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AcparianA PACTHE AUSTRALIAN

CLINICAL PSYCHOLOGYASSOCIATION THE OFFICIAL NEWSLETTER OF THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION

ISSUE 5: JAN 2013

ACPARIA

N Issue 5 JA

N 2013

Anxiety Disorders

In this issue

GAD: Practical help for clinicians

Safety-seeking behaviours: good or bad?

Advances in Social Phobia treatment

Malcom Macmillan prize: clinical psychology and ethics in the electronic age

Transdiagnostic approaches

Medication or not?

Ethics anxiety

THE

ACPARIAN: ISSUE 5: January 2013 © Australian Clinical Psychology Association 2013

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EDITORIAL Kaye Horley, PhD Editor

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. 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. 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

1 Source: ABS National Survey of Mental Health and Wellbeing 2007, Summary of Results (cat. no. 4326.0).

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.

CONTENTS 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

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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 e-journal Psych-e. The College plans to link us to Mental Health patient advocacy groups in the New Year.

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. 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!


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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]

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

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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 co-morbidity 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.


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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


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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 cognitive-behavioral 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, 1281-1310.

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.


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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.

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

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

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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.


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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 de-emphasised 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 in-depth 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.


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References

Abramowitz, J., & Moore, E. (2007). An experimental analysis of hypochondriasis. Behaviour Research and Therapy, 45, 413-424. doi: 10.1016/j.brat.2006.04.0005

Beesdo-Baum, K., Jenjahn, E., Hofler, M., Lueken, U., Becker, E., & Hoyer, J. (2012). Avoidance, safety behavior, and reassurance seeking in generalized anxiety disorder. Depression and Anxiety, 29, 948-957. doi: 10.1002/da.21955

Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., … Wild, J. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 568-578. doi: 10.1037/0022-006X.74.3.568

Ehlers, A., & Clark, D. M. (2008). Post-traumatic stress disorder: The development of effective psychological treatments. Nordic Journal of Psychiatry, 62(47), 11-18. doi: 10.1080/08039480802315608

Deacon, B., & Maack, D. (2008). The effects of safety behaviors on the fear of contamination: An experimental investigation. Behaviour Research and Therapy, 46, 537-547. doi: 10.1016/j.brat.2008.01.010

Helbig-Lang, S., & Petermann, F. (2010). Tolerate or eliminate: A systematic review on the effects of safety behavior across the anxiety disorders. Clinical Psychology: Science and Practice, 17(3), 218-233.

Hood, H., Antony, M., Koerner, N., & Monson, C. (2010). Effects of safety behaviors on fear reduction during exposure. Behaviour Research and Therapy, 48, 1161-1169. doi: 10.1016/j.brat.2010.08.006

Hunter, E., Phillips, M., Chalder, T., Sierra, M., & David, A. (2003). Depersonalisation disorder: A cognitive-behavioural conceptualisation. Behaviour Research and Therapy, 41, 1451-1467. doi: 10.1016/S0005-7967(03)00066-4

Kobori, O., Salkovskis, P., Read, J., Lounes, N., & Wong, V. (2012). A qualitative study of the investigation of reassurance seeking in obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 1, 25-32. doi: 10.1016/j.jocrd.2011.09.001

McManus, F., Sacadura, C., & Clark, D. M. (2008). Why social anxiety persists: An experimental investigation of the role of safety behaviours as a maintaining factor. Journal of Behaviour Therapy and Experimental Psychiatry, 39, 147-161. doi: 10.1016/j.jbtep.2006.12.002

Meuret, A., Wilhelm, F., Ritz, T., & Roth, W. (2003). Breathing training for treating panic disorder. Behavior Modification, 27(5), 731-754.

