close

Вход

Забыли?

вход по аккаунту

?

Effects of a Single Session of Cognitive Restructuring, Cognitive Defusion and Imaginal Exposure on the Reduction of Claustrophobic Anxiety

код для вставкиСкачать
NOTE TO USERS
This reproduction is the best copy available.
UMT
Effects of a Single Session of Cognitive Restructuring, Cognitive Defusion
and Imaginai Exposure on the Reduction of Claustrophobic Anxiety
by,
Samantha H. Monk, M.A.
Dissertation Committee
William C. Sanderson, Ph.D., Sponsor
Joseph R. Scardapane, Ph.D.
Mitchell L. Schare, Ph.D., ABPP
Phyllis S. Ohr, PhD., Orals Chairperson
Kristin M. Weingartner, Ph.D., Reader
Submitted in Partial Fulfillment of the Requirements
for the Degree of Doctor of Philosophy
Hofstra University
Hempstead, N. Y. 11549
August 30th, 2010
UMI Number: 3431795
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, If material had to be removed,
a note will indicate the deletion.
UMT
Dissertation Publishing
UMI 3431795
Copyright 2010 by ProQuest LLC.
All rights reserved. This edition of the work is protected against
unauthorized copying under Title 1 7, United States Code.
®
ProQuest
ProQuest LLC
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106-1346
11
Copyright 2010
Samantha H. Monk
iii
ABSTRACT
There is considerable support for the efficacy of Cognitive Behavior Therapy
(CBT) for anxiety disorders. Within the CBT community, a "third wave" of
psychotherapies has emerged, largely based on principles of mindfulness and acceptance.
One of these therapies which have received considerable attention in the past several
years, Acceptance and Commitment Therapy (ACT), has been proposed as an alternate
approach to traditional CBT. While CBT emphasizes intervention with cognitive
modification and exposure to feared stimuli, ACT encourages thought acceptance
coupled with effective, intentional action based on personally held values. The primary
aim of this study was to isolate and compare the effect of these two conflicting
therapeutic mechanisms (cognitive restructuring versus cognitive defusion) as coping
techniques when confronted with a claustrophobic situation.
Forty-five Hofstra University undergraduate students endorsing a significant level
of claustrophobic fear were included in the study. Participants were randomly assigned to
receive one of three interventions: cognitive restructuring, cognitive defusion, or imaginai
exposure. Following a brief, single session intervention, participants engaged in a 12minute claustrophobic challenge and were asked to implement the strategy they were
taught. Based on previous findings, it was predicted that while all three interventions
would be effective, cognitive restructuring and cognitive defusion would produce
significantly lower scores than the imaginai exposure condition on self- report measures
of anxiety and measures of behavioral and experiential avoidance. Furthermore, it was
hypothesized that the cognitive restructuring group would demonstrate an improvement
iv
in symptoms of anxiety and behavioral avoidance compared to the cognitive defusion
group.
Findings indicate that cognitive restructuring, cognitive defusion, and imaginai
exposure resulted in the reduction of claustrophobic anxiety. However, there were no
differences between the groups in the amount of reduction. Results also did not support
the hypothesis that the groups would demonstrate significant reductions in anxious
arousal pre- to post-intervention. As predicted, the cognitive restructuring group,
cognitive defusion group, and imaginai exposure group exhibited a significant decrease in
distress during the challenge. However, contrary to hypotheses, there were no differences
between groups. Results indicated no differences between the groups on measures of
behavioral avoidance or experiential avoidance.
Designed as an analog study, rather than a treatment study, the essential
component of ACT and CBT were compared, allowing for an evaluation of the disparate
processes proposed in each intervention. Research on the mechanisms of action of
treatment is critical to understand the relative merits of various components of
psychotherapeutic treatment. To date, these therapies have primarily been studied in the
context of an entire treatment package, thus obscuring the specific effects of any one
component. Ultimately, understanding the effective mechanisms of action will lead to the
improvement of evidence based treatments for anxiety disorders. In particular, the results
of this study have important implications for the brief reduction of claustrophobic
anxiety, as cognitive restructuring, cognitive defusion and imaginai exposure were all
effective in reducing claustrophobic anxiety.
V
Acknowledgements
Thank you to the members of my committee for your advice, encouragement and
support throughout this project. Each of you has been instrumental in my education and I
am forever indebted. An enormous thank you to my dissertation sponsor, Dr. William
Sanderson. Your intuition as a supervisor, teacher, researcher and clinician has been a
guiding force throughout my training and has provided a model of professionalism to
which I aspire. From inception to defense of this dissertation you have contributed
tirelessly to the project's development and execution. My dissertation truly represents the
culmination of years of doctoral preparation under your supervision, and I am so grateful
for your leadership, support and guidance.
Dr. Scardapane: My mentor, teacher, role model, supervisor and dear friend. You
have contributed more than you can imagine to my development as a clinician and to my
understanding of my personal and professional identity. Your inquisitiveness, dedication,
genuineness and humor (and, let's be honest, your general H.H. brilliance) have been a
beacon of support and an unending source of encouragement. I will always value your
insight and guidance through supervision, almost as much as I'll treasure the memories of
cracking up Colby with our antics on our many conference travels and dinners.
Dr. Mitchell Schare: I am so lucky to have been a recipient of your inexorable
enthusiasm and dedication to the training of the doctoral candidates of Hofstra's PhD
program. Your steadfast passion for the field and for the development of the students you
lead is a gift for which I am eternally grateful. Your guidance as a member of my
vi
dissertation committee has been a shining demonstration of your devotion and I cannot
thank you enough for the model of professionalism you have provided.
Thank you to Dr. Phyllis Ohr, fearless Orals Chair of my dissertation committee.
You moderated the defense of this project with calm grace, as only Dr. Phyllis Ohr could.
You have played a central and instrumental role in my education ever since my first day
at Hofstra and I am so thankful for your contribution to this dissertation, my culminating
achievement. Finally, to Dr. Kristin Weingartener: Thank you for joining my committee
as a reader. Your extraordinary insight and input were invaluable. I am so grateful for
your assistance, flexibility and generosity.
I would also like thank a number of gals who started out as "grad school peers"
and became life-long friends. Frannie and Laura, my commuting buddies and
cheerleaders, thanks for keeping me awake at the wheel! Our talks over the years have
quelled so much anxiety and provided so many laughs. This process would not have been
nearly as much fun if you had not been a part of the experience. I wish you all the best in
the future! My dear Colby: No words can express the gratitude I feel for our friendship.
You have been my rock, my best friend through this journey. The combination of your
presence, devotion, dedication and genuineness is an extraordinary gift and constant
inspiration. Thank you for repeatedly reinforcing my commitment to living in line with
all that I value. I love you to pieces.
Finally, I would not be typing these words if it were not for the indefatigable love,
support, and care of my mother, Ellen Monk. Mom, your friendship has been the key to
my success. None of this would be possible if it weren't for you. This dissertation is
vii
dedicated to you and represents all of your hard work as much as it does mine. I love you
as big as the house.
VlU
TABLE OF CONTENTS
COPYRIGHT
u
ABSTRACT
ui
ACKNOWLEDGEMENTS
v
TABLEOFCONTENTS
viii
LISTOFTABLES
xi
LISTOFFIGURES
xii
CHAPTER I: Introduction
Imaginai Exposure
Cognitive Therapy
Cognitive Defusion
l
·
2
3
4
Claustrophobia
'
CBT Treatment of Claustrophobia
8
ACT Treatment for Anxiety
17
Study Rational
29
Hypotheses
CHAPTER ?: Method
3O
32
Participants
JZ-
Experimental Design
32
Independent Variables
33
Dependent Variables
33
Measures
JJ
Apparatus
-30
Procedure
J/
IX
CHAPTER ??: RESULTS
40
Claustrophobic Anxiety (CLQ)
40
Anxious Arousal (MASQ-AA)
42
Subjective Distress (SUDs)
46
Behavioral Avoidance
50
Experiential Avoidance
53
CHAPTER IV: DISCUSSION
57
Reduction in Claustrophobia
57
Previous Research
59
Relative Efficacy of the Interventions
60
Mechanisms of Action
61
Limitations
63
Clinical Implications
68
Conclusion and Future Research
69
REFERENCES
72
APPENDICES
86
Appendix A- Claustrophobia Questionnaire (CLQ)
86
Appendix B- Informed Consent Form
88
Appendix C- Debreifing Form
88
Appendix D- Action and Acceptance Questionnaire (AAQ)
90
Appendix E- The Mood and Anxiety Symptom Questionnaire (MASQ) ....92
Appendix F- Manipulation Check Assessment
94
Appendix G- Defusion Protocol
Appendix H- Cognitive Restructuring Protocol
Appendix I- Imaginai Exposure Protocol
95
101
HQ
X
Appendix J- Challenge Instructions
Appendix L- Apparatus
116
118
Xl
LIST OF TABLES
Table 1: Claustrophobia Questionnaire Scores Pre-Intervention, Post-Intervention, and
Pre-Post Intervention Differences: Sample sizes, Means, and Standard
Deviations
Table 2: Mood and Anxiety Questionnaire - Anxious Arousal Subscale (MASQ-AA)
Scores Pre-Intervention, Post-Intervention, and Pre-Post Intervention Differences:
Sample sizes, Means, and Standard Deviation
44
Table 3: Subjective Units of Distress Ratings during Claustrophobic Challenge: Sample ^
sizes, Means, and Standard Deviations
47
Table 4: Length of Time Spent in the Claustrophobic Challenge
51
Table 5: Willingness to Participate in a Second Claustrophobic Challenge
Table 6: Willingness to Participate in a Second Claustrophobic Challenge
51
5¿
Table 7: Acceptance and Action Questionnaire (AAQ) Sample size, Means and Standard
Deviations
XIl
LIST OF FIGURES
Figure 1: Effect of intervention on Claustrophobia Questionnaire
Figure 2: Effect of intervention on the Mood and Anxiety Symptom QuestionnaireAnxious Arousal subscale scores
Figure 3: Subjective Units of Distress (SUDs) ratings during the claustrophobic
challenge
1
CHAPTER I
Introduction
In 1958, Joseph Wolpe published Psychotherapy by Reciprocal Inhibition in
which he described systematic desensitization, a novel treatment for phobias and other
anxiety disorders, marking the inauguration of the ascendance of behavior therapy.
Following nearly two decades of empirical research supporting behavior therapy, Aaron
T. Beck developed and disseminated cognitive therapy in the 1970s (e.g., Beck, 1973),
which was first applied to the treatment of depression and soon thereafter to the treatment
of anxiety (Beck & Emery, 1985). During the 1980s, these two traditions merged into a
unified form of treatment, cognitive behavior therapy (CBT), signifying a "second wave"
of behavior therapy. To date, CBT is the most widely researched and empirically
supported form of psychotherapy for anxiety (e.g., Roth & Fonagy, 2005; Butler,
Chapman, Forman, & Beck, 2006).
More than two decades later, a new "wave" of behavior therapy has risen,
infusing psychotherapy with the principles of mindfulness meditation and experiential
acceptance. With the growth of the "third wave" and the development of new treatments
for psychopathology and human suffering, controversy has ensued regarding the
supremacy of acceptance based therapies over traditional CBT. Unlike the second-wave,
where cognitive interventions were added to behavioral strategies, third-wave treatments,
especially Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson,
1999) which is in the forefront of this controversy, is being advanced as an alternative to
traditional CBT. Although both treatments view thoughts as central to the development
and maintenance of psychopathology and human suffering, beliefs about the function of
2
thought, as well as how we respond to thoughts, are in opposition to one another. While
the defining principle of CBT proposes maladaptive thought content mediates negative
affect (e.g., appraisals of danger of a phobic stimulus lead to anxiety and avoidance
behavior), ACT theory maintains that fusion with one's thoughts (the behavior of
"buying into" the thought), is particularly problematic, rather than the literal cognitive
content.
It has been suggested within the ACT community that attempts to control and/or
change thoughts and feelings, such as the approach utilized in cognitive therapy, is not
only ineffective, but counterproductive and consequently result in heightened
psychological distress (Hayes & Smith, 2005). However, to date no data is available to
assert this declaration. Clearly, these two intervention strategies have very different, in
fact opposite, ideas about the treatment of cognition. This study aims to isolate and
compare these two conflicting mechanisms (cognitive analysis and modification vs.
cognitive defusion) as coping techniques when faced with an anxiety provoking situation.
Imaginai Exposure
Imaginai exposure is based on Mowrer's two-factor learning theory of avoidance
responding, which suggests that classically conditioned fear is subsequently reinforced
through avoidance of the feared stimulus. Avoidance behavior is easily acquired due to
its effective reduction or termination of conditioned fear. Although avoidance behavior is
functional in that it reduces or eliminates the source of conditioned fear rather quickly, it
can also be maladaptive. As an alternative, extinction theory stipulates that repeated
3
presentation of the conditioned stimulus without negative reinforcement will also result
in the unlearning of fear to the simulus. (Levis, D. J., 1980)
The goal of imaginai exposure is to extinguish conditioned fear and reduce
behavioral avoidance. This is achieved by repeatedly presenting the avoided stimuli and
preventing the conditioned response (escape/avoidance). While in vivo exposure attempts
to do this through real-life contact with the feared situation, this is not always possible in
the therapeutic environment due to logistical and financial constraints. As an effective
substitute, imaginai exposure uses symbolic imagery to illicit the conditioned fear. In
order to do this effectively, the therapist constructs a clear description of the cues avoided
by the individual which reinforce the aversive conditioning. The therapist then uses
verbal instruction to produce imagined scenes including relative visual, auditory and
tactile information associated with the feared stimulus. By repeated exposure to the
avoided stimulus through imagery, the process of extinction occurs and produces a
reduction in conditioned avoidance.
Cognitive Therapy
Cognitive models of anxiety view maladaptive beliefs and thoughts, which
generate inappropriate appraisals of the dangerousness of threatening stimuli, as the
primary problem for individuals suffering from anxiety disorders (Beck & Emery, 1985;
Barlow, 1988, 2002). In particular, cognitions predicting personal danger and threats to
one's physical or psychological well-being relate to increases in anxiety (Beck, 1970;
Beck, Laude, & Bohnert, 1974). In Beck's model of cognitive schemata, automatic
thoughts related to states of anxiety are the result of distorted information processing,
4
which in turn leads to dysfunctional and inappropriate anxiety responses of the behavioral
and affective systems (Beck, 1985). An example of this is when an individual in an
enclosed space has an exaggerated and disproportionate anticipation of suffocation or
entrapment. In this situation, effective coping is hindered in favor of survival-oriented
behavioral responses such attempts to escape, physiological responses including
hyperventilation and affective responses resembling anxiety. In essence, cognitive
theories of anxiety suggest that external and internal stimuli trigger erroneous attributions
and misappraisals, which in turn lead to maladaptive behavioral attempts at selfregulation and mobilization. Cognitive therapy, therefore, attacks these maladaptive
cognitions, often in conjuncture with planned exposure to the anxiety provoking
situations.
As a treatment strategy, cognitive therapy emphasizes cognitive analysis and
modification in addition to behavioral exposure to feared stimuli. Cognitive therapy seeks
to help the patient overcome difficulties by identifying and changing dysfunctional
thinking, behavior, and emotional responses. This involves helping patients develop skills
for analyzing, testing, disputing and modifying beliefs which support maladaptive
thoughts. The theory behind cognitive therapy maintains that emotions are subjective
states resulting from cognitive appraisal of internal and external stimuli, which motivate
or reinforce related behavior. Thus, cognitive therapy aims to modify dysfunctional
thinking in order to increase sought behavioral change.
Cognitive Defusion
5
Acceptance-based theories of anxiety do not view the literal content of thoughts
as problematic, or triggers for emotions. Rather, these theories hold that harm occurs
from taking these thoughts literally instead of accepting them as ongoing behavioral
processes. One novel approach to psychotherapy based upon this theory is Acceptance
and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). ACT is based on
Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), which proposes
that verbal relational connections form the core of human language, allowing us to learn
indirectly through verbal rules, thereby governing our behavior. Relational thinking
serves an adaptive learning purpose, and functions as an integral part of human
experience. However, verbal rules about our internal experiences and the control of
thoughts as means of self-regulation can lead to psychological inflexibility and human
suffering. Therefore, the fundamental objective in ACT is acceptance of one's thoughts
and feelings, coupled with the commitment to action in the direction of personally
clarified values (Hayes, et al., 1999; Eifert & Forsyth, 2005).
ACT aims to bring about change by altering the context within which private
events occur and alter the function of the experience, rather than changing, reducing or
eliminating the content of thoughts, feeling and sensation. One way this is achieved is by
changing the relationship one has with their thoughts. Cognitive defusion refers to the
process of becoming unattached to the content of one's thought by observing the process
of cognition and allowing one's thought to come and go without fusing to the content
matter. For example, one exercise often used to defuse from one's thoughts is the
repetition of a word over and over for 30 to 60 seconds. This typically results in the word
losing some of its meaning and the function of the word changes as well. As a nonliteral
context is created, the word's function changes from symbolic (the learned association) to
a more fundamental experience of the sounds and kinestetics involved.
ACT encourages cognitive defusion as a technique to increase desired behavior.
In order to reduce the believability of thoughts and behavioral impact of negative
thoughts, cognitive defusion encourages patients to "defuse" from the literal meaning of
their thoughts and instead focus on thinking as an active, ongoing process In anxious
states, one experiences anxious thoughts in the same way they would experience the reallife events that the thoughts refer to, instead of recognizing or identifying their anxious
thoughts as what they are (just thoughts). When this happens, the thoughts are said to be
"fused" with their stimuli. For example, an individual having a panic attack might have
the thought "I am going to die," and experience as much anxiety in response to that
thought as if they were really in a life threatening situation. An essential part of accepting
our thoughts is recognizing that they are separate from the events to which they refer. In
ACT, this process of experiencing our thoughts as "just thoughts" is called "cognitive
defusion."
The struggle with internal experiences (thoughts and feelings) and the resulting
avoidance of these private events is viewed as particularly problematic in the ACT model
and is targeted explicitly during treatment. Experiential avoidance involves the negative
evaluation of unwanted thoughts, feelings and sensations, and an unwillingness to
experience these private internal events. Attempts to control and/or escape these
thoughts, feeling and sensations lead to increased anxiety and suffering (Hayes, 1994;
Hayes, Strosahl, & Wilson, 1999).
7
Claustrophobia
Claustrophobia is an anxiety disorder classified in the DSM-IV TR (APA, 2000)
as a specific phobia within the subcategory of situational phobias. The defining feature of
this disorder is the fear of enclosed spaces, with the individual experiencing "marked,
persistent and excessive or unreasonable fear" when faced with the anticipation of or
actual encounter with an enclosed space. Fears of losing control or having a panic attack
are often reported, as are physiological symptoms including shortness of breath and
increased heart rate (APA, 2000). As a significant contributing factor in many
psychological disorders, including aviophobia, agoraphobia, post-traumatic stress
disorder and panic disorder, claustrophobic avoidance can interfere with occupational and
leisure activities such as travel.
Claustrophobia can also result in significant medical consequences, including
refusal to undergo necessary magnetic resonance imaging (MRI) scans. Many MRI
appointments are cancelled early or never attended (e.g., Klonoff, Janata, & Kaufman,
1986; Melendez & McCrank, 1993), likely attributable to anxious avoidance. Moderate to
severe anxiety may be experienced in up to 37% of patients undergoing MRI scans,
involving a fear of enclosed space, pain, the unknown, and fear of the results (Katz,
Wilson, & Frazer, 1994). In 1998, Mclsaac, Thordarson, Shafran, Rachman, and Poole
found 25% of individuals in need of a magnetic resonance imaging (MRI) procedure
exhibited moderate to severe anxiety during the procedure. These authors also found an
association between pre-scan reports of claustrophobia and panic during the procedure. In
line with these findings, the most important predictor of the amount of anxiety during a
scan was the amount of time spent having physical symptoms of panic and the most
8
frequent cognitions involved fears of suffocation (Thorpe, Salkovskis, & Dittner, 2008).
