Psychotherapy Brown Bag

APA Division 12 seeks feedback from therapists on their experiences with implementing empirically supported treatments

by Michael D. Anestis, M.S.

Last night, Marvin Goldfried, Ph.D., a professor of psychology at SUNY Stony Brook and the president of the Society of Clinical Psychology (APA Division 12), sent an interesting email through the listserv for the Association for Cognitive and Behavioral Therapies (ABCT).  I contacted him and asked his permission to re-post his email on PBB and he complied.  What follows is the text of Dr.Goldfried's message.

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In its desire to build a two-way bridge between research and practice, the Society of Clinical Psychology, Division 12 of APA, invites practicing therapists to complete the brief survey described below.

Wanted: Clinicians’ Feedback on Treating Panic Disorder

Once a drug has been approved by the Federal Drug Administration (FDA) as a result of clinical trials, practitioners have the opportunity to offer feedback to the FDA on any shortcomings in the use of the drug in clinical practice. The Society of Clinical Psychology, Division 12 of the American Psychological Association, is in the process of establishing a mechanism whereby practicing psychotherapists can report their clinical experiences using empirically supported treatments (ESTs).

This is not only an opportunity for clinicians to share their experiences with other therapists, but also can offer information that can encourage researchers to investigate ways of overcoming these limitations. We are starting with the treatment of panic disorder, but will extend our efforts to the treatment of other problems at a later time.

Our Web site provides the opportunity for therapists using cognitive-behavior therapy (CBT) in treating panic to share their clinical experiences about those variables they have found to limit the successful reduction of symptomotology. Although research is underway to determine if other therapies can successfully treat panic, CBT is the only approach at present that is an EST. However, in order for the field to move from an EST to an evidence-based treatment that works well in practice settings, we need to know more about the clinical experience of therapists who make use of these interventions in actual clinical practice. By identifying the obstacles to successful treatment, we can then take steps to overcome these shortcomings.

Your responses, which will be anonymous, will be tallied with those of other therapists and posted on the Division 12 Web site at a later time. The results of the feedback we receive from clinicians will be provided to researchers, in the hope they can investigate ways of overcoming these obstacles.

The survey, which should take 10 minutes, can be found at: www.div12.org/panic

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I believe this is an absolutely fantastic enterprise on the part of Division 12.  On the one hand, I believe that the development, dissemination, and implementation of therapeutic techniques should be based wholly upon what we learn from data (including effectiveness trials - those that test therapies in "real world" settings), but at the same time, I think that the entire process will be smoother if it is a dialogue that incorporates and listens to the concerns of clinicians.  There is no reason for there to be a gap between research and practice and efforts like this seem like an excellent way to develop a more civil back-and-forth amongst members of both sides of the equation.  Studies have shown that ESTs for anxiety disorders produce strong results in "real world" clinical practice (click here for our coverage of this topic), but the more information being shared, the better everyone will understand this process.

If any readers take part in this survey, we would love to hear your thoughts on this issue.

If you would like to learn more about CBT for panic disorder, we recommend the following items, which are available through our online store for scientifically-based psychological resources:

• When Panic Attacks: The New, Drug-Free Anxiety Therapy That Can Change Your Life by David Burns

• Mastery of Your Anxiety and Panic: Workbook by David Barlow and Michelle Craske

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Interoceptive exposure: Overcoming a fear of fear

by Joye C. Anestis

Exposure treatments involve asking clients to confront their most feared objects, situations, emotions, etc.  The goals for doing this vary by diagnosis, but the basic premise is that when people avoid the things that scare them, their anxiety becomes reinforced.  Take for example, a snake phobia.  If you are scared of snakes, then obviously seeing one causes you to experience great anxiety.  If you run away from the snake, your anxiety decreases.  That decrease in anxiety is highly rewarding - thus, avoidance of snakes becomes a reinforced behavior.  In exposure therapy, that pattern of reinforcement is broken.  You remain around a snake for as long as it takes for your anxiety to decrease naturally.  At the same time, if you have a snake phobia, you also probably have incorrect beliefs about the danger snakes pose, for example overestimating the likelihood that a snake would bite and kill you.  By being exposed to snakes in a variety of conditions, you also get an opportunity to correct such misinformation.  Treatments involving exposure are well-established for the treatment of a variety of anxiety disorders, including obsessive-compulsive disorder, social anxiety disorder, specific phobias, and PTSD.  Most of the time, exposure involves actively facing the thing you are afraid of in vivo (e.g., snakes, touching public bathroom doorknobs without washing one's hands) or imaginally (e.g., a trauma).  

A newer variation of exposure has been developed to help individuals who are not scared of external things or of memories but of their own bodily sensations.   This type of fear is most common in panic disorder, an  illness consisting of recurrent panic attacks and great fear of having another panic attack (APA, 2000).  Most individuals with this illness also avoid situations and places when panic attacks might occur.  As you can imagine, this can greatly limit the number of places you can go and often leads to agoraphobia.  The primary fear in panic disorder is of the panic attack sensations themselves and the implications of those attacks.  Common misappraisals of panic attacks include "I'm having a heart attack," "I'm having a stroke," "I'm dying," "I'm losing my mind," and many other interpretations of panic attacks as dangerous.  In reality, panic attacks are common, even in those without panic disorder (Norton, Cox, & Malan, 1992), and decidedly undangerous (e.g., the symptoms are vastly different from heart attacks and strokes).  So how do you expose an individual to panic attack sensations, which include heart palpitations, sweating, shortness of breath, and dizziness?  The answer: interoceptive exposure.  Interoceptive exposure lessens the fear of these specific bodily cues through repeated and systematic exposure to them.  The types of exposure differ based on each individual's cluster of panic symptoms.  Some examples I have heard of or conducted myself include (but there are many many more possibilities):

• spinning around in a chair
• cardiovascular exercise
• breathing in and out of a cocktail straw
• carbon dioxide inhalation
• sitting is a steamy room
• ingesting caffeine
• holding one's breath for as long as possible

Constructing interoceptive exposure activities can require a lot of creativity on the part of the therapist!  Click here for a clip from Good Morning America demonstrating interoceptive exposure.  As with In vivo and imaginal exposure, once individuals quit avoiding the panic attack sensations, their anxiety regarding them will be begin to naturally decrease. 

Interoceptive exposure for panic is part of a broader CBT protocol (see list of treatment manuals below), thus it is most effective when combined with cognitive restructuring, ample psychoeducation, and some in vivo exposure to situations that might induce panic attacks.  This CBT is considered to be an EST for panic disorder.  Studies have found that interoceptive exposure protocols are more effective for panic  disorder than in vivo exposure + cognitive therapy and cognitive therapy alone (Smith et al., 2004).   Panic disorder is sometimes described as a "fear of fear" - interoceptive exposure is one highly efficacious way to overcome that.

For more information on administering interoceptive exposure, try these treatment manuals:

Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
Mastery of Your Anxiety and Panic: Workbook (Treatments That Work)
Mastery of Your Anxiety and Panic: Therapist Guide (Treatments That Work)

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.