Elsevier

Behavior Therapy

Volume 52, Issue 3, May 2021, Pages 523-538
Behavior Therapy

Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD☆

https://doi.org/10.1016/j.beth.2020.07.004Get rights and content

Highlights

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    Therapist behaviors relate to clinical outcomes in exposure therapy

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    Therapist behavior should be considered in relation to patient fear during exposure

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    Future studies should determine whether therapist behavior changes patient outcomes

Abstract

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach—and less use of accommodation, unrelated talk, and externalizing language—predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher “total dose” of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the “black box” of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

Section snippets

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.

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    ☆

    This work was supported by the National Institutes of Mental Health [R21MH096828 and R33 MH096828]

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