Attention to phobic stimuli during exposure: the effect of distraction on anxiety reduction, self-efficacy and perceived control

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Abstract

To replicate and extend the finding that distraction facilitates between session anxiety reduction (Oliver & Page (2003)), 27 spider phobics underwent three 10-min sessions of in vivo exposure followed by one 10-min exposure session at a 4-week follow-up, while having either stimulus-relevant focused conversation or stimulus-irrelevant distracting conversation with the experimenter. Physiological arousal and subjective anxiety were measured during exposure, and self-efficacy, perceived control and performance on a behavioural task were measured at pre-treatment, post session-3, and follow-up. Monitoring and blunting coping styles were also measured at pre-treatment to assess their impact on treatment outcome. Despite equal physiological activation between the groups, those who underwent distracted exposure showed greater reductions in subjective fear within and between sessions, and showed greater increases in self-efficacy ratings, internal perceived control and performance on a behavioural task. Coping style did not interact with the effect of distraction or focusing during exposure, however blunters had less subjective anxiety reduction overall, particularly when they underwent focused exposure. Results are discussed in terms of the emotional processing model and self-efficacy theory.

Introduction

Understanding the impact of attention to phobic stimuli during exposure is important for the treatment of phobic anxiety for several reasons. Firstly, during “natural” exposure an “attentional shift toward threat-stimuli is counteracted by a conscious attempt to cognitively avoid the stimulus” (Craske, Street, Jayaraman, & Barlow, 1991; p. 209), a tendency often seen in exposure treatment when patients distract attention away from the phobic object/situation as a means of coping with or reducing anxiety (Craske, Street, & Barlow, 1989). Secondly, some therapists instruct patients to use distraction when approaching feared situations (Crask et al., 1989) to increase the probability and duration of exposure (Beck, Emery, & Greengerg, 1985). Thirdly, models of exposure predict that the direction of attention influences the process of anxiety reduction. In particular, the emotional processing model (Foa & Kozak, 1986) argues that distraction interferes with sensory encoding of information presented during exposure, thereby inhibiting formation of a new memory of the feared event, resulting in less anxiety reduction.

A number of studies have investigated the impact of distracting attention away from the phobic stimulus versus focusing attention towards the phobic stimulus, on anxiety reduction. However, given variation between studies in levels of participant’s stimulus bound anxiety, the types of anxiety-disordered participants treated, the duration and number of exposure sessions, and the indexes of therapeutic change, the findings are difficult to interpret. Perhaps the biggest obstacle to interpretation is the wide variation in the types of distraction used and consequently, the degree to which attention is distracted away from the phobic stimulus.

Some research with animal-fearful participants has found that, compared to visual focusing, visual distraction during exposure slows the therapeutic response (e.g., Mohlman and Zinbarg, 2000, Rodriguez and Craske, 1995). However, other studies have shown that when distraction was cognitive (e.g., verbal material presented auditorily) rather than visual, and when participants with a phobic level of fear underwent exposure, distraction did not have the same detrimental effects (e.g., Antony, McCabe, Leeuw, Sano and Swinson, 2001, Craske, Street, Jayaraman and Barlow, 1991). The results of studies that included a follow-up period suggest that distracted exposure may enhance anxiety reduction during exposure, but that gains are not maintained on all indexes of change. For example, two studies using obsessive–compulsive participants, found within session reductions in subjective fear failed to generalise to between session reductions in those who underwent distraction (Grayson, Foa and Steketee, 1982, Grayson, Foa and Steketee, 1986). Research using other participant populations has also found poorer longer-term treatment outcomes for those who underwent distraction during exposure (e.g., Haw & Dickerson, 1998: mildly spider-fearful participants with a same day follow-up; Kamphuis & Telch, 2000: moderate to severe claustrophobic participants with a 2-week follow-up; and Craske et al., 1989: agoraphobic participants with a 6-month follow-up).

However, a recent series of studies has demonstrated the benefits of using distraction during exposure. Penfold and Page (1999) investigated the impact of stimulus-irrelevant neutral conver sation with mild to severe blood and injection-fearful participants in a single exposure session. Participants having a distracting conversation during exposure reported significantly lower subjective fear compared to those having a focusing conversation about the phobic stimuli, their thoughts, feelings and physiological responses. Aside from the 1982 study by Grayson et al. (replicated and extended by Grayson et al., 1986), Penfold and Page’s study is the first to be followed by a published replication and extension. Oliver and Page (2003) extended on the previous study by including three weekly exposure sessions and a 1-month follow-up, using the same manipulation of attention and participant group. The study found that from the end of exposure session-1 onwards, distracted participants had lower self-reported fear than focused participants, and the focusing group had the largest return of fear (ROF) at follow-up. The replicated finding that a clinically relevant form of attentional distraction facilitated treatment outcome, needs to be explained theoretically. The emotional processing model (Foa & Kozak, 1986) is the framework within which these findings are considered.

