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ACPA
THE AUSTRALIAN
CLINICAL PSYCHOLOGY
ASSOCIATION
Acparian
THE
THE OFFICIAL NEWSLETTER OF THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION
ISSUE 5: JAN 2013
ACPARIAN Issue 5 JAN 2013
Anxiety
Disorders
In this issue
GAD: Practical help for clinicians
Transdiagnostic approaches
Safety-seeking behaviours: good or bad?
Advances in Social Phobia treatment
Malcom Macmillan prize: clinical psychology and ethics in the electronic age
Medication or not?
Ethics anxiety
EDITORIAL
Kaye Horley, PhD
Editor
W
elcome to our next edition of ACPARIAN and its
focus on anxiety. We all experience anxiety, yet for
some of us it becomes extremely distressing and
disabling. The 2007 National Survey of Mental
Health and Wellbeing in Australia indicated that anxiety
disorders were the most prevalent of the mental disorders,
experienced by 14% of all people in the age range 16 – 85
years. Women, when compared with men, had a higher
prevalence in their lifetime (32% and 20%, respectively) and
in the previous 12 months (18% and 11%, respectively) 1 .
Various conditions come under the aegis of anxiety
disorders, having some commonalities yet also defining
features.
The specific features of Generalised Anxiety Disorder (GAD)
and consequent difficulties in treatment are articulated by
Maree Abbott and Caroline Hunt. Differing conceptual
models are summarised and the authors offer practical
guidance for the clinician. Safety-seeking behaviours are
implicit in anxiety disorders such as GAD; Lee Kannis and
Ron Chambers provide an overview of their role and
function in the maintenance of the various disorders.
Consideration is given to their usefulness and effectiveness
within therapy. The use of such safety seeking behaviours is
exemplified in A Client's Perspective in which Linda describes
how her anxiety significantly affected her ability to travel.
practice and the theoretical bioethical paradigm. We are
delighted to present in Student and Training Matters
Margaret Nelson's winning inaugural ACPA Malcolm
Macmillan prize Clinical Psychology and Ethics in the
Electronic Age. Her essay examines the ethical challenges
presented by the new rapidly growing communication
technologies, as well as the benefits in disseminating
treatments.
Finally, we welcome our new copy editor, John Moulds
(Head of Psychology Community Health in Sydney Local
Health District), and three new associate editors who bring a
wealth of diverse experience and expertise to the
ACPARIAN: Christina Brock (St George Hospital, Sydney),
Tamera Clancy (Melbourne Children’s Psychology Clinic), and
Dixie Statham (University of the Sunshine Coast).
Many thanks to all our contributors and special thanks to
Linda for sharing a client's view with us.
Best wishes to all for the New Year.
Some recent developments in the treatment of social
phobia are explored by Ron Rapee, Carol Newall, and
Alexandra Crawford who specifically examine cognitive
shifts associated with attentional bias, motivational
interviewing, and the facilitation of exposure therapy with
adjunct pharmacotherapy. Individuals with social anxiety are
characterised as having poor eye contact. In the Research
Article Kaye Horley reports her findings on what aspect of
faces we tend to focus on in interpersonal communication
and how this differs for the social phobic individual. In
comparison with the more traditional conceptualisation of
specificity of diagnosis and treatment of the anxiety
disorders, there has been an increasing interest in a
transdiagnostic approach in more recent years. The utility of
this approach is explored by Peter McEvoy. Michael Baigent
provides food for thought in exploring the reasons as to
why medication might or might not be prescribed for
anxiety disorders.
CONTENTS
As clinicians we may be confronted with complex ethical
challenges and, as a consequence, we may experience
"ethics anxiety". Giles Burch explores possible causes for
such anxiety, specifically the struggle between intuitive
2
Editorial
3
From the President
4
From 'famine to feast' for theoretical models of GAD:
Understanding and treating 'The Worried Well'
8
Safety seeking behaviours: A review and reflection from a
specialist anxiety treatment centre
12
Recent advances in the treatment of social phobia
16
Transdiagnostic approaches to treating mental disorders
20
Medication used in anxiety disorders
23
A client's perspective
25
Research article:
Eye to eye in social phobia: Fear of faces
29
Ethics and legal dilemmas:
A brief review of 'ethics anxiety' and the 'limits of
bioethics'
30
Student and training matters:
Inaugural Malcolm Macmillan student prize:
Clinical psychology and ethics in the electronic age
1
Source: ABS National Survey of Mental Health and Wellbeing 2007,
Summary of Results (cat. no. 4326.0).
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
1 We have undergone much change in the past year and the
Board has said a sad farewell to Associate Professor Caroline
Hunt who has needed to focus her energies on other areas
of the profession for the greater good. Caroline was a
central force in ACPA from its commencement and will be
sadly missed.
We have also lost Dr Marjorie Collins from the Board but
gained Associate Professor Vida Bliokas, Mr Tony Merritt, Dr
Jordana Bayer, and Mr Paul McEvoy. This brings fresh
perspectives and new energy to the Board.
FROM THE PRESIDENT
Judy Hyde, PhD
ACPA President
My Fellow Acparians,
ACPA is a young, strong, vibrant, and exciting organisation,
fresh and alive and with a mission to make ourselves known
and our evidence-based expertise acknowledged for the
good of the public and the profession of psychology. We
continue to grow and prosper.
Our achievements this year have been many and have
shown that the fire in which we were forged has been
tempered into steel. We have met with the Minister for
Health, the Shadow Minister for Mental Health, and
representatives of the Department of Human Services and
the Department of Health and Ageing. We have been
informed we are known politically and respected for our
qualifications. We are to meet in February with Ms Robyn
Kruk, CEO of the National Mental Health Commission, to
explain the best use of clinical psychologists in the mental
health system.
We have made multiple submissions to Government and
governing bodies representing the expertise of qualified
clinical psychologists. We have a regular place in the media
as required and as other demands allow, writing for Hospital
and Aged Care Magazine. Most recently, submissions have
been made to the Australian Psychology Accreditation
Council on proposed training pathways and the
competencies required of clinical psychologists. The State
and Federal Health Ministers have been lobbied to open the
way for clinical psychology to be recognised as a speciality
area of psychology in the best interests of the public.
We have also formed a strong collegial relationship with the
Royal Australian and New Zealand College of Psychiatrists
that has assisted us in disseminating information about
psychology qualifications to their members via their ejournal Psych-e. The College plans to link us to Mental Health
patient advocacy groups in the New Year.
I, personally, feel greatly privileged to be again given the
opportunity to represent ACPA members and lead us into
the future for another term.
ACPA always has new plans for the future and the new
website is the next off the rank. This will enable online
applications, renewals, and changes of membership types.
Designing the functioning of the website has been a
demanding journey and we hope all members will acquire
ready access to the members’ materials through the forum
and take advantage of the resources there.
The Finance Committee is looking into providing members
with clinical psychology journal access in the first half of
2013.
The ACPA conference in Perth was a good opportunity to
meet with fellow members and listen to excellent and
informative presentations. The next ACPA conference is to
be held in Brisbane on Sunday 14 July immediately following
the International Society for Psychotherapy Research
conference on 10 - 13 July. Both conferences will offer
much of clinical interest to ACPA members. The ACPA
conference will showcase the work of Nancy McWilliams
with the self-defeating personality... save the dates!!!! I look
forward to seeing you there.
ACPA is thriving! ACPA ensures that the expertise of clinical
psychologists is promoted and understood by decision
makers who wish to bring the best services possible to
those members of the public suffering from mental health
problems and disorders. ACPA constantly works against the
downgrading of professional standards and the strong
forces that do not acknowledge the value of professional
clinical training in the work we undertake with society’s
most vulnerable.
Thank you for your ongoing support of ACPA and the
encouragement and warmth you send in response to the
efforts of the Board. These are much appreciated and
continue to fuel the passion to move forward together to
claim our expertise and enhance the provision of high
quality mental health services through our training and
experience. 2013 will bring new challenges and
opportunities. Together we will continue to grow and
develop into the force we need to be!
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
2 From 'famine to feast' for
theoretical models of
GAD: Understanding and
treating 'The Worried
Well'
Maree J. Abbott, PhD
Senior Lecturer & Director of Clinical Training
School of Psychology
University of Sydney
Caroline Hunt, PhD
Associate Professor & Associate Head (Clinical)
School of Psychology
University of Sydney
Maree Abbott's research interests primarily focus on the nature
and treatment of anxiety disorders and on better
understanding ruminative thought processes. Maree has
published a number of studies that aim to enhance treatment
effectiveness and delivery for child and adult anxiety disorders
as well as experimental studies aimed at further
understanding the factors maintaining a range of clinical
disorders and problems. Maree has also co-authored
treatment manuals for adult generalised anxiety disorder and
child anxiety disorders. Previously, Maree held the Royce
Abbey Postdoctoral Fellowship from the ARHRF at Macquarie
University. Maree has served on the NSW Clinical College
Executive and currently serves on ACPA's Professional
Standards and Membership Committee.
Caroline Hunt has been coordinating the post-graduate
clinical training programmes at the University of Sydney since
2000, and played a key role in the development of the Doctor
of Clinical Psychology programme. Prior to this role, Caroline
held various clinical, research, and academic positions at the
Clinical Research Unit for Anxiety Disorders, University of New
South Wales, based at St. Vincent's Hospital, Sydney. Caroline
is currently President of the NSW Psychology Council and sits
on the Board of the Australian Psychology Accreditation
Council. Her clinical and research interests are adult and
childhood anxiety disorders, comorbid anxiety and aggression
in childhood, and school-based bullying and she has
published books and journal articles in these areas.
Please address all correspondence to:
Dr Maree J Abbott
School of Psychology
University of Sydney
Email: [email protected]
or
Associate Professor Caroline Hunt
School of Psychology
University of Sydney
Email: [email protected]
G
eneralised Anxiety Disorder (GAD) is characterised
by chronic and uncontrollable worry and symptoms
of anxious apprehension. Those who meet
diagnostic criteria for GAD experience frequent
worry that is difficult to control for periods of at least six
months, as well as experiencing three or more associated
symptoms including fatigue, muscle tension, irritability,
concentration difficulties, and sleep difficulties (American
Psychiatric Association [APA], 2000). Most patients describe
being 'worriers' for most of their lives, with onset of
symptoms estimated to have been in childhood (Noyes et
al., 1992). Symptoms interfere substantially in the lives of
sufferers and impact on health service use and costs (Hunt,
Issakidis, & Andrews, 2002). The content of worries in GAD
is ego-syntonic, typically focussing on areas such as
finances, health worries, and relational concerns. GAD has
been conceptualised as the 'basic anxiety disorder', and it
has been suggested that other anxiety disorders are likely to
resolve with the successful treatment of symptoms of
generalised anxiety (Barlow, 2000).
There has been a tendency over past decades to believe
that generalised anxiety, the disorder of 'the worried well',
is easy to treat, perhaps because of the high prevalence of
the disorder, the universal experience of worry, and the
ability of patients with GAD to engage positively with
therapists and be seemingly compliant and willing to attend
ongoing therapy. However, therapists
can feel
overwhelmed and 'derailed' in sessions, wondering how
the session lost focus and unsure how to get it back. GAD is
characterised by relatively low probability but high cost
fears, often leaving therapists unclear about how they might
impact both the cognitive and behavioural components of
GAD. Standard cognitive restructuring strategies often
impact particular worries positively, but more often than not
a new worry or set of worries will emerge, and the process
repeats. Similarly, unlike other anxiety disorders, patterns of
overt avoidance are not obvious in GAD, perhaps because
behaviours largely comprise safety strategies like
reassurance seeking, pleasing behaviours, perfectionism,
thought monitoring, and covert patterns of avoidance, such
as distracting oneself from thinking about feared negative
outcomes.
Clinicians are more likely to agree nowadays that they
are often lost and lacking in clarity when treating patients
with GAD. The research backs up their clinical intuition.
Cognitive behavioural therapy has shown statistically
significant gains in treating symptoms of GAD (Borkovec,
2002; Gould, Safren, Washington, & Otto, 2004). However,
outcomes are poor in terms of clinical significance
(Borkovec, 2002) and don't improve by spending more time
on individual treatment components (Durham, Murphy,
Allan, Richard, Treliving, & Fenton, 1994). Meta-analyses have
demonstrated that patients with GAD do not typically
discontinue treatment, showing low mean attrition rates
(11%; Gould et al., 2004). However, mean effect sizes for
our best evidence-based cognitive behavioural treatments
are modest (0.7; Gould et al., 2004). This led a leader in the
field, Professor Tom Borkovec (2002), to comment that
"after 16 years of concerted effort, applications of
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
3 behavioural and cognitive therapy techniques for treating
this anxiety disorder continue to fail to bring about 50% of
our clients back to within normal degrees of anxiety" (p. 76).
These figures provide cause for reflection.
Some have wondered whether these poor treatment
outcomes could be attributed to the application of
treatments developed for panic and phobic disorders to
GAD - such that little attention was paid to worry as a key
construct - and called for the development of conceptual
models that were specific to GAD (Hunt, 2000; Ost &
Breiholtz, 2000). Since that time, there has been an upsurge
of theoretical models for GAD developed by independent
research groups. Current models of other anxiety disorders,
such as cognitive models of social phobia, tend to comprise
more common than competing processes. However,
theoretical models of GAD present with more differences
than similarities, differing with regard to the key processes
hypothesised to maintain GAD symptoms and the primary
function of worry. All such models of GAD have been
influential in generating research and treatment programs,
and four of the more influential models are described
below.
Wells' Metacognitive Model suggests those with GAD
experience two types of worry (e.g., Wells, 2005). Type 1
worry is an 'everyday' form of worry that occurs when an
individual is exposed to a threatening situation. This type of
worry is based upon positive beliefs regarding the benefit
of worry to allow people to cope and deal with threat more
effectively. However, during the course of Type 1 worry,
negative beliefs about worry are activated, leading
individuals to believe that their worry is uncontrollable or
even dangerous. The anxiety caused by Type 2 worry can
lead to strategies to avoid worry such as experiential or
behavioural avoidance, and distraction. However, these
strategies are often unsuccessful and their use also
prevents individuals from disconfirming their maladaptive
beliefs that worry is dangerous and uncontrollable.
