercises as a self-help intervention presents the opportunity to acquire foundational skills to address social anxiety. The current study evaluates the feasibility and effectiveness of a novel smartphone application for social interaction anxiety.MethodsParticipants (n = 82) were adults meeting criteria for social anxiety disorder. They were randomly assigned to imaginal exposure (IE; n = 39) or self-monitoring (n = 43) delivered multiple times daily via a smartphone application for a one-week trial. It was expected that participants using the IE exercises would demonstrate significantly greater declines in social anxiety in addition to increases in self-efficacy and that compliance would serve as a predictor of outcome. Mixed-effects models were utilized.ResultsParticipants using IE (vs. self-monitoring) evidenced significantly greater reductions in social anxiety from pre- to post-treatment and at 1-month follow-up. Similarly, IE (vs. self-monitoring) led to significantly greater increases in self-efficacy from pre- to post-treatment and 1-month follow-up. Further, more completed IE exercises predicted significantly greater changes in social anxiety and self-efficacy at subsequent timepoints compared with self-monitoring.ConclusionsFindings suggest that a brief IE self-help intervention was effective in targeting social interaction anxiety.     

Dissemination of psychosocial treatments for anxiety: The importance of taking a broad perspective

Dissemination methods are used to increase the likelihood that a given treatment or form of clinical practice is implemented by clinicians in the community. Therapist training in treatment methods is an important component of dissemination. Successful dissemination also requires that roadblocks to treatment implementation are identified and circumvented, such as misconceptions that clinicians might hold about a given treatment. The present article offers a commentary on the papers included in the special issue on treatment dissemination for anxiety disorders. Most papers focus on issues concerning the training and education of clinicians with regard to exposure therapy. Training and education is an important step but should be part of a broad, multifaceted approach. There are several other important methods of treatment dissemination, including methods developed and implemented with success by the pharmaceutical industry, might also be used to disseminate psychosocial therapies. Optimal dissemination likely requires a broad perspective in which multiple dissemination methods are considered for implementation.     

Motivational interviewing and cognitive behaviour therapy for anxiety following traumatic brain injury: A pilot randomised controlled trial

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21–73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI?+?CBT (n?=?9), non-directive counselling (NDC)?+?CBT (n?=?10) and treatment-as-usual (TAU) (n?=?8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.     

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

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.     

Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial

Public speaking anxiety (PSA) is a common condition which can be treated effectively with exposure therapy. However, inherent difficulties in stimuli presentation and control limits dissemination and the therapeutic potential. Virtual Reality (VR) technology has the potential to resolve these issues and provide a scalable platform for self-help interventions. No previous study has examined whether this can be achieved using the first generation of consumer VR hardware and software. In the current trial, n = 25 + 25 participants were randomized to either one-session therapist-led VR exposure therapy for PSA followed by a four-week internet-administered VR to in-vivo transition program, or a waiting-list. Linear mixed effects modeling revealed significant, large (within Cohen’s d = 1.67) decreases in self-reported PSA. The waiting-list was then given access to an internet-administered, self-led version of the same VR exposure therapy to be conducted at home, followed by the same transition program. Dual-slope mixed effects modeling revealed significant, large (d = 1.35) decreases in self-reported PSA. Results were maintained or improved at six- and twelve-month follow-ups. We show for the first time that low-cost, off-the-shelf consumer VR hardware and software can be used to conduct exposure therapy for PSA, both in the traditional, previously impractical one-session format, and in a novel self-led, at-home format.     

Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: a randomized controlled trial

This study examined the efficacy of a multicomponent cognitive-behavioral therapy, Trauma Management Therapy, which combines exposure therapy and social emotional rehabilitation, to exposure therapy only in a group of male combat veterans with chronic posttraumatic stress disorder (PTSD). Thirty-five male Vietnam veterans with PTSD were randomly assigned to receive either Trauma Management Therapy (TMT) or Exposure Therapy Only (EXP). Participants were assessed at pre-treatment, mid-treatment, and post-treatment. Primary clinical outcomes were reduction of PTSD symptoms and improved social emotional functioning. Results indicated that veterans in both conditions showed statistically significant and clinically meaningful reductions in PTSD symptoms from pre- to post-treatment, though consistent with a priori hypotheses there were no group differences on PTSD variables. However, compared to the EXP group, participants in the TMT group showed increased frequency in social activities and greater time spent in social activities. These changes occurred from mid-treatment (after completion of exposure therapy) to post-treatment (after completion of the social emotional rehabilitation component); supporting the hypothesis that TMT alone would result in improved social functioning. Although the TMT group also had a significant decrease in episodes of physical rage, that change occurred prior to introduction of the social emotional component of TMT. This study demonstrates efficacy of exposure therapy for treating the core symptoms of PTSD among combat veterans with a severe and chronic form of this disorder. Moreover, multi-component CBT shows promise for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement/interpersonal functioning in a cohort of veterans with severe and chronic PTSD.     