In other reports, claustrophobia has been isolated and identified in 5-10% of MRI patients
(Melendez & McCrank, 1993).
Claustrophobia was chosen as the target representation of anxiety for this study,
because it is relatively easy to induce and manipulate the distress, therefore providing a
degree of experimental control over the anxiety provoking situation. In addition,
claustrophobic anxiety and behavioral avoidance is easy to measure in an experimental
analysis. Claustrophobia is a relatively common fear, with the National Co-Morbidity
Study reporting a lifetime prevalence of roughly 4%, surpassed only by animal phobia
(5.7%) and acrophobia (5.3%) (Curtis, Magee, Eaton, Wittchen, & Kessler, 1998).
CBT Treatment of Claustrophobia
Cognitive behavior therapy is widely accepted as the premier treatment for
anxiety disorders (Nathan & Gorman, 2007). Numerous theory-driven cognitive
behavioral treatment "package" protocols (e.g., Panic Control Treatment [PCT: Barlow,
Cohen, et al., 1984; Barlow, Craske, Cerny, & Klosko, 1989]; Exposure and Response
Prevention [ERP: Foa, Steketee, & Ozarow, 1985]; Cognitive Behavioral Group Therapy
for social phobia [CBGT: Heimberg, et al., 1990]) have been developed, disseminated
and subjected to rigorous scientific evaluation. An enormous collection of empirical
support for cognitive behavioral treatment has been published, including research in the
areas of generalized anxiety (e.g., Borkovec & Ruscio, 2001), social phobia (e.g.,
Heimberg, Saltzman, Holt, & Blendell, 1993; Heimberg, et al., 1998), panic disorder,
(e.g., Clark, et al., 1994; Barlow, Gorman, Shear, & Woods, 2000) and obsessive
compulsive disorder (e.g., Foa, et al., 1983). These therapies have triumphed when
9
compared to other forms of treatment and have subsequently been administered with
great success. As a result, CBT has become the gold standard treatment for anxiety
disorders, against which novel forms of treatment must now be measured.
In vivo exposure has been well documented as the most robust treatment for many
simple phobias (Choy, Fyer, & Lipsitz, 2007). However, high dropout rates coupled with
low treatment approval and acceptance have been an impetus for advanced exploration
into more palatable and perhaps more effective techniques. As such, the research
literature on the treatment of claustrophobia has grown from strictly behavioral
interventions to cognitive behavioral interventions wherein cognitive strategies are
utilized as well. The literature on cognitive behavioral treatment of claustrophobia will be
summarized below.
In 1961, Arnold Lazarus demonstrated the efficacy of systematic desensitization
as a treatment for individuals with phobic disorders, laying the groundwork for further
investigations of behavioral interventions in this area. Systematic desensitization and
counter-conditioning continued to be investigated as techniques to reduce the
physiological symptoms of claustrophobia throughout the 1970s. For example, in 1976,
Koulack, LeBow and Church successfully used systematic desensitization to treat a 22year-old male with fear of closed space and noise. Taken together, these early studies
demonstrated the effectiveness of behavioral exposure in the reduction of claustrophobic
avoidance.
In the late 1960s, Leitenberg and colleagues at the University of Vermont
demonstrated the additional benefit of verbal reinforcement and feedback in the reduction
of claustrophobia in a series of case studies (Agras, Leitenberg, Barlow & Thomson,
10
1969; Leitenberg, Agres, Thomson & Wright, 1968; Leitenberg, Agras, Edwards,
Thomson & Wincze, 1970). In subsequent single subject design studies, claustrophobia
was successfully targeted using a variety of behavioral techniques, including imaginai
exposure and participant modeling with exposure (Speltz & Bernstein, 1979).
In 1971, Leitenberg, Agras, Butz and Wincze produced a groundbreaking report
contradicting the longstanding belief that reduction in the physiological manifestation of
anxiety was necessary to reduce anxious avoidance. In this study, the relationship
between heart rate and approach behavior was examined in nine phobic individuals, four
of whom were claustrophobic. During treatment with reinforced practice (with and
without feedback), the relationship between heart rate and approach was inconsistent
across patients (Leitenberg et al., 1971). Interestingly, some patients demonstrated an
inverse relationship, with heart rate increasing as phobic behavior decreased (one
claustrophobic). Others demonstrated a parallel relationship with heart rate decreasing as
phobic behavior decreased (two claustrophobies). Still, some demonstrated no
relationship between heart rate and approach behavior, without any overall change in
heart rate (one claustrophobic). Although no data regarding generalization to the natural
environment limits the clinical utility of this study, the result suggest that the
physiological symptoms of anxiety do not necessarily need to be targeted in order to treat
phobias including claustrophobia. These findings were groundbreaking in that they
indicated anxious avoidance could be treated without reducing physiological arousal.
Early investigations into the treatment of claustrophobia were primarily case
studies, strictly behavioral interventions, and often simultaneously treating multiple
phobias. Although case studies pioneered the exploration of behavioral interventions for
11
claustrophobie behavior, the small number of patients described and lack of controlled
experimental designs made it difficult to draw any concrete clinical conclusions about the
treatment of claustrophobia. As the field developed, randomized controlled studies were
executed which resulted in the establishment of cognitive behavioral therapy as the gold
standard treatment for individuals with claustrophobia.
The first randomized, experimental study in this area was published by Ost,
Johansson, and Jerremalm (1982), investigating claustrophobic response patterns as
individual differences to be targeted in treatment. Thirty-four psychiatric outpatients
diagnosed with claustrophobia were assessed on measures of heart rate and behavioral
avoidance and grouped as behaviorally responsive (based on degree of claustrophobic
avoidance) or physiologically reactive (based on amount of heart rate increase). Members
of each group were randomly assigned to one of three treatment groups: physiologically
targeted treatment (applied relaxation), behaviorally targeted treatment (exposure) or
waitlist control.
Ost et al. demonstrated that both treatment conditions were more effective than
the waitlist control. Furthermore, treatment targeting an individual's particular response
pattern was found to be more effective than the alternative. For behavioral reactors,
exposure was significantly more successful than applied relaxation and for physiological
reactors applied relaxation was significantly more successful than exposure. When
treatment focus was matched to response style, there was 100% clinical improvement;
50% clinical improvement was demonstrated when treatment was mismatched with
response style and 0% clinical improvement was found in the waitlist condition (Ost et
al., 1982). This study bolstered previous findings regarding the efficacy of behavioral
12
techniques in the treatment of claustrophobia and paved the way for future experimental
investigations.
In the following years, cognitive factors mediating claustrophobic fears moved to
the forefront of research in this area. Based on novel developments in cognitive theory
and therapy, particularly in panic disorder treatment research, Rachman and colleagues
initiated research into the utility of cognitive modification in the process of fear
reduction. Until then, phobias were considered to be unresponsive to cognitive
interventions. It was hypothesized that because claustrophobia shared many cognitive
features of panic disorder (Craske, Zarate, Burton, & Barlow, 1993; Rachman, Levitt, &
Lopatka, 1988), and panic disorder was successfully treated with cognitive interventions,
one may expect that claustrophobia would be responsive to similar interventions (e.g.,
Foa & Kozak, 1985; Sanderson, Rapee & Barlow, 1989; Clark, 1994). This hypothesis
led to an increase in research on cognitive interventions for claustrophobia.
In fact, the similarities between panic disorder and claustrophobia were quite
striking. Like panic disorder patients, claustrophobies are more responsive to
interoceptive or internal cues (e.g., shortness of breath, increased heart rate) than
individuals with other phobias focused on exteroceptive or external cues (e.g., snakes,
spiders). Claustrophobies are highly anxious when presented with a hyperventilation
challenge, and cognitive fears similar to those of panic disorder (fear losing control,
going crazy or dying) are a key component of claustrophobia, more so than other specific
phobias (Craske & Sipas, 1992). Furthermore, claustrophobia co-occurs more frequently
with panic attacks than any other specific phobia (Curtis, Hill, & Lewis, 1990).
Similar to panic disorder with agoraphobia, claustrophobia involves the fear of
what might happen to the person in the enclosed space, rather than the enclosed space
itself (Rachman, 1990). Specifically, many claustrophobic individuals fear that they will
suffocate in an enclosed space due to insufficient oxygen supply, and this fearful thought
is associated with the physiological symptom of shortness of breath (Rachman, 1988). In
one experimental manipulation, panic responses in claustrophobic college students
exposed to a small chamber were associated with thoughts of suffocation (Rachman,
Levitt, & Lopatka, 1987). However, cognitions were not uniform among participants,
indicating at least a second fear which contributes to claustrophobic anxiety. Indeed, a
number of individuals experiencing claustrophobia complain of fears that they will be
restricted and unable to escape, implicating two different components of claustrophobic
cognitions; fear of restriction and fear of suffocation (Rachman & Taylor, 1993).
In a series of studies investigating the inhibitory impact of "safety signals" on
claustrophobic panic, Rachman and Levitt found that attempts to behaviorally condition
safety signals were marginally effective (Rachman, 1998; Rachman & Levitt, 1985). In
subsequent experiments, they induced safety signals by directly providing the participants
with relevant safety information. In an effort to modify cognitive misappraisals, the
information contained reassuring information regarding oxygen availability and
consumption in the test chamber. Paradoxically, safety information did not have an
impact on thoughts regarding the claustrophobic situation, one's estimation of how much
fear or safety they would experience, or one's actual report of how much fear and safety
they experienced. However, providing safety information to the individual none the less
reduced the frequency of panics. Rachman (1998) hypothesized that this was likely due
14
to variation between participants' cognitions. While the provided information
successfully modified distortions of those who feared suffocation, individuals fearing
restriction were likely to be unaffected by the safety information because it was not
relevant to their fear.
To further investigate the utility of cognitive restructuring in the treatment of
claustrophobia, Booth and Rachman (1992) investigated the effects of interoceptive
exposure and a purely cognitive technique without exposure. The primary objective of
the study was to evaluate the interoceptive and cognitive approaches, as little was known
about their effects on claustrophobia. Forty-eight individuals who reported a fear score
greater than 50 on a Visual Analog Scale (1-100) were randomly assigned to one of four
intervention conditions: exposure, interoceptive exposure, a purely cognitive
intervention, and a control group. The exposure group received information regarding
fear acquisition and the rational for using exposure, created hierarchies and participated
in graduated exposure. The interoceptive exposure group received information about
acquisition of fear related to sensations in situations, created hierarchies regarding feared
sensations and participated in graduated exposure to induced panic related sensations
(i.e., hyperventilation). In the cognitive group information was provided about the impact
thoughts have on provoking anxiety and participants learned to identify and challenge
automatic thoughts in order to reduce anxiety, without any direct exposure. Training
occurred over three days and assessments of predicted fear, reported fear, reported panic,
negative cognitions, unpleasant physical sensations, heart rate and anxiety sensitivity
were made before training and after training for comparison.
15
As expected, the exposure group had significantly reduced anxiety on all
measures and the control group generally showed no improvement. Compared to the
control group, the cognitive group displayed significant reductions in their reported fear
and panic, as well as decreased predictions of fear in a future enclosed space. This was
encouraging evidence supporting the efficacy of cognitive techniques in the treatment of
phobias. The interoceptive group was considered unsuccessful, as reported reductions in
anxiety related sensations were not accompanied by a significant decline in predicted or
reported experience of fear or panic (Booth & Rachman, 1992).
Using data from the study discussed above, Shafran, Booth and Rachman (1993)
discovered that the removal of beliefs about suffocating, being trapped, and losing control
led to a prolonged reduction in claustrophobia. Specifically, low belief in these
claustrophobic cognitions during post-test assessment was significantly associated with
reduction in fear, compared to those with high belief in the claustrophobic cognitions. In
the individuals whose fear was successfully reduced, there was a greater correlation with
their belief in their cognitions compared to those who did not demonstrate a significant
reduction in fear, suggesting that reduced fear was related to the reduced belief in
cognitive misappraisal. Furthermore, at follow-up, individuals who experienced a high
return of fear had a greater return of anxious cognitions than those who did not.
Reduction in the number of claustrophobic thoughts was also associated with reduced
return of fear at follow-up (Shafran et al., 1993). These authors concluded that both the
quantity and believability of thoughts are associated with fear reduction in claustrophobic
situations. Consistent with other studies, this suggests that while exposure is dramatically
16
effective in acute situations, cognitive modification can lengthen these effects and
promote generalization.
In addition to an analysis of cognitive mediators in claustrophobia, Shafran,
Booth & Rachman also measured bodily sensations and the association between
physiological arousal, appraisals of these sensations, and claustrophobic fear. Based on
research on the reduction of panic (e.g., Clark, 1993; Clark & Ehlers, 1993), it was
predicted that reduction in body sensations would be associated with reduction in fear.
There was indeed a significant positive correlation between pre-treatment sensations and
fear. Across conditions, there was a positive relationship between reduction in sensation
and reduction in cognitions, though this association was only significant for the cognitive
and interoceptive groups (Shafran, Booth & Rachman, 1993).
Findings from the Rachman data were replicated by Craske, Mohlman, Yi,
Glover, and Valeri (1995), in an investigation of the impact of a panic control paradigm
on claustrophobic fear reduction. When compared to individuals with snake or spider
phobia, individuals who feared enclosure in small spaces reported greater fear of bodily
sensations. Furthermore, disconfirmation of fears regarding bodily sensations was
effective in reducing claustrophobic fear. These gains were specific to the claustrophobia
groups. Individuals with spider and snake phobia did not benefit from reappraisal of
sensations. Therefore, when compared to exposure with response prevention and
relaxation training, exposure plus disconfirmation of sensation misappraisals was more
effective in reducing claustrophobic fear (Craske et al., 1995). This study further justified
using cognitive behavioral techniques for treatment in this population.
17
Most recently, Ost, Alm, Brandberg, Breitholtz (2001) completed a study that
further bolstered the literature supporting cognitive behavioral therapy for claustrophobia.
Forty-six patients meeting DSM-IV criteria for claustrophobia were randomly assigned to
one of four treatment groups: one 3-hour session of prolonged therapist-directed
exposure, five 1-hour sessions of gradual therapist-directed exposure, five 1-hour
sessions of cognitive therapy with no practice, and a waitlist control group. The one
session exposures were tailored to the individual based on anxiety provocation. Target
situations included riding in an elevator, being a small locked room with no windows, or
traveling by bus/underground train. The five session exposure condition targeted a variety
of situations and in vivo practice was assigned for homework between sessions. The
cognitive therapy focused on identifying and modifying negative automatic thoughts and
beliefs about claustrophobic situations, without in vivo exposure training. However,
patients were not discouraged from practicing on their own volitions in between sessions.
Therefore, some limited exposure may have occurred within this group. The results
indicated that all three treatment groups were successful in treating claustrophobia and
each was superior to the waitlist control. The study also found that one prolonged session
of exposure was equally effective as five brief exposure sessions. Finally, the experiment
demonstrated the efficacy of cognitive interventions in the treatment of this population,
as there were no statistical differences between the cognitive and exposure treatment
conditions.
ACT Treatment ofAnxiety
ACT is a relatively new psychotherapeutic approach. As such, empirical support
is somewhat sparse. During the last two decades, as research has grown and "third-
18
wave" treatments (e.g., Mindfulness Based Cognitive Therapy [MBCT: Segal, Teasdale
& William, 1994]; Dialectical Behavior Therapy [DBT: Linehan, 1993]) have gained
visibility within the cognitive behavioral tradition, a number of studies have been
released assessing the efficacy of acceptance-based therapies. As a result, a developing
body of evidence for this therapy is emerging, as highlighted in a recent meta-analysis
(Hayes, Luoma, Bond, Masuda, & Ullis, 2006). More specifically, ACT has proven
effective for many psychological disorders, including: Depression (Zettle & Hayes, 1986;
Zettle & Raines, 1989), mathematics anxiety (Zettle, 2003), stress (Bond & Bunce,
2003), trichotillomania (Woods, Wetterneck, & Flessner, 2006), obsessive compulsive
disorder (Twohig, Hayes & Masuda, 2006), social anxiety (Ossman, Wilson, Storaasli &
McNeill, 2006; Dalrymple & Herbert, 2007) and psychosis (Bach & Hayes, 2002).
However, no reports of utility with specific phobias are available for reference and no
articles are available to date on acceptance-based techniques for the treatment of
claustrophobia. Although one study looked at cognitive therapy (CT) versus ACT for
mixed mood and anxiety disorders, no direct comparisons of CBT and ACT for anxiety
have been reported. However, an examination of the efficacy of ACT for other anxiety
disorders has implications for the treatment of claustrophobia.
A number of studies have shown that experiential avoidance is associated with
various measures of anxiety (e.g., Tuli, Gratz, Salters, & Roemer, 2004; Marx & Sloan,
2005; Roemer, Salters, Raffa, & Orsillo, 2005). Experiential avoidance is also related to
less adaptive coping strategies, maladaptive emotional responding and increased reports
of uncontrollability (Kashdan, Barrios, Forsyth, & Steger, 2006). In individuals with a
history of un-cued panic attacks, fears of interoceptive triggers predicts experiential
19
avoidance (Tuli, Rodman, & Roemer, 2008). It has been demonstrated experimentally in
a non-clinical sample that emotional avoidance is also associated with reports of panic
related symptoms when individuals are asked to suppress their emotions during panic
induction (Feldner, Zvolensky, Eifert, & Spira, 2003). This holds true when controlling
for variables like pre-experimental anxiety sensitivity (Karekla, Forsyth, & Kelly, 2004;
Spira, Zvolensky, Eifert, & Feldner, 2004). As these studies were conducted in healthy
samples of individuals with no history of anxiety disorder, it appears that experiential
avoidance is also a contributing factor in anxiety.
Based on findings such as these, ACT attempt to increase contact with, and
develop tolerance for, internal thoughts, feelings and sensations, while at the same time
committing to performing behaviors in line with one's goals and values (Hayes, et al.,
1999). Along with weakening experiential avoidance, ACT aims to undermine literalized
language, defuse oneself from the content of cognitions, and teach acceptance and
willingness as responses to inevitable and necessary internal human experiences.
Furthermore, ACT attempts to teach individuals to maintain contact with the present
moment through exercises of mindfulness, as well as establish an experience of oneself as
context for their thoughts and feelings. Finally, ACT interventions are designed to clarify
one's life goals and values, and to help individuals perform committed action in harmony
with these chosen values (Hayes, Pankey, & Gregg, 2002).
The first clinical outcome study evaluating the efficacy of ACT against an
established treatment for anxiety compared ACT with systematic desensitization for
mathematics anxiety (Zettle, 2003). Zettle chose to implement systematic desensitization
for the comparison therapy because it was well-established as effective in the treatment
20
for specific phobias. Twenty-four college students were randomly assigned by coin toss
to either a systematic desensitization group or to the ACT group. ACT was administered
using metaphors as teaching tools, based on guidelines by Hayes et al. (1999), with
adaptations tailored for mathematics anxiety. Two sessions were devoted to creating a
state of creative hopelessness, followed by two sessions focused on willingness, defusion
and decreased experiential avoidance as an alternative response to anxiety. The final
sessions focused on values and committed action.
The alternative treatment in Zettle's study, systematic desensitization, was based
on Wolpe's (1973) guidelines. The first session entailed a discussion of the rational for
treatment and instruction in progressive muscle relaxation. Participants were given a tape
to practice for homework and as treatment progressed, relaxation techniques used also
included relaxation by recall and cued relaxation. Hierarchy development was completed
by the third sessions and the remaining sessions focused on imaginai exposure to
hierarchy items during concurrent relaxation induction.
Zettle found significant, equal reductions in mathematics anxiety from pre- to
post-treatment, and gains were maintained at 2-month follow-up. Both the ACT group
and the systematic desensitization group demonstrated equivalent reductions in
experiential avoidance at post-test and at 2-month follow-up. Participants in the
systematic desensitization condition demonstrated significantly reduced trait anxiety at
post-treatment. Interestingly, experiential avoidance measured at pre-treatment was
significantly correlated with reductions in anxiety for individuals in the ACT group, and
this was significantly greater than the corresponding correlation in the systematic
desensitization group. There was also a significant relationship between experiential
21
avoidance and change scores in trait anxiety for individuals in the ACT group. Therefore,
it was concluded that the two treatments were equally effective for treating math anxiety,
though this occurred through different processes (Zettle, 2003).
