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Abstract
Exposure therapy is one of the most powerful and generalizable treatments available to
cognitive-behavioral psychologists. During exposure, subjects often engage in behaviors
that reduce their anxiety. Some studies indicate that these safety behaviors reduce the
effectiveness of exposure treatment. This paper reviews the evidence for two major
models: distraction, in which safety behaviors draw attention away from disconfirming
evidence, and misattribution, in which subjects believe that their own actions prevented
the feared outcome, causing them to reconceptualize safe (fear-disconfirming) situations
as dangerous (fear-confirming). I advance a third hypothesis, that safety behaviors are
detrimental only when they restrict access to disconfirmatory information.
Spider-phobic subjects were given 15 minutes of exposure to a live tarantula. One group
was instructed to trap the spider in a small space. Another was given a shield but did not
restrain the tarantula. They were compared to each other and to no-safety-behavior
controls. The number of subjects was too small to analyze the data on fear reduction and
fear reduction maintenance, but the safety behaviors were found to be similar enough that
they control for all factors other than access to disconfirmatory evidence. A larger study
is planned with minor modifications.
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Acknowledgements
My work and I are dedicated to:
Christine Hoff, who helps me think, for mutual support.
John Kraemer, who always has something to show me, for more mutual support.
Steven Hazel and Liza Ferneyhough, ever-tolerant friends, for yet more support – mostly in
my direction.
Barry and Linda, my parents, for believing.
Tarantula Brad and Tarantula Skywise – very cooperative, for giant spiders.
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A Note on the text
My thesis was submitted with only cosmetic changes to the psychology department
as a psychology honors project. The language and style are not what I would choose for
conveying the vitality and excitement of this work to my Plan II colleagues. I also didn’t
think up the big ugly “Insert figure 1 about here” notes. However, I have preserved them for
authenticity’s sake.
Plan II readers are encouraged to see the personal note in the afterward. This thesis
may also be read online at http://azrael.dyn.cheapnet.net/~mikethecrow/spider. Comments
and questions are welcome. Please send email to mikethecrow@azrael.dyn.cheapnet.net or
traiben@yahoo.com.
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Table of Contents
Abstract ........................................................................................................2
Acknowledgements ......................................................................................3
A Note on the text ........................................................................................4
Table of Contents .........................................................................................5
Introduction ..................................................................................................6
Cognitive and behavioral etiology of safety and anxiety .....................7
Safety behaviors in exposure therapy .................................................10
Theoretical explanations for safety behavior effects ..........................12
Weaknesses of current theories ..........................................................16
Escape vs. coping: an alternate distinction .........................................19
Reconceptualization of past studies ....................................................21
The current study ................................................................................24
Methods......................................................................................................27
Results ........................................................................................................36
Manipulation Checks ..........................................................................36
Outcome measures: .............................................................................37
Discussion ..................................................................................................38
Manipulation Checks ..........................................................................40
Outcome Measures .............................................................................41
Changes to the Protocol ......................................................................42
References ..................................................................................................43
Tables .........................................................................................................46
Appendix A – Instructions and instruments...............................................53
Afterward ...................................................................................................64
About the Author .......................................................................................66
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Introduction
Cognitive-behavioral therapy is the current treatment of choice for anxiety
disorders, and its paradigm of exposing subjects to their feared stimulus has been widely
successful in reducing anxiety and avoidance in panic disorder (Craske & Rodriguez,
1994; Marks, et al., 1993), claustrophobia (Thorpe & Burns, 1983; Sloan, 2000), and
simple phobias (Rachman, 1990b). The clear effectiveness of this general method has led
to more nuanced explorations of its differential effects across subjects and situations.
Currently, much research is focused on how subjects respond when placed in feared
circumstances, and how these responses can act as moderators to treatment effectiveness.
One promising avenue is the use of safety behaviors, actions that fearful
individuals use to reduce anxiety. Safety behaviors can take the form of overt actions,
covert behaviors (thoughts), or comforting or protective objects. For example, an
individual with panic disorder might react to the fear of having a heart attack by moving
very slowly, by concentrating hard on relaxing thoughts, or by fingering an alprazolam
tablet. It appears that these safety behaviors can potentially interfere with the benefits of
exposure therapy, but the evidence is far from conclusive. This paper reviews the
cognitive mechanisms of safety behaviors, their ability to reduce fear, and theories
explaining their effects on exposure, culminating with a proposed revision to current
categories of safety behaviors and their expected effects. Initially, our examination of
safety behaviors must begin with the origins of anxiety.
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Cognitive and behavioral etiology of safety and anxiety
Procedures for experimentally creating a fear response to a neutral stimulus are
well-established and satisfactorily explained by classical conditioning: when a
conditioned stimulus (CS) is followed by a punishing unconditioned stimulus (UCS), the
negative reaction to the UCS becomes associated with the CS as well. Subjects, both
animal and human, will then attempt to avoid the CS, or respond to its presence with
anxiety and escape behavior (Gray 1987). Often this escape behavior is highly successful,
and the feared UCS is rarely or never encountered. With the negative stimulus gone, one
might expect the avoidance or escape behavior to self-terminate through extinction (i.e.,
the CS triggering escape is repeatedly encountered without the aversive UCS). On the
contrary, escape behaviors are notoriously persistent. Dogs will expend great effort to
flee a negative CS, continuing for hundreds of trials during which no UCS is ever
administered (Kamin, 1956). Analogously, humans with anxiety disorders will continue
to avoid situations they perceive as dangerous, even when those situations do not lead to
negative experiences (because the situation is inherently benign, or because they flee
from it). Why do these natural outcomes differ so markedly from the successes of
exposure therapy noted above?
The theoretical model to which most modern understanding of avoidance
behavior traces back is Mowrer's two-stage theory (Gray, 1987). Classical conditioning is
responsible only for the first stage, the initiation of avoidance. In the second stage, the CS
elicits anxiety on its own, and escape functions to reduce that anxiety. This negative
reinforcement strengthens the escape behavior. At the same time, a successful escape
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gives the subject no opportunity to observe that the feared situation may actually be
benign. Thus, the interpretation of avoidance as a successful flight from danger is
preserved. This can explain both the problem of persistence and the seeming
contradiction of exposure therapy. In exposure therapy, subjects are required to tolerate
the CS rather than experiencing it briefly and "escaping." As a result, they have an
opportunity to learn that their perceptions of danger may be incorrect. This cognitive
process is known in cognitive-behavioral theory as disconfirmation (Beck, 1976), and it
is the source of the therapeutic dictum that exposure must not be terminated until anxiety
has decreased. To do otherwise would simply constitute another reinforcement of escape
(Rachman, 1986)
Mowrer’s model is internally consistent and can explain the essential origins and
maintenance of anxiety disorders. However, it does not account for some common
clinical phenomena. Often, an anxiety reaction may develop without a distinct fearinducing event that could be responsible for the original respondent conditioning.
Rachman's (1990a) three-process theory explains many such cases as arising from
cognitive events. An individual who has had no direct interaction with snakes may
develop a phobia through modeling (e.g., seeing a peer bitten by one) or abstract learning
(e.g., finding out that a certain snake which was previously regarded as harmless is
actually poisonous). In these cases, the individual uses new information to mentally
associate the CS (the snake) with the feared UCS (pain or danger). The resulting fear is
the same as that produced by a negative experience in vivo.
Once the initial fear is established, these variations meld seamlessly with the
operant-avoidance stage of Mowrer's theory. A more drastic departure from Mowrer is
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safety-signal theory, which suggests that escape and avoidance should not be modeled as
flight from an undesired stimulus but rather as approach towards stimuli that indicate
safety. Rachman (1984) cites the significant percentage of individuals who develop
agoraphobia without ever having any fear-provoking experience (even an informational
one) outside the home. In many of these cases, however, they did suffer the loss of a
close relative or spouse who could be conceptualized as a major source of security and
reassurance - a safety signal. Additionally, many agoraphobic and panic disorder subjects
show significant reduction in anxiety when accompanied by a trusted person (Rachman,
1984). These observations are difficult to fit into a purely avoidance-based model, but
accord well with the idea that certain people use cues to infer safety as well as danger.
Additional support for the use of safety information in the generation or
suppression of anxiety comes from an animal study by Rescorla and LoLordo (1965).