Buhr and Dugas's (2004) Intolerance of Uncertainty
model proposes that individuals with GAD have a trait-like
intolerance of uncertainty (IU), which influences the way
they process information. This model has four components
that link IU to worry through indirect and direct pathways: (i)
intolerance of uncertainty leads directly to worry as those
with GAD view uncertain life events as intolerable and
dangerous. As uncertainty is extremely common in modern
life, many environmental circumstances trigger worry for
those with IU. The other three components are: (ii) positive
beliefs about worry, such as worrying helps solve problems;
(iii) cognitive avoidance or the mental avoidance of aversive
or fear-evoking thoughts; and (iv) negative problem
orientation or reduced problem-solving confidence.
The Emotional Dysregulation model (Mennin, Heimberg,
Turk, & Fresco, 2005) proposes that poor emotional
regulation causes individuals with GAD to use maladaptive
regulatory strategies to alter aversive states, with worry
being one such strategy. The components of this model
include: (i) heightened intensity of emotions and a lower
threshold for the experience of emotions, especially
negative emotions, than others; (ii) poor understanding of
emotions; (iii) increased 'negative reactivity' to one's
emotional state; and (iv) maladaptive management of
emotions including suppression of emotions, use of
excessive and uncontrollable worry, or emotional outbursts
which in themselves can lead to heightened emotions.
The Cognitive Avoidance model (Borkovec, Alcaine, &
Behar, 2004) emphasises the (verbal linguistic) function of
worry as avoiding the intense affect associated with
imaginal processing, as well as arguing that those with GAD
hold positive beliefs about the benefits of worry. The
avoidant function of worry leads to a disabling of the
emotional processing of fear that is necessary for
habituation and extinction to be achieved (Foa & Kozac,
1986).
So what should guide the clinician in the face of this
'feast' of conceptual models? Ongoing complex case
formulation is the necessary basis of any treatment.
Developing an understanding of the key predisposing
factors, maintaining factors, and relational dynamics of
patients, combined with a process of ongoing reflection,
creates a sound basis for planning treatment (and allows
therapists to be aligned with, and attuned to, patients). As
each of the theoretical models has a degree of empirical
support, key aspects of each model, including intolerance of
uncertainty, poor emotional regulation strategies, and
various forms of cognitive avoidance, may form part of the
clinical picture. Table 1 lists a series of questions that may
help therapists to develop 'individual threat profiles' for
patients, aiding both case formulation and treatment
planning. Threat appraisal in GAD is complex to the extent
that it encompasses multiple threat expectancies, triggering
anxiety and associated safety strategies. Such beliefs include
standard negative automatic thoughts (or Type 1 worries in
Wells’ (2005) model), meta-beliefs about worry (both
positive and negative), beliefs about coping with negative
outcomes, and meta-beliefs about affect, as well as
negative underlying assumptions and core beliefs about
oneself, others, and the world. It is likely that triggers can
activate more than one threat appraisal simultaneously.
Table 2 proposes a sequence of modules for
targeting key areas in treating patients with GAD, where
each module builds on the skills learnt in earlier modules.
We would argue that our suggested treatment sequence
becomes increasingly experiential. In keeping with this
approach, we advocate challenging inflated perceptions of
the probability, cost, and perceived ability to cope with
feared outcomes. Importantly, most modules readily
incorporate graded exposure, imaginal exposure, exposure
and response prevention, and behavioural experiments, in
addition to standard cognitive techniques. Where comorbidity of major depression and dysthymia present with
GAD, we suggest incorporating standard strategies for
managing mood, including pleasant activity scheduling and
structured problem solving. Clinical skill is necessary to
gently help patients maintain focus in session and to help
patients experience 'feared feelings' within a framework of
working collaboratively toward clearly defined (behavioural)
goals. Sometimes the most difficult sessions for patients
and their therapists become the ones where most insight is
gained and the best outcomes are achieved.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
4 Table 1
Questions for therapists to consider in relation to their patients with GAD to aid and enhance case formulation
Questions to aid case formulation
Example responses
Which situations are perceived as threatening?
Noticing physical sensations or thoughts
Situations with ambiguous outcomes
Interpersonal situations
What type of affect is perceived as threatening?
(positive, anxious, depressed, frustration/anger)?
My feelings will be overwhelming
My feelings are dangerous
These feelings mean something about me
Is worry perceived as helpful, unhelpful, or both?
My worry is uncontrollable
Worry is harmful to myself/others
Worry helps me cope
Worry stops bad things happening
Worry makes me a good person
What beliefs are held about one's capacity to cope
with negative events?
I can't cope with stress
I have to cope perfectly
I always have to be in control
What are the primary assumptions held about
oneself, others, and the world?
The world is a dangerous place; unfair place
If I make a mistake, then others will think …
I am inadequate, worthless, defective …
Bad things will happen to me…
What would the feared negative outcomes look like if
they occurred?
Financial ruin, relational loss, serious health problems
Which behaviours are adopted to reduce perceived
threats?
Avoiding triggers, reassurance seeking, pleasing others,
perfectionism, busyness, procrastination, controlling feelings
and situations, controlling others, distraction
What is the patient's typical relational style?
Engaged; enmeshed; avoidant; demanding, controlling
Table 2
A suggested sequence for planning the focus of treatment
Sequence
Assess and set goals
Provide psycho-education; introduce monitoring
Develop individualised formulation, treatment plan, pros and cons of engaging in treatment
Introduce the cognitive model
Introduce and practise realistic thinking
Identify and challenge negative meta-beliefs about worry
Begin imaginal exposure to feared outcomes (including worry stories)
Identify and challenge beliefs about coping
Introduce graded exposure and stepladders to reduce safety behaviours and increase exposure to uncertainty
Identify and challenge positive meta-beliefs about worry
Identify and challenge unhelpful assumptions and core beliefs
Introduce and practise attention training and mindfulness meditation
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
5 References
American Psychiatric Association (APA; 2000). Diagnostic
and Statistical Manual of Mental Disorders, 4th
Edition, Text Revision (DSM-IV-TR). Washington, DC:
American Psychiatric Association.
Barlow, D. H. (2000). Unravelling the mysteries of anxiety
and its disorders from the perspective of emotion
theory. American Psychologist, 55, 1247-1263.
Borkovec, T. (2002). Life in the future versus life in the
present. Clinical Psychology: Science and Practice, 9,
76-80.
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance
theory of worry and generalized anxiety disorder. In
R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.).
Generalized Anxiety Disorder. Advances in Research
and Practice (pp. 77-108). New York, NY: Guilford
Press.
Buhr, K., & Dugas, M. J. (2004). Investigating the construct
validity of intolerance of uncertainty and its unique
relationship with worry. Journal of Anxiety Disorders,
20(2), 222-236.
Durham, R. C., Murphy, T., Allen, T., Richard, K., Treliving, L.
R., & Fenton, G. W. (1994). Cognitive therapy,
analytic psychotherapy and anxiety management
training for generalized anxiety disorder. British
Journal of Psychiatry, 165, 315-323.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of
fear:
Exposure
to
corrective
information.
Psychological Bulletin, 99(1), 20-35.
Gould, R. A., Safren, S. A., Washington, D. O., & Otto, M. W.
(2004). A meta-analytic review of cognitivebehavioral treatments. In R. G. Heimberg, C. L. Turk,
& D. S. Mennin (Eds.). Generalized Anxiety Disorder.
Advances in Research and Practice (pp. 248-264).
New York, NY: Guilford Press.
Hunt, C. (2000). The treatment of generalised anxiety
disorder. Clinical Psychologist, 5, 41-48.
Hunt, C. Issakidis, C., & Andrews, G. (2002) DSM-IV
generalised anxiety disorder in the Australian
National Survey of Mental Health and Well-Being.
Psychological Medicine, 32, 649-659.
Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M.
(2005). Preliminary evidence for an emotion
dysregulation model of generalised anxiety
disorder. Behaviour Research and Therapy, 43, 12811310.
Noyes, R., Woodman, C., Garvey, M. J., Cook, B. L., Suelzer,
M., Clancy, J., & Anderson, D. J. (1992). Generalized
anxiety
disorders
versus
panic
disorder:
Distinguishing characteristics and patterns of
comorbidity. Journal of Nervous and Mental Disease,
180, 369-370.
Ost, L-G., & Breiholtz, E. (2000). Applied relaxation vs.
cognitive therapy in the treatment of generalized
anxiety disorders. Behaviour Research and Therapy,
38, 777-790.
Wells, A. (2005). The Metacognitive Model of GAD:
Assessment of meta-worry and relationship with
DSM-IV generalized anxiety disorder. Cognitive
Therapy and Research, 29(1), 107-121.
Helpful clinical resources
Leahy, R. (2005). The Worry Cure: Seven steps to stop worry
from stopping you. New York, NY: Three Rivers
Press.
Rygh, J. L., & Sanderson, W. C. (2004). Treating Generalized
Anxiety Disorder. New York, NY: Guilford Press.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
6 Ron Chambers is Psychology Professional Advisor and a
Consultant Clinical Psychologist at the Specialist Mental
Health Service, Canterbury District Health Board (CDHB). He
has specialised in treating people with anxiety disorders at
the CDHB Anxiety Disorders Unit for the last 18 years
Please address all correspondence to:
Dr Lee Kannis
Department of Psychology
University of the Sunshine Coast
Locked Bag 4
Maroochydore, QLD 4558
Australia
Email: [email protected]
Phone: +61 7 5459 4879
O
SAFETY SEEKING
BEHAVIOURS: A REVIEW
AND REFLECTION FROM
A SPECIALIST ANXIETY
TREATMENT CENTRE
Lee Kannis, PhD
Lecturer in Clinical Psychology
University of the Sunshine Coast
Ron Chambers, PGDipClinPsych MA(Hons)
Psychology Professional Advisor &
Consultant Clinical Psychologist
Anxiety Disorders Unit
Canterbury District Health Board
Christchurch NZ
Lee Kannis is a lecturer in Clinical Psychology at the
University of the Sunshine Coast. He received his
Postgraduate Diploma in Clinical Psychology and PhD in
Psychology from the University of Canterbury, NZ in 2003,
and a Postgraduate Diploma in Cognitive Therapy from the
University of Oxford in 2008. His clinical experience has been
primarily with adolescents and adults experiencing excessive
anxiety. This includes working in the UK at the Centre for
Anxiety Disorders and Trauma at the Maudsley Hospital,
London, and Priory Hospital, Bristol. More recently, he
worked alongside a number of skilled therapists, including
Ron Chambers, who have substantial experience of treating
those with anxiety at the Anxiety Disorders Unit, Canterbury
District Health Board, NZ.
ver 20 years ago Paul Salkovskis identified the role
of safety seeking behaviours (safety behaviours) in
the maintenance of anxiety (Salkovskis, 1991).
Salkovskis noted that, "For any individual, safety
seeking behaviour arises out of, and is logically linked to,
the perception of serious threat. Such behaviour may be
anticipatory (avoidant) or consequent (escape)" (p. 6).
Importantly, he added that safety seeking behaviour is
viewed by the patient to be preventative of negative
consequences, such as illness or humiliation, and prevents
disconfirmation of threat-related cognitions, thus
contributing to the maintenance of an anxiety disorder.
Further, safety behaviours maintain the preoccupation with
the feared consequence and increase an anxious
individual's selective attention to the perceived threat
(Deacon & Maack, 2008; Kobori, Salkovskis, Read, Lounes, &
Wong, 2012).
Since Salkovskis' pioneering work, safety behaviours
have been recognised across many anxiety disorders.
Commonly used safety behaviours include the use of
distraction, individuals slowing their breathing down or
using breathing retraining, the use of relaxation strategies,
and avoidance of anxiety-related situations altogether.
However, some safety behaviours may be more related to
specific anxiety disorders and the cognitive themes
associated with that disorder. For example, in Social Phobia
patients may try to prevent social embarrassment by
avoiding eye contact or thinking about the next sentence
they will say (Wells et al., 1995). In Panic Disorder,
individuals may leave a situation in which they believe a
catastrophe may occur or do something to prevent the
worst from happening (e.g., hold on to a rail to stop
themselves from fainting, slow their breathing down to
prevent a perceived heart attack) (Salkovskis, Clark, &
Gelder, 1996; Schmidt et al., 2000). In Obsessive
Compulsive Disorder (OCD), clients may use excessive
hand-washing to prevent contamination (Deacon & Maack,
2008). In Generalised Anxiety Disorder (GAD), individuals
may engage in frequent checking of loved ones' safety or
be overly protective (Beesdo-Baum et al., 2012). In
Posttraumatic Stress Disorder (PTSD), individuals may be
vigilant to possible threat (Ehlers & Clark, 2008). Further,
safety behaviours have been identified and found to be
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
7 maintaining factors in other anxiety-related conditions,
such as health anxiety (Hypochondriasis), Body Dysmorphic
Disorder (BDD),
and Depersonalisation Disorder
(Abramowitz & Moore, 2007; Hunter, Phillips, Chalder,
Sierra, & David, 2003; Veale, 2004).
Certainly, in our clinical practice of working with many
clients with anxiety disorders, we have treated clients who
display the above examples of safety behaviours. However,
careful assessment and formulation of clients' anxiety
presentations is required to uncover the diverse range of
idiosyncratic and subtle safety behaviours that people
utilise and the role they play. In our work at the Anxiety
Disorders Unit we are frequently amazed by the unique
and creative safety strategies that people have developed
to try to manage their particular symptoms.
When undertaking an assessment of a client's anxiety
symptoms, it is important to consider that safety strategies
can be either behavioural or cognitive in nature. Cognitive
safety behaviours might involve activities that provide
distraction from emotional distress or the physical
symptoms they are experiencing, such as reading,
watching TV, trying to suppress or control anxious
thoughts, or make themselves think of something other
than the situation they are in. They may also repeat specific
statements to themselves that they believe will be helpful.
Clients with Social Phobia not only think ahead about what
to say, but also frequently report rehearsing conversations
in their mind.
Behavioural safety strategies people use are also
diverse and quite obscure at times. People who
experience social anxiety symptoms may report wearing
sun glasses to avoid eye contact, but also sometimes
describe "dressing down" or dressing in a bland way so as
not to draw attention to themselves. They may also choose
to stay in the background or not say much in social
situations they cannot avoid entering. Some clients report
that taking their children with them into feared social
situations is a safety strategy because it gives them
something to focus on (distraction) and they hope it will
shift others' attention away from them. People with Panic
Disorder who are highly sensitised to their somatic
symptoms, may, for example, sit by open windows if they
are fearful of feeling hot or breathless. Fears of
breathlessness or elevations in heart rate can lead people
to avoid or reduce the amount of physical exertion or
exercise they do. They may choose to walk close to walls or
lean on them, or sit down when feeling panicky (typically
related to a fear of collapsing or falling over). It is not
uncommon for clients to acknowledge that when
shopping (in supermarkets, for example) they will walk fast
and try to minimise the time they are in a situation they
see as dangerous. In other conditions such as health
anxiety and BDD, they may continually touch or look at
certain parts of their body, often look at themself in the
mirror or other reflective surfaces, or may hold their face or
body a certain way because of a concern about how they
appear to others.