Ossman, Wilson, Storaasli and McNeill (2006) published a study evaluating an
ACT-based group therapy for social phobia. Twenty-two individuals meeting DSM-IV
criteria for social phobia participated in 10 sessions of treatment based on an ACT
protocol for social phobia. Treatment targeted creative hopelessness, the problem of
control, acceptance, defusion, values clarification and committed action. In line with
ACT guidelines, metaphors and experiential exercises were favored over didactic
presentation. Mindfulness was used to increase awareness of internal experiences without
trying to change them. Individualized, systematic exposures were introduced to teach
patients to respond with flexibility to life events, rather than to use exposure as a form of
extinction (as in traditional behavior therapy). Twelve patients completed treatment and
were included in the primary analyses. Drop outs were included in secondary analyses as
an intent-to-treat group with participants' last data point carried forward.
Ossman et al. found significant decreases on measures of social phobia and
experiential avoidance in the completer groups, an interesting finding given that social
phobia was not being targeted in treatment. This suggests that the acceptance and nonavoidance of anxiety provoking symptoms and situations resulted in symptom reduction
as well. Ratings of effectiveness of living, especially with regard to social relationships,
increased (Ossman et al., 2006). While the results of this study are intriguing, the lack of
a control or comparison group does not allow for drawing any conclusions about the
relative efficacy of ACT over other psychotherapeutic treatments.
22
A second study on ACT for social anxiety was published in 2007 by Dalrymple &
Herbert. Nineteen participants meeting DSM-IV-TR (APA, 2000) primary diagnostic
criteria for social anxiety disorder (SAD) were treated at a university-based anxiety clinic
and included in the study. Individual therapy, based on an ACT protocol adapted for
social anxiety, was administered over 12 sessions, following a baseline period of 4
weeks. Topics addressed included creative hopelessness, willingness/acceptance as an
alternative to emotional and cognitive control, cognitive defusion, values clarification and
valued action. Mindfulness was introduced as a means for nonjudgmental awareness of
internal experiences, and assigned in vivo exposure exercises were utilized beginning
after session three. Consistent with ACT, metaphors and experiential exercises were used
to facilitate understanding. Treatment also included role-play, in vivo exposure, and
social skills training, as in standard behavior therapy for SAD.
Overall, Dalrymple & Herbert found significant reductions in social anxiety and
improvements in quality of life. From pre- to post- treatment, perceived control over
emotional reactions was significantly greater, and experiential avoidance was
significantly decreased. Furthermore, earlier changes in experiential avoidance lead to
later changes in outcome (Dalrymple & Herbert, 2007). However, again, the lack of a
control or comparison group does not allow one to draw conclusions about the efficacy of
this treatment.
Evidence for ACT can be gieaned from the treatment of other anxiety disorders,
including obsessive compulsive disorder (OCD). Twohig, Hayes, and Masuda (2006)
conducted a four subject, non-concurrent, multiple baseline, across-participant analysis of
ACT as a treatment for OCD. Following a baseline period, treatment entailed eight
23
weekly 1-hour sessions based on Hayes, et al., (1999) ACT guidelines. The first author,
who was trained directly by Steven C. Hayes, served as the therapist for all patients, with
25% of sessions subjected to videotape review by a third therapist to control for treatment
allegiance. Techniques used included creative hopelessness to demonstrate the
ineffectiveness of trying to control obsessions, willingness to experience the obsessions
and the associated anxiety, defusion, mindfulness and self-as-context exercises to change
the meaning of the obsession from something distressing to a simple verbal event.
Towards the conclusion of treatment (sessions seven and eight), patients discussed their
values and performed behavioral commitment exercises in the direction of these values.
In order to distinguish ACT from exposure plus response prevention, no in-session
exposures took place.
Twohig et al. found a significant reduction in compulsion frequency, as well as
clinically significant improvement in OCD symptoms from pre- to post- treatment. No
patients demonstrated a reduction in compulsive behavior during the 7-week baseline
period. All patients demonstrated significant reductions in compulsive behavior during
treatment, and most gains were maintained at 3-month follow-up (Twohig et al., 2006).
Interestingly, a large reduction in obsessions was also found, even though ACT does not
target the content of internal events and ideas. ACT-inconsistent techniques, such as
attempts to change cognitive content or use cognitivebehavioral models for
psychoeducation, were successfully circumvented as assessed by measurement of
allegiance. However, behavioral commitment exercises used as assignments to practice
ACT techniques, which frequently involved exposure to anxious stimuli, were assigned
24
for homework. The use of an already established technique creates a potential confound
for ACT, and limits the reliability of the results.
Acceptance-Based Behavior Therapy is similar to ACT and places an emphasis
on experiential avoidance and intentional action. However, unlike ACT, AcceptanceBased Behavior Therapy aims to incorporate these principles but is not based on a strict
ACT protocol. The first phase of treatment involves sharing an empirically supported
model of GAD including avoidance theory of worry (Borkovec, Alcaine, & Behar, 2004),
emotion regulation theory (Linehan, 1993) and experiential avoidance (Hayes et al.,
1999). Understanding of this model is imparted through presentation, experiential
exercises and in vivo monitoring. Individuals are taught to increase awareness of and
compassion for their emotional and cognitive processes while decreasing fusion and
emotional reactivity. This is achieved using mindfulness, diaphragmatic breathing and
progressive muscle relaxation (adapted to promote awareness rather than change), with
an emphasis on the use of metaphors. Throughout treatment, the focus of AcceptanceBased Behavior Therapy remains on intentional actions patients can take to live life in
their chosen direction, rather than changing thoughts and emotions. Planned exposure
exercises are used during the final phase of treatment, often promoting the use of
mindfulness and committed action.
Roemer and Orsillo (2007) conducted an open trial of Acceptance-Base Behavior
Therapy for Generalized Anxiety Disorder (GAD) with 16 clients at a university-based
anxiety clinic. Written exercises were used to monitor the extent to which experiential
avoidance impacted their quality of life, and the extent to which they were engaging in
valued behavior. Roemer and Orsillo found significant symptom reduction on a range of
25
measures for GAD, as well as reduced experiential avoidance and improvements in
quality of life. These gains were maintained at 3-month follow-up. Once again, no control
group was included in this study, limiting conclusions regarding efficacy of AcceptanceBased Behavior Therapy. Though not a direct study of ACT, these findings highlight the
potential value of acceptance-based techniques in anxiety treatment.
As discussed previously, claustrophobia shares many symptomatic features with
panic disorder and may therefore have a similar underlying psychopathology. Thus,
findings regarding ACT in panic disorder populations would be expected to be
particularly relevant to the present study. In 2003, Eifert and Heffner found an
acceptance-based approach was more effective than relaxation in reducing symptoms of
panic attacks. Sixty college females scoring greater than one standard deviation above the
norm on a measure of anxiety sensitivity engaged in two 10-minute inhalations of 10%
carbon dioxide enriched air. This procedure was implemented to induce the sensation of
panic and anxiety. Prior to exposure, the participants were assigned to one of three
groups: Acceptance, control and no instruction.
The acceptance group participants were taught the Chinese finger trap metaphor
and attempted the task as an experiential exercise. The finger trap is a woven straw tube,
roughly the diameter of a human fìnger. A person puts their fingers into the tube and is
instructed to try to remove their fingers. However, when the person attempts to pull out
their fingers, the straw tightens around their fingers rather than releasing. The only way to
release oneself from the trap is to push further into the straw, creating room to remove
their fingers. In this manner, participants were taught that although logical, attempts to
control and reduce uncontrollable symptoms are futile, with the attempts paradoxically
26
increasing the struggle. Rather, leaning further into the symptoms helps to end the
struggle. In the second group, the control context group, participants were taught a
standard diaphragmatic breathing strategy, including deep breathing and verbal repetition
of the word "relax." Participants were told that this would serve to control their
symptoms during the C02 challenge. Finally, a no instruction group was used as an
experimental comparison control group.
Following instruction, all three groups were told they would undergo three C02
challenge trials. Avoidance was measured as latency to inhalation of C02-enriched air
which the participants were allowed to begin at their discretion. Although latency
measures were obtained for the third trial, the C02 challenge was not induced. Despite no
differences between groups on the first and second C02 challenge latency to inhalation
scores, the acceptance group demonstrated a significantly faster rate of inhalation
initiation on the third trial, suggesting that acceptance led to decreased avoidance. In the
acceptance group, mean latency scores initially increased followed by a significant
decrease. In comparison, the relaxation group took increasingly greater time on each trial,
indicating that attempts to control symptoms resulted in greater avoidance. These authors
also found that catastrophic cognitions were related to avoidance, and that the acceptance
group experienced fewer catastrophic cognitions ("I am going to lose control", "I need
help") than the relaxation and no-instruction groups. There were no differences between
the groups on measures of physiological arousal (skin conductance and heart rate) or on
measures of subjective distress during either phase of the challenge.
Eifert and Heffner concluded that both active strategies, controlled
breathing/relaxation or acceptance, are not mutually exclusive and may be beneficial at
27
different times within a panic cycle (Eifert & Heffner, 2003). It is likely that relaxation
and breathing may impact anxiety sensitivity and be useful in the prevention of panic,
while acceptance may be more effective during an initiated panic attack. This study
provided preliminary support for the effectiveness of acceptance-based strategies in the
reduction of panic symptoms, including behavioral avoidance, of individuals high on
anxiety sensitivity - a trait associated with panic disorder.
Acceptance-based approaches have also been shown to be more effective than
thought suppression in reducing panic. In 2004, Levitt, Brown, Orsillo, and Barlow
showed that acceptance of one's experience of panic resulted in decreased anxiety and
decreased avoidance. Their sample was drawn from an outpatient clinic and participants
met DSM-IV criteria for panic disorder. A pre-treatment assessment revealed that
individuals with panic disorder tended to use suppression strategies in their everyday
lives (e.g., attempting to avoid or eliminate anxious thought). Sixty panic disorder
patients were randomly distributed to one of three groups, each of which received
differential 10-minute instruction in emotion regulation strategies prior to panic induction
via C02 challenge. The acceptance instruction was based on ACT (Hayes et al., 1999)
and focused on the futility of attempts to suppress of control anxiety and the functionality
of behavior change in valued directions. The suppression instruction encouraged the
patient to push their feelings away and attempt to not feel any anxiety or think any
anxious thoughts. The no-instruction group listened to a 10-minute national geographic
article.
Levitt et al. found the suppression group experienced significantly greater anxiety
during the C02 challenge when accounting for differences in resting anxiety levels.
28
Furthermore, the acceptance group was significantly more willing to participate in a
second challenge, demonstrating decreased behavioral avoidance compared to the
suppression group (Levitt et al., 2004). This finding supports the utility of acceptance in
the amelioration of panic symptoms. However, the use of a suppression comparison
limits the generalization of the findings to preferable treatment for panic, as suppression
is significantly different than the process of cognitive restructuring. Therefore, this study
does not establish superiority of acceptance over cognitive restructuring.
Forman, Herbert, Moitra, Yeomans, and Geller (2007) compared ACT and
cognitive therapy (CT) directly. One hundred and one patients presenting with varying
forms and combinations of mood and anxiety disorders were treated at a university
student counseling center. Patients were randomly assigned to either the CT or ACT
group. Treatment was not limited by number of sessions, nor was it manualized. Rather,
therapists were trained in the core aspects of CT and ACT with fidelity to intervention
emphasized. The CT group was socialized to the cognitive model, focused on automatic
thoughts, distortions, core beliefs and schémas, and used challenge techniques including
disputation and cognitive restructuring. The ACT group was ACT to the standard model
and treatment focused on willingness and experiential acceptance, discussion of the role
of human language in human distress, mindfulness, values clarification, and an
understanding of "clean" vs. "dirty" suffering. Classical behavior therapy techniques,
including exposure, behavior activation, skills training and homework were implemented
as warranted in both conditions.
Forman et al. found no differences between the two groups on self-report outcome
measures of symptom reduction, quality of life measures, and clinician assessed
29
functioning and well being. Furthermore, both conditions demonstrated large effect sizes
for clinically significant improvements following treatment (Forman et al., 2007).
Although formal mediational analyses could not be performed due to lack of a control
group, exploratory analyses indicated that as suspected, changes in observing and
describing one's thoughts was associated with improvement in the CT group, while
experiential acceptance and behavioral awareness were more associated with success in
the ACT group. Although it was likely that there may have been some unintended
overlap between the conditions, adherence data suggest that the treatments were reliable
and relatively pure.
Study Rational
Although the emergent literature supporting the efficacy of ACT for a wide range
of conditions is promising, as noted in the review presented above, there are a number of
methodological limitations of these studies. Most importantly, with regard to internal
validity, the majority of studies did not employ a control or comparison group, and as a
result, the ability to confirm the efficacy of the treatment itself is questionable, given the
many alternative explanations that must be ruled out by the inclusion of a control group.
With respect to the present study, to date, there is little information on the relative
efficacy of ACT versus CBT. Given the theoretical claims made by those advocating
ACT, especially the notion that processing and modifying cognitions is contra-indicated,
this is an important area of investigation since cognitive restructuring is one of a few core
components of nearly all evidence-based treatment protocols for anxiety disorders. While
some studies compared ACT to thought suppression, in fact, as mentioned above, thought
suppression does not in any way resemble the process of cognitive restructuring.
30
This analog experiment examined the mechanism of action of the cognitive
therapeutic processes of CBT and ACT (i.e., how each approach deals with cognitions or
thoughts), and investigated the impact of cognitive restructuring vs. cognitive defusion on
claustrophobic anxiety and behavioral avoidance. Two protocols employed forms of
behavioral exposure coupled with a focus on how to address fearful thoughts. Based on
previous research demonstrating the efficacy of imaginai exposure in the treatment of
claustrophobia, a third protocol was added and implemented imaginai exposure. This
study isolated and compared the discrete cognitive techniques used in each treatment
(cognitive defusion and cognitive restructuring), rather than using full treatment packages
of each approach. This study is not a treatment outcome study. However, findings
provide insight into mechanisms underlying therapeutic change and inform practical
application of effective therapy. Claustrophobic anxiety is particularly detrimental to
patients in need of MRI scans. Pre-procedure assessment and treatment of anxiety is
crucial in this subset of medical patients, and a brief, single session intervention for this
population could prove very useful.
Hypotheses
Hypothesis #1: Based on previous research, it was predicted that all conditions
would result in reduced claustrophobic anxiety. However, it was predicted that the
cognitive restructuring and cognitive defusion conditions will produce significantly lower
scores than the imaginai exposure condition on self report measures of anxiety during the
provocation task, including the subjective units of distress (SUDs) ratings and the Mood
and Anxiety Symptom Questionnaire- Anxious Arousal scale (MASQ-AA). It was
further predicted that both experimental conditions would exhibit decreased scores on the
31
post-test Claustrophobia Questionnaire (CLQ) compared to the imaginai exposure
condition indicating a reduction of anxiety from pre- to post-test.
Hypothesis #2: Insufficient seminal data exists regarding the impact of cognitive
defusion on claustrophobic anxiety. Based on previous research confirming the efficacy
of cognitive therapy for claustrophobia, it was predicted that the cognitive restructuring
group would be more effective than the acceptance group in the amelioration of
claustrophobic anxiety, as measured by the CLQ. In fact, the purpose of this study is to
establish whether one of these techniques is superior because data are currently
nonexistent.
Hypothesis #3: It was predicted that both the acceptance and cognitive
restructuring groups would exhibit less behavioral avoidance than the imaginai exposure
group, as measured by time spent in the claustrophobic situation and willingness to
participate in a second challenge.
Hypothesis M: It was expected that the individuals in the acceptance condition
would display higher scores on the Action and Acceptance Questionnaire (AAQ)
compared to the cognitive restructuring and imaginai exposure groups. This prediction
was based on previous findings which reveal a negative association between ACT and
experiential avoidance.
32
CHAPTER ?
Method
Participants
Participants included 45 Hofstra University undergraduate students ages 17-25
identified as having significant symptoms of claustrophobia. With regard to race, 67.39%
identified as white/Caucasian, 15.22% identified as black/African American, 2.17%
identified as Asian American, 4.35% identified as Latin American, and 10.87% identified
as "other." Males comprised 30.43% of the sample; 69.57 were female. Students were
recruited through Hofstra University's undergraduate mass testing pool and received
credits required for their introductory psychology course. The Claustrophobia
Questionnaire (CLQ; Radomsky, Rachman, Thordarson, Mclsaac, & Teachman, 2001)
was used as a screening measure to identify individuals with claustrophobic fear
(Appendix A). Individuals scoring within one standard deviation of the CLQ mean for
claustrophobic students, will be included in the study sample. Informed consent
(Appendix B) will be obtained prior to participation.
Experimental Design
This study implemented a completely randomized repeated measure analysis of
variance design with three treatment levels: Cognitive restructuring, cognitive defusion
and imaginai exposure. Participants included 45 undergraduate students who were
randomly distributed into the three groups, resulting in 15 participants per level.
Independent Variables
33
In this experiment, the intervention served as the independent variable with three
levels: Cognitive restructuring, cognitive defusion and imaginai exposure.
Dependent Variables
All subjective and behavioral measures served as dependent variables resulting in
six primary dependent variables. Primary variables include the CLQ, AAQ, MASQ-AA,
SUDs ratings, avoidance measure during the challenge (time spent in the apparatus) and
willingness to participate in a second challenge.
Measures
Claustrophobia Questionnaire (CLQ). The CLQ (Radomsky, Rachman,
Thordarson, Mclsaak, & Teachman, 2001) was used to identify individuals who were
likely to respond to claustrophobic anxiety induction via the experimental task. This
measure appears to be a valid measure of claustrophobia. Specifically, the CLQ
significantly predicts participants' distress during an MRI, and is able to discriminate
between participants who do and do not report panic during the scan (Mclsaac,
Thordarson, Shafran, Rachman, & Poole, 1998). Based on the fears of restriction/fears of
suffocation theory of claustrophobia, the CLQ is designed to assess claustrophobia along
these two distinct but related factors. The suffocation subscale is comprised of 14 item
related to situations invoking fears of suffocation, ("Swimming while wearing a nose
plug", "using an oxygen mask") while the restriction subscale contains 12 situations
evoking restriction fears, ("Caught in tight clothing and unable to remove it", "lying in
the truck of a car with air flowing freely"). Individuals report the amount of anxiety they
predict they would experience in 26 specific situations involving enclosed spaces using a
34
5-point Likert style rating scale, (O= not at all anxious; 1= slightly anxious; 2=
moderately anxious; 3= very anxious; 4= extremely anxious). Scores range from 0 to 104.
The CLQ has predictive validity, discriminant validity, internal consistency, and
test-retest reliability (Radomsky et al., 2001). In a normative sample, the mean score for
non-claustrophobic adults was 28.9 (SD=19.4), with a mean score of 9.1 (SD= 7.9) on the
suffocation subscale and mean score of 19.9 (SD=12.8) on the restriction subscales. For
claustrophobic students drawn from the normative population, the total CLQ mean score
was 51.8 (SD=16.6), the suffocation subscale mean score was 23.8 (SD= 8.4) and the
restriction subscale mean score was 27.6 (SD=9.6). A widely used benchmark for
determining "clinical significance" is a value greater than one standard deviation from the
standardization sample mean (e.g., Spreen & Strauss, 1998). Based on the normative
data of the CLQ, individuals scoring greater than 35.2 (one standard deviation below the
mean for claustrophobic students), were include included as eligible participants for the
study.
Action and Acceptance Questionnaire (AAQ). The AAQ is a 9-item self-report
questionnaire designed to measure experiential avoidance (Hayes, Strosahl, Wilson,
Bisse«, Pistorello, Toarmino, et al., 2004; Appendix D). Items on the AAQ assess one's
tendency to negatively evaluate their internal experiences and their willingness to accept
their thoughts and feelings while performing behavior in line with their values.