Milosevic, I., & Radomsky, A. S. (2008). Safety behaviour does not necessarily interfere with exposure therapy. Behaviour Research and Therapy, 46, 1111-1118. doi: 10.1016/j.brat.2008.05.011

Plasencia, M., Alden, L., & Taylor, C. (2011). Differential

effects of safety behaviour subtypes in social anxiety disorder. Behaviour Research and Therapy, 49, 665-675. doi: 10.1016/j.brat.2011.07.005

Rachman, S., Radomsky, A., & Shafran, R. (2008). Safety behaviour: Reconsideration. Behaviour Research and Therapy, 46, 1163-173. doi: 10.1016/j.brat.2007.11.008

Salkovskis, P. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy, 19, 6-19.

Salkovskis, P., Clark, D. M., & Gelder, M. (1996). Cognition-behaviour links in the persistence of panic. Behaviour Research and Therapy, 34, 453-458.

Salkovskis, P., Hackmann, A., Wells, A., Gelder, M., and Clark, D. M. (2006). Belief disconfirmation versus habituation approaches to situational exposure in panic disorder with agoraphobia: A pilot study. Behaviour Research and Therapy, 45, 877-885.

Schmidt, N., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive-behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424.

Sloan, T., & Telch, M. (2002). The effects of safety-seeking behaviour and guided threat reappraisal on fear reduction during exposure: An experimental investigation. Behaviour Research and Therapy, 40, 235-251.

Sy, J., Dixon, L., Lickel, J., Nelson, E., & Deacon, B. (2011). Failure to replicate the deleterious effects of safety behaviours in exposure therapy. Behaviour Research and Therapy, 49, 305-314. doi: 10.1016/j.brat.2011.02.005

Thwaites, R., & Freeston, M. (2005). Safety-seeking behaviours: fact or function? How can we clinically differentiate between safety behaviours and adaptive coping strategies across anxiety disorders? Behavioural and Cognitive Psychotherapy, 33, 177-188. doi: 10.1017/S1352465804001985

Veale, D. (2004). Advances in cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125. doi: 10.1016/S1740-1445(03)00009-3

Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviours in maintaining anxiety and negative beliefs. Behavior Therapy, 26, 153-161.

Westbrook, D., Kennerley, H., & Kirk, J. (2011). An introduction to cognitive behaviour therapy: Skills and applications. (2nd ed.). London, UK: Sage.


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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

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; Garcia-Palacios & 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 (D-cycloserine), 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

C


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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: D-cycloserine (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.


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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 self-report 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 post-treatment 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.

References

Amir, N., Beard, C., Taylor, C. T., Klumpp, H., Elias, J., Burns, M., & Chen, X. (2009). Attention training in individuals with generalized social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 77, 961-973.

Amir, N., Weber, G., Beard, C., Bomyea, J., & Taylor, C. T. (2008). The effect of a single-session attention modification program on response to a public-speaking challenge in socially anxious individuals. Journal of Abnormal Psychology, 117, 860-868.

Arkowitz, H., & Miller, W. (2008). Learning, applying and extending motivational interviewing. In H. Arkowitz et al. (Eds.). Motivational interviewing in the treatment of psychological problems. New York, NY: Guilford Press.

Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin, 133(1), 1-24.

Bögels, S. M. (2006). Task concentration training versus applied relaxation, in combination with cognitive

therapy, for social phobia patients with fear of blushing, trembling, and sweating. Behaviour Research and Therapy, 44(8), 1199–1210.

Buckner, J. D., Ledley, D. R., Heimberg, R. G., & Schmidt, N. B. (2008). Treating comorbid social anxiety and alcohol use disorders: Combining Motivation Enhancement Therapy with Cognitive-Behavioral Therapy, Clinical Case Studies, 7(3), 208-223.

Buckner, J. D., & Schmidt, N. B. (2009). A randomized pilot study of motivation enhancement therapy to increase utilization of cognitive–behavioral therapy for social anxiety. Behaviour Research and Therapy, 47(8), 710-715.