Research into the treatment of anxiety disorders has
repeatedly demonstrated that using a cognitive therapy
framework that includes targeting the reduction of safety
behaviours is effective and more efficacious than earlier
therapeutic approaches based on exposure alone that does
not target safety behaviours (Sloan & Telch, 2002; Wells et
al., 1995). Salkovskis, Hackmann, Wells, Gelder, and Clark
(2006) evaluated a habituation approach in contrast to a
belief disconfirmation approach, which included dropping
of safety behaviours, in the treatment of a small number of
patients with Panic Disorder. They found those patients
who received cognitive behaviour therapy (CBT) that
included a focus on identifying and reducing safety
behaviours
showed
significant
improvement
in
comparison to those who received habituation based
exposure therapy. Recent research (Beesdo-Baum et al.,
2012) in the treatment of GAD, noted that safety
behaviours that were not sufficiently addressed in
treatment and that remained present at the end of therapy
predicted poorer long-term outcome.
Clark et al. (2006) compared cognitive therapy to
exposure therapy with relaxation in 62 patients with Social
Phobia. They found that 84% of those who received
cognitive therapy, including the dropping of safety
behaviours, no longer met a diagnosis of Social Phobia at
post-treatment. In contrast, 42% of those who received
exposure therapy with applied relaxation (safety behaviour)
no longer met Social Phobia diagnosis at post-treatment.
Notably, at one-year follow-up, outcomes remained similar
for both groups; however, those who had exposure
therapy with applied relaxation were found to have been
more likely to seek further treatment. Additionally,
research by McManus, Sacadura, and Clark (2008) found
that those with higher levels of social anxiety, when
compared to those with lower levels of social anxiety,
exhibited higher numbers of safety behaviours, used them
more frequently, and employed them in more situations.
They added that experimental manipulation of safety
behaviours (i.e., increased use of them) was found to be
associated with increased levels of anxiety and increased
conviction in social threat-related beliefs. Importantly, they
noted that safety behaviours increased self-monitoring and
self-focus in social situations, which means individuals
engaging in this process may come across as distant or not
interested in socialising as their attention is focused
inwardly.
Plasencia, Alden, and Taylor (2011), in a sample of 93
patients with social anxiety, reported that the type of safety
behaviour, that is, either avoidance behaviour (e.g., limiting
speech, limited eye contact) or impression management
(e.g., monitor and control one's behaviour to present as
more socially pleasing), was related to different social
consequences. Avoidance safety behaviours were related
to elevated state anxiety during social interactions and
negative responses from others, whereas impression
management safety behaviours hindered corrections to
negative social predictions.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
8 However, some researchers have questioned the
move towards targeting safety behaviours in treatment
and suggest that therapy may be just as effective by not
reducing their use by patients (Meuret, Wilhelm, Ritz, &
Roth, 2003; Sy, Dixon, Lickel, Nelson, & Deacon, 2011).
Milosevic and Radomsky (2008) noted that there had been
some controversy about whether or not the use of safety
behaviours inhibits exposure-based therapy. Based on
research with 62 individuals, Milosevic and Radomsky
suggested that reliance on a safety behaviour during
exposure therapy in anxiety disorder treatment might not
impede treatment outcome. However, their research used
individuals with a fear of snakes and not individuals with an
anxiety disorder per se. Similarly, a study (Hood, Antony,
Koerner, & Monson, 2010) on individuals with a fear of
spiders found that exposure therapy with and without the
use of safety behaviours generated similar effectiveness
outcomes. Nonetheless, in this study, as with much of the
research questioning the dropping of safety behaviours,
most participants did not have an anxiety disorder but, if
they did, it was of the phobic kind (35% had Specific
Phobia, Animal Type). To date there appears to be limited
evidence in the literature demonstrating increased efficacy
for exposure therapy where safety behaviours are not
specifically targeted for reduction or elimination.
Rachman, Radomsky, and Shafran (2008) noted that
there is substantial evidence that safety behaviours can
impair the progress of therapy. However, they were
somewhat critical of the broad targeting of safety
behaviours and noted that exposure therapy without a
focus on dropping of safety behaviours is still effective.
Nevertheless, they recommended that "judicious" (p. 169)
use of safety behaviours, particularly in the early stages of
therapy, may enable fear reduction. However, they believe
that this approach is best reserved for those who are
extremely distressed and suggested that using safety
behaviours this way in treatment should be limited.
In 2005, Thwaites and Freeston posed the question:
"Safety-seeking behaviours: fact or function?". They raised
the important issue of determining if an individual's
behaviour was a safety behaviour or an adaptive coping
strategy, noting that such clarification may be problematic
for the therapist. They suggested that establishing the
intention of the behaviour may be valuable in deciding if
the behaviour is adaptive or a safety behaviour. They
recommended that clinicians dedicate time to
understanding the distinctive function of patient's
behaviour to determine if a behaviour is adaptive or
maladaptive (safety behaviour). Certainly, this fits with
good clinical practice as formulation of an individual's
presenting problem is essential to the successful use of
CBT (Westbrook, Kennerley, & Kirk, 2011). Indeed, Wells et
al. (1995) noted that safety behaviours should be included
in the shared case conceptualisation and should be
removed or reversed during the course of therapy.
When the Anxiety Disorders Unit was initially set up in
1989, the CBT treatment approach was focused primarily
on exposure and habituation principles with breathing and
relaxation techniques taught as a key part of treatment.
Over the past 10 – 15 years there has been a move
towards the use of more specific cognitive models that
target the role and function of safety behaviours in the
maintenance of symptoms. In this context, breathing and
relaxation techniques are discussed as being potential
safety behaviours. Generally, depending on the client's
individual formulation, breathing and relaxation techniques
may be used only in the context of treatment for GAD and
PTSD. Initially, some clinicians who were used to working
with the original treatment protocols were concerned
about whether techniques that clients typically reported to
be helpful (e.g., breathing and relaxation) should be deemphasised or dropped from being a standard part of
treatment of conditions such as Panic Disorder. To some
extent, clinicians were concerned that patients would want
and expect such techniques to be provided and also that
treatment might not be as effective if they were not
routinely offered to all people with anxiety problems.
However, overall at the Anxiety Disorders Unit it
appears that the move to conceptualising these
techniques as potential safety behaviours and closely
examining their role and function, along with other safety
behaviours, for each individual has been successful. In
particular, it does not appear to have led to increased
treatment drop-out or worse treatment outcomes for
people with Panic Disorder. Our experience has been that
once the concept of safety behaviours and their potential
maintaining role in anxiety (and other) conditions is
explained to clients, they usually see that breathing or
relaxation techniques they have heard about (or previously
been taught) fit into this formulation. As a result, people
who have learnt them are usually willing to experiment
with dropping them. In our experience, it is often more
difficult to convince health clinicians who do not have indepth knowledge of the cognitive behavioural
conceptualisations of the various anxiety conditions and
other emotional disorders that breathing and relaxation
techniques and the like can function as safety behaviours;
they should, therefore, be used judiciously, if at all, on a
case by case basis. In this respect, as noted above, what is
required is a thorough assessment and formulation to
determine what strategies (cognitive or behavioural)
function as unhelpful safety behaviours and what are
adaptive coping strategies. Treatment can then focus on
reducing and eliminating the maladaptive safety
behaviours.
Lastly, Helbig-Lang and Petermann (2010) published an
excellent review of the role of safety behaviours across
anxiety disorders and concluded that current evidence
largely supports that most types of safety behaviour
heighten discomfort and avoidance, as well as obstruct
therapeutic effects in exposure-based treatments. Based
on our combined clinical experience of treating many
individuals with a wide range of anxiety conditions, of
varying severity, we would agree with this assertion and
strongly encourage evidenced-based treatments that
incorporate the identification and reduction of safety
behaviours.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
9 References
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ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
10 RECENT ADVANCES IN
THE TREATMENT OF
SOCIAL PHOBIA
Alexandra Crawford, BSc (Hons)
Carol Newall, PhD
Ronald M. Rapee, PhD
Alexandra Crawford is a research assistant at the Centre for
Emotional Health, Macquarie University. She primarily assists
in coordinating the social phobia group treatment program.
She is also involved in a study investigating the relationship
between change talk during preparatory treatment
expectation and engagement (TEE) sessions, and social
phobia group treatment outcomes.
Carol Newall is a postdoctoral fellow at the Centre for
Emotional Health, Macquarie University. Her primary
research specialties are translational research on fear
learning and extinction in children, and the influence of
parental factors in childhood anxiety disorders.
Ron Rapee is Distinguished Professor in the Department of
Psychology and Director of the Centre for Emotional Health
at Macquarie University. His research interests span anxiety,
depression, and related emotional disorders across the
lifespan.
Please address all correspondence to:
Professor Ron Rapee
Department of Psychology
Macquarie University
Sydney NSW 2109
Australia
Email: [email protected]
Fax: +61 2 9850 8032
C
lients with social phobia experience many barriers to
obtaining benefit from even the most effective
treatment
programs.
Well-practised
safety
behaviours and the fear of negative evaluation can
make simply attending a therapy session extremely
difficult, let alone engaging in, challenging exposure
activities. Given these barriers, it is unsurprising that social
phobia has the smallest treatment effect size of any
anxiety disorder (Norton & Price, 2007). However, current
models describing core factors that maintain social phobia
(e.g., Clark & Wells, 1995; Hofmann, 2007; Rapee &
Heimberg, 1997) have been used to develop additional
strategies that are able to increase the effects of standard
cognitive behavioural treatments (Bögels, 2006; GarciaPalacios & Botella, 2003; Harvey, Clark, Ehlers, & Rapee,
2000; Kim, 2005). While treatment approaches based on
traditional techniques, such as exposure, relaxation, and
social skills training, lead to some symptom reductions in
socially anxious clients (Wlazlo, Schroeder-Hartwig, Hand,
Kaiser, Münchau, 1990), treatments based on current
models that address these more specific cognitive and
behavioural patterns appear to show incremental efficacy
(Clark et al., 2006; Rapee, Gaston, & Abbott, 2009).
The enhanced cognitive behavioural treatment for
social phobia (Clark et al., 2003, 2006; Stangier,
Heidenreich, Peitz, Lauterbach, & Clark, 2003) is the most
widely evaluated clinical approach based on current models
(Rapee et al., 2009). Enhanced cognitive behaviour therapy
(CBT) builds on the basic CBT techniques of cognitive
restructuring and systematic in vivo exposure by
identifying the underlying beliefs maintaining clients' fears,
and formulating hypotheses based on these beliefs to be
tested by clients through exposure. Thus, exposure is used
to gather evidence to challenge unrealistic assumptions
about the world and the self. Reductions in symptom
severity following enhanced CBT have been significant
(Clark et al., 2003, 2006; Rapee et al., 2009; Stangier et al.,
2003). However, effect sizes have varied greatly and there
remains room even for these enhanced treatments to be
further improved.
This article summarises three recent research
developments that could be used to further enhance CBT
for social phobia: the modification of attention bias, the
facilitation of exposure using pharmacotherapy (Dcycloserine), and the enhancement of treatment
expectations and engagement using motivational
interviewing. It should be noted that these directions of
research are still in "experimental" phase and do not yet
have the evidence base to be used in clinical practice. This
paper provides an overview for therapists of current areas
of investigation, which might one day lead to further
improvements in the treatment of social phobia.
Attention bias modification
There is now substantial empirical evidence indicating
that anxiety is linked to, and is causally influenced by,
attentional biases toward threat (Amir, Weber, Beard,
Bomyea, & Taylor, 2008; Bar-Haim, Lamy, Pergamin,
Bakermans-Kranenburg, & van Ijzendoorn, 2007). In the
case of social anxiety, the attentional bias is focussed
primarily on social threat (e.g., indicators of negative
evaluation). Given this attentional bias that appears to
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
11 maintain anxiety, it makes logical sense that teaching
people to redeploy attentional resources away from threat
should reduce anxiousness. A number of controlled trials
have begun to examine the efficacy of attention bias
modification (ABM1 ) training in anxiety disorders (MacLeod,
2012). In ABM, anxious clients are trained to increase
attention to neutral stimuli presented on a computer
screen (e.g., a face with a neutral expression) and to
reduce excessive attention that is usually allocated to a
threatening stimulus (e.g., an angry face). Randomised
controlled studies have now shown that giving socially
anxious participants several sessions of ABM with no other
treatment (i.e., no standard therapy) results in significantly
greater reductions in diagnoses and symptoms than a
control/placebo condition (Amir et al., 2009; Schmidt,
Richey, Buckner, & Timpano, 2009). Unfortunately,
however, an initial attempt to add ABM to standard CBT for
social phobia did not demonstrate additional benefits
above the CBT alone (Rapee et al., 2012). Current evidence
suggests that ABM may not work outside the laboratory
(e.g., practised at home or taught over the internet)
(Carlbring et al., 2012; Rapee et al., 2012). Therefore, more
work is needed before this technique might become a
useful adjunct to clinical practice. Despite these caveats, it
appears that ABM might represent an innovative and
alternative approach to CBT for socially anxious individuals.
For example, ABM might prove valuable as a first step for
those highly avoidant clients who are unwilling to engage
in any exposure and may even avoid presenting to a
therapist.
Advances in adjunctive pharmacological intervention: Dcycloserine (DCS) facilitation of exposure therapy
Some fascinating research in animals has shown that a
particular chemical called D-cycloserine (DCS) can increase
the rate at which rats learn to extinguish a conditioned fear
(Richardson, Ledgerwood, & Cranney, 2004). Following this
work, DCS has been used over the past few years to
increase the rate of extinction of various human fears (see
Deveney, McHugh, Tolin, Pollack, & Otto, 2009 for a review).
One of the fascinating things about DCS is that it is not
anxiolytic - in other words, DCS does not, by itself, reduce
anxiety. As a result, it has none of the side-effects related
to anxiolytics, such as drowsiness and numbing, which can
interfere with exposure therapy (Davis & Myers, 2002).
Rather, DCS seems to increase the ability of organisms to
learn that a cue is safe - in other words, it seems to
enhance the effects of exposure and memories for safety
cues. This is one of the first examples of a medication that
works through a psychological intervention.