Individuals answer nine items on a 7-point Likert style rating scale (1= never true; 7=
always true; range of scores = 9 to 63), with higher scores indicating greater avoidance.
The AAQ has good psychometric properties in both clinical and non-clinical samples
35
(e.g., Bond & Bunce, 2000, 2003; Hayes et al., 2004; Feldner, Zvolensky, Eifert, & Spira,
2003; Karekla, Forsyth, & Kelly, 2004).
Subjective Units ofDistress (SUDs). SUDs ratings were used for assessment of
participants' anxiety throughout the procedure. SUDs ratings were based on a range of 0
to 100, with zero representing no distress and 100 representing the most distress
imaginable. Participants were asked to report a SUDs rating after entering the
claustrophobic environment, and again after 4 minutes, 8 minutes and 12 minutes. This
resulted in four time-points for measurement of subjective distress.
The Mood and Anxiety Symptom Questionnaire- Anxious Arousal scale (MASQAA). The Anxious Arousal scale of the MASQ (Watson & Clark, 1991; Appendix E) was
administered prior to and following the challenge, in order to assess anxiety experienced
while in the claustrophobic environment and potential discrepant reductions from pre-test
to post-test. The MASQ-AA consists of 17 items targeting physiological, (e.g., was short
of breath) and cognitive symptoms of anxiety, (e.g., fear of dying). Items are rated on a 5point Likert style rating scale (1= not at all; 5= extremely), producing a score ranging
from 17-85. Good reliability and validity have been demonstrated in student, adult
volunteer, and clinical populations (Watson, Weber, Assenheimer, Clark, Strauss, &
McCormick, 1995; Watson, Clark, Weber, Assenheimer, Strauss, & McCormick, 1995).
Behavioral Avoidance Measures. Behavioral avoidance was measured by
participants' willingness to enter and remain in the claustrophobic situation. Participants
were told they were allowed to escape from the situation at any point, however, they were
told that they were expected to remain in the closet for the duration of the experiment.
These instructions were presented on paper so that no experimenter unwittingly conveyed
36
that the participants were encouraged to escape early. At the 8-minute point, participants
were given the opportunity to exit the apparatus but were encouraged to remain in the
setting for the remainder of the challenge. Willingness to participate in a second
claustrophobia challenge was also used to measure behavioral avoidance. Following the
first challenge, participants were given the opportunity to participate in a second
challenge. This was also provided in writing to control for inter-experimenter variability
in instruction.
Manipulation Check Assessment. In order to ensure the integrity of each
intervention, as well as to establish that the respective strategy was implemented during
the challenge, an experimenter-developed manipulation check was administered
(Appendix F). Following the delivery of the coping instructions, participants answered a
multiple-choice question evaluating comprehension of the core aspect of the cognitive
restructuring or cognitive defusion or imaginai exposure instruction module.
Apparatus
The experimental apparatus used was a Rubbermaid Large Storage Shed®
(Appendix L), 77"H ? 56"L ? 32"D "closet", placed in a room used for laboratory space
in Hofstra University's Hauser Hall. The apparatus is constructed from heavy duty plastic
and is built by snapping together eight interlocking panels. There are no lights or
windows in the apparatus. The doors to the apparatus close by snapping into place, and
were secured with a chain around the closet which was fastened with a keyed lock. A few
modifications were made to the apparatus in order to increase claustrophobic anxiety.
Electrical tape was applied to the seams of the closet doors in order to prevent light from
entering the apparatus. In. addition, cardboard was used to lower the ceiling by roughly
37
one foot, altering the height of the chamber to approximately 65 inches. Cardboard boxes
were used to reduce the width as well. Boxes were stacked inside the closet on the right
side, reducing the internal width to roughly 30 inches.
Participants were seated on a chair in the apparatus to control for the contribution
of physical exhaustion in early termination. The experimenter remained in the room
while the participant was in the chamber, and was in close proximity to facilitate any
necessary communication at all times. However, in order to reduce safety cues in the
environment, the overhead lights were turned off leaving only the light from a small desk
lamp for the benefit of the experimenter.
Procedure
Individuals meeting inclusion criteria were contacted via telephone or email and
invited to participate in a 75-minute session. Interested participants who attended a
session received three credits in fulfillment of their introductory psychology course
requirement. Upon their arrival on the day of their participation, individuals were
informed that as part of the study, they would be asked to enter and remain in a closet for
an extended period of time after watching a video and answering some questions. The
experimenter answered any questions the participant had before individuals were asked to
read and sign the informed consent statement.
Upon agreeing to participate in the study, individuals were randomly assigned to
one of three intervention groups: Cognitive restructuring, cognitive defusion or imaginai
exposure. The cognitive defusion group learned that attempts to control or change
thoughts and feelings are futile, while allowing one's thoughts to come and go, without
"buying into them" is more functional. This intervention closely followed excerpts from
38
The Mindfulness and Acceptance Workbookfor Anxiety (Eifert & Forsyth, 2008;
Appendix G) which is considered an acceptable application of ACT and endorsed by
Steven C. Hayes. The cognitive restructuring group received instruction which
emphasized identifying and decatastrophizing anxious thoughts, and reducing the
interpretation of danger and threat of suffocation/restriction. The cognitive restructuring
intervention closely followed excerpts from Mind over Mood (Greenberger & Padesky,
1995; Appendix H) which is considered an acceptable application of cognitive therapy.
The imaginai exposure group received information on the effectiveness of exposing
oneself to feared stimuli in order to reduce phobic avoidance. Exercises focused on
imaginai exposure to claustrophobic situations, beginning with an assessment and
constructing a fear hierarchy (Appendix I).
Each instructional session lasted approximately 30 minutes and was administered
using video recording to ensure protocol adherence and fidelity, to reduce therapist
allegiance to alternative techniques, and reduce extraneous between subject variance.
Administering the protocols by video recording was favored over retrospective coding of
therapist adherence as a more efficient and reliable method of experimental control. At
three intervals, participants were asked to pause the video and participate in interactive,
experiential exercises with the experimenter. Throughout the intervention, participants
answered questions related to the material and used real-life examples to maximize the
effectiveness of the strategy. Following the intervention instruction, participants
completed the brief assessment of understanding as a manipulation check.
The claustrophobia challenge occurred following the brief intervention. At that
time, participants completed the MASQ-AA. The initial SUD rating was elicited
39
immediately after participants enter the apparatus, where they remained for up to 12
minutes. Participants were told they would be allowed to leave the situation at any point,
however, they were told that they were expected to remain in the closet for the duration
of the challenge. These instructions were also provided in writing in order to control for
variation in the amount of encouragement given by experimenters. At the 8-minute point,
participants were given the opportunity to exit the apparatus, but were encouraged to
remain in the setting for the full duration of the challenge. Reports of subjective anxiety
were reported four times throughout the challenge; at the 1 -minute, 4-minute, 8-minute,
and 12-minute points. The experimenter asked the participant to say their rating out loud
from the apparatus at each of these time points. Standardized challenge instructions can
be found in Appendix J.
Following the claustrophobia challenge, participants completed the MASQ-AA,
the CLQ, and the AAQ. After this phase of data collection, instructions explained that
there was a second, 5-minute challenge they could take. Individuals were informed that if
they chose not to participate in the challenge, they would remain at the experiment and
complete a packet of additional self-report forms. Willingness to engage in the second
challenge was recorded and participants either completed the challenge or additional
report forms. Data from the reports forms were not scored or analyzed. Once the
participant completed this last step, they were informed that all necessary data had been
collected and that they had completed the study. See Appendix K for a timeline of
experiment procedures and assessments.
40
CHAPTER ??
Results
To ensure fidelity to the cognitive restructuring and cognitive defusion
interventions, participants answered a multiple choice question following the video
intervention. This was done to ensure they had understood the material the way it was
intended to be presented. Of the individuals who received the cognitive defusion
intervention, 80% (12 out of 15) of correctly identified the strategy of the intervention. Of
the individuals who received the cognitive restructuring intervention, 86% (13 out of 15)
correctly understood the crux of the intervention. This indicates that the video scripts
remained faithful to the techniques they were intended to replicate.
A one way ANOVA was used to assess for baseline differences between the
groups on the Claustrophobia Questionnaire (CLQ) scores prior to the intervention (see
Table 1). Results revealed no significant pre-test CLQ differences between the cognitive
restructuring group (M = 60.47, SD = 15.24), the cognitive defusion group (M = 58.20,
SD = 12.02) and the imaginai exposure group (M = 65.93, SD = 18.10), F(2, 42) = 1.01,
? = .37.
A 3 ? 2 repeated measures ANOVA was conducted, in which intervention group
(cognitive restructuring versus cognitive defusion versus imaginai exposure) served as
the between-subject variable, and CLQ score (pre-intervention versus post-intervention)
served as the within-subject variable (results are depicted in Figure 1). As hypothesized,
the within group main effect for change in CLQ score over time did reach significance F
(1, 39) = 17.71, MSE = 3225.03, ? = <.001, indicating there was a significant reduction in
pre-intervention to post-intervention CLQ score within the groups. However, the main
41
Table 1
Claustrophobia Questionnaire (CLQ) Scores Pre-Intervention, Post-Intervention, and
Pre-Post Intervention Differences: Sample sizes, Means, and Standard Deviations
Sample sizea
Mean
15
60.47
15.24
15
42.27
19.29
Pre-post difference
15
18.20
21.84
Pre-intervention
15
58.20
12.02
Post-intervention
15
51.27
17.31
Pre-post difference
15
6.93
14.96
Pre-intervention
15
65.93
18.10
Post-intervention
12
54.83
19.61
Pre-post difference
12
12.25
19.98
Pre-intervention
Cognitive
Post-intervention
restructuring
Cognitive
Standard deviation
defusion
Imaginai
exposure
Note. Possible CLQ scores range from 0 to 104.
a The post-intervention Claustrophobia Questionnaire scores for two subjects in the
imaginai exposure group were excluded from all CLQ analyses due to incomplete
measures.
42
80
— ¦»- — Cognitive Restructuring
75
-—¦-—
¦
Cognitive
Imaginai Exposure
Defusion
70
65
60
55
50
45
40
35
30
Pre-lntervention
Post-Intervention
Time
Figure 1. Effect of intervention on Claustrophobia Questionnaire.
43
effect for intervention was not significant, F (2, 39) = 1.56, MSE - 621.08 ? - .22,
indicating that there was not a significant difference between groups, and the intervention
by time interaction was not significant, F (2, 39) = 1.31, MSE = 238.22, ? = .28. The
results of the ANOVA show that while there was a significant CLQ score reduction
within the groups, there was an equal decrease across interventions. The hypothesis that
the cognitive restructuring group and cognitive defusion groups would demonstrate a
greater treatment effect than the imaginai exposure groups was not supported.
Furthermore, the prediction that the cognitive restructuring group would exhibit a greater
treatment effect than the cognitive defusion group was not supported either.
A one way ANOVA was used to assess for baseline differences on the Mood and
Anxiety Symptom Questionnaire- Anxious Arousal subscale (MASQ-AA) (see Table 2).
There were no significant pre-test MASQ-AA differences between the cognitive
restructuring group (M =23.71, SD = 4.10), the cognitive defusion group (M = 23.67, SD
= 5.00) and the imaginai exposure group (M = 26.20, SD = 8.00), F(2, 41) = 1.26, ? =
.30.
A 3 ? 2 Repeated Measures ANOVA was conducted on the MASQ-AA scores
from pre- to post-intervention. Intervention (cognitive restructuring versus cognitive
defusion versus imaginai exposure) served as the between-subject variable, and MASQ-
AA score (pre-intervention versus post-intervention) served as the within-subject variable
(results are depicted in Figure 2). The ANOVA revealed no significant main effect for
change in MASQ-AA score over time, F(I, 41) = 3.39, MSE = 67.49, ? = .07. The
ANOVA also revealed no significant main effect for intervention, F (2, 41) = 2.87, MSE
= 129.63 ? = .07. However, both main effects approached significance at the .05 level,
44
Table 2
Mood and Anxiety Questionnaire - Anxious Arousal Subscale (MASQ-AA) Scores PreIntervention, Post-Intervention, and Pre-Post Intervention Differences: Sample sizes,
Means, and Standard Deviations
Sample sizea
Cognitive
restructuring
Mean
deviation
Standard
Pre
14
23.71
4.10
Post
15
24.33
4.62
difference
14
.14
2.60
Pre
15
23.67
5.00
Post
15
26.00
6.43
difference
15
-2.33
6.91
Pre
15
26.20
5.66
Post
15
29.27
8.00
15
-3.07
7.91
Pre-post
Cognitive
defusion
Pre-post
Imaginai
exposure
Pre-post
: difference
Note. Possible MASQ-AA scores range from 17-85
^he pre-intervention Mood and Anxiety Symptom Questionnaire - Anxious Arousal
scale score was excluded for 1 subject in the cognitive restructuring group for all analyses
using MASQ-AA data due to an incomplete measure.
45
— -? — ¦ Cognitive Restructuring
— » — Cognitive Defusion
* Imaginai Exposure
Pre-lntervention
Post-Intervention
Time
Figure 2. Effect of intervention on the Mood and Anxiety Symptom QuestionnaireAnxious Arousal subscale scores.
46
indicating a trend towards significant changes in MASQ-QAA over time, as well as a
trend towards a difference between groups. The interaction between intervention and time
was not significant, F(2, 41)= 1.02, ? = .37. These results do not support the hypothesis
that the groups would demonstrate significant reductions on the MASQ-AA scores pre- to
post-intervention. The results also do not support the hypothesis that the cognitive
restructuring group and the cognitive defusion group would outperform the imaginai
exposure group.
Subjective Units of Distress (SUDs) ratings were elicited at four time points
during the claustrophobic challenge (see Table 3). These data were analyzed using a 3 ? 4
repeated measures ANOVA, in which intervention group (cognitive restructuring versus
cognitive defusion versus imaginai exposure) served as the between-subject variable, and
SUDs rating (1 -minute versus 4-minutes versus 8-minutes versus 12-minutes) served as
the within-subject variable (results are depicted in Figure 3). There was a significant
within group main effect for change in SUDs rating, F (3, 123) = 13.71, MSE = 3497.23,
? = <.001 indicating a reduction in distress over time within the groups. While there was
a trend towards significance at the .05 level, the between group main effect of
intervention did not attain significance, F (2, 41) = 2.59, MSE = 4748.01 ? = .09,
indicating there were no differences between the intervention in SUDS reductions, and
the interaction between intervention and time was also not significant, F (2, 41) = 2.29,
MSE - 1081.48, ? = .1 1. As predicted, the cognitive restructuring group, cognitive
defusion group, and imaginai exposure group exhibited a significant decrease in distress
during the challenge. However, the prediction that the cognitive restructuring group and
the cognitive defusion group would demonstrate a greater reduction in SUDs ratings than
47
Table 3
Subjective Units of Distress Ratings during Claustrophobic Challenge: Sample sizes,
Means, and Standard Deviations
_______________________________Sample size
Cognitive
Mean
Standard deviation
1 -minute
15
42.67
29.33
4-minute
15
42.13
28.09
8-minute
15
30.00
16.37
12-minute
15
19.20
16.70
restructuring
_______________________________Sample size
Cognitive
Mean
Standard deviation
1 -minute
15
50.87
27.15
4-minute
15
38.00
28.46
8-minute
15
24.67
15.17
12-minute
15
22.80
14.16
delusion
_____________________Sample size
Mean
Standard deviation
1 minute
14
55.71
33.16
4-minute
14
47.50
29.53
Imaginai
exposure3
48
______________________
Imaginai
Sample size
Mean
Standard deviation
8-minute
14
48.21
28.60
12-minute
14
46.79
30.17
exposure3
Note. SUDs ratings ranged from 1 to 100.
a One participant from the imaginai exposure group was excluded from the analyses
because they refused to participate in the challenge, thus preventing collection of SUDS
ratings.
49
80
Cognitive restructuring
70
Cognitive Defusion
Imaginai Exposure
60
?
¦?re
50
\
"N
ce
??
Q
\
3
40
?
30
??
C
ID
F
X\
\
20
10 -
0
I-minute
4-minutes
8-minutes
12-minutes
Time
Figure 3. Subjective Units of Distress (SUDs) ratings during the claustrophobic
challenge.
50
the imaginai exposure group was not supported.
During the claustrophobic task, participants were given the opportunity to leave
the situation after eight minutes, rather than complete the full duration of the challenge
(see Table 4). It was predicted that both the cognitive restructuring and cognitive
defusion groups would exhibit less behavioral avoidance than the imaginai exposure
group, as measured by time spent in the claustrophobic situation and willingness to
participate in a second challenge. One person (6.67%) in the cognitive restructuring
group chose to terminate the challenge prematurely, and two people (13.33%) for each
the cognitive defusion and imaginai exposure conditions chose to premature termination.
One person from the imaginai exposure group refused to enter the claustrophobic
chamber at all and was excluded from the analyses of behavioral avoidance. Contrary to
predictions, a Chi Square analysis revealed no statistically significant association
between the intervention received and premature termination of the challenge after eight
minutes, X2 (4, N = 44) = .50, ? = .78.
With regard to willingness to engage in a second challenge (see Table 5), six
participants in the cognitive restructuring group refused (40%), six agreed (40%) and
three gave an excuse why they could not stay longer (20%). In the cognitive defusion
group, two refused (13.33%), eleven agreed (73.33%) and two gave an excuse why they
could not stay longer (13.33%). In the imaginai exposure group, three refused (21.43%),
ten agreed (71.43%) and one gave an excuse why they could not stay longer (7.14%).
One participant in the imaginai exposure group refused to enter the closet at all.
Contrary to predictions that individuals in the cognitive restructuring group and in the
51
Table 4
Length of Time Spent in the Claustrophobic Challenge
____________________________8 minutes (%)
12 minutes (%)
Cognitive Restructuring
1 (6.67)
14 (93.33)
Cognitive Defusion
2(13.33)
13(86.67)
Imaginai Exposure3
1(7.14)
13(92.86)
Note. Chi Square analysis revealed no statistically significant association between the
intervention received and premature termination of the challenge after eight minutes, X'
(4, N = 44) = .50, ? = .78
aOne participant in the imaginai exposure group refused to enter the challenge at all.
52
Table 5
Willingness to Participate in a Second Claustrophobic Challenge
_________________________Willing (%)
Not Willing (%)
Excuse (%)
Cognitive Restructuring
6(40.00)
6(40.00)
3(20.00)
Cognitive Defusion
11(73.33)
2(13.33)
2(13.33)
Imaginai Exposure"
10(71.43)
3(21.43)
1(7.14)
Note. Chi Square analysis revealed no statistically significant association between the
intervention received and willingness to engage in a second challenge, X~ (4, N= 44) =
4.81, p = . 31.
Note. "Excuse" refused to participate in a second challenge, but gave an excuse for why
they could not.
aOne participant in the imaginai exposure group refused to enter the challenge at all.
53
cognitive defusion group would demonstrate less behavioral avoidance than members of
the imaginai exposure group, a Chi Square analysis revealed no statistically significant
association between the intervention received and willingness to engage in a second
challenge, X2 (4, TV = 44) = 4.8 1 , ? = .3 1 . All groups were equally willing to engage in a
second task.
Data was recalculating with giving an excuse included as a refusal to participate
in a second challenge (see Table 6). Six participants in the cognitive restructuring group
refused (40%) and nine agreed (60%). In the cognitive defusion group, four refused
(26.67%) and eleven agreed to participate in a second challenge (73.33%). In the
imaginai exposure group, four refused to participate in a second challenge (28.57%) and
ten agreed (71.43%). As noted above, one participant in the imaginai exposure group
refused to enter the closet at all and was excluded from analyses of behavioral avoidance.
Contrary to predictions that individuals in the cognitive restructuring group and in the
cognitive defusion group would demonstrate less behavioral avoidance than members of
the imaginai exposure group, a Chi Square analysis revealed no statistically significant
association between the intervention received and willingness to engage in a second
challenge, X2 (2, /V = 44) = 4.39, ? = . 1 1. When giving an excuse was considered a
refusal to participate, all groups were equally willing to engage in a second task.