Dogs were shocked in association with a CS, unless a second CS (the safety signal) was
also presented. The dogs were then shocked in association with a new CS and taught to
escape from it. When this new CS was presented in conjunction with the safety signal,
the dogs’ escape behavior decreased even though the two had never been paired before,
and the dogs were still being shocked. Evidently the safety signal was interpreted in a
generalized fashion, distinct from any particular fear-provoking stimulus
Humans also appear to take advantage of safety information that is not
immediately relevant to the feared stimulus. Rapee, Tefler, & Barlow (1991) studied the
severity of response to a CO2 challenge in subjects with panic disorder with agoraphobia
when the circumstances of administration were varied. Subjects’ impressions of the
experimenter's orderliness and professionalism, and the availability of help available
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were found to correlate inversely with severity of response. However, this result was
found only in a retrospective analysis across groups. The experimenters were unable to
manipulate subjects' perceptions of the situation, suggesting that the causation may be
bidirectional: subjects who are less prone to feel threatened may be more attentive to the
information conceptualized as safety signals.
Safety behaviors in exposure therapy
Research on the potential of safety behaviors to reduce anxiety in the short term
has generated interest in their effects on therapy for the anxiety disorders, the goal of
which is long-term and generalized anxiety reduction. Based on the construct of safety
signals, Rachman (1983, 1984) suggested that therapy for agoraphobia incorporate
safety-inducing stimuli into exposure treatment. For example, a man might not want to
leave the house because he relies on the reassurance provided by his wife’s presence, and
going out typically involves leaving her behind. His wife could be asked to wait for him
some distance outside the home, allowing him to experience going out in public as
movement towards safety. Through both operant conditioning (with travel as the desired
behavior and his wife as a positive reinforcer) and by encouraging exposure (with the
associated disconfirmation), this method would ultimately help eliminate his avoidance
and anxiety in a wider variety of circumstances.
Supporting the proposition that safety behaviors can usefully be integrated with
exposure treatment are two studies adding an element of escape to a validated exposure
paradigm for agoraphobia. In one (de Silva & Rachman, 1984), subjects were told to
terminate exposure as soon as their fear reached a predetermined high level; in another
(Rachman, Craske, Tallman, & Solyom, 1986) they were told to leave but return when
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their fear had decreased to a predetermined low level. These experimental groups showed
fear and avoidance reduction equal to or greater than that of exposure-only controls.
Smits and Telch (2000) found similar effects for safety behaviors in the realm of simple
phobias, using a graded-exposure treatment for spider-phobia. Subjects viewed,
approached, and eventually touched a large spider, with the option of wearing various
pieces of protective gear or choosing to leave the situation if they felt too anxious.
Groups with and without these safety behaviors available showed no difference in
reduction of fear or disgust at post-treatment or two-week follow-up.
The studies reviewed above offer theoretical and empirical support for the
proposition that safety behaviors may be integrated with exposure therapy. Allowing
subjects to reduce their immediate feelings of fear would be beneficial in improving
compliance with exposure therapy, which is understandably unpleasant.
However, closely-related procedures have also produced contrasting results. A
paradigm similar to Smits and Telch’s (2000) which used claustrophobic subjects
produced significantly less fear reduction when subjects were permitted to stand near an
escape route, talk to the experimenter, or open a small window (Sloan, 2000). Salkovskis,
Clark, Hackmann, Wells, and Gelder (1999) compared exposure in which agoraphobic
subjects were permitted to maintain already-present safety behaviors with exposure
including specific instructions not to engage in safety behaviors. Eliminating safety
behaviors led to a greater reduction in anxiety and catastrophic beliefs. Similar results
were achieved by Wells, Clark, Salkovskis, Ludgate, Hackmann, and Gelder (1995) using
a within-subjects variation: trials in which subjects were allowed to use their safety
behaviors produced less reduction in anxiety than trials in which safety behaviors were
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prohibited. Soltysik, Wolfe, Nicholas, Wilson, and Garcia-Sanchez (1983), experimented
with an animal conditioning model, in which cats learned that several CSs preceded
shock. A large number of extinction trials were then presented in which the CSs were not
paired with shock. Additionally, one “protected” CS was consistently paired with a new
stimulus, a CI (conditioned inhibitor). The cats showed a reduction in physiological
response to all of the CSs. However, when the protected CS was presented without the
CI, they reacted as if no extinction had taken place. Evidently, the CI kept the absence of
shock from being directly related with the CS. In an analogy with human anxiety, the CI
is a safety signal, and its use detracts from the disconfirmation one would expect when
the feared circumstances (the CS) are experienced without aversive results.
It is difficult to draw any general conclusions from the results discussed thus far.
Some combinations of safety behaviors, specific situations, and subject variables detract
from the effectiveness of exposure therapy, but very similar procedures have
demonstrated no such interaction. A review of current models for the effects of safety
behaviors is necessary to make the finer distinctions that will be necessary to determine
which behaviors will interfere and which will not.
Theoretical explanations for safety behavior effects
Two major safety behavior theories are distraction from evidence and
misattribution of safety:
The distraction hypothesis suggests that we cannot look merely at the objective
exposure scenario; we must evaluate the degree of functional exposure, based on both the
available evidence and the receptivity of the subject. As an extreme example, consider
two spider-phobic subjects, one alert and one in a coma. An exposure exercise that helps
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the first disconfirm his fears will obviously have no effect on the second. A more subtle
investigation (Grayson, Foa, & Steketee, 1982) exposed OCD subjects with fears of
contamination to two sessions with their most feared object. Subjects were forced to
concentrate on and talk about the feared object in the first session, and were distracted
with video games in the second; a second group received the treatments in the opposite
order. Groups showed equivalent within-session anxiety reduction, but the ones who
received distraction first returned to a high level of fear on the next session, while the
group instructed to focus on the object maintained its gains. Craske and Rodriguez (1994)
report similar results for distracted vs. focused exposure in agoraphobia, suggesting that
the need for attention as well as mere presence generalizes across types of anxiety and
exposure. Distraction from the feared stimulus thus appears to be sufficient, if not
necessary, for the detrimental effects of safety behavior utilization to occur.
Additional evidence for the distraction hypothesis comes from manipulations that
heighten attention. In addition to a safety behavior and a no-safety-behavior group,
Sloan's (2000) claustrophobia study included a “guided threat reappraisal” (GTR) group
in which subjects not only had no safety aids, but were explicitly encouraged to "focus on
their perceived threat… and to look for evidence that would weaken their belief in the
threat” (70). As distraction theory would predict, increased focus on threat produced even
greater treatment gains than were observed in the group given no safety aids and no other
instructions. Furthermore, these gains showed the same pattern as in the studies above:
in-session fear reduction was equivalent among the three groups, but maintenance at
follow-up was lowest for the safety aid group and highest for the GTR group. It appears,
then, that acute anxiety reduction occurs on a preattentive level, similar to simple sensory
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habituation. More clinically-relevant long-term anxiety reduction requires cognitive
involvement in exposure and suffers when the subject’s attention is divided.
Competing with distraction theory is Salkovskis’s concept of misattribution
(Salkovskis, 1991, Salkovskis & Clark, 1991), which also brings the focus from the
environment to the cognitive conceptualization of exposure. Subjects who use safety
behaviors do not experience disconfirmation because, in their understanding of the
situation, they did not experience safety. Rather, they had the experience of being on the
verge of a terrible disaster, which their prompt action was able to prevent. A woman with
panic disorder who is frightened when her pulse rises might respond by sitting down,
which she believes will prevent a heart attack. She is correct that she will not have a heart
attack, but rather than reassuring her the experience provides further evidence of the need
for constant vigilance and worry. Indeed, subjects with panic disorder report safety
behaviors which are plausible, though often technically incorrect, responses to their
individual fears: those who fear heart attack tend to request aid and decrease activity,
those who fear fainting hold on to things, and so forth. Few report mismatched or magical
anxiety-reducing behaviors (Salkovskis, Clark, & Gelder, 1996). It is important to note
that there is nothing inherently pathological about these safety behaviors, given the
subjects’ understanding of their situations. Their perceptions become destructive as a
result of the constant stress and restriction of activity induced when common and
innocuous stimuli are perceived as threatening (Salkovskis & Clark, 1991).
Attribution of improvement was probed directly in a study comparing daily
alprazolam, exposure, and combined treatment in panic disorder (Basoglu, et al. 1994).
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Among subjects who improved during the eight weeks of therapy, degree of relapse in
both drug and placebo groups was most strongly predicted by the extent to which they
attributed their gains to the medication. Consistent with the misattribution hypothesis,
subjects will apparently experience disconfirmation only if they do not have some other
explanation for safety. However, the generalizability of these results is questionable.
Many panic-prone individuals do use anti-anxiety drugs when they feel they may have an
attack, but this ad-lib usage differs from the scheduled regimen used in the study.