Some research has begun to show that DCS can
increase the speed of exposure to fears of public speaking
1
A closely related body of research has shown that anxiety is also
characterised by biases in interpretations and hence some work
has now begun to train people to develop benign interpretations
of ambiguous stimuli. Thus, this area is often referred to as
cognitive bias modification (CBM) indicating retraining in attention
and/or interpretation biases.
(Guastella et al., 2008; Hofmann et al., 2006). For example,
in one study people with diagnosed social phobia were
given five sessions of exposure to public speaking while
taking either DCS or a pill placebo. Participants in the DCS
condition reported less social fear, avoidance, and
dysfunctional cognitions, and improved daily functioning at
the end of treatment compared to participants in the
placebo condition (Guastella et al., 2008). Several practical
difficulties limit the likely clinical value of DCS, in particular
its development of tolerance after a few uses and its
relatively small effects. However, the paradigm that
pharmacological agents can enhance psychological
treatments has great promise and may herald a new
method of clinical intervention as more effective
medications are developed. Given the relatively small
treatment effects currently shown by social anxiety
disorder (Norton & Price, 2007), people with this disorder
may stand to benefit the most from pharmacological
interventions that can enhance psychotherapeutic
outcomes.
Using motivational interviewing to enhance treatment
expectations, engagement, and efficacy
Avoidance, hesitancy, and withdrawal are core defining
features of social phobia and therefore its treatment relies
on powerful motivation. A low level of treatment
engagement (homework compliance) in socially anxious
clients has been observed in several studies (Edelman &
Chambless, 1995; Leung & Heimberg, 1996; Woody &
Adessky, 2002), which is a concern, given its association
with treatment outcome (Kazantzis, Deane, & Ronan,
2000). Thus, low client motivation may be one reason for
the relatively poor effects of even the best available social
phobia treatments. Therefore, methods to increase
motivation may be especially useful for this disorder. One
such method is motivational interviewing (MI) which aims
to enhance clients' motivation by enabling them to focus
on reasons for change and the challenges that may arise
during the change process (Arkowitz & Miller, 2008). There
is a history of positive effects of MI in treatments for
substance-use (Arkowitz & Miller, 2008) and more recently
it has begun to be used with several anxiety disorders
(Meyer et al., 2010; Westra, 2004; Westra, Arkowitz, &
Dozois, 2009; Westra & Dozois, 2006), including social
phobia (Buckner, Ledley, Heimberg & Schmidt, 2008;
Buckner & Schmidt, 2009). While most findings have been
positive, they have not all been consistent (Simpson et al.,
2010).
In line with recent research by Bucker and Schmidt
(2009), a study from our clinic evaluated the efficacy of
adding MI principles to an enhanced social anxiety CBT
program (Peters, Gaston, Baillie, & Rapee, 2012). Treatment
Expectations and Engagement (TEE) is a preparatory
program founded in MI principles that was developed for
this trial, involving three preparatory individual sessions
prior to commencing a group CBT program. It was
designed to enhance treatment outcomes by addressing
the likely challenges to full treatment engagement and
enhancing expectations about positive outcomes.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
12 Compared with clients who received enhanced group CBT
alone, those who participated in the three TEE sessions
with CBT reported lower symptom severity on both selfreport and clinician severity rating scales following
treatment.
Current work being led by Lorna Peters at the Centre
for Emotional Health is examining the reasons behind the
observed benefits of TEE sessions by comparing posttreatment outcomes from a combined group (CBT + TEE)
program with those of a control program (group CBT +
supportive counselling). The trial has been designed to
determine whether the inclusion of TEE's motivational
components produces superior post-treatment outcomes
when compared with individual sessions involving no
motivational components, only basic therapist contact. It is
expected that this trial will run until late 2014.
Conclusion
In summary, although the enhanced CBT treatment for
social phobia has led to some improvements in outcomes
over traditional CBT treatments (Clark et al., 2003, 2006;
Rapee et al., 2009; Stangier et al., 2003), there are still
considerable barriers preventing socially anxious clients
from fully benefiting from effective treatment programs.
Recent research has begun to address some of these
barriers by attempting to develop automatic methods of
shifting cognitive biases using pharmacological agents to
facilitate faster learning following exposure sessions
(Guastella et al., 2008), and enhancing clients' motivation
and expectations for treatment through MI (Peters et al.,
2012). This research is still in experimental stages but is
showing some promising results. Further work will
ultimately help to determine which, if any, of these
directions can enhance future clinical practice for social
anxiety disorder.
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ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
14 TRANSDIAGNOSTIC
APPROACHES TO
TREATING MENTAL
DISORDERS
Peter M. McEvoy, PhD
Centre for Clinical Interventions, Northbridge WA
Peter McEvoy is a specialist clinical psychologist at the Centre
for Clinical Interventions and an Adjunct Senior Lecturer in
the School of Psychology at the University of Western
Australia. He is a clinician, applied researcher, and trainer
who spent several years working at the Clinical Research Unit
for Anxiety and Depression at St Vincent's Hospital in Sydney
before moving back to Perth. Dr McEvoy has published over
forty journal articles and book chapters on emotional
disorders, including treatment outcome evaluations,
transdiagnostic processes, internet-based treatments, and
the epidemiology of anxiety disorders. He is an ad hoc
reviewer for around 20 national and international journals
and is on the editorial board of the Journal of Anxiety
Disorders. He carries an individual caseload but also
specialises in group treatments, having personally run over 40
social phobia groups and many more transdiagnostic and
diagnosis-specific groups for anxiety disorders and
depression.
Please address all correspondence to:
Dr Peter McEvoy
Centre for Clinical Interventions
223 James Street
Northbridge WA 6003
Australia
Web: www.cci.health.wa.gov.au
Email: [email protected]
Phone: + 61 8 9227 4399
A
s new knowledge about the phenomenology of
mental disorders accumulates, each edition of the
Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 2000) presents an
increasingly differentiated and re-organised classification
system. Changes to the so-called meta-structure of the
manual, where more closely related disorder groups are
adjacent to each other, are designed to reflect this new
knowledge. For instance, DSM-V, which is due to be
published in May 2013, plans to remove obsessivecompulsive disorder from the anxiety disorders chapter
and place it within an adjacent Obsessive-compulsive and
related disorders chapter along with body dysmorphic
disorder, hoarding disorder, hair-pulling disorder, and skin
picking disorder. Acute stress disorder and post-traumatic
stress disorder will also be removed from the anxiety
disorders chapter and will be placed in a Trauma- and
stressor-related disorders chapter with reactive attachment
disorder, disinhibited social engagement disorder, and
adjustment disorders. DSM-V is designed to be a living
document that will allow more frequent revisions,
potentially paving the way for even more rapid
differentiation.
Diagnosis-specific approaches
The pursuit of diagnostic differentiation has merit if it
facilitates (a) communication, (b) diagnostic reliability, (c)
diagnostic validity ("carving nature at its joints"), (d)
identification of diagnosis-specific vulnerability, and
precipitating and maintaining factors, and (e) ultimately,
the development of more targeted, effective, and efficient
treatments. Contemporary diagnostic nosologies almost
certainly achieve the first two goals. Structured diagnostic
interviews can identify constellations of symptoms that
define a diagnostic category with high internal and interrater reliability. As new evidence accumulates, revisions of
the classification system ensue to increase diagnostic
validity (goal (c)), on which goals (d) and (e) mutually and
reciprocally depend.
Over the last three or four decades diagnosis-specific
models have been developed for virtually all emotional
disorders. The metaphorical trees have been propagated at
a rapid rate and they have borne considerable fruit.
Diagnosis-specific models have generated substantial
bodies of research identifying risk and maintaining factors,
testing purported causal relationships, and developing
effective treatments. Our deeper understanding of the
relationships between cognitive, behavioural, physiological,
interpersonal, and emotional experiences has increased
the sophistication of our formulations and ultimately the
effectiveness of our treatments. Recently, however, it has
been argued that it may be time to stand back from the
forest and identify the most valuable wood through the
trees.
Transdiagnostic approaches
The pursuit of disorder-specific processes has arguably
obscured important commonalities across emotional
disorders. Whereas disorder-specific approaches suggest
that (a) key maintenance processes are not shared across
the disorders, (b) diagnostic assessment is always
necessary to deliver effective treatment, and (c) future
developments will benefit from disorder-specific models,
the transdiagnostic approach argues that the key
maintenance processes are shared across disorders,
diagnostic assessment is not always necessary to deliver
effective treatment, and future developments will benefit
from theories that conceptualise processes shared across
disorders (Mansell, Harvey, Watkins, & Shafran, 2009).
Transdiagnostic approaches to treatment have been
defined as "…those that apply the same underlying
treatment principles across mental disorders without
tailoring the protocol to the specific diagnosis. Instead, the
emphasis is on functional links between components of
the transdiagnostic formulation (e.g., thoughts, behaviours,
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
15 physiology, and emotions), which is then individualised
during therapy" (McEvoy, Nathan, & Norton, 2009, p. 21).
The
theoretical and empirical rationale
for
transdiagnostic treatments derives from an extensive
diagnosis-specific and transdiagnostic evidence base.
Harvey, Watkins, Mansell, and Shafran (2004) conducted a
comprehensive review of attentional, memory, reasoning,
thought, and behavioural processes and found evidence
that many were applicable across emotional disorders. For
instance, various forms of repetitive negative thinking such
as worry, rumination, and post-event processing, which
have been traditionally studied within the generalised
anxiety disorder (GAD), depression, and social anxiety
disorder (SAD) literatures, respectively, appear to be more
similar than different (Mahoney, McEvoy, & Moulds, 2012;
McEvoy, Mahoney, & Moulds, 2010; Watkins, Moulds, &
Mackintosh, 2005). Evidence is accumulating that models
developed with reference to a specific disorder may
actually apply across emotional disorders (e.g., intolerance
of uncertainty, negative metacognitive beliefs) to drive
common processes such as repetitive negative thinking
although, consistent with a dimensional (rather than a
categorical) approach, different processes may play a
greater role in some disorders than others (McEvoy &
Mahoney, 2012). The argument is that although the
specific cognition may differ across anxiety disorders, the
emotional outcome may be the same (increasing anxiety).
Similarly, differences between the specific avoidance
behaviours may be less important than the common
function of the behaviours (short term reduction in anxiety
but maintenance of the anxiety disorder). If both sets of
cognitions share the same consequence and both
behaviours serve the same function, could a formulation
that captures the common functional links adequately
guide treatment without having to develop separate
formulations for each disorder?
Transdiagnostic treatments
The breadth of the key processes targeted by a
transdiagnostic treatment may be narrow or broad. For
instance, experiential avoidance is targeted in Acceptance
and Commitment Therapy (ACT) as the principal
maintaining factor for emotional disorders (Hayes, Wilson,
Gifford, Follette, & Strosahl, 1996), and positive and
negative metacognitive beliefs are one of the main targets
of metacognitive therapy (Wells, 2007), regardless of the
client's diagnostic profile. Fairburn and colleagues'
transdiagnostic treatment for eating disorders has multiple
targets, including over-evaluation of eating, shape and
weight and associated weight-control behaviour, core low
self-esteem, perfectionism, and mood intolerance
(Fairburn, Cooper, & Shafran, 2003). Likewise, Barlow and
colleagues' unified treatment for emotional disorders has
multiple targets, including psychoeducation about the
adaptive and functional nature of emotions, restructuring
maladaptive cognitive appraisals, changing maladaptive
action tendencies associated with emotions, preventing
emotion avoidance, and emotion exposure procedures
(Barlow, Allen, & Choate, 2004; Farchione et al., 2012).
Treatments designed to target transdiagnostic
processes across anxiety disorders have shown
considerable promise. For instance, Peter Norton and
colleagues from the University of Houston have developed
and evaluated a transdiagnostic group treatment for
anxiety disorders that de-emphasises clients' diagnostic
profile and instead focuses on the commonalities across
disorders (Norton, 2012). Norton's protocol has four key
components: (1) psychoeducation about the nature of
anxiety and fear, (2) restructuring of negative thoughts, (3)
exposure and response prevention, and (4) restructuring
of core beliefs and assumptions. Regardless of principal or
comorbid diagnoses, clients learn about the function of
anxiety and fear, strategies to modify their threat appraisals
and underlying schemas, and how to gradually confront the
feared experience without avoidance or escape so that
they can pursue their goals. Importantly, Norton found that
clients' particular principal and comorbid disorders had no
impact on outcomes, suggesting that all diagnostic groups
benefited equally.
Advantages of transdiagnostic approaches
There are a number of potential advantages to a
transdiagnostic approach. Comorbidity is the norm rather
than the exception in clinical practice. Targeting the
commonalities across disorders may have a greater impact
on comorbid disorders by enabling clients to more flexibly,
creatively, and comprehensively apply treatment principles
to their emotional experiences more broadly rather than
within a restricted range of circumstances. In this way,
transdiagnostic treatments may be more efficient at
treating comorbid disorders than sequentially treating each
disorder, and may reduce risk of relapse. A pragmatic and
financial advantage to transdiagnostic treatments is a
reduction in the number of diagnosis-specific manuals,
thereby reducing training costs and removing
impediments to the dissemination of empirically
supported treatments (Addis, Wade, & Hatgis, 1999).
Mixed-diagnosis groups are also more feasible in many
services that do not receive enough referrals for diagnosisspecific groups.
Extending the transdiagnostic philosophy to the
identification of trans-therapy processes
Clinicians who are natural 'lumpers' rather than
'splitters' also notice many commonalities across different
brands of psychotherapy, even though different language
or rationales may be used to describe very similar (if not
identical) principles and procedures. Re-branding of
essentially the same therapeutic principles introduces
unnecessary complexity and training requirements.
Research on common transdiagnostic mechanisms across
different forms of therapy is important for identifying
universal processes that are most strongly and reliably
associated with change. For instance, Arch, Wolitzky-Taylor,
Eifert, and Craske (2012) recently assessed the relationship
between session-by-session change in purported
mediators and treatment outcomes from cognitive
behaviour therapy (CBT) and ACT in a mixed anxiety
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
16 disorder sample. These researchers found that cognitive
defusion, the ability to flexibly distance oneself from the
literal meaning of cognition and thereby reduce the
influence of negative cognitions on behaviour, was a
common mechanism across both treatments. These
treatments use different tools for achieving defusion, but
it appears that both arrive at the same destination. The
benefits of knowing that defusion matters, regardless of
principal diagnosis or brand of treatment, enables us to
focus our attention towards identifying the most efficient
and effective strategies for achieving it, rather than getting
caught up in turf wars or semantics. Carey (2011) cogently
argues that differences between CBT and ACT "…might
become less important if more attention is devoted to
underlying principles and mechanisms rather than practicebased procedures and techniques" (p. 239).