Finally, it was predicted that the cognitive defusion group would display lower
scores on the Action and Acceptance Questionnaire (AAQ) compared to the cognitive
restructuring and imaginai exposure groups following the intervention and challenge,
indicating less experiential avoidance. This measure was administered one time, post
54
Table 6
Willingness to Participate in a Second Claustrophobic Challenge
_________________________________Willing (%)
Not Willing (%)
Cognitive Restructuring
6 (40.00)
9 (60.00)
Cognitive Defusion
1 1 (73.33)
4 (26.67)
Imaginai Exposure3
10(71.43)
4(28.57)
Note. Chi Square analysis revealed no statistically significant association between the
intervention received and willingness to engage in a second challenge, X (2,N = 44) =
4.39, p = . 11.
Note. "Not Willing" refers to participants who either refused to participate in a second
challenge or gave an excuse for why they could not.
aOne participant in the imaginai exposure group refused to enter the challenge at all.
55
challenge (see Table 7). Contrary to this prediction, a one way ANOVA revealed no
significant differences in AAQ score between the cognitive restructuring group (M =
35.07, SD = 3.67), the cognitive defusion group (M = 35.60, SD - 5.83) and the imaginai
exposure group (M = 35.73, SD = 6.58), F(2, 42) = .06, ? = .94.
56
Table 7
Acceptance and Action Questionnaire (AAQ) Sample size, Means and Standard
Deviations
Sample size
Mean
Standard deviation
Cognitive restructuring
15
35.07
3.67
Cognitive defusion
15
35.60
5.83
Imaginai exposure
15
35.73
6.58
Note. Possible AAQ score range from 9 to 63.
57
CHAPTER rV
Discussion
The primary aim of the current study was to determine the relative merits of three
interventions (cognitive restructuring, cognitive defusion, and imaginai exposure) in
decreasing self-reported anxiety and behavioral avoidance in a claustrophobic situation.
This study was not performed as a treatment outcome study. Rather, it was intended to
be an analog study which isolated and compared the cognitive components of two widely
used therapies, acceptance and commitment therapy (ACT) and cognitive behavioral
therapy (CBT). The imaginai exposure group was implemented as a pure "behavioral"
comparison which does not directly target cognition. It was hypothesized that both of the
interventions targeting cognition would outperform the purely behavioral approach.
Reduction in Claustrophobia
As hypothesized, cognitive restructuring, cognitive defusion, and imaginai
exposure led to significant reductions in self-reported claustrophobic anxiety, as
measured by the Claustrophobia Questionnaire (CLQ). Contrary to the stated
hypotheses, there was no difference between the cognitive interventions (defusion and
restructuring groups) and the imaginai exposure intervention. These results indicate that
cognitive restructuring, cognitive defusion, and imaginai exposure are equally effective in
reducing self-reported claustrophobic anxiety.
Participants in each of the three intervention groups reported significant decreases
in subjective distress while in the claustrophobic situation, as measured by Subjective
Unit of Distress (SUD) ratings during the "claustrophobic challenge." It was
hypothesized that the cognitive restructuring and cognitive defusion interventions would
58
lead to greater reductions in SUDs than imaginai exposure. This hypothesis was not
supported by the findings, as there were no significant differences between the three
interventions in decreased SUDs reported during the claustrophobic task. However, there
was a trend towards significance (p = .09), consistent with the hypothesis that the
interventions targeting cognitions would provide a greater reduction in claustrophobic
anxiety.
Anxious arousal, as measured by the Mood and Anxiety Symptom Questionnaire
- Anxious Arousal subscale (MASQ-AA), a self-report inventory, was not reduced
significantly from pre- to post- intervention by any of the interventions. However, there
was a trend towards significance (p = .07) indicating an increase in anxious arousal for
the entire sample. Furthermore, there was a trend towards significance at the .05 level (p
= .07) for differences between the groups on this measure, with imaginai exposure
providing the greatest increase in arousal, followed by cognitive defusion. Cognitive
restructuring produced a minimal, though non-significant, decrease in anxious arousal.
It was hypothesized that employing cognitive restructuring or cognitive defusion
would lead to less behavioral avoidance than providing imaginai exposure prior to the
claustrophobic challenge. This was based on the theory of cognitive therapy which
postulates that emotions are subjective states that results from the cognitive appraisal of
internal and external cues, which in turn motivate or reinforce adaptive behavior (Clark,
Beck & Alford, 1999). Therefore, it was expected that techniques which target cognition
would be more successful at reducing behavioral avoidance.
59
Avoidance was measured by duration of time participants remained in the
claustrophobic situation, as well as their willingness to engage in a second claustrophobic
task. This hypothesis was not supported. There were no significant differences between
the interventions with regard to duration of time an individual remained in the challenge.
There were also no differences between the interventions with regard to whether or not
individuals were willing to engage in a second claustrophobic challenge. Although more
individuals who received cognitive defusion (73.33%) or imaginai exposure (71.43%)
were willing to repeat the task than those who received cognitive restructuring (40%), the
difference did not reach significance at the .05 level (p = .11).
It was hypothesized that cognitive defusion would produce decreased experiential
avoidance compared to cognitive restructuring and imaginai exposure. This was
measured using the Acceptance and Action Questionnaire (AAQ), an assessment of one's
willingness to experience thoughts and emotions. Cognitive defusion was expected to
decrease experiential avoidance, as this technique is aimed directly at facilitating one's
ability to observe and accept (rather than change) one's thoughts. However, the
hypothesis that cognitive defusion would reduce experiential avoidance more than
cognitive restructuring or imaginai exposure was not supported. There was no significant
difference between any of the groups on experiential avoidance.
Previous Research
The findings from the present study validate an extensive body of literature in
support of cognitive treatments for claustrophobia (Booth & Rachman, 1992; Shafran,
Booth & Rachman, 1993; Shafran et al., 1993; Craske et al., 1995; Ost, Alm, Brandberg,
& Breitholtz, 2001). This investigation also confirms previous findings in support of an
60
exposure approach without targeting cognition (Koulack et al,. 1976; Agras et al., 1969;
Leitenberg et al., 1968; Leitenberg et al., 1970; Speltz & Bernstein, 1979; Ost et al.,
1982; Booth & Rachman, 1992). No research to date has investigated the effect of
cognitive defusion on claustrophobia. These preliminary findings indicate the potential
efficacy of this technique for this population, especially if administered in more than a
brief one session intervention, as was done in the present study.
The results of the present study also support previous research which has
determined cognitive restructuring to be equally effective as guided exposure in the
reduction of claustrophobia (Ost et al., 2001). Ost et al. (2001) randomly assigned
claustrophobic patients to either 1) one 3-hour session of prolonged therapist-directed
exposure, 2) five 1-hour sessions of gradual therapist-directed exposure, 3) five 1-hour
sessions of cognitive therapy with no practice, or 4) a waitlist control group. Their results
indicated that all three treatment groups were successful in decreasing claustrophobia and
each was superior to the waitlist control.
Relative Efficacy of the Interventions
No research to date has been published which compares the efficacy of cognitive
defusion, cognitive restructuring, and imaginai exposure on the reduction of
claustrophobic anxiety. Data from the current study provide preliminary evidence that
"defusing from one's thoughts" is as effective in reducing subjective distress, anxious
arousal, and claustrophobic fear in claustrophobic situations as are cognitive restructuring
and imaginai exposure, two well established techniques. The findings from the current
study also indicate that the three techniques are equally effective in reducing behavioral
and experiential avoidance.
61
There is also no research to date investigating the comparative effects of the full
treatment protocols for ACT and CBT on claustrophobia. However, a number of studies
have attempted to compare ACT with CBT in the reduction of other types of anxiety.
Unfortunately, these studies implemented thought suppression or thought "control" (i.e.,
thinking positive thoughts) as a comparison rather than using a procedure more
representative of cognitive restructuring (e.g., Eifert & Heffner, 2003; Guttierrez et al.,
2004; Levitt et al., 2004). It is recognized that thought suppression is typically an
ineffective coping strategy, and is believed to result in the rebound of unwanted thoughts.
It is essential to note that when administered appropriately, cognitive restructuring is not
thought suppression. Rather, additional information is utilized in assessing the validity of
one's thoughts in an effort to increase logical thinking. So in fact, during cognitive
restructuring, thoughts are "processed and analyzed" rather than suppressed. Future
research should be conducted comparing ACT to CBT using cognitive defusion and
cognitive restructuring, rather than thought suppression. Although preliminary, the
present findings suggest there may be no differences in the effectiveness of these
interventions for claustrophobia.
Mechanisms ofAction
No published research is available that isolates and compares cognitive
restructuring and cognitive defusion in the reduction of anxiety. Rather than comparing
these isolated components, the majority of studies providing preliminary research in this
area come from investigations of treatment packages promoting cognitive defusion
(ACT) or cognitive restructuring (CT) (e.g., Forman et al., 2007). Unlike research
comparing complete treatment packages, the present study focused on single components
62
of these packages, specifically what one does with their anxious thoughts. This was done
to maximize control in order to investigate the mechanisms of action which may be
responsible for the efficacy of these treatments.
The finding that imaginai exposure, cognitive restructuring, and cognitive
defusion had equivalent impacts on experiential avoidance has a number of implications.
Although the AAQ was developed as a measure of defusion (Hayes et al., 2004), no
research has been published that has isolated the mechanism of defusion and assessed it's
impact on the AAQ. Instead, research on experiential acceptance has largely been
completed using treatment packages that are delivered over multiple encounters
(sessions) with a clinician (Zettle, 2003; Ossman et al., 2006; Twohig, 2006; Dalrymple
& Herbert, 2007; Roemer & Orsillo, 2007). The ACT treatment package includes other
potential effective interventions (e.g., values clarification, self as context, acceptance)
and thus to the degree that these other interventions are effective, it is hard to know the
specific contribution of cognitive defusion alone. Therefore, based upon the present state
of research, a reasonable explanation is that cognitive defusion is necessary, though
insufficient to create a significant change in experiential avoidance. Other facets of the
ACT treatment package may need to be included to achieve the full impact of the
treatment on experiential avoidance. The reduction of experiential avoidance may the
product of multiple, simultaneous therapeutic mechanisms, as found in treatment
packages such as ACT.
The results of this study also contradict the supposition promoted by the ACT
community that cognitive restructuring is ineffective and counterproductive and
consequently results in heightened psychological distress (Hayes & Smith, 2005). In fact,
63
these findings re-confirm that restructuring one's thoughts is an effective technique in the
reduction of claustrophobic distress (e.g., Booth & Rachman, 1992; Shafran et al., 1993;
Ost et al., 2001). The current findings further indicate restructuring one's thoughts is as
effective as defusing from them. The assumption is that there are two different processes
occurring with these techniques. However, there may be similarities that are not
accounted for. For example, distancing has long been implicated in the process of
cognitive restructuring. In the course of cognitive restructuring, patients are taught to
distance themselves from their thoughts in order to evaluate them more rationally. This is
done by identifying thoughts as mental representations and separating thoughts from
feelings and behavior. In this way, cognitive restructuring may involve a form of
defusion, indicating the processes are more similar than different.
Limitations
The current study has several limitations. First, missing data led to the loss of
three participants from the imaginai exposure group for the ANOVA investigating
reduction in claustrophobia, three participants form the imaginai exposure group and one
from the cognitive restructuring group for the ANOVA regarding change in anxious
arousal, and one participant from the imaginai exposure group for the ANOVA assessing
change in subjective distress. In addition, one participant from the imaginai exposure
group refused to enter the claustrophobic situation, resulting in the loss of data for one
person on the measures of behavioral avoidance. As there were a total of 45 participants
in the study, this equals a loss of data for between 2.22% and 8.89% of the sample. It is
possible that the results would have changed were these data available, as the power to
detect differences was possibly hindered by the loss of data.
64
Second, the study implemented avoidance measures at post- intervention without
accounting for baseline differences prior to the intervention. Following the
claustrophobic challenge, individuals completed the AAQ, an assessment of experiential
avoidance. They were also asked to re-enter the claustrophobic situation and repeat the
task in order to assess behavioral avoidance. The decision to exclude a pre- intervention
behavioral avoidance assessment was made in order to avoid a possible confounding
effect of exposing individuals to the claustrophobic challenge before they received an
intervention. This way, post-intervention reductions in claustrophobia could be attributed
to the interventions, rather than to multiple exposures to the claustrophobic chamber.
Still, it may have proved beneficial to measure baseline behavioral avoidance to control
for baseline differences in avoidance between and within the groups. It is possible that
the equal observation of avoidance between the groups in the present study was due to
unaccounted for baseline differences between the groups.
Future research in this area could use a behavioral approach task, similar to that
used by Ost and colleagues (Ost et al., 2001; Ost et al., 1982) to assess for baseline
avoidance. In these studies, individuals were asked to complete the claustrophobic task
(e.g., sitting in a small locked room, riding an elevator, or sitting in a small locked
chamber) prior to receiving any intervention. This allowed the researchers to control for
baseline differences in behavioral avoidance. In addition, this allowed for a direct
comparison of the change in avoidance from pre- to post- intervention.
Third, this study used only self-report and behavioral measures of anxiety and
claustrophobia and did not utilize physiological measurements such as heart rate. This
decision was based on findings that heart rate can be unreliable in the measurement of
65
phobie fear (Leitenberg et al., 1971). These authors found that the relationship between
heart rate and phobic avoidance was inconsistent across patients. Some patients
demonstrated an inverse relationship, with heart rate increasing as phobic behavior
decreased. Others demonstrated a parallel relationship with heart rate decreasing as
phobic behavior decreased. Still, some demonstrated no relationship between heart rate
and approach behavior, with no overall change in heart rate. This suggests that the
physiological symptoms of anxiety vary among individuals with phobias, including
claustrophobia, rendering the measure unreliable. This phenomenon was explained in
1982, when Ost and colleagues showed that only a subset of individuals with
claustrophobic fear demonstrated a physiological response (Ost et al., 1982). Some
individuals responded to claustrophobia with a physiological response (such as increased
heart rate) and others respond through avoidance behavior. Therefore, it is likely that a
subset of the sample of the present study would have no physiological response during
the claustrophobic task, regardless of which intervention they received. Measuring heart
rate during the challenge for the entire sample might lead to erroneously concluding that
low heart rate was attributable to an intervention.
An additional issue with measurement in this study involves the assessment of
experiential acceptance using the AAQ. While the AAQ remains the most widely used
measure of acceptance in this growing area of research, it has a number of limitations.
For example, the AAQ has been shown to measure multiple construct rather than a
unitary construct of "acceptance" (Shallcross, Troy, Boland, & Mauss, 2009).
Unfortunately, it may be difficult to isolate the construct of acceptance for valid
measurement as it likely involves a number of correlated processes with a related focus
on the acceptance of negative emotions (Hayes et al., 2004). None the less, additional
research into the measurement of experiential acceptance is warranted.
Fourth, this study used a sample of students with fears of enclosed places, rather
than a true clinical sample. This research was designed as an analog study conducted to
isolate the cognitive components of two different cognitive interventions and investigate
the relative impact of these mechanisms. While participants were not patients presenting
for treatment, they were indeed selected for inclusion based on responses to a wellvalidated measure of claustrophobia. In fact, this measure has been validated specifically
with a college student population (Radomsky et al., 2001) and the sample selected was
comprised of students within one standard deviation from the mean of the clinical
population. All participants scored high on this measure and reported high levels of
claustrophobic fear. Thus, the participants in the present study clearly resembled actual
patients presenting for treatment.
Fifth, the scripts for the interventions utilized during this study have not been
implemented in previous research to assess for validity. Several steps were taken to
ensure the utilized video scripts reliably represented each intervention. The cognitive
defusion intervention closely followed excerpts from The Mindfulness and Acceptance
Workbookfor Anxiety (Eifert & Forsyth, 2008; Appendix G) which is considered an
acceptable application of ACT and endorsed by Steven C. Hayes. Exercises were also
taken from ACTfor Depression (Zettle, R. D., 2007) and Get Out of Your Mind and Into
Your Life (Hayes, S. C, 2005). The cognitive restructuring intervention closely followed
excerpts from Mind over Mood (Greenberger & Padesky, 1995; Appendix H) which is
considered an acceptable application of cognitive therapy. Finally, an expert in each
67
approach approved the interventions. The imaginai exposure script was developed under
the supervision of an expert in this technique.
To ensure fidelity to cognitive restructuring and cognitive defusion interventions,
participants completed a forced choice quiz following the video intervention. This was
done to ensure they had understood the material in the way it was intended to be
presented. Eighty percent (12 out of 15) of individuals who received the cognitive
defusion intervention correctly identified the strategy of the intervention. Eighty-six
percent (13 out of 15) of individuals who received the cognitive restructuring intervention
correctly understood the crux of the intervention. This indicates that the video scripts
remained faithful to the techniques they were intended to replicate.
Despite the fidelity of the interventions, there remain concerns about "dosage."
The present study was designed to isolate mechanisms for experimental evaluation whose
protocols were not considered to be stand-alone treatments. However, it is possible that
one-session is not enough to elicit the true effect of these interventions as they are
intended to be used. For example, isolating and delivering cognitive defusion techniques
in a 70-minute interaction may not be potent enough to truly impact experiential
avoidance. It is possible that experiential avoidance is a complex trait that is intractable
through only a single 70-minute intervention.
Nevertheless, the results of the present study suggest a single session of cognitive
restructuring, cognitive defusion, or imaginai exposure may indeed be effective. Still, it is
possible that additional "sessions" would provide greater effectiveness and one technique
might emerge more effective than another. Clearly, treatment in the real world is quite
68
different than the way it was administered in the present study. Future research is
warranted to investigate whether there are differences between these mechanisms when
they are included in treatment packages for claustrophobia in a therapeutic situation, and
whether the effects are modified through additional treatment sessions.
Finally, the claustrophobic chamber has not been previously validated as a
challenge for claustrophobic anxiety. To determine the potency of this challenge, a pilot
study was conducted with six subjects in order to assess for claustrophobic anxiety
induction. The induction of significant fear was observationally verified and assessed
using the measures from the research protocol during the pilot phase. In addition, during
both the pilot phase and the extended study, significant anxiety was reported in the
claustrophobic chamber, and a number of individuals demonstrated significant behavioral
avoidance. Therefore, it seems to have been a valid "challenge."
Clinical Implications
Despite the limitations discussed above, this study adds to the literature in a
number of ways. These findings further demonstrate that cognitive restructuring,
cognitive defusion, and imaginai exposure appear to be effective techniques for reducing
claustrophobic anxiety. Although this study was not designed as a treatment study, there
remain several clinical implications which are appropriate to discuss. First, the present
research suggests that a single session intervention can significantly reduce
claustrophobic anxiety. This reinforces previous findings that single session treatments
can have significant impact in the reduction of claustrophobia (Ost et al., 2001).
69
On a practical level, this is an important finding. For example, individuals with
claustrophobia facing magnetic resonance imaging (MRI) prescriptions may be more
willing to undergo a brief, time limited intervention rather than a lengthy course of
therapy to address behavioral avoidance of medical appointments. Because
claustrophobia can result in significant medical consequences related to phobic avoidance
of MRI scans (Katz et al., 1994; Thorpe et al., 2008; Melendez & McCrank, 1993), it is
essential to continue developing methods to treat the anxious avoidance of enclosed
spaces. The present study suggests that a full course of treatment may not be necessary to
reduce claustrophobic avoidance enough to make the situation at least tolerable.
Conclusion and Future Research
The findings presented here indicate that cognitive restructuring, cognitive
defusion, and imaginai exposure are equally effective in reducing self-reported
claustrophobic anxiety, subjective distress, anxious arousal, and phobic avoidance. This
suggests that CBT and ACT may be equally effective despite theoretically working
through distinct mechanisms. Clearly, the results of this study must be taken with
caution, as these findings are preliminary, and additional research incorporating larger
"doses" of treatment are essential to further elucidate the relative efficacy of cognitive
restructuring, cognitive defusion, and imaginai exposure. Given the results of this study it
is recommended that future research implement analytical designs whose hypotheses
support the finding that cognitive restructuring, cognitive defusion and imaginai exposure
are equally effective in reducing claustrophobia.
