Department of Psychiatry, Pusan National University College of Medicine, Pusan, Korea
Department of Psychiatry, Imperial College School of Medicine, London
Imperial College School of Medicine and King's College London
Siriraj Hospital, Bangkok, Thailand
Institute of Psychiatry, King's College London
Universidad de Chile, Santiago, Chile
Baghdad, Iraq
Correspondence: Professor Isaac M. Marks, Department of Psychiatry, Imperial College School of Medicine, Stress Self-Help Clinic, 303 North End Road, London WI4 9NS, UK. Tel: 0207 610 2594; fax: 0207 385 7471; e-mail: I.Marks{at}ic.ac.uk
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ABSTRACT |
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Aims Completion of such a follow-up.
Method Two-year follow-up was achieved in 68 (85%) of 80 patients with phobias who had completed a previous 14-week randomised controlled trial comparing therapist-accompanied self-exposure, self-exposure or self-relaxation. Measures were self-reported ratings of symptoms, satisfaction and use of other treatment.
Results Improvement at week 14 was maintained 2 years later. Clinician-accompanied exposure and self-exposure did not differ on any measure. Compliance with self-exposure homework during weeks 0-8 predicted more improvement 2 years later. Patients who failed to improve with relaxation by week 14 improved after subsequent crossover to exposure. A need for more treatment for their phobias was still felt by 33 patients (49%).
Conclusions Patients with phobias maintained their improvement to 2-year follow-up after the end of self-exposure therapy.
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INTRODUCTION |
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METHOD |
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Design
Details of the RCT are reported by Al-Kubaisy et al
(1992). Patients were
randomised to one of three treatment conditions: clinician-accompanied
self-exposure (Ee); self-exposure only (e); and self-relaxation
(r). During weeks 0-8, all patients had six 60-min sessions with a
clinician. The Ee sessions totalled 150 min to include an extra 90 min
doing clinician-accompanied live exposure. At week 14, exposure therapy was
offered to patients who had not improved (mean target fear reduction <2 on
0-8 scale) after self-relaxation; acceptors were crossed over to have
Ee or e (rEe/r
e). The r patients who
did not cross over are called r-only hereafter.
Two years after the end of treatment, patients were invited by letter to attend for assessment; those who did not attend were posted outcome scales to rate and return.
Measures
At weeks 0, 8, 14 and 26 after study entry, patients had self- and
independent assessor ratings (higher scores=more severe symptoms) using the
following measures: the target phobias
(Watson & Marks, 1971)
(each patient negotiated with the therapist individualised targets (usually
three or four) of exposure homework): fear and avoidance (each with mean range
0-8); the Fear Questionnaire (FQ; Marks & Mathews, 1979), containing
15-item total phobia (FQT; total score range 0-120), single-item global phobia
severity (0-8) and single-item depression (0-8) subscores
(McKenzie & Marks, 1999);
the Beck Depression Inventory (BDI: 0-52;
Beck et al, 1974); and
the Work, Home Management, Social and Private Leisure Adjustment scale
(four-item WSA: 0-32; Marks,
1986).
At 2 years' post-treatment, patients were asked to rate the above according to satisfaction with treatment during weeks 0-14 and any subsequent treatment, and treatment success: Success (0-8: 0-2 failure, 3-5 moderate success, 6-8 marked success); Improved as much as expected? (0-8: 0-2 less than expected, 3-5 about what was expected, 6-8 more than expected); Needed further treatment (and which) for your phobia and/or other psychological problems?; and Choose same treatment again if need further help?
Statistical analysis
Only self-rated measures were analysed because assessor-rated measures were
unavailable for patients who did not attend follow-up and so could be biased.
Self- and assessor-rated measures had correlated highly at baseline and week
14. Pearson's correlation coefficients were 0.65-0.93 (n=66-75,
P<0.001) on the target phobias and on the WSA, and for the
self-rated BDI v. assessor-rated Hamilton Rating Scale for Depression
(Hamilton, 1960). Because at
weeks 8 and 14 the three treatment conditions had differed similarly
regardless of type of phobia (Al-Kubaisy
et al, 1992), the three types of phobia were pooled for
analysis of inter-treatment differences at 2 years. Data from
rEe/r
e patients were pooled to boost cell size, a further
rationale being the absence of significant differences between Ee and
e at 2 years (see below).
Clinical ratings were tested by repeated-measures analysis of variance
(ANOVAs) in each treatment group. Paired t-tests were used as a
post hoc analysis with reference points of weeks 0, 8 and 14. Group
comparison on symptom severity is valid for Ee v. e
because r patients were not assigned randomly to r-only or
rEe/r
e after week 14. Two-way ANOVAs were used to test the
influence of compliance or co-therapist on the outcome of Ee and
e. The
2 and Fisher's exact test were used for
categorical data. All statistical tests were two-tailed and the significance
level was set at P<0.05.
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RESULTS |
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At 2 years, numbers from each of the original treatment conditions were
(numbers at week 14 in italic): Ee 25 (27); e 23
(26); r-only 10 (15). Numbers from the crossover
conditions were rEe 3 (4) and r
e 7
(8); more r-only patients had been followed up (33%
v. 11%, P=0.043).
Patients with follow-up had improved more than the non-followed-up patients during weeks 0-8 on all measures except FQT, with a week 0-8 mean fall in: target fear, 2.8 v. 1.1 (t(78)=2.48, P=0.015); target avoidance, 3.4 v. 0.9 (t(78)=3.56, P=0.001); global phobia severity, 2.3 v. 0.4 (t(78)=2.87, P=0.005); WSA total, 5.4 v. 1.2 (t(74)=2.10, P=0.039); single-item depression, 4.7 v. -2.1 (t(78)=2.87, P=0.017); and BDI, 1.9 v. -0.9 (t(77)=2.28, P=0.025).