A brief case example
Joan is a 35-year-old woman with two young children
who suffered from post-natal depression after both of her
children. She reports always being 'a worrier' but this has
escalated since becoming a mother to the point where she
suffers severe panic attacks in places where escape is difficult
with her two young children, such as in shopping centre
queues, on public transport, and when she is a long way
from home. Joan has always been somewhat shy and also
experiences significant social anxiety, which means she tends
to avoid her mother's group and family as sources of social
support.
A diagnosis-specific approach requires the clinician to
conduct a comprehensive diagnostic workup so that a
principal disorder can be identified and targeted first
(typically the one nominated by the client as most
disabling) before moving on to the next most debilitating
disorder. In Joan's case, this may be the most acute panic
symptoms (panic disorder), or the more chronic worry
(generalised anxiety disorder) or social anxiety (social
anxiety disorder), but this decision may be a very difficult
one to make. Once a decision is made, comorbid disorders
may also get in the way of making progress with the
principal disorder (e.g., if Joan's depression affects her
motivation to leave the house and gradually confront her
fear of panic).
A transdiagnostic approach would identify and target
common factors across Joan's problems, with less
emphasis on determining her principal disorder. Instead,
the question becomes, what theory-driven, evidencebased mechanisms might be operating to maintain Joan's
depression, worry, panic attacks, and social anxiety? The
clinician may identify several key mechanisms. For instance,
positive metacognitions (worrying is helpful) and negative
metacognitions (worry is uncontrollable) may be
formulated as maintaining her engagement in repetitive
negative thinking about her role as a mother, her physical
symptoms of anxiety, and her expectation of negative
evaluation from others. Identifying, testing, and modifying
these metacognitive beliefs may enable her to better
disengage from her negative ruminations, thereby
reducing the intensity of her symptoms and enabling her
to begin the process of confronting previously avoided
situations. Experiential avoidance may also be formulated
as a key process maintaining her negative beliefs and
undermining her coping self-efficacy. Joan may benefit
from learning strategies that enable her to gradually
confront and increase her acceptance of, and tolerance for,
uncomfortable experiences so that she can continue to
pursue her values. Targeting these mechanisms is likely to
reduce her reliance on counter-productive cognitive and
behavioural avoidance strategies regardless of the specific
trigger, and may have a greater impact on comorbid
problems and ultimately reduce vulnerability to relapse. As
Joan challenges and modifies her positive beliefs about
worry, demonstrates that she is in fact able to disengage
from her worry more easily than she thought, and her
confidence in her ability to manage uncomfortable
emotions increases, it would be expected that she will be
less vulnerable to debilitating worry about daily
responsibilities, panic attacks, and negative evaluation. The
brand of psychotherapy from which the specific
techniques derive is less important than whether the
strategies efficiently and effectively target the
mechanisms identified within Joan's transdiagnostic case
formulation.
Conclusion
Diagnostic systems are invaluable for communicating
important information about psychological disorders.
Individuals with emotional disorders have also benefited
greatly from decades of research developing and testing
diagnosis-specific theories and interventions. These
discoveries have rightfully earned clinical psychology a
reputation as a rigorous, scientific, and well-respected
profession. It may be time to take a step back and
consolidate all that we have learned by distilling our
theories and treatments into the most potent evidencebased principles. Consistent with the principles of
parsimony and pragmatism, perhaps the next wave of
psychotherapy should involve a greater recognition of the
commonalities across disorders, theories, and treatments,
with distinctions being valued only when they have
demonstrable and replicable impacts on improving
treatment outcomes.
References
Addis, M. E., Wade, W. A., & Hatgis, C. (1999). Barriers to
dissemination of
evidence-based practices:
Addressing practitioners' concerns about manualbased psychotherapies. Clinical Psychology: Science
and Practice, 6, 430–441.
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text
revision). Washington DC: Author.
Arch, J. J., Wolitzky-Taylor, K. B., Eifert, G. H., & Craske, M. G.
(2012). Longitudinal treatment mediation of
traditional cognitive behavioural therapy and
acceptance and commitment therapy for anxiety
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
17 disorders. Behaviour Research and Therapy, 50, 469478.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a
unified treatment for emotional disorders. Behavior
Therapy, 35, 205–230.
Carey, T. A. (2011). Exposure and reorganization: The what
and how of effective psychotherapy. Clinical
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Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive
behaviour therapy for eating disorders: A
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Thompson-Hollands, Carl, J. R., Gallagher, M. W., &
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Strosahl, K. (1996). Experiential avoidance and
behavioral disorders: A functional dimensional
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ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
18 Why is medication prescribed?
The reasons fall into the following areas:
MEDICATION USED IN
ANXIETY DISORDERS
Michael Baigent MBBS, FRANZCP, FACHAM
Associate Professor, Department of Psychiatry,
Flinders University
Michael Baigent MBBS, FRANZCP, FAChAM is a psychiatrist
specialising in anxiety and addiction. He is the Clinical
Director of the Centre for Anxiety and Related Disorders,
Flinders Medical Centre and directs the Mental Health
Sciences course, part of the Flinders Human Behaviour and
Health Research Unit. He has lectured extensively in the area
of co-morbidity and been a member of a number of national
and state advisory committees and reference groups. He was
the immediate past Chair of the Section on Addiction
Psychiatry for the Royal Australian and New Zealand College
of Psychiatrists. In 2006, he was invited to be the Clinical
Advisor to beyondblue, the National Depression Initiative.
Please address all correspondence to:
A/Prof Michael Baigent
Department of Psychiatry, Flinders University
Flinders Medical Centre
Bedford Park SA 5042
Australia
Email: [email protected]
Phone: +61 8 8204 5237
A
nxiety disorders are the most prevalent mental
disorder in our community and most who do not
have a lived experience of one of these disorders are
unaware how disabling they can be. Many do not
seek treatment or recognise that their symptoms are a
mental disorder. Often the first professional seen for
treatment is their general practitioner. Many are
appropriately diagnosed, educated, and referred for
psychological treatment. This is the most efficacious and
often the treatment preferred by the patient. Although
access to psychological treatments and the methods by
which psychological treatments are delivered has grown,
many patients are still prescribed medication for their
anxiety disorder, either with psychological therapy or as a
standalone treatment.
1. Patient preference. "I tried CBT once before and it
didn't help". There is no doubt that symptom
reduction through medication in two to eight weeks
(if it is going to be effective) is preferable to some
than the work and commitment involved with eight
(for most anxiety disorders) to 20 (e.g., for
obsessive-compulsive disorder (OCD)) sessions of
cognitive behaviour therapy (CBT). Higher relapse
rates after discontinuation is a distant, abstract
concern in these cases.
2. Delay in accessing psychological treatment intolerable.
At presentation the distress from anxiety can be
overwhelming, impairing comprehension of the
rationale for using psychological approaches and
driving the desire for a quicker resolution. The doctor
may be aware of a long wait for CBT and initiate
medication as a "stop gap".
3. Failure of psychological approaches to help or to
resolve symptoms to the patient's satisfaction. A 49year-old patient of the clinic with OCD had attended
for cue exposure response prevention on and off
over several years, including a number of admissions
to hospital for inpatient therapy. He had
contamination obsessions and related compulsions
preventing him from working as a general electrician.
He tried but made limited progress with CBT. He was
reluctant to adhere to a medication regime for any
length of time. He was finally able to make real
progress after he had been taking 80mg of
fluoxetine for six months and is now about to carry a
piece of roofing insulation in his pocket as his
penultimate exposure task. Before re-starting the
CBT treatment, on the fluoxetine 80mg daily, his
anxiety was less marked but he was still impaired
functionally.
4. Patient assessed or proven to be unsuitable for
psychological treatment. Obviously reasons vary for
this. Often patients with long histories of
polysubstance dependence have developed strong
beliefs about the role their own substances have in
modulating their affect. Medication for anxiety fits
easily into their formulation of their problems. Their
reluctance to embrace a psychological treatment
model will quickly become apparent. They may
respond very well to CBT if given the chance but
many will decline the offer in the earlier stages.
However, they may be more willing later in their drug
use history as often their view of their problems
evolves.
5. Severity of the disorder. Complex and severe OCD or
post-traumatic stress disorder (PTSD) at presentation
are examples. Medication has a role in these cases to
reduce the arousal state to allow the person to then
make use of the psychological approaches.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
19 generally the first line in the treatment of anxiety
disorders. To generalise, there are very small
differences in effect between these agents in
the treatment of specific anxiety disorders. The
rates and types of side effects vary noticeably
within the class as does tolerance within
individuals. The main side effects are nausea,
headache, insomnia, anxiety, and sexual
dysfunction. All but the latter generally diminish
after the first week of treatment but, if not, an
alternative is best considered. They are relatively
safe in overdose.
6. The presence of significant comorbidity that may
interfere or impede progress with psychological
treatments (e.g., a patient who is depressed and
about to begin graded exposure for agoraphobia).
7. Treatment targeting anxiety symptoms that are not the
result of an anxiety disorder (e.g., in desperation
when the anxiety experienced by the person is
overwhelming
and
really
attributable
to
temperament, trait, or personality).
Which medications are used to treat anxiety disorders?
The Government, through the Pharmaceutical Benefits
Scheme (PBS; Department of Health and Ageing, 2012),
subsidises the cost of some medications that can be used
for anxiety disorders. Many of these medications are
unrestricted which means they can be prescribed for any
condition (e.g., amitriptyline, diazepam). Some are
restricted in what they can be prescribed for but have one
of their indications listed as for one of the anxiety
disorders. In these cases, the manufacturers have shown
sufficient evidence to satisfy the cost effectiveness of their
use. Medications which do not have approval on the PBS for
anxiety disorders can still be prescribed but will not in
theory attract the subsidy if prescribed for anxiety. Many
have evidence for some benefit but have not been given a
PBS indication for an anxiety disorder. For example,
sertraline, a commonly prescribed antidepressant, has a
restricted benefit for major depression, OCD, and panic
disorder (where other treatments have failed or are
inappropriate). It is in fact also commonly prescribed in
cases of PTSD, with some supporting evidence, but in
theory should not attract a cost subsidy for this indication.
Medications commonly used in Australia
b)
Serotonin and Noradrenaline Re-uptake Inhibitors
(SNRIs) such as venlafaxine, desvenlafaxine
(synthetic version of venlafaxine's metabolite),
and duloxetine. These are generally not first line
because they are less well tolerated than SSRIs.
They share similar side effects to SSRIs but nausea
is more noticeable, and in higher doses
tachycardia and raised blood pressure can occur.
c)
Tricyclic Antidepressants
(TCA)
such as
amitriptyline, doxepin, and clomipramine. This
class predated by decades the above two classes.
They share many effects on serotonin and
noradrenaline receptors and side effects with
their successors but have additional adverse
effects which, because of the other options, have
limited their use for many. Dry mouth, sedation,
postural dizziness, urinary retention, blurred
vision, and potentially fatal outcomes in overdose
have relegated them as a possibility for more
treatment resistant individuals. There is still the
belief that clomipramine is a gold standard when
treating difficult to control OCD.
d)
Other antidepressants. Mirtazepine does not have
extensive research to support its use in anxiety
but has sedating effects so may be prescribed to
those with high levels of arousal. Its side effects
are somnolence and weight gain.
Medications from the following groups are commonly
used in Australia:
1. Antidepressant medications. These are effective even if
the patient is not depressed; however, one would be
more likely to prescribe if the patient appeared to be
depressed as well as anxious. It is generally necessary to
start low and increase the dosage slowly as the side
effects can be heightened anxiety initially. Expected
response can be delayed compared to the response
time in depression (early signs of improvement may be
noted in depression after two weeks). It is inaccurate to
simplify the mechanism of action of these agents to
correcting a "chemical imbalance". Their mode of action
is unclear and seems to involve modulation of amygdala
activity (fear pathway) and alteration in the long term of
the mediation of the release of cortisone. Examples
include:
a)
Serotonin Specific Re-uptake Inhibitors (SSRIs)
such as sertraline, citalopram, escitalopram,
fluoxetine, fluvoxamine, and paroxetine. They are
2. Benzodiazepines. Despite being classified as anxiolytics,
they should not be prescribed as a long term treatment
for anxiety disorders due to tolerance and withdrawal
symptoms, lack of evidence for long term benefits, and
their adverse effects such as sedation, impaired
memory and learning, depression, induced anxiety and
depression, cognitive problems, and falls and fractured
hips in the elderly. At modest doses they will interfere
with the process of habituation impeding progress with
exposure based treatments. If they must be prescribed,
it is best to use them for a limited duration of no more
than six weeks. They may have a place for symptomatic
relief of overwhelming anxiety symptoms in defined
situations. Examples from experience include the case
of a man who was stuck in an Asian country unable to
take the return flight because of a flying phobia and a
woman who was reluctant to continue a course of
chemotherapy treatment for cancer because of
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
20 debilitating conditioned
nausea
and
anxiety.
Benzodiazepines vary according to their half lives,
rapidity of onset, and whether there is an active
metabolite which prolongs their effect. Examples
include:
a)
alprazolam - this is available on an authority script
with the indication of panic disorder "where other
treatments have failed or are inappropriate". They
have a rapid onset of action which makes them
attractive as substances of abuse and diversion
for sale. This, combined with a relatively short half
life, makes them very uncomfortable to stop if
taken for prolonged periods. Despite having an
indication for panic disorder, there is no evidence
to support its long-term use.
b)
diazepam and oxazepam are commonly
prescribed and on the PBS. Lorazepam is a
relatively short acting benzodiazepine which is
obtained by a private script (not available by PBS
script).
3. Antipsychotic
medications.
Second
generation
antipsychotics - quetiepine is the most frequently
prescribed although others such as olanzapine and
risperidone are sometimes recommended. These
medications are generally authority prescription only
with bipolar type 1 or schizophrenia as the indications. If
required to pay the unsubsidised amount, they can be
expensive for the patient. Side effects, such as weight
gain, sedation, and Parkinson-like effects, are common
and limit their use.
4. Propanolol. Propanolol is a beta blocker used in blood
pressure management. It is useful for situation specific
anxiety with infrequent exposure, such as performance
anxiety, but is not useful for a general social phobia. It
works by reducing the sympathetic drive or physical
manifestations of anxiety, such as increased pulse and
blood pressure. Adverse effects such as postural
dizziness, lowered blood pressure, and bronchoconstriction (asthma-like symptoms) mean that the
decision to use it should be carefully considered and the
person may like to take a trial dose prior to the
performance.
