Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD☆
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therapist behaviors and treatment mechanism
Measuring observable therapist behaviors during exposure could offer a window into clinical trial delivery approaches and provide concrete information for training. Moreover, behaviors of interest might be guided by the mechanistic theory that underpins exposure. In general, theorized mechanisms of behavioral treatments usually relate to a core learning process (e.g., reinforcement, extinction) and context variables that influence learning are defined using function (i.e., what they do) rather
therapist behaviors and mechanism in exposure therapy
Exposure is rooted in a strong behavioral theory of mechanism that centers on fear extinction learning (Craske et al., 2018). Exposure also elicits other forms of acute distress (e.g., disgust, incompleteness), which we include under the term “fear” for parsimony. Variants of mechanistic theory differ with respect to the neurocognitive underpinnings of exposure learning (e.g., inhibitory learning, emotional processing; Craske et al., 2018), yet there are many more similarities than differences
Fear-Decreasing Therapist Behaviors
Therapist behaviors that function to reduce short-term fear could interfere with habituation occurring “on its own” and result in poorer outcomes. This idea is consistent with guidelines from exposure specialists, who generally recommend against a “cautious” delivery style using techniques such as distraction, relaxation, or accommodation (e.g., Abramowitz et al., 2011). However, translational work has yielded mixed findings for distraction during exposure (e.g., Senn and Radomsky, 2018). While
Fear-Increasing Therapist Behaviors
Behaviors that increase or maintain fear might provide opportunities for habituation within exposures. Several theories describe the importance of sustained fear during exposure (e.g., Jacoby and Abramowitz, 2016) and specialists generally recommend an “intense” delivery style (Abramowitz et al., 2011). While there is some evidence that sustained intensity produces better outcomes (Deacon, Kemp, et al., 2013), it has been difficult to disentangle effects of delivery intensity (i.e., manner of
Fear-Neutral Therapist Behaviors
Fear-neutral strategies may keep patients engaged and/or support learning without having a clear function on short-term fear (e.g., by improving motivation, self-efficacy, or cognitive processing). Treatment manuals often include cognitive or coping strategies, education about the principles of treatment, and strategies that “externalize” symptoms so that they are discussed as separate from a patient (e.g., Freeman and Garcia, 2008). There is some evidence that coping during exposure tasks does
Therapist Behaviors for Exposure “Titration”
There may be a need to balance exposure difficulty with tolerability despite clear theorized disadvantages of fear-decreasing behaviors and advantages of fear-increasing behaviors. Specialists suggest that skilled therapists monitor ongoing fear changes during exposure and facilitate a “delicate balance between exposure intensity and optimal anxiety” (Chu et al., 2015, p. 12). In addition to overall use of fear increasing, decreasing, or neutral behaviors, therapist titration—selection of these
summary and current study
Defining therapist behaviors according to short-term function on fear (increase, decrease, or neutral) generally mirrors specialist recommendations for delivering exposure. These categories are also relevant for habituation, a possible marker of initial exposure learning. Linking therapist behaviors to habituation within an exposure task could facilitate feedback in practice, which might aid therapist learning, enhance exposure quality, and ultimately improve outcomes. Despite this, it is
original treatment trials
Relevant Institutional Review Boards approved procedures for the original trials and the current study. Treatment in the Pediatric OCD Treatment Study (POTS) trials occurred at three sites and results support the efficacy of exposure-based CBT (Franklin et al., 2011; Freeman et al., 2014; Pediatric OCD Treatment Study [POTS] Team, 2004). In POTS I, 112 participants age 7–17 were randomly assigned to receive CBT alone, medication management (MM) alone, CBT and MM, or pill placebo. In POTS II,
Results
Descriptive statistics for exposure- and patient-level variables are presented in Table 2. Therapist behaviors that address parent accommodation and those that encourage use of relaxation were present in too few exposures (< 3%) to complete analyses.
Discussion
Overall, results support several specific therapist behaviors that significantly predict both habituation and clinical outcomes in exposure therapy. More therapist behavior that encourages approach, less accommodation, less unrelated talk, and less use of externalizing language were consistently linked with greater habituation and better clinical outcomes. These results are broadly consistent with clinical recommendations and the behavioral theory that underpins exposure. Findings also point to
Conflict of Interest Statement
The authors declare that there are no conflicts of interest.
References (44)
- et al.