Experiments with more environmentally valid safety behaviors such as ad-lib
benzodiazepene usage, sitting still, and deep breathing have not directly probed
attribution, something which future studies should incorporate. Additionally, subjects in
the Basoglu study were asked to report the attribution for anxiety reduction that took
place over several weeks, rather than their safety in a specific situation. Studies
investigating misattribution have concentrated on attributions of safety rather than
attributions of fear reduction. Because some studies (e.g., Sloan, 2000) have shown that
subjects with safety aids may temporarily improve before relapsing, misattribution theory
would be significantly strengthened if such individuals also attributed their short-term
reductions in fear to having safety aids.
Both distraction and misattribution prevent subjects from being meaningfully
exposed to the CS. Under distraction, the subject is present but unable to fully process the
sensory information, thereby reducing its impact. Under misattribution, safety behaviors,
though subtle, actually have the same effect as escape. When subjects believe they are
actively preventing the feared outcome, they never learn that the aversive UCS (e.g.,
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passing out in public) will not follow the CS (symptoms of panic or an actual panic
attack) even without the safety behavior. The differences may be subtle: an individual
who avoided even tame dogs if they weren't leashed would be misattributing safety to the
leash, but one who focused attention on a dog's leash as a way of ignoring the dog would
be using distraction.
Weaknesses of current theories
It would seem a simple task to distinguish between evidence for the distraction
model and evidence for the misattribution model. Distraction models hypothesize that
anything that moves attention away from the feared stimulus will interfere with exposure,
regardless of its relevance to the situation. Misattribution models require no shift in
attention, but predict effectiveness only for behaviors that could be conceptualized as
somehow addressing the perceived threat. Yet despite the variety of experiments
discussed above, it remains difficult to find evidence that clearly and exclusively supports
one model or the other. Any evidence supporting misattribution can also be construed as
supporting distraction, because safety behaviors offer an alternative attentional focus.
Checking for signs of choking or working to move with exaggerated slowness can
distract from feared stimuli just as well as something entirely irrelevant. It may be that
distraction is the mechanism for interference, but misattribution is required for distraction
-- subjects may be unable to draw their focus away from a threat unless they feel they are
doing something to address it. Even the fear-behavior congruence found by Salkovskis,
Clark, & Gelder (1996) only demonstrates that subjects initially select their safety
behaviors because they think they will prevent disaster. The correspondence does not
necessarily indicate anything about why these behaviors can interfere with exposure.
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Along similar lines, Sloan (2000) argues that any experiment requiring safety
behavior withdrawal (e.g., Wells, et al. 1995; Salkovskis, et al. 1999) is inherently
manipulating attentional focus: when there are fewer options for focus, subjects are
bound to take greater notice of the threatening stimulus. Unfortunately, a similar problem
exists in the interpretation of Sloan's experiment, and emphasizes the difficulty of
independently manipulating attribution and attention. Although subjects in the control
group with neither safety behaviors nor GTR (Guided Threat Reappraisal, the technique
used to heighten attention) did not have any safety aids provided, they were left free to
use any pre-existing, idiosyncratic techniques, and such use was not assessed. The
assumption that they differed from the GTR group only in terms of attention, then, is
unfounded. They may have experienced a degree of misattribution, which GTR would
have prevented. Similarly, their difference from the safety behavior group would then be
in the type of safety behaviors used, rather than their presence or absence. Resolving such
confounds will require that subjects in all conditions be prevented from using any safety
behaviors except for those provided. This will ensure that only the prescribed safety
behaviors influence the results.
An experiment designed to compare misattribution and distraction hypotheses
would require a clear distinction between plausible and implausible safety behaviors,
which may require more subtlety than is readily apparent. Many panic subjects’ feared
catastrophes are entirely mental. A common error is to misinterpret an anxiety-induced
feeling of unreality as a sign that one is about to go mad, and to attempt to prevent this by
asserting control over one’s thoughts. Focusing on an irrelevant stimulus or cognitive
task could then be given credit for continued sanity. Even simple phobias may have such
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a “fear-of-fear” element; in spider-phobia there is a strong correlation between fear and
disgust towards spiders that is independent of the belief that spiders can cause harm of
any kind (Armfield & Mattiske, 1996). Many spider-phobics endorse the statement “if I
can’t escape from the spider I will go insane” (Salkovskis, 1991), again showing a fear of
their reactions which is unrelated to the spider's behavior. Subjects whose fear is
primarily of this type might attribute safety to any distracting behavior. A design using
behaviors intended to be purely distracting risks having its results obscured by these
subjects, whose prevalence in the population is unknown. Nonetheless, the simple
phobias are considerably more externally-directed than other anxiety disorders, and thus
provide a clearer window into the distinct features of behaviors that are distracting as
contrasted with behaviors that seem to provide safety.
A further difficulty in testing the two models of safety behavior interference is
that they are by no means mutually exclusive. Both may be active concurrently, and any
interaction is not easily predictable from theory. It may be that both attentional focus and
lack of an alternate explanation for safety are required for disconfirmation to occur.
Alternately, distraction may interfere with gathering disconfirmatory evidence, but
interfere equally with gathering the misperceived confirmatory evidence that contributes
to continued fear and misattribution of safety. It may also be, as argued above, that aids
to which safety can be misattributed have greater potential to distract from the feared
stimulus than ones that seem irrelevant.
Finally, the distinction between the two models may not be as strong as it seems.
As the GTR evidence (Sloan, 2000) indicates, distraction is just one manifestation of a
larger attentional variable, which can be lowered by distraction or raised by intentional
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concentration. Furthermore, this variable can be reconceptualized as dealing with locus
rather than quantity of attention, with distracting behaviors moving focus away from the
feared stimulus. But even a "purely misattributional" behavior (i.e., one requiring little
thought or effort) may lead to a refocusing of attention on the behavior's ability to
forestall the feared disaster. This is consistent with both hypotheses: attention is not
focused on the feared stimulus and its failure to cause harm, while its new focus is
generating the danger-confirming perceptions which fuel misattribution.
Escape vs. coping: an alternate distinction
Rather than blaming the complex entanglements between misattribution- and
distraction-linked behaviors on our experimental methods, it may be that this is not the
correct primary distinction to use. Because the basic mechanism of both distraction and
misattribution is interference with the gathering of disconfirmatory evidence, we should
consider first trying to distinguish between safety behaviors that interfere and those that
do not. De Silva and Rachman (1983) found anxiety reduction in agoraphobic subjects
who were removed from exposure at high levels of anxiety. They speculate that this lack
of interference may have been due to the relatively small number of trials on which
subjects actually escaped. That is, in some trials subjects used the safety behavior of
escape, which certainly would prevent the observation of disconfirmatory evidence. But
in the majority of cases, they simply knew that they might escape. Knowing that one's
anxiety will not be allowed to become unbearable clearly does not interfere with
exposure to disconfirmatory evidence, but it could easily reduce anxiety. Smits and Telch
(2000) gives a similar explanation for his findings of no interference by suggesting that
safety behavior utilization subjects might not have attributed the spider's failure to bite to
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their protective gear. Armored subjects might feel less anxious due to reduced
expectation of harm or disgusting contact if they are attacked, but their protection does
not stop them from seeing that the spider has no intention of doing so.
Another precursor to this alternate distinction appears in discussions of
misattribution (e.g., Salkovskis, Wells, & Gelder, 1996), which frequently note that
subjects may be permitted to retain comforting behaviors as long as they acknowledge
that they provide a feeling of safety as opposed to actual protection from harm. However,
these discussions frame the distinction as entirely cognitive, related to subjects'
understanding of their own actions. They do not deal with the possibility that some
behaviors are more amenable to anxiety reduction and others to misattribution of safety.
It is true that panic subjects might view breathing deeply in response to anxiety as either a
chance to collect their thoughts or as a necessary response to prevent themselves from
going berserk. However, subjects who respond by taking an alprazolam tablet are in a
similar position to our comatose spider-phobic. Completely eliminating their anxiety also
eliminates the relevance of the potentially disconfirmatory evidence. If the use of
medication offers a clear and correct rationale for the absence of fear, they have no
reason to consider the possibility that the situation might be inherently benign. They can
reassure themselves that they were never in any real danger, and indeed such educational
interventions can help immensely (Salkovskis & Clark, 1991). In terms of effects on
simple exposure, though, this type of behavior is clearly counterproductive.