5. Others. Topiramate, an anticonvulsant, is more readily
available and used in the veteran setting. It is useful for
the nightmares associated with PTSD.
Specific anxiety disorders and medication
Specific anxiety disorders with their medications are:
1. OCD. This is the most likely anxiety disorder to benefit
from medication. SSRIs bring about twice the symptom
reduction as placebo in most trials (Soomro, Altman,
Rajagopal, & Oakley Browne, 2008). There is little
difference in efficacy among the SSRIs, only variation in
the rates of adverse effects. In treatment resistant
cases, augmentation with quetiapine or risperidone can
help.
2. Social phobia. The evidence is strongest in favour of
SSRIs over other antidepressants and that longer-term
use is required to prevent relapse if used alone. There is
likely to be some publication bias.
3. Generalised anxiety disorder. The frequently quoted
figure of needing to treat five persons with a
medication for one responder applies to imipramine,
venlafaxine, and paroxetine (Kapczinski, Silva de Lima,
dos Santos Souza, Batista Miralha da Cunha, & Schmitt,
2003). They have been the subject of most of the
research. However, it is likely that there is little
difference in benefits from other antidepressants.
Quetiapine has some supporting research for its use in
this condition although the adverse effects are a
limitation.
4. PTSD. SSRIs are the first line medication for this disorder
and often yield benefit in reducing the arousal
symptoms and irritability. They are less useful for
nightmares. Avoidances of reminders and many of the
other features often still require trauma focussed CBT.
Second generation antipsychotics, as noted above, have
been shown to have some benefit but research has
shown negative results for benzodiazepines.
5. Specific phobia. Medication (propanolol) only rarely has a
role.
6. Panic disorder. After the acute phase treatment,
antidepressants alone (generally SSRIs) have been found
to be less effective than CBT alone or in combination
with CBT.
For me, as a psychiatrist, medication is not the first line
treatment for anxiety and it should never result in an
opportunity cost, meaning that the patient will then either
not pursue or consider psychological treatments. When
doing their job, medications can make the difference for
patients struggling to make a recovery. I have seldom seen
them
provide
all the
solutions
to
patients;
if prescribed, they are ideally placed alongside evidencebased therapy.
References
Department of Health and Ageing. (2012). Pharmaceutical Benefits
Scheme.
Retrieved
November
21,
2012
from
http://www.pbs.gov.au/pbs/home
Kapczinski, F. F. K., Silva de Lima, M., dos Santos Souza, J. J. S. S.,
Batista Miralha da Cunha, A. A. B. C., & Schmitt, R. R. S.
(2003). Antidepressants for generalized anxiety disorder.
Cochrane Database of Systematic Reviews 2003, Issue 2. Art.
No.:
CD003592.
DOI
10.1002/14651858.CD003592.
Retrieved
November
21,
2012
from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD0
03592/pdf
Soomro, G. M., Altman, D. G., Rajagopal, S., & Oakley Browne, M.
(2008). Selective serotonin re-uptake inhibitors (SSRIs)
versus placebo for obsessive compulsive disorder (OCD).
Cochrane Database of Systematic Reviews 2008, Issue 1. Art.
No.: CD001765. DOI: 10.1002/14651858.CD001765.pub3.
Retrieved
November
21,
2012
from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD0
01765.pub3/pdf
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
21 A CLIENT'S PERSPECTIVE
Linda
Linda is a 43-year-old woman who presented with Panic
Disorder with Agoraphobia, associated with planes and
trains. She had been aware of her predisposition to anxiety
for approximately ten years, but it had increased in the
previous six months. Over time she gradually decreased many
of her safety behaviours.
I
have always been a cautious sort of person. When we
were growing up, my younger sister would invariably
make it to the top of the climbing frame with my
brothers following close behind, while I would still be on
the first rung. I work as a pharmacist, a profession that I
think is more likely to be viewed as conservative rather
than cutting edge. I also have a family history of anxietyrelated issues. My maternal grandmother struggled with
leaving her home for any length of time. Quite often she
would start out on a shopping trip only to have to return in
a taxi part way through her planned outing. My father took
early retirement as he was unable to cope with the stress
of his work and the resulting anxiety. I believe my paternal
grandfather had similar problems. Although I knew these
things when I was growing up, they were never discussed
openly at home. My mother would joke that given our
family history it was amazing that any of us had turned out
to be 'normal' (whatever that is….!).
When I reached my mid-thirties, feelings of anxiety
gradually crept into my own life. I can't recall a single
occasion that triggered these feelings but there was a
series of small events that were uncomfortable and
eventually these became difficult for me to handle. For
example, I had flown to London a number of times on my
own, but then one day on a short flight from Brisbane to
Sydney, for no obvious reason, I had intense feelings of
panic and needing to get out of the plane. This type of
event became more frequent and I started to avoid certain
situations, such as getting into lifts or sitting in the back
seat of a car.
I didn't realise how much this type of anxiety had
become part of my life until I began to find it hard to make
the 15 minute train journey to work every day. I would start
to think about the journey the evening before and then all
the way to the station. I would stand on the end of the
platform and look out for the train in the distance to see
whether it was an older style one with opening windows (a
good thing!) or a more modern type of train. The windows
on the more modern trains do not open as the train is air
conditioned. I started to find this type of train very
uncomfortable. What if it stopped between stations? How
would I get out? What would I do if I couldn't get out?
Would I do something crazy? What would people think? I
would let a train go past without getting on if I thought it
looked too crowded or noisy.
The fear I had was more about experiencing the
feelings of panic rather than fear of the situation itself.
When I started to feel panicked, I would feel my heart rate
rise suddenly. My heart would start thudding in my chest
and I would feel hot and fidgety. I would feel like I needed
to get out immediately even though it was obvious that
there was nothing inherently dangerous about sitting on a
train in broad daylight. I'm not sure quite what I thought
would happen if I didn't get out. I began to think that I was
going mad.
I finally decided that enough was enough when my
husband booked flights six months in advance to go back
to England to visit our families. I realised that I was lying
awake at night imagining scenarios of how I would feel
about being 'trapped' in the aeroplane for 24 hours. I
worried about how I would cope with this. Just thinking
about it would bring on all the physical feelings of panic. I
was tempted to ask my husband to cancel the tickets. That
was when I decided to seek some professional help. I was
concerned that not only would I have to give up my job
because I couldn't make the journey to work, but also I
would never be able to visit my family again. Seeking help
was a big step for me because until then I had tried to
make myself believe that I could control the situation
myself.
I made a series of appointments to see a clinical
psychologist. I didn't tell my friends or work colleagues that
this was what I was doing. I hold a middle management
position in our company and I did not want my team, my
boss, or the HR department to have any idea about why I
needed the time off. I'm sure they all thought that I had a
serious illness as I took regular time off to go to
appointments over a number of weeks. This has made me
aware of the stigma associated with any type of mental
illness. It seems ridiculous that I felt that it would have
been more acceptable for me to say that I was attending
appointments for the treatment of a life threatening
condition rather than to say that I was addressing issues
around anxiety.
Talking through the issues with my psychologist helped
me understand that anxiety is fairly common and I am not
the only sufferer. This was a huge relief. I think anxiety is
quite an isolating problem. Certainly I saw it as a sign of
weakness and I have not told any of my friends or work
colleagues about it. My husband is very supportive of me
seeking help but I don't think he understands what it is like
to experience the symptoms.
My psychologist suggested that to start with I keep a
journal of my experiences on the train every day. I found
the very act of writing helped me to cope as it provided a
distraction from the journey itself. Looking back over my
entries I found that I struggled more when I was tired or
feeling unwell, or when I considered the train to be noisy,
hot, or crowded. The psychologist also gave me some
articles to read about the physiology behind the feelings of
panic. This was quite helpful as, having a science
background, I could understand how the reactions
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
22 occurred in the body and what symptoms could be
expected. Although this didn't solve the problem, at least I
knew I wasn't imagining the physiological effects that I was
experiencing, and that they were normal responses to a
stressful event or environment.
My psychologist suggested a number of strategies for
me to try. Ones that I found particularly helpful included
slow, deep breathing and having a positive attitude before
entering into a potentially stressful situation. I had been
recording my worrying thoughts and as they became more
positive I began to gain more control. Distractions such as
reading or listening to music or my "talking book" were a
great help. I also started to carry a small hand-held fan that
might help if I suddenly felt hot. A strategy that I am still
working on is that of using relaxation techniques. This takes
time and the commitment to practise the techniques in
order to feel the full benefit. Taking some annual leave that
was due to me has helped me feel a lot better. I didn't
realise how tired, stressed, and in need of a break I was.
I was well prepared for my flight to London. I took
plenty of reading material, a puzzle book, and some audio
books. I tried to keep a positive attitude by telling myself I
had made this trip many times before and survived the
experience so this time it would be no different. The
journey there was fine. The puzzle book was a great help
and I enjoyed reading one of my favourite novels again. It
was only in the last hour of the return journey that I
suddenly started experiencing the symptoms of increased
heart rate, feeling hot, and the urgent sense of needing to
get out. It was an uncomfortable last hour back to Sydney,
but out of 48 hours of travel I considered that that was not
too bad. I think that what happened in that last part of the
journey was that I was thinking ahead to landing and being
in the fresh air. Comparing those thoughts to being
cooped up in the plane was too much and I gave in to my
anxious feelings. That is something I can remember for
next time – always imagine the journey is at least an hour
longer than it is really going to be.
What I have learned this year is that anxiety is a
common complaint; however, most people do not discuss
it as they see it as a sign of weakness. Sadly there is no cure
or 'quick fix'. There will continue to be good days and bad
days. It takes time to try a few strategies and see which
ones work best. It may never be possible to be completely
free of the symptoms; however, with perseverance it is
possible to manage them.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
23 as it reduces the threat for socially anxious individuals. It
has been described as a safety behaviour that lessens
vulnerability and increases control (Clark & Wells, 1995). A
key feature considered to be associated with anxiety
disorders such as SP is hypervigilance, or hyperscanning
(Beck & Emery, 1985; Eysenck, 1992; Rapee & Heimberg,
1997), the tendency to constantly scan the environment
for threat.
RESEARCH ARTICLE
EYE TO EYE IN SOCIAL
PHOBIA: FEAR OF FACES
Kaye Horley PhD
Private practice, Gordon, Sydney
Kaye has worked for many years in various heath care
settings as teacher, researcher, and clinician. She is
currently in private practice in Gordon. She is the author of
various papers in refereed journals. Kaye has always been
interested in the “why” of behaviour and has a continued
fascination with the mind, particularly the cognitive and
emotional processes underlying psychological disturbance.
Please address all correspondence to:
Dr Kaye Horley
Suite 5, 780A Pacific Hwy
Gordon NSW 2075
Australia
Email: [email protected]
Introduction
S
ocial Phobia (SP), Generalised, is a common anxiety
disorder characterised by intense and irrational fear
of social situations. One of the most striking
observations in clinical studies of SP is the avoidance
of eye contact in social interactions (Greist, 1995; Marks,
1969; Öhman, 1986) that may be a consequence of
these fears. Since Darwin (1872/1955), psychoevolutionary research has shown that the eyes are the
most fear-inducing feature in situations of social appraisal
by others (Öhman, 1986). Cognitive models link this
disturbed social behaviour to exaggerated fears of
negative evaluation (Beck & Emery, 1985; Clark & Wells,
1995; Rapee & Heimberg, 1997).
Fear of eye contact in SP has been conceptualised as
"epitomising social fear" (Öhman, 1986, p. 129), and an
"exaggeration of the normal human sensitivity to eyes"
that is evident from infancy (Marks, 1987, p. 36). Avoidant
behaviour is a common defensive strategy (Argyle, 1983)
The eye movement path of an individual when
looking at a stimulus or pattern has been designated the
"scanpath" after Noton and Stark (1971). It is a
psychophysiological marker of visual attention that
provides a measure, or map, of where a person looks
(spatial) and for how long they look (temporal), revealing
the features attended to and the order of processing.
The fovea (the central region of the retina) 'fixates' upon
salient features in the environment, providing the visual
system with detailed input about the stimulus
(Henderson, 1992). Scanpath parameters include fixation
duration as a measurement of the time fixating on
selective areas of interest. The fixation scanpath length
signifies the total extent of such fixations whereas the
raw scanpath provides a measure of the total extent of
visual scanning, irrespective of fixations.
Visual scanpath studies have shown that healthy
subjects produce a regular pattern of eye movement and
fixations to face stimuli. Subjects focus in particular on
the salient facial features of eyes, nose, and mouth that
define facial expressions, producing scanpaths that
represent an inverted triangle in shape (Mertens,
Siegmund, & Grüsser, 1993). Of these features, the
greatest attention is usually paid to the eyes as the most
revealing source of information about emotional
expression in social interactions (Lundqvist, Esteves, &
Öhman, 1999).
Clinical observations of avoidance of eye contact in
social phobic individuals point to a possible dysfunction in
their processing of faces. The underlying assumption is
that when looking at faces, visual processing by the social
phobic individual is affected by vulnerability to social
stressors, especially fear of negative evaluation as
explicated in the cognitive model. Excessive scanning of
the environment and hypervigilance towards social threat
also indicate a possible effect upon visual strategies.
Visual scanpath studies of emotional expression
processing1
Studies employing a marker of visual attention (the
visual scanpath) examined whether avoidant strategies
are a feature of the perceptual strategies employed by
social phobic individuals. Provision of a visual scanpath
additionally examined for evidence of hyperscanning. A
computerised infra-red eye gaze monitor that sampled
gaze every twenty milliseconds, provided an objective
1
The substance of these studies formed a publication in the
Journal of Anxiety Disorders (Horley, Williams, Gonsalvez, &
Gordon, 2003), and in Psychiatry Research (Horley, Williams,
Gonsalvez, & Gordon, 2004).
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
24 psychophysiological marker of directed visual attention in
real time (Just & Carpenter, 1976). As such, they are
potentially informative about the mechanics of social
interaction and concomitant cognitive processes during
the processing of face stimuli in disorders such as SP.
Biologically relevant face stimuli were employed. The use
of such stimuli is particularly pertinent to SP, as it is faces
that convey the evaluative aspect that is the underlying
preoccupation and fear in social phobic individuals. The
employment of the visual scanpath for the first time was
in contrast with previous cognitive studies, employing
the Stroop and dot probe paradigms considered more
indirect measures of attention in reflecting cognitive
processes mediated by verbal and motor confounds
respectively.