70
With regard to the limitations noted above, there are a number of modifications
which could be made to this study in order to enhance future research. First, the loss of
data encountered in the present study may have had a significant impact on the resulting
statistical analyses. A larger sample size would increase the power to determine
differences between the techniques and minimize the impact of missing data. In addition,
this research implemented a student population who were identified using a true clinical
sample would allow researchers to form stronger clinical implications from the data.
It is recommended that future research in this area use a behavioral approach task,
similar to that used by Ost and colleagues (Ost et al., 2001; Ost et al., 1982) to assess for
pre-intervention differences in baseline avoidance. In the Ost studies, individuals were
asked to complete the claustrophobic task (e.g., sitting in a small locked room, riding an
elevator, or sitting in a small locked chamber) prior to receiving any intervention. This
allowed the researchers to control for baseline differences in behavioral avoidance. In
addition, this allowed for a direct comparison of the change in avoidance from pre- to
post- intervention.
One limitation of this study was the lack of previous validation regarding the
experimental manipulations. Preliminary data from this investigation indicates that the
video scripts remained faithful to the techniques they were intended to replicate.
Therefore, it is recommended that future research implement the same video scripts and
continues to develop measures to test the validity of these brief single-session
interventions. It is also recommended that future experimenters continue to modify the
claustrophobic chamber to increase claustrophobic fear in the challenge. Suggested
71
modifications include turning off all lights in the laboratory and having the experimenter
leave the room to reduce safety cues on the environment.
Finally, a major limitation of the current study was the brevity of the intervention.
In future investigations, it is recommended that sessions be repeated with assigned
homework to reinforce the learned material. It is possible that additional "sessions"
would provide greater effectiveness and one technique might emerge more effective than
another. This would more directly mimic clinical intervention and would therefore
provide implications for the treatment of claustrophobia.
72
REFERENCES
Agras, S., Leitenberg, H., & Barlow, D. H. (1968). Social reinforcement in the
modification of agoraphobia. Archives of General Psychiatry, 79(4), 423-427.
Agras, S., Leitenberg, H., Barlow, D. H., & Thomson, L. E. (1969). Instructions and
reinforcement in the modification of neurotic behavior. American Journal of
Psychiatry, 125(10), 1435-1439.
Agras, W. S., Leitenberg, H., Barlow, D. H., Curtis, N. ?., Edwards, J., & Wright, D.
(1971). Relaxation in systematic desensitization. Archives of General Psychiatry,
25(6), 511-514.
American Psychiatrie Association (2000). Diagnostic and statistical manual ofmental
disorders (4th ed. text revision). Washington, DC: Author.
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to
prevent the rehospitalization of psychotic patients: a randomized controlled trial.
Journal of Consulting and Clinical Psychology, 70(5), 1129-1139.
Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and
panic. New York, NY, US: Guilford Press.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment ofanxiety and
panic. (2nd ed ed.). New York, NY, US: Guilford Press.
Barlow, D. H., Cohen, A. S., Waddell, M., Vermilyea, J. A., Klosko, J. S., Blanchard, E.
B., et al. (1984). Panic and generalized anxiety disorders: Nature and treatment.
Behavior Therapy, 15, 431-449.
Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behaviorl treatment
of panic disorder. Behavior Therapy, 20, 261-282.
73
Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitivebehavioral therapy, Imipramine, or their combination for panic disorder: A
randomized controlled trial. JAMA, 283(19), 2529-2536.
Beck, A. T. (1970). Cognitive therapy: Nature and relation to behavior therapy. Behavior
Therapy, 7(2), 184-200.
Beck, A. T. (1973). The diagnosis and management of depression. . Oxford, England: U.
Pennsylvania Press.
Beck, A. T. (1985). Theoretical perspectives on clinical anxiety. In A. H. Tuma & J. D.
Maser (Eds.), Anxiety and the anxiety disorders (pp. 183-196). Hillsdale, NJ,
England: Lawrence Erlbaum Associates.
Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias :a cognitive perspective
New York: Basic Books.
Beck, A. T., Laude, R., & Bohnert, M. (1974). Ideational components of anxiety
neurosis. Archives of General Psychiatry, 31(3), 319-325.
Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused
worksite stress management interventions. Journal of Occupational Health Psychology, 5(1), 156-163.
Bond, F. W., & Bunce, D. (2003). The role of acceptance and job control in mental
health, job satisfaction, and work performance. Journal ofApplied Psychology,
88(6), 1057-1067.
Booth, R., & Rachman, S. (1992). The reduction of claustrophobia—I. Behaviour
Research and Therapy, 30(3), 207-221.
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
74
(Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 77108). New York, NY, US: Guilford Press.
Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety
disorder. J Clin Psychiatry, 62 Suppl 11, 37-42; discussion 43-35.
Butler, A. C, Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status
of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology
Review, 26(1), 17-31.
Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of specific phobia in adults.
Clinical Psychology Review, 27(3), 266-286.
Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientificfoundations of cognitive
theory and therapy of depression. New York, NY, US: John Wiley & Sons, Inc.
Clark, D. M. (1993). Cognitive mediation of panic attacks induced by biological
challenge tests. Advances in Behaviour Research & Therapy. Special Issue:
Panic, cognitions and sensations, 15(1), 75-84.
Clark, D. M. (1994). Cognitive therapy for panic disorder. In B. E. Wolfe & J. D. Maser
(Eds.), Treatment ofpanic disorder: A consensus development conference (pp.
121-132). Washington, DC, US: American Psychiatric Association
Clark, D. M., & Ehlers, A. (1993). An overview of the cognitive theory and treatment of
panic disorder. Applied & Preventive Psychology, 2(3), 131-139.
Clark, D. M., Salkovskis, P. M., Hackmann, ?., Middleton, H., Anastasiades, P., &
Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and
Imipramine in the treatment of panic disorder. Brittish Journal ofPsychiatry,
164(6), 759-769. -
75
Clark, L. ?., & Watson, D. (1991). Tripartite model of anxiety and depression:
psychometric evidence and taxonomic implications. Journal ofAbnormal
Psychology, 100(3), 316-336.
Cottraux, J., Note, I., Yao, S. N., Lafont, S., Note, B., Mollard, E., et al. (2001). A
randomized controlled trial of cognitive therapy versus intensive behavior therapy
in obsessive compulsive disorder. Psychotherapy and Psychosomatics, 70(6),
288-297.
Craske, M. G., Mohlman, J., Yi, J., Glover, D., & Valeri, S. (1995). Treatment of
claustrophobias and snake/spider phobias: fear of arousal and fear of context.
Behaviour Research and Therapy, 33(2), 197-203.
Craske, M. G., & Sipsas, A. (1992). Animal phobias versus claustrophobias:
exteroceptive versus interoceptive cues. Behaviour Research and Therapy, 30(6),
569-581.
Craske, M. G., Zarate, R., Burton, T., & Barlow, D. H. (1993). Specific fears and panic
attacks: A survey of clinical and nonclinical samples. Journal ofAnxiety
Disorders, 7(1), 1-19.
Curtis, G. C, Hill, E. M., & Lewis, J. A. (1990). Heterogeneity of DSM-III-R simple
phobia and the simple phobia/agoraphobia boundary: Evidence from the ECA
study. Preliminary report to the Simple Phobia subcommittee of the DSM-IV
Anxiety Disorders Work Group.
Curtis, G. C, Magee, W. J., Eaton, W. W., Wittchen, H. U., & Kessler, R. C. (1998).
Specific fears and phobias. Epidemiology and classification. Brittish Journal of
Psychiatry, 775,212-217.
Dalrymple, K. L., & Herbert, J. D. (2007). Acceptance and commitment therapy for
generalized social anxiety disorder: a pilot study. Behavior Modification, 31(5),
543-568.
Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and Commitment Therapy for anxiety
disorders. U.S.A.: New Harbinger Press.
Eifert, G. H., & Heffner, M. (2003). The effects of acceptance versus control contexts on
avoidance of panic-related symptoms. Journal of Behavior Therapy and Exp
Psychiatry, 34(3-4), 293-312.
Feldner, M. T., Zvolensky, M. J., Eifert, G. H., & Spira, A. P. (2003). Emotional
avoidance: An experimental test of individual differences and response
suppression using biological challenge. Behaviour Research and Therapy, 41(4),
403-411.
Foa, E. B., Grayson, J. B., Steketee, G. S., Doppelt, H. G., Turner, R. M., & Latimer, P.
R. (1983). Success and failure in the behavioral treatment of obsessive-
compulsives. Journal of Consulting and Clinical Psychology, 51(2), 287-297.
Foa, E. B., Steketee, G. S., & Ozarow, B. J. (1985). Behavior therapy with obsessive-
compulsives: From theory to treatment. In M. R. Mavissakalian, S. M. Turner &
L. Michelson (Eds.), Obsessive-compulsive disorders: Psychological and
pharmacological treatment. New York: Plenum Press.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A
randomized controlled effectiveness trial of acceptance and commitment therapy
and cognitive therapy for anxiety and depression. Behavior Modification, 31(6),
772-799.
77
Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Brandsma, L. L., &
Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies
for coping with food cravings: an analog study. Behaviour Research and Therapy,
45(10), 2372-2386.
Frankel, A. S. (1970). Treatment of a multisymptomatic phobic by a self-directed, selfreinforced imagery technique: a case study. Journal ofAbnormal Psychology,
76(3), 496-499.
Gaudiano, B. A. & Herbert, J. J. (2006). Believability of hallucinations as a potential
mediator of their frequency and associated distress in psychotic inpatients.
Behavioural and Cognitive Psychotherapy. 34(4), 497-502.
Greenberger, D., & Padesky, C. (1995). Mind over mood: A cognitive therapy treatment
manualfor clients. New York: Guilford Press.
Hayes, S. C. (1994). Relational frame theory: A functional approach to verbal events. In
S. C. Hayes, L. J. Hayes, M. Sato & K. Ono (Eds.), Behavior analysis of language
and cognition (pp. 9-30). Reno, NV, US: Context Press.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relationalframe theory: a postSkinnerian account of human language and cognition. New York, NY, US:
Kluwer Academic/Plenum Publishers.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and
commitment therapy: model, processes and outcomes. Behaviour Research and
Therapy, 44(1), 1-25.
78
Hayes, S. C, Pankey, J., & Gregg, J. (2002). Acceptance and commitment therapy. In R.
A. DiTomasso & E. A. Gosch (Eds.), Comparative treatments for anxiety
disorders (pp. 1 10-136). New York, NY, US: Springer Publishing Co.
Hayes, S. C, & Smith, S. (2005). Get Out of Your Mind and Into Your Life. Oakland,
CA: New Harbinger Publications, Inc.
Hayes, S. C, Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., & Toarmino, D.
(2004). Measuring experiential avoidance: A preliminary test of a working model.
The Psychological Record, 54, 553-578.
Hayes, S. C, Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment
Therapy: An Experiential Approach to Behavior Change. New York: Guilford
Press.
Hayes, S. C, & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the
verbal support for experiential avoidance. Behavior Analyst, 17(2), 289-303.
Hayes, S. C, Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996).
Experimental avoidance and behavioral disorders: a functional dimensional
approach to diagnosis and treatment. Journal of Consulting and Clinical
Psychology, 64(6), 1152-1168.
Heimberg, R. G., Dodge, C. S., Hope, D. A., Kennedy, C. R., Zollo, L. J., & Becker, R.
E. (1990). Cognitive behavioral treatment for social phobia: Comparison with a
credible placebo control. Cognitive Therapy and Research, 14, 1-23.
Heimberg, R. G., Liebowitz, M. R., Hope, D. ?., Schneier, F. R., Holt, C. S., Welkowitz,
L. ?., et al. (1998). Cognitive behavioral group therapy vs phenelzine therapy for
79
social phobia: 12-week outcome. Archives of General Psychiatry, 55(12), 1 1331141.
Heimberg, R. G., Salzman, D. G., Holt, C. S., & Blendell, K. A. (1993). Cognitive
behavioral group treatment for social phobia: Effectiveness at five-year follow-up.
Cognitive Therapy and Research, 17, 325-339.
Karekla, M., Forsyth, J. P., & Kelly, M. M. (2004). Emotional Avoidance and
Panicogenic Responding to a Biological Challenge Procedure. Behavior Therapy,
55(4), 725-746.
Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential
avoidance as a generalized psychological vulnerability: comparisons with coping
and emotion regulation strategies. Behaviour Research and Therapy, 44(9), 13011320.
Katz, R. C, Wilson, L., & Frazer, N. (1994). Anxiety and its determinants in patients
undergoing magnetic resonance imaging. Journal of Behavior Therapy and
Experimental Psychiatry, 25(2), 131-134.
Klonoff, E. A., Janata, J. W., & Kaufman, B. (1986). The use of systematic
desensitization to overcome resistance to magnetic resonance imaging (MRI)
scanning. / Behav Ther Exp Psychiatry, 17(3), 189-192.
Koulack, D., Lebow, M. D., & Church, M. (1976). The effect of densensitization on the
sleep and dreams of a phobic subject. Canadian Journal of Behavioural
Science/Revue canadienne des Sciences du comportement, 8(A), 418-421.
80
Lafemina, R. (1979). Sexual arousal as a sympathetic inhibitor in the treatment of
claustrophobia. Journal of Behavior Therapy and Experimental Psychiatry, 10(1),
57-60.
Lazarus, A. A. (1961). Group therapy of phobic disorders by systematic desensitization.
The Journal ofAbnormal and Social Psychology, 63(3), 504-5 10.
Leitenberg, H., Agras, S., Butz, R., & Wincze, J. (1971). Relationship between heart rate
and behavioral change during the treatment of phobias. Journal ofAbnormal
Psychology, 78(1), 59-68.
Leitenberg, H., Agras, S., Edwards, J. A., Thomson, L. E., & Wincze, J. P. (1970).
Practice as a psychotherapeutic variable: an experimental analysis within single
cases. Journal of Psychiatric Research, 7(3), 215-225.
Leitenberg, H., Agras, W. S., Thompson, L. E., & Wright, D. E. (1968). Feedback in
behavior modification: an experimental analysis in two phobic cases. Journal of
Applied Behavior Analysis, 1(2), 131-137.
Levis, D. J. (1908). Implementing the technique of implosive therapy. In A. Goldstein &
E. B. Foah (Eds.), Handbook of behavioral interventions: A clinician's guide, (pp.
92-151). New York, NY, US: John Wiley & Sons.
Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The Effects of
Acceptance Versus Suppression of Emotion on Subjective and
Psychophysiological Response to Carbon Dioxide Challenge in Patients With
Panic Disorder. Behavior Therapy, 55(4), 747-766.
Linehan, M. M. (1993). Cognitive-Behavioral Treatment ofBorderline Personality
Disorder. New York, NY: New Guilford Press.
81
Luoma, J. B., Hayes, S. C, & Walser, R. D. (2007). Learning ACT: Acceptance and
commitment therapy skills-training manual for therapists. Oakland, CA: New
Harbinger Publications.
Marx, B. P., & Sloan, D. M. (2005). Peritraumatic dissociation and experiential
avoidance as predictors of posttraumatic stress symptomatology. Behaviour
Research and Therapy, 43(5), 569-583.
Mclsaac, H. K., Thordarson, D. S., Shafran, R., Rachman, S., & Poole, G. (1998).
Claustrophobia and the magnetic resonance imaging procedure. Journal of
Behavioral Medicine, 21(3), 255-268.
Melendez, J. C, & McCrank, E. (1993). Anxiety-related reactions associated with
magnetic resonance imaging examinations. Journal of the American Medical
Association, 270(6), 745-747.
Nathan, P. E., & Gorman, J. M. (2007). A guide to treatments that work (3rd ed.). New
York, NY, US: Oxford University Press.
Ossman, W., Wilson, K. G., Storaasli, R. D., & McNeill, J. W. (2006). A preliminary
investigation of the use of Acceptance and Commitment Therapy in a group
treatment for social phobia. / Una investigación preliminar del uso de la Terapia
de la Aceptación y el Compromiso en un tratamiento del grupo para la fobia
social. International Journal of Psychology & Psychological Therapy, 6(3), 397416.
Ost, L. G., Alm, T., Brandberg, M., & Breitholtz, E. (2001). One vs five sessions of
exposure and five sessions of cognitive therapy in the treatment of claustrophobia.
Behaviour Research and Therapy, 39(2), 167-183.
82
Ost, L. G., Johansson, J., & Jerremalm, A. (1982). Individual response patterns and the
effects of different behavioral methods in the treatment of claustrophobia.
Behaviour Research and Therapy, 20(5), 445-460.
Rachman, S., & Levitt, K. (1985). Panics and their consequences. Behaviour Research
and Therapy, 23(5), 585-600.
Rachman, S., Levitt, K., & Lopatka, C. (1987). Panic: the links between cognitions and
bodily symptoms—I. Behaviour Research and Therapy, 25(5), 41 1-423.
Rachman, S., Levitt, K., & Lopatka, C. (1988). Experimental analyses of panic—III.
Claustrophobic subjects. Behaviour Research and Therapy, 26(1), 41-52.
Rachman, S., Lopatka, C, & Levitt, K. (1988). Experimental analyses of panic-II. Panic
patients. Behaviour Research and Therapy, 26(1), 33-40.
Radomsky, A. S., Rachman, S., Thordarson, D. S., McIsaac, H. K., & Teachman, B. A.
(2001). The Claustrophobia Questionnaire. Journal ofAnxiety Disorders, 15(4),
287-297.
Roemer, L., & Orsillo, S. M. (2007). An open trial of an acceptance-based behavior
therapy for generalized anxiety disorder. Behavior Therapy, 38(1), 72-85.
Roemer, L., Salters, K., Raffa, S. D., & Orsillo, S. M. (2005). Fear and Avoidance of
Internal Experiences in GAD: Preliminary Tests of a Conceptual Model.
Cognitive Therapy and Research, 29(1), 71-88.
Roth, A., & Fonagy, P. (2005). What works for whom: A critical review ofpsychotherapy
research (2nd ed ed.). New York: Guilford Publications.
Segal, Z. V., Teasdale, J. D., & Williams, M. G. (1994). Mindfulness-based cognitive
therapy: Theoretical rational and empirical status. In S. C. Hayes, V. M. Follette
83
& M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitivebehavioral tradition (pp. 45-64). New York: The Guilford Press.
Shafran, R., Booth, R., & Rachman, S. (1993). The reduction of claustrophobia—II:
Cognitive analyses. Behaviour Research and Therapy, 31(1), 75-85.
Shallcross AJ., Troy, A. S., Boland M., & Mauss, I. B. (in press). Let It Be: Accepting
negative emotional experiences predicts decreased negative affect and depressive
symptoms. Behaviour Research and Therapy.
Speltz, M., & Bernstein, D. A. (1979). The use of participant modeling for
claustrophobia. Journal of Behavior Therapy and Experimental Psychiatry, 10(3),
251-255.
Spira, A. P., Zvolensky, M. J., Eifert, G. H., & Feldner, M. T. (2004). Avoidanceoriented coping as a predictor of panic-related distress: a test using biological
challenge. Journal ofAnxiety Disorders, 18(3), 309-323.
Spreen, O., & Strauss, E. (1998). A compendium ofneuropsychological tests :
administration, norms, and commentary (2nd ed.). New York Oxford University
Press.
Stampfl, T. G., & Levis, D. J. (1976). Essentials of implosive therapy: A learning-theorybased psychodynamic behavioral therapy. Journal ofAbnormal Psychology,
72(6), 496-503.
Thorpe, S., Salkovskis, P. M., & Dittner, A. (2008). Claustrophobia in MRI: the role of
cognitions. Magnetic Resonance Imaging.
84
Tuli, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential
avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety,
and somatization. Journal of Nervous and Mental Disease, 192(1 1), 754-761.
Tuli, M. T., Rodman, S. ?., & Roemer, L. (2008). An examination of the fear of bodily
sensations and body hypervigilance as predictors of emotion regulation
difficulties among individuals with a recent history of uncued panic attacks.
Journal ofAnxiety Disorders, 22(4), 750-760.