Exercise training in mitochondrial myopathy: a randomized controlled trial

Patients with mitochondrial myopathies (MM) usually suffer from exercise intolerance due to their impaired oxidative capacity and physical deconditioning. We evaluated the effects of a 12-week supervised randomized rehabilitation program involving endurance training in patients with MM. Twenty MM patients were assigned to a training or control group. For three nonconsecutive days each week, patients combined cycle exercise at 70% of their peak work rate with three upper-body weight-lifting exercises performed at 50% of maximum capacity. Training increased maximal oxygen uptake (28.5%), work output (15.5%), and minute ventilation (40%), endurance performance (62%), walking distance in shuttle walking test (+95 m), and peripheral muscle strength (32%-62%), and improved Nottingham Health Profile scores (21.47%) and clinical symptoms. Control MM patients did not change from baseline. Results show that our exercise program is an adequate training strategy for patients with mitochondrial myopathy.     

Cognitive behavioural techniques reduce exercise anxiety and improve adherence to a resistance training program for people with anxiety-related disorders: A randomized controlled trial

Exercise is a cost-efficient alternative to other interventions for anxiety-related disorders (ARDs; e.g., psychotherapy, pharmaceutical) that is also associated with health benefits. Several exercise modalities, including resistance training (RT), have demonstrated efficacy at reducing symptoms of ARDs; however, there are challenges associated with effectively implementing such protocols, most notably, exercise avoidance or early discontinuation. Researchers have identified exercise anxiety as a contributor to exercise avoidance for people with ARDs. Exercise-based interventions for people with ARDs may need to include strategies for helping these individuals cope with exercise anxiety to facilitate long-term exercise engagement; however, research in this area is lacking. The primary purpose of this randomized controlled trial (RCT) was to examine the effects of combining cognitive behavioural techniques (CBT) with a RT program on changes in exercise anxiety, exercise frequency, disorder-specific anxiety symptoms, and physical activity for people with ARDs. A secondary purpose was to explore group differences in exercise motivation and exercise self-efficacy across time. A total of 59 physically inactive individuals with ARDs were randomized into either RT + CBT, RT, or waitlist (WL). Primary measures were assessed at baseline, weekly during the 4-week active phase, and at 1-week, 1-month, and 3-month follow-ups. Findings indicate both RT and RT + CBT can reduce exercise anxiety; however, the addition of CBT techniques may help facilitate improvements in exercise self-efficacy, reductions in disorder-specific anxiety, and increases in long-term exercise behaviour and vigorous physical activity. These techniques may be useful for researchers and clinicians alike in supporting individuals with ARDs interested in using exercise to cope with elevated anxiety.     

Cognitive behaviour therapy for specific phobia of vomiting (Emetophobia): A pilot randomized controlled trial

This is the first randomised controlled trial to evaluate a protocol for cognitive behaviour therapy (CBT) for a Specific Phobia of Vomiting (SPOV) compared with a wait list and to use assessment scales that are specific for a SPOV.Method24 participants (23 women and 1 man) were randomly allocated to either 12 sessions of CBT or a wait list.ResultsAt the end of the treatment, CBT was significantly more efficacious than the wait list with a large effect size (Cohen’s d = 1.53) on the Specific Phobia of Vomiting Inventory between the two groups after 12 sessions. Six (50%) of the participants receiving CBT achieved clinically significant change compared to 2 (16%) participants in the wait list group. Eight (58.3%) participants receiving CBT achieved reliable improvement compared to 2 (16%) participants in the wait list group.ConclusionsA SPOV is a condition treatable by CBT but further developments are required to increase efficacy.     

Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials

Trials of virtual reality exposure therapy (VRET) for anxiety-related disorders have proliferated in number and diversity since our previous meta-analysis that examined 13 total trials, most of which were for specific phobias (Powers & Emmelkamp, 2008). Since then, new trials have compared VRET to more diverse anxiety and related disorders including social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and panic disorder (PD) with and without agoraphobia. With the availability of this data, it is imperative to re-examine the efficacy of VRET for anxiety. A literature search for randomized controlled trials of VRET versus control or in vivo exposure yielded 30 studies with 1057 participants. Fourteen studies tested VRET for specific phobias, 8 for SAD or performance anxiety, 5 for PTSD, and 3 for PD. A random effects analysis estimated a large effect size for VRET versus waitlist (g = 0.90) and a medium to large effect size for VRET versus psychological placebo conditions (g = 0.78). A comparison of VRET and in vivo conditions did not show significantly different effect sizes (g = −0.07). These findings were relatively consistent across disorders. A meta-regression analysis revealed that larger sample sizes were associated with lower effect sizes in VRET versus control comparisons (β = −0.007, p < 0.05). These results indicate that VRET is an effective and equal medium for exposure therapy.