Interference with the gathering of disconfirmatory evidence is a critical
determinant of whether a behavior will interfere with exposure. Whether this will occur is
affected by both the nature of the behavior and the subject's understanding of the
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behavior's function. This study seeks to formalize this new distinction between safety
behaviors: escape behaviors are ones that hinder or prevent the acquisition of
disconfirmatory evidence; coping behaviors do not. Thus, a spider-phobic who leaves the
room and one who shuts his eyes and ears until the experimenter removes the spider
would both be employing an escape behavior; one who wore a suit of armor or observed
from behind a glass barrier could see that attack was not imminent, and so would be
employing a coping behavior. The term "escape" is something of a misnomer because it
is quite possible for subjects to remain in the presence of the feared stimulus; it is used to
emphasize the fact that, whether physically or cognitively, they are no longer exposed to
the specific situation they fear.
Most distraction behaviors can be reframed as mild escape behaviors, which
prevent the subject from attending to disconfirmatory evidence. However,
misattributional behaviors may be either escape or coping. The protective gear in the
previous paragraph would be considered a misattribution-type aid, because it would keep
the subject safe in the event of an attack. Asking the experimenter to restrain the spider,
which is also misattributional, is an escape behavior because it does not provide any
opportunity for disconfirmation. The escape-coping distinction is between behaviors that
provide safety contingent on the non-occurring disaster and those that seem to actually
forestall the disaster.
Reconceptualization of past studies
These new categories lead to a more complex hypothesis regarding safety
behavior effects on exposure: escape behaviors should hinder long-term fear reduction;
coping behaviors should not. By dividing behaviors this way, the apparently
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contradictory results of previous studies can be reconciled. Sloan (2000) separated
attention and attribution of safety, but the safety-behaviors group had several options,
among which were both escape and coping behaviors. Subjects who stood near the door
were still in the situation and disconfirming their fears of suffocation; those who opened a
window actually let in air, changing the situation so that it was no longer the one they
feared. Smits and Telch’s (2000) safety behavior subjects who chose to leave the room
were obviously escaping, while those who opted to wear galoshes and goggles were using
coping behaviors. There may have been some interference with exposure among subjects
who primarily or exclusively used escape behaviors. However, analysis of differential
effects of safety behaviors was not provided and, because subjects had many
opportunities to utilize different behaviors, may not be possible.
Rachman’s findings of improvement in agoraphobic subjects who were allowed to
escape when anxiety was high (1986) may be due to the fact that his “escape” was
actually a coping behavior. Subjects retreated to a safe distance that did not entirely
remove them from the (individualized) exposure situation. They may have viewed this
experience as remaining exposed with a reduced level of anxiety. Another potentially
significant element is the manner in which escape was triggered: subjects were regularly
asked to report their fear on a SUDS (subjective units of distress) scale ranging from zero
to 100, and told to “escape” after reporting a 70. These levels were predetermined and
applied across the board to all subjects. For many, the time required for anxiety to reach
this level may have provided ample opportunity to gather disconfirmatory evidence.
Recalling the evidence that there is a strong cognitive, between-sessions element to longterm fear reduction (Grayson, Foa, & Steketee, 1982; Sloan, 2000; Craske & Rodriguez,
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1994), there is no reason to assume that failure to reduce in-situation anxiety on a single
exposure trial indicates a failure of exposure to operate on the more general level.
Studies that involved the cessation of already-present safety behaviors
(Salkovskis et al., 1999; Wells, et al., 1995) require little reinterpretation to fit into this
model. Indiscriminate removal of safety behaviors clearly includes removal of all
deleterious ones. The success of these methods merely provides confirmation for the
unsurprising proposition that people who have long-term anxiety disorders tend to use
safety behaviors that do not contribute to their resolution.
This perspective also offers an opportunity for a rapprochement with Rachman's
work on safety-signal theory (1983, 1984). If a safety signal is conceptualized as similar
to a safety aid, then neither misattribution nor distraction would predict any benefits from
its use. Rachman's suggestion that allowing subjects to travel towards home or loved ones
would be either harmful or irrelevant. But if the knowledge that a feeling of safety awaits
at the end of the exposure task merely reduces anxiety, then having this knowledge is a
coping safety behavior, and such an arrangement can be seen as a positive aid to
exposure.
One remaining complication is that if subjects fear their own reaction to anxiety,
any behavior that reduces anxiety will constitute an escape. The need to carefully
distinguish fear of external disasters from fear of fear remains. Subjects must still be
probed to determine the exact nature of their concerns and the function of their safety
behaviors, and studying simple phobias is still preferable to studying panic disorder,
which is fundamentally a fear of physiological fear reactions.
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The current study
In summary, a study designed to investigate this new model should supplement
the standard manipulations of safety behaviors with the following:
1) Use of simple phobias to reduce the escape properties of anxiety reduction,
2) Probing of attention to ensure that ostensible coping behaviors do not constitute
an escape from the feared stimulus via distraction,
3) Probing of covert or idiosyncratic safety behaviors used in all conditions,
4) Probing of subjects' attribution of safety immediately following exposure,
5) Distinction between fears of external disasters and fears of reactions (e.g.,
going mad in response to anxiety).
The current experiment combines these refinements in a study of spider-phobic
subjects, comparing long-term reductions in fear and avoidance among three groups:
escape behavior utilization, coping behavior utilization, and no-safety-behavior control.
All subjects were exposed to spiders for a period of time sufficient for their fear to
decrease. Their anxiety on approaching a spider was assessed with a behavioral approach
test (BAT) prior to treatment, post-treatment, and at two-week follow-up. On all three
assessment occasions, subjects also completed questionnaires dealing with specific fears
regarding spiders to provide additional information about their anxiety and test the
accuracy of their knowledge about spider behavior.
During exposure, but not during the BAT, the subjects in the coping behavior
group were given a shield to keep the spider from touching them. Thus they were
protected from the potential of attack, but were free to observe the spider’s behavior.
Escape behavior subjects were instructed to use a long-handled plastic cube to trap the
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spider from a distance. Control subjects were exposed under the same conditions but had
no safety behavior prescribed. All three groups were instructed to focus their attention on
the fact that a spider was present and not told to take any actions other than those
explicitly mentioned.
That the subject is holding a shield should have no plausible effect on the spider's
behavior. Thus, subjects’ perceived sense of safety should not have interfered with their
ability to see that the spiders were peaceful and lethargic. The two shields should offer
equal degrees of protection, making subjective assessment of their protective quality
equal. Subjects in both conditions engaged in a safety behavior that could be credited
with keeping them safe from harm, so the potential degree of misattribution was constant.
The instruction to focus on the spider's presence (along with probing of attention to
ensure that it was effective) equalized attention as well. If subjects in the escape
condition show any less reduction in fear, the critical factor must be their inability to
observe the spider’s natural behavior-- that is, the ability of the safety behavior to block
disconfirmatory evidence.
It was hypothesized that:
1) The groups would show no significant differences in attentional focus or
utilization of covert safety behaviors,
2) the two experimental groups (coping and escape) would show no differences in
attribution of safety to their safety behaviors or sense of threat from the spider.
3) subjects in the escape behavior group would show less reduction in fear of spiders
at follow-up than subjects in the other two groups,
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4) subjects in the escape behavior group would show less improvement in their
knowledge of how spiders can be expected to act than subjects in the other two
groups, and
5) if subjects in the coping behavior group showed less long-term fear reduction than
subjects in the control group, their fear reduction would still be greater than that
in the escape behavior group.
If the hypothesized differences between groups bear out, they will support the
current conceptualization and provide evidence against the distraction and misattribution
hypotheses.
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Methods
Design:
Spider-phobic subjects received 15 minutes of self-guided graduated exposure to
a large tarantula in one of three conditions: escape behavior utilization, coping behavior
utilization, and no-safety-behavior control. Subjects' spider-related anxiety was assessed
with a Behavioral Approach Test (BAT) prior to treatment, at post-treatment, and at twoweek follow-up. Prior to each BAT, subjects completed questionnaires dealing with
specific fears and beliefs regarding spiders in order to provide additional information
about their anxiety, expectations, and degree of disconfirmation.
Subjects:
Subjects (n=10) were drawn from a large (n=~500) pool of introductory
psychology students at the University of Texas at Austin, and received course credit for
participation. In the current pilot study, all subjects were white females. A larger spiderphobia study at the same university indicates that in a larger sample, all subjects will be
female but ~50% will be non-white (Smits & Telch, 2000).
Due to failure to attend all sessions of the study, only eight subjects provided data
on treatment, and only seven provided data at follow-up. It would be inappropriate to
attempt a full analysis on a population of this size, but they can be used for manipulation
checks and to tentatively assess the effectiveness of treatment.