The comparison of a face (neutral) to a control
stimulus, a complex geometric figure, the Rey-Osterrieth
complex figure (Rey, 1941/1993; Osterrieth, 1944/1993),
was an initial critical step to determine whether social
phobic individuals would show visuo-cognitive
disturbances specific to faces or generalised to all stimuli.
A subsequent study examined the processing of happy
(positive), neutral, and sad (negative) faces, and the
control geometric figure, compared to age and gendermatched healthy control subjects. A final study examined
attentional responsiveness to an explicit threat-related
(angry) face in comparison to the less explicitly
threatening facial expressions of negative (sad), positive
(happy), and neutral control faces. Age and sex-matched
social phobic subjects were compared to a healthy
control group and an anxiety control group, Panic
Disorder with Agoraphobia (PDA), to determine whether
face processing disturbances are specific to SP or
common to all anxiety disorders.
Happy
Neutral
1a
1b
2a
2b
Figure 1 Example scanpaths for the happy and neutral faces in a social phobia subject (1a, 1b) and control subject (2a,
2b). (Note. Larger dot size indicates increased number of fixations.)
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
25 Discussion of findings
These visual scanpath studies provided the first
empirical verification that SP is associated with specific
visuo-cognitive disturbances in processing face stimuli. The
visual scanpath was employed for the first time to examine
directly how individuals with SP process feared
interpersonal (face) stimuli. The scanpaths of social phobic
individuals revealed a decreased engagement to faces and
an avoidance of eyes, but extensive scanning of nonfeatures, compared with the controls. These scanpaths
were markedly different from the inverted triangular
scanpaths representative of control subjects who focused
particularly upon salient facial features. Findings were
reliable and robust across the eye movement studies. The
comparison of a face to a control stimulus, an initial critical
step in the examination of face processing in SP, provided
evidence of disturbances specific to faces. A subsequent
study confirmed these disturbances in an examination of
the processing of happy (positive), neutral, and sad
(negative) faces and the control geometric figure,
compared to age and gender-matched healthy control
subjects.
Anxiety disorders are characterised by a number of
common characteristics representing a susceptibility to
anxiety, yet the phenomenological presentation of these
disorders differs according to the specific nature of their
fears. Significantly, the aberrant scanpaths of the social
phobic individuals, as distinct from the control groups,
suggested strongly that the pattern of face processing
deficits appeared specific to SP. Face processing, considered
for the first time in relation to a specific anxiety control
group, provided evidence of differential face processing
between the two anxiety groups. This suggested that
responses in the SP group were modulated more by the
degree of threat attributable to the level of social anxiety
rather than to general anxiety effects, adding to the
research supporting evidence for specificity of attentional
biases. There have been few eye movement studies
examining face processing in clinical populations; however,
findings of extensive scanpaths in social phobic individuals
are clearly distinct from the restricted scanpaths in
schizophrenia (Loughland, Williams, & Gordon, 2002;
Williams, Loughland, & Gordon, 1999) and the disorganised
scanpaths in autism (Klin, Jones, Schultz, Volkmar, & Cohen,
2002; Pelphrey et al., 2002), which may be attributed to
fundamental deficits in forming an integrated gestalt of
social stimuli (Frith, Stevens, Johnstone, Owens, & Crow,
1983; Williams et al., 1999). By contrast, findings of a
decreased engagement to faces and an extensive scanpath
may be associated more with a reliance on automatic,
gestalt processing, providing additional support for the
specificity of findings to SP.
Avoidant strategies appeared a prominent feature of the
perceptual strategies employed by social phobic individuals.
In particular, the SP group showed a specific avoidance of
eyes and the eye region to all facial stimuli, suggesting that
these salient features were particularly threatening. These
visual scanpath findings provided the first empirical
confirmation for the noted clinical assertion that individuals
with SP have reduced eye contact during social interaction. It
was proposed that findings of avoidant behaviour may be a
defensive strategy for coping with a hyperattention to the
perceived threat of faces, in accordance with cognitive
models of SP proposing that fear of social appraisal is the
core fear in SP and avoidance a prominent feature. The
notable finding that individuals with SP showed a distinctive
'hyperscanning' strategy for processing faces, in comparison
to the control groups, suggested a heightened attention to
a threatening cue and provided credence for cognitive
models proposing that evaluative fears in SP result in a
'hyperattention', or hypervigilance (Beck & Emery, 1985;
Eysenck, 1992; Rapee & Heimberg, 1997), to social threat
cues. It was suggested that the excessive scanning
observed may be a reflection of a displaced hypervigilance,
conceivably associated with excessive engagement of social
threat. Although evidence of both a hypervigilance towards
threat and avoidance of threat appear opposing behaviours,
it is suggested that in SP, hypervigilance and avoidance may
be a complementary part of the same mechanism. For
example, in SP, an automatic hypervigilance for salient
features (such as the eyes) that tap into evaluative fears may
direct subsequent focal attention away from these features,
consistent with the vigilance-avoidant hypothesis.
Notably, there was no evidence of SP specificity for the
threat-related (angry) face stimulus, as hypothesised.
Preliminary evidence providing for a reduction in fixation
scanpath length across groups may be linked with findings
of attentional prioritising of a specifically threat-related
signal that has evolutionary significance (Damasio, 1994).
Clinical implications
Given that face processing is so critical in social
communication, these findings have particular relevance for
clinical intervention. If a large part of cognitive capacity is
engaged in scanning for threatening stimuli, the amount
available for attending to other demands is significantly
restricted. Misappraisal of social situations is a core feature
of SP (Beck & Emery, 1985; Clark & Wells, 1995). If individuals
with SP engage in avoidance of significant features, as
suggested by their scanpath patterns, it is likely that they are
furthered disadvantaged in social situations by a decreased
ability in obtaining the significant information that is
necessary for accurate interpretation of social situations. It is
also likely to constrain the social responsiveness of others
and contribute to the maintenance of this distressing
disorder. It is essential that clinicians incorporate these
findings in treatment methods, providing information and
specifically tailored strategies for increasing eye contact.
References
Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias:
A cognitive perspective. New York, NY: Basic Books.
Clark, D. M., & Wells, A. (1995). A cognitive model of social
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Press.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
26 Damasio, A. R. (1994). Descartes' error: Emotion, reason and
the human brain. London: Papermac.
Darwin, C. (1872/1855). The expression of the emotions in
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General Psychiatry, 59, 809-817.
Loughland, C. M., Williams, L. M., & Gordon, E. (2002). Visual
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Clinical Neuropsychologist, 7, 9-15.
Pelphrey, K. A., Sasson, N. J., Reznick, J. S., Paul, G., Goldman,
B. D., & Piven, J. (2002). Visual scanning of faces in
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Rapee, R. M., & Heimberg, R. G. (1997). A cognitivebehavioral model of anxiety in social phobia.
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ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
27 paralysis) could have negative consequences for patient
care, including our own clients as clinical psychologists, but
what is the genesis of this anxiety?
ETHICS AND LEGAL
DILEMMAS
In a subsequent paper, Stephen Scher and Kasia
Kozlowska (2011) of Sydney Medical School highlighted that
the tension described previously has arisen from the
development of the model of principled decision-making
driven by the bioethics movement. This paper described
how principled decision-making has replaced the previously
predominant paradigm within medical ethics, that of
intuitive moral reasoning, as "the moral voice of health
professionals was displaced by those of philosophers,
sociologists, theologians, lawyers, commissions, courts, and
legislatures" (p. 18).
A BRIEF REVIEW OF 'ETHICS
ANXIETY' AND THE 'LIMITS OF
BIOETHICS'
Giles Burch PhD
Associate Editor
Scher and Kozlowska acknowledged the critical and
central importance that the bioethics movement has had on
healthcare. However, the issue at hand highlights a
particular limitation of the principled decision-making
model, whereby the bioethical paradigm is driven from
theory not practice and does not take into account that
ethical principles are already held, and applied, by healthcare
professionals in their day-to-day work. It is highlighted that
while there is a clear role for the bioethical model, clinical
decision-making requires other factors too, such as
emotional sensitivity and engagement, and without a moral
voice the bioethics movement has provided a disservice to
those it intended to serve (Scher & Kozlowska, 2011).
I
n an edition of ACPARIAN dedicated to anxiety, I have
been racking my brain to find something to write about
that is specifically related to the ethics of anxiety or the
treatment of anxiety. While there are some obvious issues
to tackle at one level, at another this was a surprisingly
difficult task. However, from a slightly different perspective,
I stumbled across the notion of 'ethics anxiety', which
particularly excited me and led me down an interesting
path! I felt this was something worthy of sharing with the
wider readership, given its relevance to our practice and
research as clinical psychologists, as it takes us down a trail
that is important for us to reflect upon in relation to our own
ethical practice.
So where does this leave us? As usual, I will leave the
final words with someone else:
I came across the term 'ethics anxiety' in an article
written by Stephen Scher (2010) of Harvard Medical School
and published in the Australian and New Zealand Journal of
Family Therapy. He described a phenomenon characterised
by "a feeling of uncertainty as to what is ethically required or
permitted, leading to clinical delay and confused decisions"
(p. 35).
This imposition of bioethics on diverse clinical fields
essentially silenced the moral voice of clinicians. It is
this moral voice and those embedded ethical
resources that need to be recognized, restored, and
refined if the bioethics movement's own goal of
improving the ethical quality of modern health care
is to be achieved (Scher & Kozlowska, 2011, p. 29).
The purpose of Scher's article was to highlight the
difficulties experienced by clinicians when having to make
difficult ethical decisions when under particular time
pressure and unable to access necessary advice. More
specifically, Scher stated that clinicians from all professions
experience tension between:
1.
2.
applying their clinical knowledge and experience in
order to solve a problem; and
recognising the ethical and legal characteristics and
complexities of a situation, with an accompanying
feeling/belief that their clinical expertise is not
sufficient to address the ethical/legal dimensions of
the problem.
This in turn, Scher stated, leads to the clinician becoming
"intellectually paralysed" (p. 39) and unsure how to move
forward. There can be little doubt that such an anxiety (or
Clearly there is much food for thought here, and my
brief review of Scher and Scher and Kozlowska's articles only
throws out some titbits … but I hope these will encourage
you to read further over the holiday period!
References
Scher, S. (2010). Ethics anxiety. The Australian and New
Zealand Journal of Family Therapy, 31, 35-42.
Scher, S., & Kozlowska, K. (2011). The clinician's voice and the
limits of bioethics. The Australian and New Zealand
Journal of Family Therapy, 32, 15-32.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
28 STUDENT AND TRAINING
MATTERS
Inaugural Malcolm
Macmillan student prize
CLINICAL PSYCHOLOGY AND
ETHICS IN THE ELECTRONIC
AGE
Margaret Nelson
MPsych/PhD candidate
University of Melbourne
This essay earned Ms Nelson the Australian Clinical
Psychology Association's inaugural Malcolm Macmillan
Student Prize of $1000 along with a trip to the 2012 ACPA
conference in Fremantle to receive the prize.
Please address all correspondence to:
Margaret Nelson
MPsych/PhD Candidate
University of Melbourne
Parkville VIC 3010
Australia
Email: [email protected]
Phone: + 61 3 8344 4009
S
ince the 1980s, innovation in computing and
communication technologies has led to rapid
worldwide change in what has come to be known as
the Digital Revolution. Personal computers, mobile
phones, mp3 players, smartphones, and tablets are some
of the many devices pioneered during this period that are
now common-place. Modern communication networks
such as the Internet, email, video conferencing, blogs, and
social media now permeate developed and developing
countries alike. Widespread adoption of these
technologies has rippled through the globe, affecting the
daily lives of most people across Australia and the world
(Australian Psychological Society [APS], 2011; Hoare, 1998;
Keen, 2012). Clinical psychologists too have had their lives,
work, and communication altered by ongoing digital and
electronically-based development (APS, 2011; Symons,
2010).
For some clinical psychologists (Marks, Shaw, & Parkin,
1998; Proudfoot, 2004; Rapee, 2012), these developments
have provided exciting avenues through which to reach
socially isolated individuals, communicate quickly and
easily, keep good medical records, and stay up-to-date with
recent global developments in evidence-based practice. In
this sense, the Digital Revolution facilitates many ethical
principles cherished by clinical psychologists –
beneficence, propriety, and competence to name a few.
On the other hand, the scale and pervasiveness of
technological
change
can
seem
unstoppable,
uncontrollable, and unpredictable, and brings with it
considerable ethical challenges for clinical psychologists
(APS, 2011; Heinlen, Welfel, Richmond, & O'Donnell, 2003;
Heinlen, Welfel, Richmond, & Rak, 2003; Symons, 2010).
Privacy and confidentiality are of particular concern here
(APS, 2011; Heinlen, Welfel, Richmond, & O'Donnell, 2003;
Heinlen, Welfel, Richmond, & Rak, 2003) as are potential
boundary issues, with increasingly blurred distinctions
between public and private online personas (APS, 2011;
Symons, 2010).
Although ethical issues such as these should not be
glossed over, it is also important to consider that
unquestioning endorsement of alarmist rhetoric, and
subsequent branding of all technology as dangerous,
would also be unhelpful. It would result in missed
opportunities to embrace what digital technology has to
offer in terms of client care, professional development,
and scientific progress. It is the aim of this essay, therefore,
to broadly outline the ethical costs and benefits of
widespread employment of digital technology in the field
of clinical psychology. It will ultimately be argued that if
appropriate care and consideration is taken in the
implementation of digital technologies, they have much to
offer in facilitating ethically sound psychological work.
Ethical risks of digital technology
There are many ethical difficulties to be faced by clinical
psychologists when navigating new technology. The
importance of these ethical challenges was recently
highlighted when the APS (2011) published its 'Guidelines
for providing psychological services and products using the
Internet and telecommunications technologies'. Reflecting
the permeability and pervasiveness of the digital
revolution, technologies falling within the scope of these
ethical guidelines include the internet, email, text
messages, telephones, Skype, and video-conferencing
(APS, 2011). Examples of services provided through digital
means include not only counselling, but a full range of
psychological work such as provision of treatment
programs, psychological testing and assessment, group
support, access to therapeutic materials, advertising of
services, professional training, supervision, and research
(APS, 2011).
Some of the major ethical concerns raised in the APS
guidelines are as follows. First, the guidelines outline the
potential for lapses in informed consent whereby
psychologists communicating through electronic means
may omit details of their own qualifications, the nature of
services they intend to provide, and the benefits and
limitations of services provided electronically (APS, 2011).