Twohig, M. P., Hayes, S. C, & Masuda, A. (2006). Increasing willingness to experience
obsessions: acceptance and commitment therapy as a treatment for obsessivecompulsive disorder. Behavior Therapy, 37(1), 3-13.
Watson, D., Clark, L. A., Weber, K., Assenheimer, J. S., Strauss, M. E., & McCormick,
R. A. (1995). Testing a tripartite model: II. Exploring the symptom structure of
anxiety and depression in student, adult, and patient samples. Journal of
Abnormal Psychology, 104(1), 15-25.
Watson, D., Weber, K., Assenheimer, J. S., Clark, L. A., Strauss, M. E., & McCormick,
R. A. (1995). Testing a tripartite model: I. Evaluating the convergent and
discriminant validity of anxiety and depression symptom scales. Journal of
Abnormal Psychology, 104(1), 3-14.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Oxford, England: Stanford
Univer. Press.
Wolpe, J., Brady, J. P., Serber, M., Agras, W. S., & Liberman, R. P. (1973). The current
status of systematic desensitization. American Journal of Psychiatry, 130(9), 961965.
85
Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of
acceptance and commitment therapy plus habit reversal for trichotillomania.
Behavior Research and Therapy, 44(5), 639-656.
Zettle, R. D. (2005) ACT for depression. Oakland, CA: New Harbinger.
Zettle, R. D. (2003). Acceptance and commitment therapy (ACT) versus systematic
desensitization in treatment of mathematics anxiety. The Psychological Record,
53, 197-215.
Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The
context of reason giving. The Analysis of Verbal Behavior, 4, 30-38.
Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in
treatment of depression. Journal of Clinical Psychology, 45, 438-445.
86
Appendix A
Claustrophobia Questionnaire (CLQ)
How anxious would youfeel in these places or situations? Circle the most
appropriate number.
0= Not at all Anxious
1= Slightly Anxious
2= Moderately Anxious
3= Very Anxious
4= Extremely Anxious
SS
(1) Swimming while wearing a nose plug
(2) Working under a sink for 15 min
(3) Standing in an elevator on the ground floor with the doors closed
(4) Trying to catch your breath during vigorous exercise
(5) Having a bad cold and finding it difficult to breathe through your nose
(6) Snorkeling in a safe practice tank for 15 min
(7) Using an oxygen mask
(8) Lying on a bottom bunk bed
(9) Standing in the middle of the third row at a packed concert realizing that
you will be unable to leave until the end
(10) In the center of a full row in a cinema
(11) Working under a car for 15 min
(12) At the furthest point from an exit on a tour of an underground mine
shaft
(13) Lying in a sauna for 15 min
(14) Waiting for 15 min in a plane on the ground with the door closed
87
RS
(1) Locked in a small DARK room without windows for 15 min
(2) Locked in a small WELL-LIT room without windows for 15 min
(3) Handcuffed for 15 min
(4) Tied up with hands behind back for 15 min
(5) Caught in tight clothing and unable to remove it
(6) Standing for 15 min in a straitjacket
(7) Lying in a tight sleeping bag enclosing legs and arms, tied at the neck,
unable to get out for 15 min
(8) Head first into a zipped up sleeping bag, able to leave whenever you wish
(9) Lying in the trunk of a car with air flowing through freely for 15 min
(10) Having your legs tied to an immovable chair
(11) In a public washroom and the lock jams
(12) In a crowded train which stops between stations
88
Appendix B
INFORMED CONSENT FORM
Hofstra University
Hempstead, NY 11549
Department of Psychology
The following research study about anxiety is part of a Ph.D. dissertation being
conducted at the Hofstra University Department of Psychology by Samantha Monk,
M.A., under the supervision of William C. Sanderson, Ph.D.
As a participant you will be asked to answer three questionnaires, which assess thoughts
and feelings. In addition, you will be asked to participate in a challenge which involves
sitting in an enclosed 7-foot by 2-foot space for part of the experiment. During the
challenge, you will be able to speak with the experimenter, and will be asked to report on
your experience. As an expected benefit of this study, the results will allow us to increase
our knowledge about the experience of different emotions, and will help us develop better
procedures for the reduction of claustrophobic anxiety.
Your responses will be held in confidence and will not be released to anyone. Data will
be grouped and, without identification of individuals, will be analyzed and reviewed by
members of the Department of Psychology.
Upon completion, you will receive 3 research credits toward the Introductory Psychology
class you are taking this semester. You may withdraw from the project at any time
without penalty of any sort. I anticipate that 45 undergraduate college students will
participate and that it will take approximately 75 minutes for you to complete the project.
I am very appreciative of your help and will be happy to answer any questions you may
have. In addition, you may call Dr. Mitchell Schare, Director of the Ph.D. program if
there are other questions at (516) 463-5624.
Finally, if you would like, I would be happy to share the findings of the study with you
when it is completed. Again, thank you for your cooperation.
Sincerely,
Samantha Monk, M.A.
I have read and understand the information given above and agree to participate in this
project. I understand that I may receive a copy of this consent form.
Signed
Date
89
Appendix C
Debriefing Form
This study aims to isolate and compare the effectiveness of three different interventions
as coping techniques when faced with claustrophobic anxiety. Research in this area is
critical to understand the effective components of psychological treatments for anxiety
disorders. Results of this study will also help identify potential treatments for reducing
claustrophobia associated with the avoidance of medically necessary procedures such as
MRI scans.
Participants were chosen from mass testing sessions based on their scores on the
Claustrophobia Questionnaire (CLQ), a self-report questionnaire used to identify
individuals with claustrophobic fear. At the time of the experiment, you were also given a
second questionnaire, the Mood and Anxiety Questionnaire (MASQ), which is used to
measure symptoms of anxiety. Participants were randomly assigned to receive one of
three interventions: cognitive defusion which involves detaching from and accepting
one's thoughts, cognitive restructuring which involves changing one's distorted thinking,
or imaginai exposure which involves imagining an experience to decrease the association
between the situation and anxiety. Following the brief intervention, you engaged in a
claustrophobic challenge and were asked to implement the strategy you were taught.
When an individual experiences anxiety they often attempt to avoid whatever it is that is
making it anxious. Therefore, we measured avoidance by measuring how long you stayed
in the claustrophobic situation once given the option to leave, as well as how willing you
were to participate in a second challenge. We also measured the amount of anxiety you
reported during the challenge.
As stated earlier, your responses on all of the measures will be absolutely confidential.
Your name will be converted to a code number, and only experimenters and research
assistants who are associated with this study will see your name or your responses. In
return, we ask you to honor our confidentiality — please do not tell anyone about the
details of this study. If the other students know about the purpose of the study before they
participate, their data will be biased and thus cannot be included.
Your participation in this study is greatly appreciated. If you'd be interested in obtaining
a copy of the results once the study is complete, you may contact the primary researcher,
Samantha Monk, at smonkl @pride.hofstra.edu. If you have any complaints, concerns, or
questions about this research, please feel free to contact the research supervisor, Dr.
William Sanderson, at (516) 463-5633 orWilliam.C.Sanderson@hofstra.edu.
If you feel that you are suffering from emotional distress and you would like to
speak to someone about your thoughts, please contact Hofstra University's Student
Counseling Services at (516) 463-6791.
Thank you very much for participating!
Appendix D
90
Action and Acceptance Questionnaire (AAQ)
Below you will find a list of statements. Please rate the truth of each statement as it
applies to you. Use the following rating scale to make your choices.
1. 1 am able to take action on a problem even if I am uncertain what is the right thing to do.
Never
Very rarely
True
True
Seldom
True
Sometimes
True
Frequently
Almost
Always
True
Always True
True
2. 1 often catch myself daydreaming about things I've done and what I would do differently
next time.
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
True
Almost
Always True
Always
True
3. When I feel depressed or anxious, I am unable to take care of my responsibilities.
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
True
Almost
Always True
Always
True
4. 1 rarely worry about getting my anxieties, worries, and feelings under control.
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
True
Almost
Always True
Always
True
91
5. I'm not afraid of my feelings.
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
True
Almost
Always True
Always
True
6. When I evaluate something negatively, I usually recognize that this is just a reaction, not
an objective fact.
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
True
Almost
Always True
Always
True
7. When I compare myself to other people, it seems that most of them are handling their
lives better than I do.
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
True
Almost
Always True
Always
True
Seldom
Sometimes
Frequently
Almost
Always
True
Always True
True
8. Anxiety is bad.
Never
True
Very rarely
True
True
True
9. If I could magically remove all the painful experiences I've had in my life, I would do so.
1-
Never
True
Very rarely
True
Seldom
True
Sometimes
True
Frequently
Almost
Always
True
Always True
True
92
Appendix E
The Mood and Anxiety Symptom Questionnaire (MASQ)
© Copyright, 1991, D. B. Watson & L. A. Clark
Name/ID#
Below is a list of feelings, sensations, problems, and experiences that people sometimes
have.
Read each item and then mark the appropriate choice in the space next to that item. Use
the choice that best describes how much you have felt or experienced things this way
during the past week, including today. Use this scale when answering:
12
3
4
5
not at all
moderately
quite a bit
extremely
a little bit
1 . Felt cheerful
2. Felt afraid
3. Startled easily
4. Felt confused
5. Slept very well
6. Felt sad
7. Felt very alert
8. Felt discouraged
9. Felt nauseous
10. Felt like crying
11. Felt successful
12. Had diarrhea
13. Felt worthless
14. Felt really happy
15. Felt nervous
16. Felt depressed
17. Felt irritable
18. Felt optimistic
19. Felt faint
20. Felt uneasy
21. Felt really bored
22. Felt hopeless
. 23. Felt like I was having a lot of fun
. 24. Blamed myself for a lot of things
25. Felt numbness or tingling in my body
26. Felt withdrawn from other people
27. Seemed to move quickly and easily
. 28. Was afraid I was going to lose control
29. Felt dissatisfied with everything
. 30. Looked forward to things with enjoyment
.31. Had trouble remembering things
32. Felt like I didn't need much sleep
. 33. Felt like nothing was very enjoyable
34. Felt like something awful was going to happen
35. Felt like I had accomplished a lot
36. Felt like I had a lot of interesting things to do
37. Did not have much of an appetite
38. Felt like being with other people
39. Felt like it took extra effort to get started
40. Felt like I had a lot to look forward to
.41. Thoughts and ideas came to me very easily
42. Felt pessimistic about the future
43. Felt like I could do everything I needed to do
44. Felt like there wasn't anything interesting
93
or fun to do
MASQ cont.
© Copyright, 1991, D. B. Watson & L. A. Clark
1
2
3
4
not at all
a little bit
moderately
quite a bit
45. Had pain in my chest
46. Felt really talkative
47. Felt like a failure
48. Had hot or cold spells
49. Was proud of myself
50. Felt very restless
51. Had trouble falling asleep
52. Felt dizzy or lightheaded
.53. Felt unattractive
54. Felt very clearheaded
55. Was short of breath
56. Felt sluggish or tired
. 57. Hands were shaky
58. Felt really "up" or lively
59. Was unable to relax
. 60. Felt like being by myself
.61. Felt like I was choking
. 62. Was able to laugh easily
. 63. Had an upset stomach
. 64. Felt inferior to others
. 65. Had a lump in my throat
. 66. Felt really slowed down
. 67. Had a very dry mouth
extremely
68. Felt confident about myself
69. Muscles twitched or trembled
70. Had trouble making decisions
71. Felt like I was going crazy
72. Felt like I had a lot of energy
73. Was afraid I was going to die
74. Was disappointed in myself
75. Heart was racing or pounding
76. Had trouble concentrating
77. Felt tense or "high-strung"
78. Felt hopeful about the future
. 79. Was trembling or shaking
80. Had trouble paying attention
81. Muscles were tense or sore
. 82. Felt keyed up, "on edge"
83. Had trouble staying asleep
. 84. Worried a lot about things
85. Had to urinate frequently
86. Felt really good about myself
. 87. Had trouble swallowing
88. Hands were cold or sweaty
.89. Thought about death or suicide
. 90. Got tired or fatigued easily
Appendix F
Manipulation Check
Comprehension of Strategy Assessment
When I have anxious thoughts during the challenge I will:
(a) Do as the thoughts say
(b) Ignore them
(c) Allow them to come and go without buying into them
(d) Look at the evidence and replace them with balanced, alternative thinking
(e) Expose myself to the thoughts
Other:
95
Appendix G
Defusion Protocol
The Mindfulness and Acceptance Workbook for Anxiety (Forsyth& Eifert, 2007)
Get Out of Your Mind and Into Your Life (Hayes, S. C, 2005)
ACT for Depression (Zettle, R. D., 2007)
Hello, my name is Samantha and today I'll be teaching you a strategy you can use
to better handle anxiety you may experience when enclosed in a small space. Following
this presentation, we'll be asking you to sit in an enclosed space for up to 12 minutes. I
want to teach you a new way you can increase the amount of time you are able to stay in
an enclosed space. This method has been extensively researched and has shown to be
clinically successfully in helping individuals experiencing different types of anxiety.
Throughout this video presentation, I'll be asking you to pause the tape and
participate in a few brief exercises with the experimenter to ensure that you get the most
out of this information. If you have any questions during the presentation, please pause
the tape and ask the experimenter for clarification.
The first thing I'd like you to do is think about what occurs when you are
enclosed in small spaces. What are the thoughts, images, feelings and sensations that you
experience? I would also like you to please consider what happens when you experience
these thoughts, feelings and sensations. What do you do when you experience
claustrophobic fear? For example, many people might cut and run, or avoid situations all
together. Using the worksheet provided, please pause the tape and work with the
experimenter to assess what triggers your claustrophobia, how you experience it, and
what you do in response to the fear.
96
TAPE PAUSED FOR ASSESSMENT EXERCISE: "Taking Inventory".
TAPE RESUMED.
If you look at your list what you'll notice is that many of the ways you experience
claustrophobia and the reasons you respond how you do can be characterized as thoughts.
Either you don't have the right thoughts motivating you, or you think that you'll have
uncomfortable thoughts, feelings or sensations if you enter an enclosed space. So let's
understand that one of your barriers to staying in an enclosed space is often your
thoughts.
Let's take a look at thoughts in general. . .
Your mind is constantly at work, producing a never-ending stream of thoughts. It
creates. It evaluates. It solves problems. It helps you make sense of your experience. Of
course there is nothing wrong with thinking. Language and cognition have allowed
humans to be enormously successful in the evolutionary sense, and people who are good
at them generally do well in many areas, especially in academics and in their professions.
The problem arises when we only look out at the world "from our thoughts"
rather than pausing to look "at our thoughts". That narrowness and rigidity can be costly
because in some areas of life taking literally what your mind tells you is not the best
approach. This is particularly true in regard to our internal, emotional suffering. When
you buy into an emotional thought, you become trapped by you mind, and this limits your
ability to live your life in the way you would choose, were you not saddled by this
particular thought. In this way, our minds limit our range of healthy living.
97
Frequently, we choose to buy into the mind trap allow ourselves to be controlled
by our internal dialog. For example, if we buy into thoughts that we will have difficulty
breathing or be unable to escape from an enclosed cabin of an airplane, we may avoid
flying all together. By allowing ourselves to be controlled by our thoughts, we would
restrict our lives, and miss out on travel, visits to family and potential career
opportunities.
However, you have choices in how to respond to thoughts. You don't have to buy
into everything the mind does. You don't have to take the bait.
Unfortunately, the way we often approach our thoughts when they become
barriers is to try to control them. The problem with trying to control our thoughts is that
although it may work in the short term, the thoughts you are trying to control often return
after a short period of time. The truth is, we cannot control our thoughts the way we can
control our behavior. In fact, not only can you not control your thoughts, but attempts to
control them actually magnify their intensity.
Let's do an exercise to demonstrate this point. Please pause the tape for an
exercise with the experimenter that will demonstrate this point.
TAPE PAUSED FOR EXERCISE "Don't Think About the Pink Elephant".
TAPE RESUMED.
So far I've said that you cannot control your thoughts and that attempts to control
them will only intensify them. You are probably wondering what alternatives there are
then, in order to take control of your life rather than allowing your thoughts to dictate
98
your behavior. Well here's an alternative. It's simple. You can choose to step back and
watch as these thoughts come and go, and then behavior the way you choose. I know this
may seem a little too simplistic, but research being conducted across the country indicates
that this is the key to a way out of your fears and into your life.
One of the best things you can do when you have anxious thoughts about being in
enclose spaces is to sit still with them and not do as they say. This will be difficult
because the impulse to cut and run is so great and so automatic. Doing nothing about the
thoughts is more difficult. However, it's important to learn this skill because the urge to
act on the anxious thoughts greatly diminishes your life experience. Practicing watching
thoughts come and go will teach you to become a true observer of your mind rather than
allowing your mind to control your behavior.
I know that even though the concept is simple, observing your mind without
reacting to your thoughts will not be easy. Your thoughts will be screaming at you to
respond by trying to control them or avoid the situation all together. But by learning this
skill and practicing today, it will become easier to observe and take note of your thoughts
and images rather than doing as they say. One you learn to observe your thoughts as they
come and go without being pulled into them, you will be free to behave how you choose,
based on your goals, rather than your fears!
Please pause the tape for two exercises with the experimenter which will teach
you how to observe your thoughts without giving in to them when you are in an enclosed
space.
TAPE PAUSED for exercise "Mind Watching".
TAPE RESUMED;
99
These exercises show use that we cannot control what comes into our minds or
how we feel. We can only choose what we pay attention to, how we pay attention and,
what we do in response. In a little bit you'll do another exercise that will help you
develop the skill of observing your thoughts, and allowing them to come and go without
them taking over and controlling what you do. If you practice this skill with openness and
a willingness to try this technique, you will notice that these experiences, the thoughts
feelings and urges, do indeed come and go on their own without effort on your part. Keep
in mind that this exercise is not about making you feel different, better, relaxed or calm.
This may happen, or it may not. The idea is to bring awareness to your experience, and
acceptance to gny_ sensation that shows up, including any thoughts or worries that come
into your mind. By becoming aware and learning to accept that thoughts, images and
sensations come and go, we can learn that these thoughts do not have to dictate how you
behave. You can learn to behave how you choose, even when you are experiencing
anxiety.
Please pause the tape for another exercise with the experimenter.
TAPE PAUSED FOR EXERCISE "Leaves on a Stream".
TAPE IS RESUMED
Recognizing that buying into your anxious thoughts is a barrier to being in an
enclosed space is an important skill. As with any other skill, learning to be an observer of
your thoughts takes practice. The more you practice, the better you become at it. You can
get something different out of your life if you're willing to try and relate to your thoughts
in a different way. With time, you'll discover that no matter how bad a thought seems, it
100
neither lasts forever, nor can it do any harm. Developing acceptance of your anxious
thoughts is one of the most powerful ways to confront claustrophobia.
In a few minutes you are going to be asked to enter the experimental closet and
remain there for an extended period of time. You have a choice. We have seen that trying
to get rid of your unwanted thoughts won't help, and that telling yourself reasons why
you cannot do this task will not get you closer to your goal. So, perhaps you can apply
what you have learned today and face your claustrophobic fears by looking at your
thoughts, rather than from them. You have the choice to observe your anxious thoughts
and accept them, and to behave the way you want to, rather than allowing your thoughts
to control you.
Please stop the tape to practice one more time with the experimenter before attempting to
use this skill in an enclosed space.
101
Appendix H
Cognitive Restructuring Protocol
Mind over Mood (Greenberger & Padesky, 1995)
Hello, my name is Samantha and today I'll be teaching you a strategy you can use
to better handle anxiety you may experience when enclosed in a small space. Following
this presentation, we'll be asking you to sit in an enclosed space for up to 12 minutes. I
want to teach you a new way you can increase the amount of time you are able to stay in
an enclosed space. This method has been extensively researched and has shown to be
clinically successfully in helping individuals experiencing different types of anxiety.
Throughout this video presentation, I'll be asking you to pause the tape and
participate in a few brief exercises with the experimenter to ensure that you get the most
out of this information. If you have any questions during the presentation, please pause
the tape and ask the experimenter for clarification.