According to the emotional processing model (Foa & Kozak, 1986), attention plays a crucial role in anxiety reduction. In this model, the process of exposure begins with activation of the fear prototype in memory, followed by habituation of physiological responding. Since the stimulus is paired with decreased physiological responding, dissociation within the prototype between the response elements (programs for physiological mobilisation) and the stimulus elements (sensory information about the stimulus) follows. Lowered arousal results in corrective information, for example, decreased perceptions of harm and decreased negative valence, becoming incorporated into the meaning elements. Activation of the fear prototype during exposure is typically indexed by the presence of subjective fear and physiological arousal, and although “there is no means of directly measuring emotional processing” (Mohlman and Zinbarg, 2000; p. 127), modification of the network is indexed by within and between exposure session reductions on fear measures. Indicators of incomplete processing include a lack of between session habituation, and a ROF after a period where the fear has decreased for some time (Rachman, 1979)1.

The emotional processing model identifies sensory encoding of the phobic information as a prerequisite for emotional processing. Therefore, “distraction strategies such as pretending to be somewhere else, distorting a fearful image, concentrating on non-fearful elements of a situation, and so on, diminish encoding of fear-relevant information and thus impede activation of fear” (Foa and Kozak, 1986; p. 30). Because the prototype is not completely activated during distraction, dissociation between the response and stimulus elements is impaired, and less corrective information is incorporated into the meaning elements, resulting in incomplete emotional processing, demonstrated by less subjective, behavioural, and physiological anxiety reduction. Alternatively, focusing on fear-relevant information during exposure should enhance encoding of fear-relevant information and facilitate activation of the fear structure, resulting in greater emotional processing, demonstrated by increased subjective, behavioural, and physiological anxiety reduction.

The sequence of events underlying short-term “processing”, as described by the emotional processing model, is unable to account for how distracting conversation during exposure could produce greater anxiety reduction. However, the model describes the process of stable longer-term change in the fear structure which “constitute[s] additional information that accumulates to modify general beliefs and attitudes about ability to cope with feared situations” (Foa and Kozak, 1986; p. 29), and cites self-efficacy as one of these “global beliefs”. While remaining within the framework of the emotional processing model, an explanation for how distracting conversation impacts global beliefs, is found in self-efficacy theory.

Self-efficacy is defined as the beliefs and attitudes that people hold about their ability to cope, or perform various levels of a given behaviour. According to self-efficacy theory, “it is mainly perceived inefficacy in coping with potentially aversive events that makes them fearful” (Bandura, 1983; p. 465), and phobic behaviour is caused and maintained by beliefs about inability to cope. Self-efficacy is conceptualised as a “generative capability” that can be developed through behavioural accomplishment (Bandura, 1983; p. 467), and treatments that have emphasised behavioural mastery have indeed led to increased self-efficacy perceptions and superior treatment response (e.g., Williams, Dooseman, & Kleinfield, 1984). Following exposure, increased self-efficacy has been found to be predictive of several types of psychological change (e.g., Jones and Menzies, 2000, Zoellner, Echiverri and Craske, 2000), with low self-efficacy related to relapse (Craske & Rachman, 1987).

According to self-efficacy theory, it is both the quality and quantity of efficacy enhancing information provided during exposure, and how individuals weight and integrate this information, that mediates changes in anxiety. Consistent with self-efficacy theory, the rationale for the clinical use of distraction during exposure is conceptualised as helping the patient to cope, which increases the probability of successful “performance” in the presence of the phobic stimuli. From the perspective of self-efficacy theory, engaging in stimulus-irrelevant conversation that is personally meaningful in the presence of the feared stimuli, is powerful efficacy enhancing information. For example, the thought “I can have a normal conversation about myself in the presence of my worst fear” may be weighted more heavily in efficacy evaluations than simply feeling anxious and experiencing a slow decline in anxiety in the presence of the phobic stimulus. Both Penfold and Page (1999), and Oliver and Page (2003) describe their results as consistent with self-efficacy theory, however, thus far no studies manipulating attention towards the phobic stimulus have considered the therapeutic benefit of distraction in terms of its impact on self-efficacy.

Closely related to self-efficacy, are beliefs about perceived control. According to self-efficacy theory “if people believe that they can exercise control over the occurrence of events that can be injurious, they do not fear them” (Bandura, 1983; p. 465). Several studies have demonstrated that non-specific aversive stimulation results in less anxiety and distress when participants have a sense of perceived control over the aversive stimulus (e.g., Glass and Singer, 1973, Zvolensky, Eifert, Lejuez and McNeil, 1999). With regard to the effect of distraction on perceived control, Craske et al. (1989) found no differences between participants who underwent distraction and those who underwent focusing during exposure, on measures of predicted or actual control over responses to feared somatic sensations. However, Penfold and Page (1999) found that of those with low perceived control over anxiety at pre-treatment, those who underwent distracted exposure had greater anxiety reduction than those who underwent focused exposure or exposure alone, suggesting that distraction either increased perceived control or acted to compensate for low perceived control. Extending on this finding, Oliver and Page (2003) found all three groups had significant and equal increases in perceived control over anxiety from pre to post-treatment, but at follow-up, the distraction group had significantly higher perceived control compared with those in the focusing group, who demonstrated a significant reduction. Regardless of its causal relationship with anxiety reduction, perceived control appears to be modified following stimulus-irrelevant conversation during exposure.