For instance, there is some question over the feasibility of
establishing a genuine therapeutic relationship when
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
29 psychologist and client are not physically in the same room
(Cook & Doyle, 2002; Manhal-Baugus, 2001; Postel, de
Haan, & de Jong, 2008). Clients would need to be made
fully aware of this potential limitation before engaging in
online psychological services (Manhal-Baugus, 2001).
Confidentiality is also a major concern in the APS
guidelines, particularly in situations where psychologists
not only fail to inform clients of the normal limits to
confidentiality (for example, when there is risk of harm to
self or others, or when records are subpoenaed by a court),
but also when they fail to acknowledge that confidentiality
may be further limited by the security of the technology
being used (APS, 2011). A related issue is that of privacy
for both psychologist and client. For instance, there is
potential for clients' information to be accessed without
authority by psychologists through search engines or social
networking sites such as Facebook (APS, 2011). Similarly,
boundary issues may be created if clients are able to access
psychologists' personal online information through social
media and 'blogging' (APS, 2011; Symons, 2010).
Indeed, there is some research evidence to suggest
that psychological services provided through electronic
means may not satisfy standards of good ethical conduct
by psychologists. Heinlen, Welfel, Richmond, and
O'Donnell (2003) identified 44 websites providing
psychological services from doctoral level psychologists
and assessed them according to the established ethical
principles of the International Society for Mental Health
Online and the American Psychological Association.
Fulfilment of ethical standards varied widely. For example,
in regards to information about fees, a minority of
websites provided no information, others charged flat fees
of between $15 and $80 for email correspondence, and
still others charged $2 per minute of therapists' email
time. All but one site disclosed the identity of their
respective therapist/s; however, only 34% provided access
(links) to external verification of therapists' credentials.
Most websites listed therapists' areas of competency but
many did not outline the strengths and limitations of
psychological services conducted electronically. Only half
outlined details of confidentiality and 57% made no
mention of how to access crisis services.
However, in comparison with the speed of
technological development, this study is relatively old. It
could be that the psychologists whose websites were
included in the study were not yet used to encountering or
dealing with the ethical dilemmas that can arise out of
digital technology. It is arguable that with appropriate care
and consideration, these difficulties can be addressed and
dealt with in the same manner that clinical psychologists
would use to ensure satisfactory ethical conduct in the
'non-digital' world. The recent creation of APS guidelines in
relation to use of digital technologies (APS, 2011) is in
itself a good example of how ethics is beginning is 'catch
up' with the runaway Digital Age. Suggested solutions to
the above problems include: full disclosure of therapists'
credentials, services, and therapeutic methods via all
electronic devices used; ensuring use of digital
technologies is in accordance with (newly established)
professional guidelines and in accordance with current
'best practice'; encouraging psychologists to use high
privacy settings on social network sites; and 'googling'
themselves to ensure that online personas remain
professional (APS, 2011; Symons, 2010).
In other words, the digital world becomes just another
setting through which psychologists use their extensive
training, skills, expertise, professional guidelines, peer
support, and common sense to uphold professional and
ethical standards as they would in any other context.
Ethical benefits of digital technology
If appropriate professional conduct according to the
above is upheld, the Digital Age may actually be able to
assist clinical psychologists in acting ethically. Most notably,
digital technology can help to promote the ethical principle
of beneficence as it allows psychologists to access and
provide services to individuals who are otherwise unwilling
or unable to meet a therapist in person (APS, 2011; Klein,
Meyer, Austin, & Kyrios, 2011). People who fit into this
category include those who live in rural and remote areas,
those who are physically and socially isolated (such as
young people and people who are unable to leave home),
those who have limited time to see a therapist, and those
who value anonymity (APS, 2011).
In further relation to beneficence, there is very recent
evidence to suggest that on a population level digital
technology may assist in reducing the cost of providing
psychological services (Klein et al., 2011; Rapee, 2012). This
is because psychologists can reach more people
simultaneously, and can to some extent digitally manualise
therapy, which reduces the time involved in one-to-one
therapist engagement (Klein et al., 2011). This reduction in
resources also appears to be possible without reducing the
efficacy of treatment (Griffiths & Christensen, 2006;
Griffiths, Farrer, & Christensen, 2010; Klein et al., 2011;
Rapee, 2012). For instance, Klein et al. (2011) provided
fully-automated e-therapy to 225 people, for five selfchosen anxiety disorders (Generalised Anxiety Disorder,
Social Anxiety, Panic Disorder, Obsessive Compulsive
Disorder, and Post-Traumatic Stress Disorder). At twelveweek follow-up, significant reductions in severity ratings
were found for all five disorders (Klein et al., 2011). The
effectiveness of e-therapies is further supported by a
review and meta-analysis of 92 studies (Barak, Hen, BonielNissim, & Shapira, 2008). Mean weighted effect size for a
range of outcome measures included in this review was
0.53 (or a medium effect size), which is comparable to
traditional face-to-face therapies (Barak et al., 2008).
Indeed, the ways in which digital technologies can be
used to promote beneficence appear only limited by
human creativity. For instance, Gorini, Gaggioli, Vigna, and
Riva (2008) reviewed the ways in which 3D virtual worlds
are being used to promote good healthcare. In relation to
mental health, they describe a 'Virtual Hallucinations Lab'
which aims to educate users about the experience of
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
30 hallucinations (Gorini et al., 2008; Second Life, 2012). They
also describe studies that have successfully used 'Virtual
Reality Exposure Therapy' to treat specific phobias and
other anxiety disorders (Gorini & Riva, 2008; Riva et al.,
2007). Albeit potentially controversial, this research does
illustrate the wide-ranging possibilities through which new
technology could be used to improve mental health.
Finally, digital technologies can also assist with a range
of other ethical aspirations of psychologists, such as
propriety, competence, and professional responsibility. For
example, in relation to propriety and professional
responsibility, digital technologies can assist in facilitating
timely, detailed, and accurate record keeping (Hillestad et
al., 2005). They can also facilitate fast communication and
exchange of information between clinicians and between
clinicians and patients (Jaded, 1999). In terms of
competence, digital technologies enable large, multicentre trials (Jirotka et al., 2005) and assist in clinicians'
abilities to keep abreast of recent global research (Boulos,
Maramba, & Wheeler, 2006). In this way, they help to
ensure the practice of clinical psychology is evidencebased. Indeed, on a personal level, presumably it would be
difficult to imagine any clinical psychologist completing his
or her day-to-day work to a satisfactory standard without
the use of electronic assistance from email, electronic
medical records, the internet, and the like.
Conclusion
Despite its permeability and pervasiveness, the Digital
Age has brought with it ethical dilemmas that cannot be
ignored. These ethical considerations need to be taken into
account when using electronic devices and communication
technologies. However, the presence of ethical dilemmas
does not in itself mean that we should avoid technology at
all costs. Certainly, as psychologists become more familiar
with the Digital Age, and as ethical guidelines and
resources become available to assist them, many of these
dilemmas can be avoided. As the work of clinical
psychologists (like that of professionals in nearly all
occupations) has become increasingly dependent on
digitisation and global communication, we can (and are)
learning to deal with ethical difficulties while
simultaneously embracing what the Digital Age has to
offer in promoting high quality, ethical practice.
References
Australian Psychological Society (APS). (2011). Guidelines
for Providing Psychological Services and Products
Using the Internet and Telecommunications
Technologies. Melbourne: Author.
Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A
comprehensive review and meta-analysis of the
effectiveness of internet-based psychotherapeutic
interventions. Journal of Technology in Human
Services, 26(2-4), 109-160.
Boulos, M. N. K., Maramba, I., & Wheeler, S. (2006). Wikis,
blogs and podcasts: A new generation of webbased tools for virtual collaborative practice and
education. BMC Medical Education, 6, 41.
Cook, J. E., & Doyle, C. (2002). Working alliance in online
therapy as compared to face-to-face therapy:
Preliminary results. Cyber Psychology and Behavior,
5(2), 95-105.
Gorini, A., Gagglioli, A., Vigna, C., & Riva, G. (2008). A second
life for eHealth: Prospects for the use of 3D virtual
worlds in clinical psychology. Journal of Medical
Internet Research, 10, e21.
Gorini, A., & Riva, G. (2008). Virtual reality in anxiety
disorders: The past and the future. Expert Reviews of
Neurotherapeutics, 8(2), 215-233.
Griffiths, K. M., & Christensen, H. (2006). Review of
randomised
controlled
trials
of
Internet
interventions for mental disorders and related
conditions. Clinical Psychologist, 10(1), 215-233.
Griffiths, K. M., Farrer, L., & Christensen, H. (2010). The
efficacy of internet interventions for depression
and anxiety disorders: A review of randomised
controlled trials. The Medical Journal of Australia,
192(11 Suppl), s4-s11.
Heinlen, K. T., Welfel, E. R., Richmond, E. N., & O'Donnell, M.
S. (2003). The nature, scope and ethics of
psychologists'
e-therapy
websites:
What
consumers find when surfing the web.
Psychotherapy: Theory, Research, Practice, Training,
40(1-2), 112-124.
Heinlen, K. T., Welfel, E. R., Richmond, E. N., & Rak, C. F.
(2003). The scope of WebCounselling: A survey of
services and compliance with NBCC Standards for
the ethical practice of WebCounselling. Journal of
Counselling and Development, 40(1), 112-124.
Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R.,
Scoville, R., & Taylor, R. (2005). Can electronic
medical record systems transform healthcare?
Potential benefits, savings and costs. Health Affairs,
24(5), 1103-1117.
Hoare, S. (1998). The Digital Revolution. Hove, UK: Wayland.
Jaded, A. R. (1999). Promoting partnerships: Challenges for
the Internet age. British Medical Journal, 319(7212),
761-764.
Jirotka, M., Proctor, R., Hartswood, M., Slack, R., Simpson, A.,
Coopmans, C., . . . Voss, A. (2005). Collaboration and
trust in healthcare innovation: The eDiaMoND case
study. Computer Supported Cooperative Work, 14(4),
369-398.
Keen, A. (2012). Digital Vertigo: How Today's Online Social
Revolution is Dividing, Diminishing, and Disorienting
Us. New York, NY: St Martin's Press.
Klein, B., Meyer, D., Austin, D., & Kyrios, M. (2011). Anxiety
Online - A virtual clinic: Preliminary outcomes
following completion of five fully automated
treatment programs for anxiety disorders and
symptoms. Journal of Medical Internet Research, 13,
e89.
Manhal-Baugus, M. (2001). E-therapy: Practical, ethical and
legal issues. Cyberpsychology and Behavior, 4(5),
551-563.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
31 Marks, I., Shaw, S., & Parkin, R. (1998). Computer-aided
treatments of mental health problems. Clinical
Psychology: Science and Practice, 5(2), 151-170.
Postel, M. G., de Haan, H. A., & de Jong, C. A. J. (2008). Etherapy for mental health problems: A systematic
review. Telemedicine and E-Health, 14(7), 707-714.
Proudfoot, J. G. (2004). Computer-based treatment for
anxiety and depression: Is it feasible? Is it effective?
Neuroscience and Biobehavioural Reviews, 28(3),
353-363.
Rapee, R. (2012, July). Current advances in the treatment of
child anxiety and depression. Paper presented at the
Victorian professional development meeting of the
Australian Clinical Psychology Association in
Melbourne, Australia.
Riva, G., Gagliolli, A., Villani, D., Preziosa, A., Morganti, F.,
Faletti, G., & Vezzadini, L. (2007). NeuroVR: An open
source virtual reality platform for clinical psychology
and behavioral neurosciences. Studies in Health
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Second Life. (2012). Virtual Hallucinations. Retrieved from
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Symons, M. (2010). The internet's ethical challenges for
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Retrieved
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h/2010/august/symons/
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
32 Editorial Policy and Guidelines
ACPARIAN is the official publication of the Australian
Clinical Psychology Association and is published three
times a year.
Aim
ACPARIAN provides for the dissemination of knowledge
on topics of interest informative to clinical psychologists.
Its focus is on the latest clinical theory and research
relevant to clinical practice including assessment and
intervention, training and professional issues.
Content
Submissions to ACPARIAN may include:
•
•
•
•
•
•
•
•
•
Letters to the Editor
General articles, viewpoints, opinions, and
comments
Articles of particular ethical and/or legal interest
to the profession
Research reviews
Theoretical perspectives
Technology updates
Students' news and viewpoints
Book reviews
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From time to time, ACPARIAN will focus on topics or
issues of interest and call for submissions accordingly.
The ACPA Editorial Board welcomes contributions and
suggestions for topics from the membership.
Contributions
Submissions should be made electronically, in a Word
document, to the Editor responsible for the relevant
section:
•
•
•
Student and Training Matters: McLytton Clever
[email protected]
Ethics and Legal Matters: Giles Burch
[email protected]
Feature articles, Research, and Client
Perspectives: Kaye Horley
[email protected]
Please observe the following word limits:
Letters to the Editor: 200 words
Client perspectives, research articles, student matters,
and ethics and legal matters: 750 to 1000 words
Feature articles: 1000 - 1500 words.
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Please ensure that submissions are made by the stated
deadline. Late submissions may not be accepted.
Authors can expect the Editorial Board to review and
change content for clarity and style. The Editorial Board
will endeavour to make any significant revisions in
consultation with the author. The Editor reserves the
right to include or reject written works at any point in the
publication process.
The views expressed by authors in ACPARIAN do not
necessarily reflect those of the ACPA Editorial Board.
Editorial Board
Editor
Kaye Horley, PhD
Associate Editors
Christina Brock, PGDipPsych
Giles Burch, PhD
Tamera Clancy, MA (Psych)
McLytton Clever, DPsych (Clin)
Dixie Statham, PhD
Copy Editor
John Moulds, PhD
Design
Ben Callegari, MPsych (Clin)
May issue:
Psychosis
Contributions are invited from those with clinical, psychotherapeutic, research, or other expertise in this area
by 22 April 2013. See Editorial Policy and Guidelines for submission requirements.
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
33 THE AUSTRALIAN
CLINICAL PSYCHOLOGY
ASSOCIATION
C
A PA
2013
www.acpa.org.au
4th Annual National Conference:
Presenting a lecture and clinical workshop by
Dr Nancy McWilliams
“Self-Defeating Patterns and
Their Clinical Implications”
Queensland University of Technology (QUT),
Brisbane: Sunday, 14 July 2013
ACPARIAN
Periodical of the Australian Clinical Psychology Association
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responsibility of the person placing the advertisement
Australian Clinical Psychology Association
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For advertising inquiries, email McLytton Clever: [email protected]
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10% discount for ACPA members
Fees may be waived in special circumstances (e.g., ACPA events, important public announcements)
ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013
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