Carlbring, P., Apelstrand, M., Sehlin, H., Amir, N., Rousseau, A., Hofmann, S. G., & Andersson, G. (2012). Internet-delivered attention bias modification training in individuals with social anxiety disorder - a double-blind randomized controlled trial. BMC Psychiatry, 12, art. no. 66.

Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., … Wild, J. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 568–578.

Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., … Louis, B. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: A randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71(6), 1058–1067.

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.). Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York, NY: Guilford Press.

Davis, M., & Myers, K. M. (2002). The role of glutamate and gamma-aminobutyric acid in fear extinction: Clinical implications for exposure therapy. Biological Psychiatry, 52, 998-1007.

Deveney, C. M., McHugh, K., Tolin, D. F., Pollack, M. H., & Otto, M. W. (2009). Combining D-cycloserine and exposure-based CBT for the anxiety disorders. Clinical Neuropsychiatry, 6(2), 75-82.

Edelman, R., & Chambless, D. (1995). Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia. Behaviour Research and Therapy, 33, 573-577.

Garcia-Palacios, A., & Botella, C. (2003). The effects of dropping in-situation safety behaviors in the treatment of social phobia. Behavioral Interventions, 18(1), 23–33.

Guastella, A. J., Richardson, R., Lovibond, P. F., Rapee, R. M., Gaston, J. E., Mitchell, P., & Dadds, M. R. (2008). A randomized controlled trial of D-cycloserine enhancement of exposure therapy for social anxiety disorder. Biological Psychiatry, 63(6), 544-549.

Harvey, A. G., Clark, D. M., Ehlers, A., & Rapee, R. M. (2000). Social anxiety and self-impression: Cognitive preparation enhances the beneficial effects of video feedback following a stressful social task.


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Behaviour Research and Therapy, 38(12), 1183–1192.

Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications. Cognitive Behaviour Therapy, 36(4), 193–209.

Hofmann, S. G., Meuret, A. E., Smits, J. A. J., Simon, N. M., Pollack, M. H., Eisenmenger, K., … Otto, M. W. (2006). Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Archives of General Psychiatry, 63, 298-304.

Kazantzis, N., Deane, F., & Ronan, K. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7(2), 189-202.

Kim, E. J. (2005). The effect of the decreased safety

behaviors on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders, 19(1), 69–86.

Leung, A., & Heimberg, R. (1996). Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behaviour Research and Therapy, 34, 423-432.

MacLeod, C. (2012). Cognitive bias modification procedures in the management of mental disorders. Current Opinion in Psychiatry, 25(2), 114-120.

Meyer, E., Souza, F., Heldt, E., Knapp, P., Cordioli, A., Shavitt, R. G., & Leukefeld, C. (2010). A randomized clinical trial to examine enhancing cognitive-behavioral group therapy for obsessive-compulsive disorder with motivational interviewing and thought mapping. Behavioural and Cognitive Psychotherapy, 38(3), 319-336.

Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease, 195, 521-531.

Peters, L., Gaston, J., Baillie, A., & Rapee, R. (2012). Enhancing treatment for social phobia with Treatment Expectations and Engagement (TEE). Manuscript submitted for publication.

Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77(2), 317-327.

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741–756.

Rapee, R., MacLeod, C., Carpenter, L., Gaston, J. E., Frei, J., Peters, L., et al. (2012). Integrating cognitive bias modification into a standard cognitive behavioural treatment package for social phobia: A randomized controlled trial. Manuscript submitted for publication.

Richardson, R., Ledgerwood, L., & Cranney, J. (2004). Facilitation of fear extinction by D-cycloserine: Theoretical and clinical implications. Learning & Memory, 11, 510-516.

Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118, 5-14.

Simpson, H. B., Zuckoff, A. M., Maher, M. J., Page, J. R., Franklin, M. E., Foa, E. B., & Wang, Y. (2010). Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder. Behaviour Research and Therapy, 48(10), 941-8.

Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. M. (2003). Cognitive therapy for social phobia: Individual versus group treatment. Behaviour Research and Therapy, 41(9), 991–1007.

Westra, H. (2004). Managing resistance in cognitive behavioural therapy: The application of motivational interviewing in mixed anxiety and depression. Cognitive Behaviour Therapy, 33(4), 161-175.

Westra, H., Arkowitz, H., & Dozois, D. (2009). Adding a motivational interviewing pretreatment to cognitive behavioural therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23, 1106-1117.

Westra, H., & Dozois, D. (2006). Preparing clients for cognitive behavioural therapy: A randomized pilot study of motivational interviewing for anxiety. Cognitive Therapy and Research, 30, 481-498.

Wlazlo, Z., Schroeder-Hartwig, K, Hand, I., Kaiser, G., & Münchau, N. (1990). Exposure in vivo vs social skills training for social phobia: Long-term outcome and differential effects. Behaviour Research and Therapy. 28(3), 181-193.

Woody, S., & Adessky, R. (2002). Therapeutic alliance, group cohesion, and homework compliance during cognitive-behavioral group treatment of social phobia. Behavior Therapy, 33, 5-27.


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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

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 obsessive-compulsive 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 inter-rater 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,

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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 diagnosis-specific 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


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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 practice-based 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, evidence-based 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 evidence-based 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 manual-based 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


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disorders. Behaviour Research and Therapy, 50, 469-478.

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 Psychology Review, 31, 236-248.

Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A 'transdiagnostic' theory and treatment. Behaviour Research and Therapy, 41, 509–528.

Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, Carl, J. R., Gallagher, M. W., & Barlow, D. H. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: A randomized controlled trial. Behavior Therapy, 43, 666-678.

Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. New York, NY: Oxford University Press.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152−1168.

Mahoney, A. E. J., McEvoy, P. M., & Moulds, M. L. (2012). Psychometric properties of the Repetitive Thinking Questionnaire in a clinical sample. Journal of Anxiety Disorders, 26, 359-367.

Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy: An international Quarterly, 23, 6-19.

McEvoy, P. M., & Mahoney, E. A. J. (2012). To be sure, to be sure: Intolerance of uncertainty mediates symptoms of various anxiety disorders and depression. Behavior Therapy, 43, 533-545.

McEvoy, P. M., Mahoney, A. E. J., & Moulds, M. L. (2010). Are worry, rumination, and post-event processing one and the same? Development of the Repetitive Thinking Questionnaire, Journal of Anxiety Disorders, 24, 509-515.

McEvoy, P. M., Nathan, P., & Norton, P. J. (2009). Efficacy of transdiagnostic treatments: A review of published outcome studies and future research directions. Journal of Cognitive Psychotherapy, 23, 20-33.

Norton, P. J. (2012). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York, NY: Guilford Press.

Watkins, E., Moulds, M., & Mackintosh, B. (2005). Comparisons between rumination and worry in a non-clinical population. Behaviour Research and Therapy, 43, 1577–1585.

Wells, A. (2007). Cognition about cognition: Metacognitive therapy and change in generalized anxiety disorder and social phobia. Cognitive and Behavioral Practice, 14, 18-25.


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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

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.

Why is medication prescribed? The reasons fall into the following areas:

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 49-year-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.

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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

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

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.

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.

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


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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 broncho-constriction (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 evidence-based 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.CD003592/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.CD001765.pub3/pdf


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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.

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 anxiety-related 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

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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.


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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

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), psycho-evolutionary 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)

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.

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).

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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 gender-matched 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.

1a 1b

2a 2b

Happy Neutral

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.)


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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 non-features, 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 phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneider (Eds.). Social phobia: Diagnosis, assessment and treatment. New York, NY: Guilford Press.


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Damasio, A. R. (1994). Descartes' error: Emotion, reason and the human brain. London: Papermac.

Darwin, C. (1872/1855). The expression of the emotions in man and animals. London: John Murray.