Measures:
All non-standard measures are reproduced in Appendix A.
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Self-report questionnaires, BAT
Armfield and Mattiske’s Disgust Scale (Armfield and Mattiske, 1996): This test presents
8 statements about the disgust-provoking aspects of spider and spider behavior. The
subject rates each statement on a scale from 0 (strong disagreement) to 6 (strong
agreement). Scores range from 0 to 48, with higher scores indicating a greater feeling of
disgust towards spiders.
Spider Belief Questionnaire (SBQ): The SBQ (Arntz, Lavy, Van den Berg, & Van
Rijsoort, 1993) measures the strength of various beliefs related to spiders. Subjects rate
their belief in 42 spider-related statements dealing with qualities such as unpredictability
and potential to cause harm. They also rate 36 statements about their own predicted
behavior, involving responses such as panic and paralysis. All ratings are on a scale from
0% (no belief at all) to 100% (complete belief). The total score ranges from 0 to 100,
with higher scores indicating a greater fear of spiders and of one’s responses to spiders.
Fear of Spider Questionnaire (FSQ): The FSQ (Szymanski & O’Donohue, 1995) focuses
on current thoughts and reactions to spiders. Questions include " currently, I sometimes
think about getting bit by a spider" and "I would feel very nervous if I saw a spider now."
Subjects rate 18 statements about spider fear on a scale from 0 (strongly disagree) to 6
(strongly agree). The total score ranges from 0 to 108, with higher scores indicating a
greater fear of spiders.
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Spider Phobia Questionnaire (SPQ): The SPQ (Watts & Sharrock, 1984) probes subjects'
reactions to spider fear on a number of subscales: vigilance, preoccupation, avoidancecoping, and cognitive-behavioral. Questions include "do you make very sure there are no
spiders around before taking a bath" (vigilance) and "are you sometimes distracted by
thoughts about spiders" (preoccupation). Subjects answer 33 questions with “yes” or
“no,” earning one point for each “yes” response. Scores range from 0 to 32, with higher
scores indicating a greater fear of spiders.
Self-report Questionnaires, Treatment
Reaction to Treatment Questionnaire (RTQ): After learning the treatment rationale and
GTR procedure, subjects will be asked four questions regarding their confidence in the
proposed treatment. Ratings will be on a scale from 0 (no confidence) to 10 (extreme
confidence).
Attentional Focus Questionnaire (AFQ) (Smits & Telch, 2000): Following the exposure,
subjects will be asked to rate the degree to which they were focused on the presence of
the spider, on their use of the shield, and on other distractors. Attention will be reported
on a scale from 0 (complete ignorance) to 4 (complete focus).
Spider Threat Questionnaire (STQ): Composed predominantly of items from the FSQ, the
STQ asks subjects to rate their fear of 12 possible outcomes of exposure, including both
extrinsic (“the spider will bite me”), intrinsic physical (“I will lose control of my
bladder”), and intrinsic emotional (“I will panic”) consequences.
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Safety Behavior Attribution (SBAI and SBAS): At the end of the exposure session,
subjects will be asked to report any idiosyncratic safety behaviors they used and to what
extent they believe these behaviors prevented each of the outcomes in the STQ.
Additionally, subjects in the two experimental conditions will be asked the same
questions about their use of the shield. Ratings will be on a scale from 0 (no belief) to 6
(complete belief).
Subjective indices, BAT and treatment
Self-Efficacy: Subjects will be asked to report their confidence that they can carry out the
exposure tasks immediately before entering the room with the spider (see procedure,
below). Ratings will be on a scale from 0 (no confidence) to 10 (complete confidence).
Fear: Subjects will be asked to report the highest level of fear they expect to feel before
beginning a task. Afterwards they will be asked for the highest level of fear they actually
experienced, and the level of fear they experienced at the end of the trial. Fear will be
reported on a scale from 0 (no fear) to 10 (most extreme fear possible).
Disgust: Subjects will be asked to report the highest level of disgust they expect to feel
before beginning a task. Afterwards they will be asked for the highest level of disgust
they actually experienced, and the level of disgust at the end of the trial. Disgust will be
reported on a scale from 0 (no disgust) to 10 (most extreme disgust possible).
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Other measures, BAT and treatment
Duration: The length of time the subject is able to remain in the room during the BAT or
exposure trial.
Heart Rate Reactivity: While the subject is exposed to the spider, heart rate will be
measured by an ambulatory heart rate monitor (Polar™ heart monitor, model M21, Polar
Electro Oy, Finland). Heart rate reactivity is defined as average heart rate during
exposure minus a baseline reading taken after the exposure and a period of rest.
Procedure:
Screening
All potential subjects completed the FSQ and answered the extra question "Could
you walk into a room containing a tarantula in an aquarium, remove the lid from the
aquarium, and touch the tarantula." Subjects with a 54 or higher on the FSQ and a 3
(severe anxiety) or 4 (could not do) on the tarantula question were invited for further
screening.
In the second stage, subjects were told they would be exposed to a tarantula and
shown a picture of the species. They then completed computerized versions of the selfreport questionnaires (see measures, above) and took the first behavioral approach test
(BAT - baseline; see below). Subjects who chose to terminate exposure on at least one
BAT before two minutes elapsed or who rated their peak fear during the BAT as 7 or
higher were invited to participate in the treatment phase.
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Behavioral Approach Test - baseline
The behavioral approach test exposed subjects to a live Chilean Rose tarantula
(species: Grammostola Rosea; body length approximately 4 cm; body width
approximately 2.5 cm). The spider was placed in the center of the exposure room
(approx. 2m X 3m). Subjects were instructed to enter the room and remain there as long
as they could. They were told that the test ended when they asked to leave, or when two
minutes had passed. The experimenter observed from outside, through a glass panel in
the door.
Before entering the exposure room, subjects reported their Self-Efficacy,
Expected Peak Fear, and Expected Peak Disgust (see measures, above). Afterwards, they
reported both Peak and End ratings for Fear and Disgust. Heart rate was recorded at 60s
intervals and at the beginning and end.
After the first trial, a second test was administered using a Mexican Redknee
spider (species: Brachypelma Smithi; body length approximately 2.5 cm; body width
approximately 1.5 cm). Subjects were asked to stand at the center of the room, and told
that the spider would enter off a ramp through a hole in the door. Their task was to wait
until the spider left the ramp, and then maintain a constant distance from the spider for as
long as possible. The test ended when subjects asked to leave, or when two minutes had
elapsed since the spider reached the floor. Subjects were also instructed that the test
would end if they changed the distance between themselves and the spider, although the
experimenter actually issued two warnings first. The hole in the door was at ~0.3m in
height, and the ramp ended ~0.7m in front of the subject. The spider was placed on the
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ramp by the experimenter, out of sight of the subject, and squirted with water from a
spray bottle to encourage it to walk down.
In both BATs, the experimenter entered at the end of the test and trapped the
spider in a box while the subject left the room. This and other steps were taken to ensure
that the tests and treatment did not involve any inadvertent modeling therapy.
After the second trial, the subject was told that they would not see any more tarantulas
that day, and instructed to sit and relax for one minute. They then stood for thirty
seconds, and their baseline heart rate was recorded.
Subjects admitted to the next phase were randomized into one of three treatment
groups: escape behavior utilization, coping behavior utilization, and no-safety-behavior
control. They returned the next day for treatment.
Exposure treatment took place the day following the baseline BAT. Subjects were
given a brief educational handout on spider and tarantula anatomy and behavior. They
then read an explanation of exposure treatment based on the disconfirmation model. The
rationale specifically discussed the dangers of distraction and misattribution, and
instructed subjects to refrain from distracting themselves or doing anything to make
themselves feel safe. Subjects in the coping and escape groups were given a description
of the shield they would be using, but were assured that they would be completely safe
even without it. No mention was made in any condition of safety behaviors or their
proposed effects. After reading the rationale, subjects completed the Reaction to
Treatment Questionnaire.
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Exposure - no-safety-behavior condition
Measures were the same as in the BAT (Self-Efficacy, Peak and End Fear, Peak
and End Disgust, and Heart Rate Reactivity). The tarantula and the procedure used were
the same as in the second BAT trial, except that the test ended three minutes after the
spider reached the end of the ramp. Subjects received a total of fifteen minutes of
exposure, over a minimum of five trials. If the subject terminated a trial early, they
completed extra trials until they amassed fifteen minutes of exposure. At the end, their
baseline heart rate was recorded as in the BAT. They then filled out the AFQ, the STQ,
the SBAS (coping and escape conditions only), and the SBAI.