The current study replicated Penfold and Page (1999) and Oliver and Page (2003) while extending on these studies in several ways. These previous studies used mildly blood and injection-fearful participants, posing two potential problems for the generalisability of the study. Firstly, it is unclear whether the facilitative effect is generalisable to individuals with phobic levels of anxiety. Penfold and Page (1999) found that participants in the distraction condition with higher levels of stimulus bound anxiety, had more anxiety reduction, suggesting that the therapeutic effect of distraction may be even more pronounced in a phobic sample. Secondly, given the atypical nature of blood-injury phobia in terms of vasovagal syncope (Page, 1994), it remains to be determined whether the facilitative effect of distraction can be replicated with phobics who do not exhibit the fainting response. For these reasons, a spider phobic sample was used in the current study.

Improved and additional indexes of change were also included in the current study. Penfold and Page (1999) found no group differences on a behavioural avoidance test, arguably due to its insensitivity (as seen in the ceiling effects), and Oliver and Page (2003) did not use a behavioural measure. The current study included a more sensitive behavioural avoidance test (with a larger number of steps than used by Penfold & Page), to explore whether undergoing exposure with distraction results in less behavioural avoidance. Unlike these previous studies, physiological indices of skin conductivity, heart rate, and blood pressure were also measured.

Finally, a measure of coping style under threat was included. Informational preference under threat has been characterised as a stable behavioural style consisting of two dimensions: monitoring (the extent one monitors and seeks out threat information) and blunting (the extent one cognitively distracts and psychologically blunts threat information; Miller, 1987). Within the emotional processing framework, blunting is classified as a distraction strategy and should therefore have a detrimental impact on encoding of phobic information and activation of fear during exposure. Although coping style has been shown to impact anxiety reduction during exposure to phobic stimuli (e.g., Muris, Merckelbach and de Jong, 1995, Steketee, Bransfield, Miller and Foa, 1989), the direction of its relationship with therapeutic benefit has been mixed. Miller, Brody and Summerton (1988) argued that high monitors/low blunters and low monitors/high blunters may cope better under stress if the conditions of the situation are consistent with their coping style preference. Further, Rodriguez and Craske (1993) suggested that monitors might experience more anxiety reduction during exposure if focused on the stimulus, while blunters might experience more anxiety reduction if distracted from the stimulus, and that this interaction may account for some of the inconsistencies in the distraction literature. Antony et al. (2001) conducted the only study to test this prediction, and found no interaction between coping style and attention on measures of heart rate, subjective fear or behavioural avoidance. However, in spite of evidence that they are independent dimensions (e.g., van Zuuren & Wolfs, 1991), the study collapsed monitoring and blunting. Therefore, the current study investigated how both high and low blunters and high and low monitors benefit from distraction versus focusing during exposure.

Based on the findings of Penfold and Page (1999), and Oliver and Page (2003), the following predictions were made about a group of spider phobics undergoing distraction (stimulus-irrelevant conversation) during exposure: (a) that they would demonstrate greater within and between session reductions in subjective anxiety and greater between session reductions in behavioural avoidance, than those undergoing focusing (stimulus-relevant conversation during exposure)2,3; (b) that they would show greater reductions on a standardised self-report measure of spider fear than those undergoing focusing during exposure; (c) that they would maintain these gains at a 4-week follow-up and would not demonstrate a ROF; and (d) that they would show a larger increase in self-efficacy and perceived control than those undergoing focusing. It was also predicted that high blunters who underwent distraction during exposure and high monitors who underwent focusing during exposure would experience greater therapeutic benefit compared with others in their experimental condition.

Section snippets

Participants

The final sample consisted of 27 University of Western Australia students, who received course credit or travel reimbursement for participation in the study. Volunteers scoring a minimum of 54 on the Fear of Spiders Questionnaire (FSQ; Szymanski & O’Donohue, 1995) were offered a place in the study. Of the 28 who began the experiment, one participant from the focusing condition withdrew after a short period of experimentation due to distress. The final sample consisted of 27 participants (26

Results

Data from 27 participants were analysed. Missing physiological data (0.4%) were replaced by the mean of the closest three data points. Prior to analysis, variables within each condition with standardised scores exceeding 2.5 were assigned a raw score equivalent to the next most extreme score on that distribution (Tabachnick & Fidell, 1996). All t values reported were conducted in accordance with Bonferroni corrections.

Discussion

This study investigated the impact of cognitive distraction during in vivo exposure on subjective, behavioural, and physiological anxiety reduction, perceived self-efficacy, perceived control, and a standardised measure of spider phobia. The study also investigated whether coping style under threat interacts with the manipulation of attention during exposure.

Overall, in vivo exposure was a beneficial treatment for spider phobia, as all participants experienced significant reductions in

Acknowledgements

The research presented in this paper was conducted as part of the Master of Psychology (clinical)/Doctor of Philosophy degree of the first author under the supervision of the second author. The research was supported by an Australian Postgraduate Award. Parts of this article were included in a paper presented at the Australian Association for Cognitive Behaviour Therapy, Western Australian State Conference, May 2001, Western Australia.

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