What I'd like you to do first today is think about what occurs when you are
enclosed in small spaces. What are the physical reactions, thoughts, and feelings that you
experience? I would also like you to please consider what happens when you experience
these physical reactions, thoughts and feelings. What do you do when you experience
claustrophobic fear? For example, many people might cut and run, or avoid situations all
together. Using the worksheet provided, please pause the tape and work with the
experimenter to assess what triggers your claustrophobia, how you respond physically,
what thoughts and feelings occur and what you do in response.
Please pause the tape now.
TAPE IS PAUSED FOR ASSESSMENT (worksheet 1.1).
TAPE RESUMED.
As you can see from this exercise, there are five components to any phobia,
including claustrophobia, or the fear of enclosed spaces. These components include the
situation, physical reactions, moods or emotions, thoughts, and behavioral responses.
While each of these components can be taken individually, it is important to
realize that each of these five areas interacts and affects the others. For example, a
claustrophobic situation may trigger an emotion like fear, which may trigger a
physiological increase in heart rate along with thoughts that one is in danger. This in turn
may cause the individual to respond by avoiding the situation.
Let's talk about the connection between thoughts and emotions...
Whenever we experience a mood or an emotion, there is a thought connected to it
which helps define our emotional reaction. For example, if you have the thought that you
will suffocate in a small closet, this thought will likely cause you to feel afraid. However,
another person may think entering an enclosed space will be a challenge which may
result in feeling excited. Yet another person may have thoughts that being in a small dark
space will be soothing and this may result in them feeing relaxed. As you can see,
different thoughts or interpretations can lead to different moods in the same situation.
You may be wondering why some people are more prone to certain thoughts and
reactions to enclosed spaces than others. Some portion of these differences may be
biological or genetically inherited. But we also know that environmental experiences can
powerfully shape the beliefs, thoughts, and emotions involved. For example, a past
experience where you were in danger in a small space may have influenced your current
fears. However, it doesn't necessarily take a traumatic event to influence beliefs. Beliefs
can be influenced by your cultural background, what you learned from your parents, and
even through stories you have heard about other people's experiences. What you think
about enclosed spaces is influenced by these parts of your early and current environment.
However, learning to look at these situations from different angles can lead to new
conclusions and increase your ability to remain in enclosed spaces.
This does not mean that our thinking is wrong when we experience a strong
mood. But when we feel intense moods, we are more likely to distort, discount, or
disregard information that contradicts our moods and beliefs. Everyone thinks in these
ways, sometimes. However, it is helpful to learn to recognize when you are thinking in
distorted ways because this understanding provides a first step toward more balanced
thoughts and emotions.
There is also a connection between our thoughts and how we behave. Thoughts
can often influence us to behave in ways that are not in our best interests. For example, if
we think that we will have difficulty breathing or be unable to escape from an enclosed
cabin of an airplane, we may avoid flying all together. The consequence of this would be
a restricted range of living, which could mean missing out on leisure travel, visits to
family and potential career opportunities. Therefore, it is important to identify what you
are thinking and to check out the accuracy of your thoughts before acting.
104
Finally, there is a connection between our thoughts and our physical reactions.
For example, thoughts that you are in danger in an enclosed space may trigger an increase
in heart rate, muscle tension, shallow breathing or perspiration. It is important to become
aware of this connection, because these physical sensations can trigger additional
thoughts and emotions, like fears of dying, which can perpetuate and intensify our
emotional reactions and influence our behavior.
Let's look at your list of what happens when you are confronted with a
claustrophobic situation. You'll notice that many of the ways you experience
claustrophobia and the reasons you respond how you do, can be characterized as
thoughts. Identifying and changing thoughts is essential to changing your behavior when
confronted with a claustrophobic situation. Fortunately, there is a set of specific skills
that can help you learn to change the thoughts getting in your way, confront your fears of
enclosed space, diminish your anxiety, and reduce your claustrophobia. These skills are
summarized on a 7-collumn worksheet you have in front of you, called a "Thought
Record".
The first part of the thought record involves identifying claustrophobic situations,
moods and automatic thoughts. Automatic thoughts are a type of thinking that influences
behavior. These are the words and images that pop into our heads throughout the day as
we do things. We know that that whenever we have strong emotional reactions, there are
also automatic thoughts present. After using the thought record to identify and clarify the
situation, emotion and automatic thoughts present, the thought record helps you look for
evidence for and against your automatic thoughts. Finally, using the thought record, we'll
105
teach you how to use this evidence to construct more adaptive ways of thinking about
enclosed spaces.
In a moment, you will pause the tape and complete the first three columns of the
thought record with the experimenter. With the experimenter's help, you will identify the
specific situation, emotions, and thoughts that may occur when you are in the
experimental enclosed space. Fd like you to please think about the claustrophobic
challenge you are about to engage in. With the help of the experimenter, I'd like you to
please write about what you are experiencing, or expect to experience, on the worksheet
provided. Using the thought record, describe the situation, your mood or emotion, and
your thoughts in as much detail as you can. This exercise is designed to help you define,
separate and understand the different parts of your experience, an important step in
learning to be more in control of your fear.
In addition to identifying moods it is also important to rate the moods to alert you
to which situations and thoughts are associated with changes in your mood. You may find
it convenient to use the rating scale provided to assist you and the experimenter in rating
your moods.
Like many people, you may have some difficulty at first identifying your
automatic thoughts, so you have also been given a list of questions that will help you to
identify automatic thoughts.
Please pause the tape now.
TAPE IS PAUSED FOR EXERCISE: First three columns of thought record.
TAPE RESUMED.
106
Identifying automatic thoughts is an important step in coping better. Now we'll
learn what to do with these thoughts.
The automatic thoughts that are most important to change are the ones that are
most connected to our moods, and in the case of claustrophobia, our fear. We call the
automatic thoughts that are most connected to our fear "hot thoughts". To learn about hot
thoughts, let's look at the automatic thoughts you identified with the experimenter. In
order to identify the hot thought, and the one we should target for change, let's try to
identify the one most connected to your fear.
Do this by considering each thought by itself to see how much that thought alone
would make you feel nervous, anxious or fearful, rating the thoughts on a scale of 1 to
100. The thought that makes you rate your anxiety highest we'll consider your hot
thought. For each automatic thought you listed during the last exercise, rate how much
this thought alone made you feel the emotion you listed, on a scale from 0-100. Please
briefly pause the tape to complete this exercise with the experimenter.
TAPE IS PAUSED FOR EXERCISE: "Hot Thoughts".
TAPE RESUMED.
Now that we have identified the hot thoughts behind your emotional reactions to
small, enclosed spaces, we will try to gather evidence that does and does not support the
hot thought. After I provide you with basic instructions, you will complete the next two
columns of the thought record with the experimenter. First, you'll look for evidence that
supports the thought, and then you will look for the evidence that does not support the hot
thought in order to achieve more balanced thinking. The goal here is to minimize the
connection between the thought and your emotional reaction, so distorted automatic
thoughts don't get in your way and control how you react, feel and behave in small
enclosed spaces.
In the first of these columns, try to list only factual information that supports the
hot thought, not interpretations of facts. Once you have completed listing evidence that
supports your hot thought, ask yourself the questions provided to help you find evidence
that does not support your hot thought. With the help of the experimenter, write down
each piece of evidence you uncover in column 5. Completing these two evidence
columns of the Thought Record will help you evaluate your hot thought in the light of
several perspectives.
Please pause the tape to complete columns 4 and 5 of the thought record.
TAPE PAUSED FOR EXERCISE: "Where's the evidence?"
TAPE RESUMED.
Alternative or balanced thinking often emerges from an expanded view of the
situation. Although balanced thinking may be more positive that your original thought, it
is not merely the substitution of a positive thought for a negative thought. Rather than
ignoring negative information, balanced thinking takes into account both positive and
negative information. It is an attempt to understand the meaning of all the available
information. With additional information, or an expanded point of view, your
interpretation of the situation may change.
In order to achieve alternative or balanced thinking, we will use the next two
columns on the automatic thought record. The first of these should include either an
alternative view of the original situation, or a balanced thought that summarizes fairly the
evidence from our last exercise. The sentence you write should be consistent with the
evidence you have gathered. Based on the evidence, you will consider if there is an
alternative way of thinking about or understanding the situation. You will write out one
sentence that summarizes all the evidence that supports your hot thought, and all the
evidence that does not support your hot thought. When you do this, see if using the word
"AND" creates a balanced thought that takes all the information you've gathered into
account. You can also use the list of questions provided to help you created balanced
alternative thinking in response to this claustrophobic situation.
The final column of the thought record asks you to re-rate your mood or emotion
you experienced when faced with the claustrophobic situation. If you have constructed a
balanced alternative thought, you will likely notice that the intensity of your
uncomfortable feelings has diminished. The amount of change you notice will vary with
how much you believe your alternative or balanced thoughts. If you do not notice a
change in your emotional response, use the trouble shooting guide provided with the
experimenter.
Please pause the tape to complete this exercise with the experimenter.
TAPE PAUSED FOR EXERCISE: "Balanced Thought".
TAPE RESUMED.
109
Now you have learned what you need to know to complete a thought record, and
have completed a thought record for a claustrophobic situation. In doing this thought
record you identified and altered the thinking contributing to your fear of enclosed
spaces. Constructing alternative or balanced thinking helps free yourself from automatic
thinking patterns that contribute to the difficulty you have with enclosed spaces. If you
are able to see the situation from a new perspective, it is possible that you will begin to
feel better when confronted with an enclosed space.
In a few minutes you are going to be asked to enter the experimental closet and
remain there for an extended period of time. I'd like you to apply what you've learned
today, and use balanced thinking to confront your claustrophobia. When I ask, please stop
the tape and review your thought record one more time with the experimenter before
attempting to use this skill in a real situation. If you notice that you have difficulty
believing your alternative or balanced thought, use the troubleshooting guidelines to
refine your thought record. Please stop the tape now.
110
Appendix I
Imaginai Exposure Protocol
Hello, my name is Samantha and today I'll be teaching you a strategy you can use
to better handle anxiety you may experience when in an enclosed space. Following this
presentation, we'll be asking you to sit in an enclosed space for up to 12 minutes. I want
to teach you a new way you can increase the amount of time you are able to stay in an
enclosed space. This method has been extensively researched and has shown to be
clinically successfully in helping individuals experiencing different types of anxiety and
phobias.
Throughout this video presentation, I'll be asking you to pause the tape and
participate in a few brief exercises with the experimenter in order to ensure that you get
the most out of this information. If you have any questions during the presentation, please
pause the tape and ask the experimenter for clarification.
Claustrophobia typically involves the strong fear and avoidance of restricted
spaces or situations. When a person with 1
claustrophobia finds herself in a
restricted space, there are common symptoms which might occur,
including*
sweating, accelerated heartbeat, nausea, fainting, light-
headedness, shaking, or hyperventilation. Some common situations that can trigger
anxiety in 1
being inside a car,!
claustrophobia sufferers include being inside a small room,
being inside an elevator, being on an airplane, or
undergoing an MRI or CAT scan, just to name a few.
Ill
Claustrophobia develops as a result of learning to associate anxiety with a
particular situation. Perhaps you once panicked when in a small space. If your anxiety
was high, it is likely that you acquired a strong association between being in that situation
and being anxious. Thereafter, being in, near, or perhaps just thinking about a similar
situation automatically triggered anxiety, and a connection between small enclosed
spaces and a strong anxiety response was established. Because this connection was
automatic and so seemingly beyond your control, you probably did all you could to avoid
putting yourself in that situation again. Your avoidance was then inherently rewarded and
reinforced because it saved you from re-experiencing your anxiety.
Exposure therapy is the process of unlearning the connection between anxiety and
a particular situation, in this case, enclosed spaces. Real-life exposure is the single most
effective available way to treat claustrophobia. Nothing works better towards overcoming
a fear than facing it. For this process of unlearning to occur, you need to enter the
claustrophobic situation you find anxiety provoking. In real-life exposure, you confront
the claustrophobic situation directly, letting your anxiety level rise and then subside while
in the situation. The point is to unlearn a connection between being in a small enclosed
space and an anxiety reaction. By forcing yourself to be exposed to what you are afraid
of, you can overcome your fears.
Today we will confront your claustrophobia in gradual steps. First, you will
discuss various situations in which you experience claustrophobic fear with the
experimenter. Then you will put these situations in order from the least anxiety provoking
to the most anxiety provoking. This will be like a road map, showing us where to begin,
where to end and the pathway in between for our exposure exercises. After constructing
112
this list, called a fear hierarchy, you will be asked to imagine these situations in imagery.
By going over these scenes, the fear that has become associated with the situations will
naturally become reduced or extinguished as the bond between the situation and anxiety
is broken. Because claustrophobia is a learned fear, it can be unlearned through this type
of exposure through imagery. After these exercises, we will do a real life exposure, where
you will confront your claustrophobia in real-life.
What I'd like you to do first, is think about what triggers your claustrophobia.
There are many different specific triggers that prompt a claustrophobic episode. For
some, it is the elevator door shutting; for others, a room with no window. Still others may
experience claustrophobia on airplanes or in cars. What are the situations that trigger
claustrophobia for you? To assess your triggers, consider all the claustrophobic situations
which cause you to experience fear, and situations that you tend to avoid or have avoided
in the past. Also consider whether certain situations trigger more anxiety than others.
Please pause the tape now, and work with the experimenter to assess what triggers your
claustrophobia.
TAPE IS PAUSED FOR ASSESSMENT: "Taking Inventory".
TAPE RESUMED.
The most effective way to overcome claustrophobia, or any phobia for that matter,
is simply to face it. Continuing to avoid a situation that frightens you is, more than
anything else, what keeps a phobia alive. Having to face a particular situation that makes
you anxious, or one that you have been avoiding for a long time may seem like an
113
impossible task. Yet this task can be made possible by breaking it down into steps, which
we will do today. Instead of entering the claustrophobic situation all at once, we will do it
gradually in small steps. Through repeated experiences facing your fear, you will begin to
weaken the association between the claustrophobic situation and your anxiety.
In order to help you identify the level of anxiety that each situation provokes, we
will use units of measurement called a SUDS scale. This stands for subjective units of
distress. It is a 100-point scale with 100 equaling the most anxiety-provoking situation
you have ever experienced in your life. 0 equals neutral, or no anxiety whatsoever. A 50
SUDS rating is neither very high nor very low anxiety. It indicates just medium anxiety.
Let's take a moment to see how that SUD scale works. Following my instructions,
you will complete this exercise with the experimenter. Think of a few situations you have
experienced in your life that have caused you the most claustrophobic anxiety and fear
you have ever experienced. Or think of a claustrophobic situation you hope you never
have to deal with. Examples might include being locked in the trunk of a car, being
zipped head first in a sleeping bag, or being locked in a coffin shaped box. Situations that
elicit these kinds of strong feelings of anxiety will earn a 100 on the SUDS scale. Next,
take a second to think of a very neutral of pleasant situation that involves an enclosed
space. For example, this might include lying in bed under the covers. These situations
would be a 0 on the SUDS scale. Finally, think of a situation that caused you a moderate
amount of anxiety- not too much and not too little. Examples might include an airplane
cabin, a small store, or being in a car. Situations like these tend to evoke moderate
amounts of anxiety- around 50 on the SUDS scale. This scale will be very useful as you
114
construct your claustrophobia hierarchy, and may take some real life practice to fully
understand.
Please pause the tape to practice using the SUDS scale with the experimenter to
rate claustrophobic situations.
TAPE PAUSED FOR EXERCISE: Hierarchy construction (0, 50 and 100 SUDs).
TAPE RESUMED.
Now that you understand how to use the SUDs scale to measure your
claustrophobic anxiety, we'll begin constructing your fear hierarchy to use for the
exposure exercises we discussed earlier. When you construct your claustrophobic fear
hierarchy with the experimenter, your list should include roughly 10 specific
claustrophobic situations that trigger different levels of fear and anxiety. Each of these
situations should differ from each other by about 10 SUDs points each. The experimenter
will help you begin your list with situations that trigger about 20-40 SUDs points each, or
low to medium anxiety. Then the experimenter will help you list situations that trigger
higher and higher levels of SUDs. The last item on your list should be the situation that
triggers your highest level of claustrophobic fear.
A sample claustrophobia hierarchy has been provided as a guideline. Please pause
the tape now to construct your hierarchy with the experimenter.
TAPE PAUSED FOR EXERCISE: Hierarchy construction.
TAPE RESUMED.
115
Now that you've completed your claustrophobia hierarchy, we are ready for the
imaginai exposure exercise. During the imaginai exposure, your task will be much like
that of an actor. You will be asked to play the part of yourself and to portray certain
feelings and emotions in imagery. Like an actor you are to "live" the scenes with genuine
emotion and affect. The experimenter will direct the scenes. You will be asked to close
your eyes and follow the scenes in imagery. Please put yourself into the scene as best you
can and imagine the events described as clearly as possible. The scenes, like movies,
might not necessarily involve real events. You only have to believe or accept the scenes
as real when you are visualizing them.
In this way, you will confront your personal claustrophobia triggers through
imagery, before attempting to do so in real-life. It is important that you allow yourself to
feel anxiety during this process, to stay with it and to not avoid it. This will allow you to
unlearn the anxiety response that has been associated with the situation.
Please pause the tape now for the imaginai exposure exercise.
TAPE IS PAUSED FOR EXERCISE: Imaginai Exposure.
TAPE RESUMED.
In a few minutes you are going to be asked to enter the experimental closet and
remain there for an extended period of time. I'd like you to apply what you've learned
today, and use this opportunity as a real life exposure and a chance to further unlearn the
associations you have learned between enclosed spaces and anxiety. Please stop the tape
for one last imaginai exposure exercise with the experimenter before engaging in the reallife exposure.
116
Appendix J
Challenge Instructions
"Now that you have learned this technique, it is time to take a challenge. You'll be in the
closet you see with the door locked for up to 12 minutes. You may exit the challenge at
anytime without penalty. However, I encourage to you face your fear and try your best by
using the technique you just learned.
"Throughout the challenge I will ask you to rate how much distress you are experiencing.
I will ask you to rate your distress on a scale of 1 to 100, with 1 being absolutely no
distress and 100 being the most distress you could ever possible experience. (Show
SUDS scale again). Do you have any questions?" (Answer questions within reason,
without revealing option to leave at eight minutes).
"Ok, let's begin... (Person enters closet and door is latch, timing begins). Ok, what is
your distress rating now, on a scale from 1-100?"
"Ok, remember to use your
coping strategy".
After 1 minute. . . "OK, what is your distress rating now on a scale from 1-100
After 4 minute... "OK, what is your distress rating now on a scale from 1-100?"
"Ok, remember to use your technique".
At 8 minutes... "OK, what is your distress rating now on a scale from 1-100?"
"Ok... Well you actually now have the option to leave the closet or to complete the
challenge. If you want to leave, you will sit quietly in the room with me for the remainder
of the 12 minutes".
If person wants to leave: "Are you sure?" If yes: "Ok, I'll open the door".
-
If person wants to leave: "Are you sure?" If no: "Ok, remember to use your coping
strategy".
If person is willing to continue: "Are you sure?" If yes: "Ok, remember to use your
technique".
-
If person is willing to continue: "Are you sure?" If no: "Ok, I'll open the door".
At 12 minutes... "OK, now what is your distress rating on a scale from 1-100?"
"Well, congratulations, you completed the challenge! I'm going to open the door now".
117
After exiting, the person completes the MASQ-AA, the AAQ, and the CLQ. When finished
with the forms:
"Thank you very much for participating. It seems we still have about 10 minutes left in
the experiment. . . It would really help us with data collection if you were willing to try a
second challenge that is the same as the one you just completed. Alternatively you may
choose to sit with me and complete additional questionnaires.
Yes response: Repeat challenge for 5 minutes.
If no response: Administer additional self-report forms for 5 minutes.
118
Appendix K
Apparatus
Rubbermaid Large Vertical Storage Shed ®
¦é
Документ
Категория
Без категории
Просмотров
0
Размер файла
4 597 Кб
Теги
sdewsdweddes
1/--страниц
Пожаловаться на содержимое документа