Exposure - coping behavior condition
The coping behavior condition was identical to the no-safety-behavior control,
except that subjects were given a wooden "shield" and instructed to use it to stop the
spider from touching them. The shield was in an inverted T-shape, ~30cm X 130cm at
the top and 100cm X 30cm at the bottom.
Exposure - escape behavior condition
The escape behavior condition was identical to the no-safety-behavior control,
except that subjects were given a clear plastic cube (~12cm) with a long wooden handle
(~1.7m). They were instructed to wait until the spider left the ramp, and then use the box
to trap the spider. They maintained the same distance from the spider as subjects in other
conditions. When the trial ended, the experimenter took the handle and kept the spider
trapped until the subject left the room.
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BAT - post-treatment and follow-up
The BAT - post-treatment was administered on the day following exposure, and
the BAT - follow-up at two weeks after exposure. Both were identical to the BAT baseline. Due to the length of time between the post-treatment and follow-up BATs,
subjects were given contact information for the study supervisor at post-treatment and
instructed to call if they experienced any continuing discomfort. However, they were not
fully debriefed until after the final BAT.
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Results
Manipulation Checks
The three conditions in the current study are designed to differ in the access they
provide to disconfirmatory information. There is the danger that they also differ in other
factors that affect fear reduction. In order to check for confounds, test results were
analyzed to check for between-group differences in treatment plausibility, attention, sense
of threat, and idiosyncratic safety behaviors. In addition, the two safety behavior groups
were compared on attribution of safety to the shield.
Treatment plausibility was assessed with the RTQ, administered just after subjects
read the rationale. Analysis of variance finds no significant difference between groups in
acceptance of the treatment (F(2,5)=0.84, p=0.48).
Attention was measured using the AFQ. The AFQ was split into two subscales,
one dealing with attention to the spider (AFQ-s) and one with attention to irrelevant
distractors (AFQ-d). ANOVA shows no difference in attention to distractors
(F(2,4)=1.24, p=.38). However, there was a significant difference in attention to the
spider between the escape group (M =4.50, SD=0.29) and the control group (M=3.67,
SD=0.71) (F(2,4)=10.00, p=0.03).
The SBAI was used to assess attribution of safety to idiosyncratic safety
behaviors. Most subjects engaged in some mental behavior, such as distraction or
reassurance. None reported any tangible aids or behaviors that they might have credited
with their physical safety. ANOVA finds no significant between-groups differences
(F(2,5)=0.79, p=0.50). Mean score across groups was 1.77 out of 7 (SD=2.09). Because
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several questions on the SBAI received scores of 0 or 1 from most subjects, a second
ANOVA was done on the subset of questions that received at least two answers greater
than 1. This raises the mean score to 2.20 (SD=2.25) but does not reveal any betweengroup differences.
The two experimental groups were compared on attribution of safety. ANOVA on
SBAS scores demonstrates no differences in attribution of safety (F(1,3)=3.68, p=0.60).
Mean score across groups was 2.9 out of 7 (SD=1.16). The low-scored questions on the
SBAI received similar responses on the SBAS. Again, this subscale showed no difference
between groups (F(1,3)=0.01, p=0.95), although it raised the mean score to 3.64
(SD=0.80). Further references to the SBAI and the SBAS will use this subscale.
ANOVA on the STQ (F(2,5)=0.28, p=0.69) reveals that subjects in all three
conditions felt equally threatened by the spider (M=2.75, SD=0.55). Extracting the same
questions as on the SBAI subscale raises the mean to 3.8 (SD=0.87), but does not change
the between-group comparison. Because the response patterns were not as clear as on the
safety behavior attribution tests, the entire STQ will be used in further analysis.
Outcome measures:
The basic treatment design showed effectiveness across all groups. Average fear
was 6.64 out of 9 (SD=1.38) during the first BAT session and 2.17 (SD=2.30) at followup. This is a significant difference (t(5)=3.80, p=0.01). Average disgust also reduced, but
was not significant.
Differential treatment effectiveness was analyzed using change in fear and disgust
between the beginning and end of treatment and between the pre-test and follow-up
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BATs. Questionnaire responses were also used. Nearly all subjects were able to stay for 2
minutes during the initial BATs, and all stayed for 2 minutes during every post-treatment
BAT. Thus, duration data are not analyzed. End fear and disgust and heart rate data were
not collected for most of the pilot and could not be used, but will be included in the
analysis of the full experiment.
ANOVA on the fear and disgust measures found significant differences only for
treatment disgust (see table 2). Average change between the first and last trials was –0.33
(SD=0.58) for control subjects, and –3.30 (SD=0.99) for coping behavior subjects
(Fisher’s PLSD=2.97, p=0.02). A similar but non-significant trend is present for BAT
disgust. There is a significant correlation (r(5)=0.76, p=0.05) between treatment disgust
and BAT disgust, and a nearly significant correlation (r(5)=0.72, p=0.07) between
treatment fear and BAT fear.
ANOVA on SBQ scores showed no significant difference between groups
(F=2.45, p=0.20).
None of the tests show significant correlations with one another or with subjective
outcome measures (see table 3). The sole exception is that the SPQ correlates very
strongly with treatment fear (r(5)=0.95, p<0.001).
Discussion
Manipulation check:
The lack of difference in RTQ scores indicates that subjects in different groups
found the treatment rationale equally believable. There is some potential for confusion in
the fact that the experimental subjects were told that their situation was harmless, yet they
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were also given tools for dealing with the spider. Apparently they did not independently
conclude that safety behaviors might interfere with gathering disconfirmatory evidence.
This lack of information was useful in establishing the experimental manipulation, but
probably contributed to their long-term spider-phobia. The established effects of safety
behaviors on exposure, as well as the experimental hypotheses, were explained to the
subjects at debriefing.
All groups showed equal attribution of safety to idiosyncratic safety behaviors.
The SBAI includes both external outcomes (e.g., "the spider did not bite me") and
internal ones (e.g., "I did not panic"), so even behaviors with purely subjective value
should have been noted. This equivalence indicates mitigates any concern about control
subjects making relatively greater use of covert safety behaviors. There was a nonsignificant trend towards greater covert safety behavior use in control subjects, but this
was the product of a single subject. She was the only one to receive an early version of
the test, which may have had unclear directions, and when her data are removed the trend
disappears.
The SBAS scores show that subjects felt the two types of shield were equally
effective in preventing feared outcomes. This is desirable, as it restricts the difference
between the two experimental groups to their access to disconfirmatory information.
On the response scale used by the subjects, the SBAI mean of 2.2 approximates a
response of "disagree" to the statements about the safety behavior preventing harm. The
SBAS mean of 3.6 is between responses of "slightly disagree" and "not sure." Thus,
while the experimental subjects may have experienced some degree of misattribution of
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safety it should not be high enough to prevent any improvement, and its effects will be
equal across the two groups.
The similarity between STQ scores is encouraging in that it further reduces the
differences between the escape and coping groups. However, it is puzzling that there is
also no difference between the experimental groups and the control groups. The SBAS
indicates that the shields are mildly plausible as sources of safety, so they should provide
some reduction in expectation of negative outcomes. It may be that by the end of the
exposure session, the control subjects had amassed sufficient experience to intellectually
refute any fears they had. This does not mean that they would be convinced in the longterm, or that their beliefs would not reappear during subsequent exposures to novel
spiders. It would be informative to administer the STQ before treatment and between
trials, to track the progress of any disconfirmation that is occurring.
Between-group differences on the AFQ present the only potential problem with
comparisons. Control subjects reported greater attentional focus on the spider, evidently
due to the lack of need to focus on a shield. This might be remedied by giving all subjects
stronger instructions to keep their focus on the spider. In any case, there was no
significant difference between the experimental groups, meaning that they can still be
directly compared.
Outcome measures:
Little can be concluded from this pilot data about between-group differences.
However, it is clear that the subjects did experience significant reduction in spider fear,
without reaching a floor that would level out any between-group differences. Along with
the manipulation checks that show the conditions to be properly controlled, this indicates
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that the current procedure is suitable to uncover any differences that are introduced by the
experimental manipulation.
It should be noted that the .95 correlation between SPQ and treatment fear is not
characteristic of SPQ predictiveness in similar studies (e.g., Smits & Telch, 2000) and is
likely an anomaly.
Changes to final protocol:
These results suggest several changes for the final protocol.
1) Remove the irrelevant questions from the STQ, SBAS, and SBAI
questionnaires.
2) Administer the shortened STQ after each treatment trial in order to track
disconfirmation more precisely.