CBT specific process in exposure-based treatments: Initial examination in a pediatric OCD sample
Journal of Obsessive-Compulsive and Related Disorders
(2012) - et al.
Mediators of exposure therapy for youth obsessive-compulsive disorder: Specificity and temporal sequence of client and treatment factors
Behavior Therapy
(2015) - et al.
Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learning: A randomized controlled trial
Behaviour Research and Therapy
(2013) - et al.
Therapist perceptions and delivery of interoceptive exposure for panic disorder
Journal of Anxiety Disorders
(2013) - et al.
Feedback-informed treatment versus usual psychological treatment for depression and anxiety: A multisite, open-label, cluster randomised controlled trial
The Lancet. Psychiatry
(2018) - et al.
Best (but oft-forgotten) practices: Mediation analysis
The American Journal of Clinical Nutrition
(2017) Exposure tasks in anxiety treatment: A black box that still needs unpacking
Journal of the American Academy of Child and Adolescent Psychiatry
(2017)Let truth be thy aim, not victory: Comment on theory-based exposure process
Journal of Obsessive Compulsive and Related Disorders
(2015)- et al.
Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder
Clinical Psychology Review
(2016) - et al.
Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and validity
Journal of the American Academy of Child and Adolescent Psychiatry
(1997)
Too little, too much, or just right? Does the amount of distraction make a difference during contamination-related exposure?
Journal of Behavior Therapy and Experimental Psychiatry
What matters more? Common or specific factors in cognitive behavioral therapy for OCD: Therapeutic alliance and expectations as predictors of treatment outcome
Behaviour Research and Therapy
Exposure therapy for anxiety: Principles and practice
The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations
Journal of Personality and Social Psychology
Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD
Journal of Consulting and Clinical Psychology
State-of-the-art and future directions for extinction as a translational model for fear and anxiety
Philosophical Transactions of the Royal Society, B: Biological Sciences
Patient, therapist, and system factors influencing the effectiveness of prolonged exposure for veterans with comorbid posttraumatic stress disorder and traumatic brain injury
Nervous and Mental Disease
Tailoring and adapting parent-child interaction therapy to new populations
Education & Treatment of Children
Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The Pediatric OCD Treatment Study II (POTS II) randomized controlled trial
JAMA
Evidence base update of psychosocial treatments for pediatric obsessive-compulsive disorder: Evaluating, improving, and transporting what works
Journal of Clinical Child and Adolescent Psychology
Family based treatment for young children with OCD: Therapist guide
Family-based treatment of early childhood obsessive-compulsive disorder: The Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr) –A randomized clinical trial
JAMA Psychiatry
Cited by (12)
Comparison of patient-reported distress during harm avoidance and incompleteness exposure tasks for youth with OCD
2022, Journal of Obsessive-Compulsive and Related DisordersThe “how” of exposures: Examining the relationship between exposure parameters and outcomes in obsessive-compulsive disorder
2022, Journal of Contextual Behavioral ScienceCitation Excerpt :These two domains are unique in that the feared stimuli are primarily intangible (e.g., feelings of uncertainty, thoughts of being a “bad” person), and so may be more difficult to access without explicit experiential instruction. As such, with less experiential guidance (i.e., lower quality of acceptance/tolerance), exposures may instead function as time spent on safety behaviors, didactic teaching, or tangential talk, which have been found to lead to poorer clinical outcomes (Benito et al., 2021). Furthermore, experiential learning is critical to successful skill acquisition from an ACT framework (Twohig, Abramowitz, et al., 2015), so less experiential guidance may also interfere with new acceptance-based learning.
Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists
2021, Behavior TherapyCitation Excerpt :Although a transdiagnostic measure, the CGI-I and CGI-S have been used successfully in pediatric OCD (Storch et al., 2010). Prior to setting benchmarks, we confirmed the relevance of each therapist behavior for youth outcomes in a prior study, which analyzed 459 EPCS-coded exposures for 111 youth who received CBT in one of three clinical trials for pediatric OCD (POTS trials; Benito et al., 2020). Twenty-six therapists delivered exposures in that sample; each was trained on the treatment manual, received weekly cross-site supervision, and was highly adherent (>80%).
A Case Example of Community-Based Supervision to Overcome Barriers and Support the Implementation of Exposure T
2022, Psychological Services
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This work was supported by the National Institutes of Mental Health [R21MH096828 and R33 MH096828]