Eysenck, M. W. (1992). Anxiety: The cognitive perspective. Hove, UK: Erlbaum.

Frith, C. D., Stevens, M., Johnstone, E. C., Owens, D. G. C., & Crow, T. J. (1983). Integration of schematic faces and other complex objects in schizophrenia. Journal of Nervous and Mental Disease, 171(1), 34-39.

Greist, J. H. (1995). The diagnosis of social phobia. Journal of Clinical Psychiatry, 56 (Suppl. 5), 5-12.

Henderson, J. M. (1992). Visual attention and eye movement control during reading and picture viewing. In K. Rayner (Ed.), Eye movements and visual cognition: Scene perception and reading (pp. 260-283). New York, NY: Springer-Verlag.

Just, M. A., & Carpenter, P. A. (1976). The role of eye-fixation research in cognitive psychology. Behavior Research Methods, Instruments, and Computers, 8, 139-143.

Klin, A., Jones, W., Schultz, R., Volkmar, F., & Cohen, D. (2002). Visual fixation patterns during viewing naturalistic social situations as predictors of social competence in individuals with autism. Archives of General Psychiatry, 59, 809-817.

Loughland, C. M., Williams, L. M., & Gordon, E. (2002). Visual scanpaths to positive and negative facial emotions in an outpatient schizophrenia sample. Schizophrenia Research, 55, 159-170.

Lundqvist, D., Esteves, F., & Öhman, A. (1999). The face of wrath: Critical features for conveying facial threat. Cognition & Emotion, 13(6) 691-711.

Marks, I. M. (1969). Fears and phobias. New York, NY: Academic Press.

Marks, I. M. (1987). Fears, phobias and rituals. New York, NY: Oxford University Press.

Mertens, I., Siegmund, H., & K. Grüsser, 0.-J. (1993). Gaze motor asymmetries in the perception of faces during a memory task. Neuropsychologia, 31, 989-998.

Noton, D., & Stark, I. (1971). Eye movements and visual perception. Scientific American, 224, 35-43.

Öhman, A. (1986). Face the beast and fear the face: Animal and social fears as prototypes for evolutionary analyses of emotion. Psychophysiology, 23, 123-145.

Osterrieth, P.A. (1944). Le test de copie d'unefigure complexe. Archives de Psychologie, 30, 206-356; translated by J. Corwin, & F. W. Bylsma (1993), The 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 autism. Journal of Autism and Developmental Disorders, 32, 249-260.

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741-756.

Rey, A. (1941). Psychological examination of traumatic encephalopathy. Archives de Psychologie, 28, 286-340; sections translated by J. Corwin, & F. W. Bylsma (1993), The Clinical Neuropsychologist, 7, 4-9.

Williams, L. M., Loughland, C. M., & Gordon, E. (1999). Visual scanpaths and recognition of positive and negative facial emotions in schizophrenia. Schizophrenia Research, 36, 268-280


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ETHICS AND LEGAL DILEMMAS

A BRIEF REVIEW OF 'ETHICS ANXIETY' AND THE 'LIMITS OF BIOETHICS' Giles Burch PhD Associate Editor

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.

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).

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. applying their clinical knowledge and experience in

order to solve a problem; and 2. 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

paralysis) could have negative consequences for patient care, including our own clients as clinical psychologists, but what is the genesis of this anxiety?

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).

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).

So where does this leave us? As usual, I will leave the

final words with someone else:

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).

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.

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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

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

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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 self-chosen anxiety disorders (Generalised Anxiety Disorder, Social Anxiety, Panic Disorder, Obsessive Compulsive Disorder, and Post-Traumatic Stress Disorder). At twelve-week 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, Boniel-Nissim, & 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


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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, multi-centre 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 evidence-based. 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 web-based 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.

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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:

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Psychosis

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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

2013A PAC

THE AUSTRALIANCLINICAL PSYCHOLOGY

ASSOCIATION


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