3) Since the few subjects who asked to leave the room during the initial BATs
did so in under 10 seconds, reduce the length of the BAT to 1 minute.
4) Collect heart rate and end fear/disgust data consistently enough to analyze
patterns in reduction.
Other changes to be made are:
1) Remove the duration of the BAT and treatment trials from the instructions, so
that subjects are not distracted or reassured by the amount of time remaining.
2) Create positive and negative versions of the SBA tests, asking subjects to rate
both (e.g.,) “because I had the shield, the spider did not bite me” and “if I had
not had the shield, the spider would have bitten me.”
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3) Make both BAT trials like trial 1, so that the only factor being varied is
spider-novelty.
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Tables
Table 1. Study population
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Entered Completed Completed
study
Treatment follow-up
Control 4
Coping 2
Escape 3
3
2
3
3
1
3
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Table 2. Experimental Timeline
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49
Screening - Spider-phobic subjects selected
Day 1 - Behavioral Approach Test (BAT) baseline. Subject completes questionnaires and
briefly approaches two tarantulas; degree of initial fear assessed.
Day 2 - Exposure treatment. Subject receives 15 minutes of exposure to tarantula.
Day 3 - BAT post-treatment. Subject completes questionnaires and briefly approaches
two tarantulas; degree of fear reduction immediately following treatment assessed.
Day 16 (approximately) - BAT follow-up. Subject completes questionnaires and briefly
approaches spider; maintenance of fear reduction assessed.
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Table 3. Analysis of Behavioral Outcome Measures
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Control
Coping
Escape
F**
*
M / SD
M / SD
M / SD
TF -3.33 / 3.51 -3.00 / 1.14 -3.33 / 0.58 2.92
TD -0.33 / 0.58 -3.30 / 0.99 -1.67 / 1.16 6.15
-4.17 / 1.53 0.13
BF -5.33 / 3.79 -4.50
-1.83 / 3.01 0.46
BD -1.33 / 3.69 -5.00
TF = change in peak fear between first and last treatment trials
TD = change in peak disgust between first and last treatment trials
BF = change in peak fear between pre-treatment and follow-up BATs
BD = change in peak disgust between pre-treatment and follow-up BATs
* Only one subject in this group provided follow-up data, so BAT measures have no SD.
** For treatment values, degrees of freedom are 2,5. For BAT values, 2,4.
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Table 4. Correlations Among Outcome Measures
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TF
TD
BF
BD
DISG FSQ
SBQ
+.27
TD
+.72 +.04
BF
+.64 +.76 +.56
BD
DISG -.43 -.09 -.01 -.21
-.23 +.16 -.43 -.14 +.54
FSQ
+.48 -.36 +.45
SBQ +.53 +.57 0
+.95 +.17 +.56 +.43 -.43 -.05 +.64
SPQ
TF = change in peak fear between first and last treatment trials
TD = change in peak disgust between first and last treatment trials
BF = change in peak fear between pre-treatment and follow-up BATs
BD = change in peak disgust between pre-treatment and follow-up BATs
Appendix A
Instructions and instruments
All materials were presented on a computer using a web-browser interface. The
tests displayed one question and a consistent set of responses on each page. Subjects
answered the question by clicking on a response. A “back” button was available to
change previous answers.
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54
Behavioral Approach Test:
This test involves spending time in a room with a live tarantula. First, we
need to fit you with a heart rate monitor that will allow us to collect data on
your pulse. Then you will look at a picture of the type of tarantula you will
be seeing.
Do not begin this test until you have done both these things.
[instructions for first BAT each session]
In a moment you will be asked to go into the room with the tarantula. You
should try to stay as long as you can, but you are free to leave at any time.
The goal of this part of the experiment is to determine how long you can
remain in the room. If you choose to leave, this will not be considered a
withdrawal from the experiment
[instructions for second BAT each session]
Now we will ask you to do another BAT with a different spider. In this one,
you will stand in the room while the spider is released into it. Once the
spider is on the floor, you need to try to maintain a constant distance from
it by moving back if the spider approaches you, or forwards if the spider
moves towards you. The test ends will end if you ask to leave the room, or
if you move closer to or farther from the spider.
If you have any questions, feel free to ask the experimenter. When you're
satisfied, press the button below to answer questions about your
expectations for this task.
[instructions for both BATs]
Please answer the following questions about your expectations for this
task. Answers are on a scale from 0 to 9, where 0 means "none at all" and
9 means "the most possible."
None
at all
0
_|_
1
_|_
2
_|_
3
_|_
4
_|_
5
_|_
6
_|_
7
_|_
8
1) How much confidence do you have that you can remain in the room
with the spider for two minutes?
2) How much fear do you expect to experience while you are in the room
with the tarantula?
3) How much disgust do you expect to feel while you are in the room with
the tarantula?
The most
possible
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[subject enters room with spider]
4) What was the highest level of fear you experienced while you were in
the room with the tarantula?
5) What was your level of fear at the end of the exposure ?
6) What was the highest level of disgust you experienced while you were
in the room with the tarantula?
7) What was your level of disgust at the end of the exposure ?
[instructions after both BATs are completed]
Thank you. You have completed the BAT and will not see any more
spiders today. Now that you can relax, we'd like to get a baseline heart
rate. Please sit in the chair and take a few deep breaths. The
experimenter will then ask you to stand up, and we'll collect data on your
normal pulse.
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Treatment Rationale:
The therapy that we use in this study, "exposure therapy," has a long
history of success in treating phobias of all kinds. When people who are
afraid of a thing undergo prolonged, uneventful exposure to it, they tend to
become less fearful. This is true regardless of whether their fear comes
from a past trauma or from having learned or heard something frightening,
or even if it has no identifiable cause at all.
The major theory explaining exposure therapy is disconfirmation. It
works like this:
1. People fear things because they think they will lead to some very
bad outcome -- for example, some people fear dogs because
they're worried about getting bitten, or they fear flying because they
are scared of being in a crash.
2. When people fear something that is actually very safe, such as
small rooms or airline flights, it's because they have incorrect
beliefs about bad things that can happen, or what the chances of
these things happening are.
3. If a fearful person spends time with the thing they fear, they will
be able to gather information that <I>disconfirms</I> their fears.
They will see that they aren't in danger after all.
One important element of the therapy is to make sure the subjects
really believe that they're safe. Otherwise, they might spend the entire
exposure session thinking they're on the verge of disaster, which just
increases their anxiety. The educational material you read should help you
understand that you don't have to be constantly on your guard when a
spider is around -- you can feel safe about feeling safe.
In order to reinforce this important information, your exposure session
will also include intentional focus on the spider. While you are in the room,
you should carefully observe the spider and pay attention to it. Don't do
anything to distract yourself or use any techniques or rituals that might
make you feel safer. Although this may help make the exposure easier, in
the long run it gets in the way of proving that you don't have to be afraid.
[following paragraph for coping condition only]
While in the room, you will have a shield with which to keep the
spider from touching you. However, it is important that you understand
that even without the shield, you would be in absolutely no danger.
Although you should use the shield in any way that makes you
comfortable, you should keep your attention focused on observing the
spider.
[following paragraph for escape condition only]
You will also have a shield that you can use to trap the spider from
a distance. However, it is important that you understand that even without
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the shield, you would be in absolutely no danger. You should keep your
attention focused on observing the spider.
Because spiders are generally peaceful and lethargic, we may have to
squirt the spider with water to make it approach you. Also note that you
may see the experimenter wearing gloves while handling the spider. This
is because picking it up quickly and repeatedly may, very rarely, make the
spider feel threatened. It does not mean that you, as an observer, are in
any danger.
It is very important that you understand this treatment and why it
works. Please feel free to ask the experimenter any questions you have.
While we can't tell you everything about the experiment until it's over, we
will do our best to make the theory and instructions presented here clear
to you.
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Reaction to Treatment Questionnaire:
On a scale of 1 (low) to 10 (high), please rate your reactions to the
explanation of treatment you have just heard. If you would like to go back,
just click on the "back to previous question" button. When you are ready to
begin, click on the button below.
Not
at all
0
_|_
1
_|_
2
_|_
3
_|_
4
_|_
5
_|_
6
_|_
7
_|_
8
_|_
9
Extremely
10
1) How logical does this type of treatment seem to you?
2) How confident would you be that this type of treatment would be
successful in eliminating your fear of spiders?
3) How confident would you be in recommending this treatment to a friend
who had a similar problem?
4) How successful do you feel this treatment would be in overcoming the
fear of spiders?
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Treatment:
In a moment you will go into a room with a tarantula for the exposure
treatment. Please put on the heart rate monitor from yesterday. If you have
any questions or concerns, please ask the experimenter
When you are done, click below to continue.
[experimenter shows treatment room to subject and answers any
questions]
1) How much confidence do you have that you can remain in the room with
the spider for three minutes?
2) How much fear do you expect to experience while you are in the room with
the tarantula?
3) How much disgust do you expect to feel while you are in the room with the
tarantula?
[exposure trial]
4) What was the highest level of fear you experienced while you were in the
room with the tarantula?
5) What was your level of fear at the end of the trial?
6) What was the highest level of disgust you experienced while you were in
the room with the tarantula?
7) What was your level of disgust at the end of the trial?
[repeat until 15 minutes of exposure are completed]
You're done with the exposure. There will be no more spiders today, so you
can relax. There are a few more tests to take, and then we'll get your baseline
heart rate.
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Attentional Focus Questionnaire:
For each of the following items, please rate the extent to which you paid
attention to it during the exposure session. Rate your level of attention by
choosing one of the options below:
I ignored it
completely
1
2
I paid some
attention
3
4
I paid
attention very
strongly
5
If you want to change an answer, just press the button marked "back to
previous question." The experimenter will be glad to answer any questions
you have. Otherwise, click on the button below to begin.
1) The spider's physical appearance
2) The way the spider acted
3) Other things in the room
[question 4 for escape and coping subjects only]
4) The shield or your use of the shield
5) Anything else you did or thought about
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Spider Threat Questionnaire:
The following section presents possible beliefs or thoughts that people
sometimes have when confronted with spiders. Please read each
statement carefully and then rate the extent to which you had the belief or
thought while you were in the room with the spider. Choose the
appropriate answer from the scale below.
0 - Strongly disagree
1 - Disagree
2 - Slightly disagree
3 - Not sure
4 - Slightly agree
5 - Agree
6 - Strongly agree
You can change any previous answer by clicking on the "back to previous
question" button. If you have any questions, the experimenter will be
happy to answer them. Otherwise, click the button below to begin.
1) The spider will bite me.
2) The spider will attack me.
3) The spider will harm me.
4) The spider disgusts me.
5) I will vomit.
6) I will lose control of my bladder.
7) I will lose control of my bowels.
8) I will become contaminated or infected.
9) I will go crazy
10) I will be unable to remain in control.
11) I will panic.
12) I will be unable to think clearly.
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Safety Behavior Attribution - Shield:
Next, we have some questions about things you might have done to
help deal with your anxiey during the exposure. Choose the appropriate
answer from the scale below.
0 - Strongly disagree
1 - Disagree
2 - Slightly disagree
3 - Not sure
4 - Slightly agree
5 - Agree
6 - Strongly agree
Note: If a question asks how much a behavior helped you
accomplish something, remember to rate how much the behavior helped,
not how well you accomplished the task in general. So, if a question were
"how much did your hair color help you learn calculus," the answer would
be low even if you're very good at calculus.
1) Because I used the shield, the spider did not bite me.
2) Because I used the shield, the spider did not attack me.
3) Because I used the shield, the spider did not harm me.
4) Because I used the shield, the spider did not disgust me.
5) Because I used the shield, I did not vomit.
6) Because I used the shield, I did not lose control of my bladder.
7) Because I used the shield, I did not lose control of my bowels.
8) Because I used the shield, I did not become contaminated or infected.
9) Because I used the shield, I did not go crazy
10) Because I used the shield, I was not unable to remain in control.
11) Because I used the shield, I did not panic.
12) Because I used the shield, I was not unable to think clearly.
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Safety Behavior Attribution - Idiosyncratic:
Next, we have some questions about things you might have done to
help deal with your anxiey during the exposure. Choose the appropriate
answer from the scale below.
0 - Strongly disagree
1 - Disagree
2 - Slightly disagree
3 - Not sure
4 - Slightly agree
5 - Agree
6 - Strongly agree
Note: If a question asks how much a behavior helped you
accomplish something, remember to rate how much the behavior helped,
not how well you accomplished the task in general. So, if a question were
"how much did your hair color help you learn calculus," the answer would
be low even if you're very good at calculus.
Did you consistently do anything to help you manage your anxiety? If so,
please describe all the things you did in the box below, using no more
than one sentence each. When you're done, click the "submit answer"
button.
If you did not do anything, click the "No Answer" button.
[If “no answer” is clicked, test ends.]
[Each question begins with:]
Because I did the following
[reported safety behavior]
1) the spider did not bite me.
2) the spider did not attack me.
3) the spider did not harm me.
4) the spider did not disgust me.
5) I did not vomit.
6) I did not lose control of my bladder.
7) I did not lose control of my bowels.
8) I did not become contaminated or infected.
9) I did not go crazy
10) I was not unable to remain in control.
11) I did not panic.
12) I was not unable to think clearly.
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Afterward
for Plan II
This is all part of my secret plan. I grant you, it’s also a stylistically and structurally
valid preliminary investigation for a large psychological treatment study that I will be running
next semester. But this is all easier and more exciting to follow if you realize what I’m up to
here.
Exposure therapy is probably the most powerful tool psychology has. If this paper
hasn’t explained it adequately, that’s because it’s easy to lose track of its beautiful simplicity:
expose a phobic person to something she’s afraid of, and after a while - given no mishaps she stops being afraid. Everything else is mechanisms, troubleshooting, and statistics.
Next semester, I will run a full study based on this pilot, and I will contribute some
of those statistics. Whether or not my hypothesis bears out, the result will be a better
understanding of how perfectly reasonable behaviors can sabotage recovery. The result will
be more effective therapy. The result will be psychological theories with more power and
fewer holes. The result will be more people who can make it through therapy and lead lives
unencumbered by irrational fear. Spider-phobia may not be life-changing, but it’s a start. In
this study, I helped a handful of freshman girls learn that they could stay in a room with a
tarantula. In the long term, I'm helping people who are terrified to go out in public, or
unable to meet new people, or thrown into convulsions with fear every time they feel an
irregular heartbeat. Of course the issues that arise with each individual anxiety disorder are
substantial. Imagine trying to map my procedure onto a population that's afriad of
thunderstorms. But every form of anxiety has its misconceptions, its avoidance, and its
safety behaviors. The similarities run deep.
That's the psychologist part of my thesis there. There's also a Plan II part:
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I want to throw psychology open to the public, as a way of dealing with everyday
troubles. Teaching kids to deal with destructive emotions should be as elementary as
teaching them to wash their hands after going to the bathroom. Worrying yourself sick about
whether you left the door unlocked should be considered more of a disease than a cute
quirk. Feeling spontaneously furious should cause you to sit down and figure out what's
really causing your feeling, rather than picking a fight with a nearby friend.
This is not to say that I want to eliminate all emotion! Quite the opposite -- I want us
to learn the difference between a real, important feeling and a transitory bad mood or
biochemical blip. I want our energy free to go into relationships with others, personally
satisfying long-term skills, and genuine, untroubled relaxation.
The first step is to make it clear how strongly psychotherapy involves the application
of reasonable, well-understood skills, skills everyone can try out on themselves. If the full
version of this study determines that some safety behaviors are acceptable, psychologists can
tell people to expose themselves to feared situations without looking like filthy sadists and
risking high dropout rates. If it appears that all safety behaviors are detrimental, at least
fewer self-improvement efforts will go to waste. Either way, I’m improving the public image
and the usefulness of the discipline.
Psychology makes sense. Use it! Go change your mind.
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About the Author
Michael Cohn was born in Slidell, Louisiana in 1978. He lived in Houston for
thirteen years, leaving in 1996 to attend the Plan II honors program at the University of
Texas at Austin. In 1998, he decided to his great pleasure that he had lived there long
enough to tell people that’s where he is “from.” He majored in chemistry for three
undistinguished semesters before moving to psychology. Those months when he spent more
time doing independent research in the library than he did in his actual classes suggest that
the new choice suits him better.
Michael co-founded the UT chapter of the Drug Policy Forum of Texas, and
provided research, copywriting, and web services for one and a half years. During his
sophomore year, he created a website dedicated to reducing harm from GHB, one of
America’s foremost demon drugs. It remains the best-researched, least propagandistic
resource for the lay public.
As part of his university’s anxiety lab, Michael has administered exposure treatment
to a great many dog-phobics and spider-phobics, and he considers it a credit that a
substantial proportion of the population doesn’t twitch and whimper when he walks across
campus. He will remain with the lab after graduation, working on WWW applications and
further anxiety reduction studies. He plans to enter a graduate program in clinical psychology
research in Fall of 2002.