Outcome on clinical ratings over 2 years
Of all the patients, 91% identified three (26%) or four (65%) most fearful
situations or activities as treatment targets (9% had very specific phobias).
The mean total amount of self-exposure homework set was 75 h in Ee and
79 h in e; the mean total amount actually done by patients was 59 h in
Ee and 52 h in e. Clinical ratings at weeks 0, 8 and 14
post-entry and 2 years after treatment ended appear in
Fig. 1 and
Table 1.
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Six 90-min sessions of clinician-accompanied exposure during weeks 0-8 did not affect the 2-year ratings interaction between Ee or e and time was not significant on any measure (Table 1). Both Ee and e improved significantly and then remained stable up to 2 years on nearly all measures. The great bulk of improvement had occurred between weeks 0 and 14 (see Table 1) rather than thereafter. From week 0 to 2 years, Ee patients improved by a mean of 58% (s.d.=27) on their target fear, nearly all of this (57%, s.d.=26) having been achieved during weeks 0-14 and almost none thereafter during follow-up. From week 0 to 2 years, e patients improved by a mean of 53% (s.d.=33), all of this having been attained during weeks 0-14 (57%, s.d.=33), with a tiny loss of gain thereafter.
The r-only patients had improved mostly by week 14 (46%, s.d.=29), with slight further gain over the next 2 years (10%, s.d.=28), and overall improvement from week 0 to 2 years was 56% (s.d.=31).
The rEe/r
e patients improved on target fear by a mean of
merely 7% (s.d.=16) during weeks 0-14 but by 45% (s.d.=43) between week 14 and
2 years; the latter was significant, as was improvement between week 14 and 2
years for target avoidance, global phobia and WSA (see
Table 1).
On target avoidance, the Ee patients improved by 65% (s.d.=25) from
week 0 to 2 years; 67% (s.d.=23) of the gains had been during weeks 0-14, with
little change thereafter. Improvement for e patients was 57% (s.d.=31)
from week 0 to 2 years; 60% (s.d.=32) of these gains had been during weeks
0-14 and almost none thereafter. Analysis of variance revealed no difference
between Ee and e. Improvement for r-only was 61%
(s.d.=28) from week 0 to 2 years, of which 45% (s.d.=24) was during weeks 0-14
and 16% (s.d.=25) thereafter. Group rEe/r
e improved by 59%
(s.d.=29) from week 0 to 2 years, of which just 10% (s.d.=11) was during
relaxation in weeks 0-14 and 49% (s.d.=32) after crossing over to exposure at
week 14.
Week 0-8 compliance predicted outcome
The therapist had rated Ee and e patients for between-session
compliance with the exposure-homework tasks negotiated during week 0-8
sessions (85% of negotiated tasks carried out=complaint, n=15;
50%=non-compliant, n=12). As in past studies (e.g.
de Araujo et al,
1996), compliant patients improved significantly more than
non-compliant patients on target phobia avoidance and fear at week 26 and 2
years.
Ee and e patients' use of a co-therapist
A relative or friend as co-therapist had been recruited during weeks 0-14
by 11 (44%) patients in Ee and by 8 (35%) in e. The presence of
a co-therapist did not relate significantly to overall improvement of target
fear or target avoidance from week 0 to 2 years in either Ee or
e, despite Ee and e patients having improved slightly
more in weeks 0-14 on target fear if they had a co-therapist
(F(1,44)=3.63; P=0.063); by including the five patients who
had no 2-year rating in this analysis, the difference became significant
(F(1,49)=4.67; P=0.036). On target avoidance, e
patients with a co-therapist tended to improve more during weeks 0-14
(F(1,44)=2.97; P=0.092). At 2 years, however, e
patients who had a co-therapist lost 22% of their former improvement, a loss
that was significantly greater than in e patients who had no
co-therapist (6% further improvement) or in Ee patients (5% further
improvement with and -8% without a co-therapist; F(1,44)=5.90;
P=0.019).
Retrospective self-evaluations of treatment
Treatment success
Ratings were similar across treatment groups: 29 patients (43%) rated
treatment as markedly successful, 19 (29%) as moderately successful and 19
(29%) as a failure. Success ratings were strongly predicted by the percentage
improvement on target fear from week 0 to 2 years (adjusted
R2=0.464, ß=0.688, t=7.36 and
P=0.0001 on stepwise multiple regression) but not by the following
variables: age; gender; education; illness duration; total time spent by
therapist or patient during weeks 0-8; 2-year BDI score.
Improvement expectancy
Thirty-five patients (52%) rated improvement as more than expected, nine
(14%) about what they had expected and twenty-two (33%) as less than expected.
More Ee than e and r patients felt that they had improved
more than expected (linear-by-linear association: 2 (1)=6.29,
P=0.012; ANOVA on expectancy scores: F(2,63)=4.28,
P=0.018).
Other treatments from week 26 to 2 years
From week 26 to 2 years, of 67 patients who had been followed up, 18 (27%)
had had other treatment for their phobia. Their frequency did not differ
significantly across diagnosis (seven with agoraphobia, three with social
phobia and eight with specific phobias) or type of treatment during weeks 0-14
or crossover from r at week 14 (five Ee, six e, three
r-only and four rEe/r
e). Six (9%) patients had had
tranquillisers, two had antidepressants, one had both types of medication, one
had counselling and eight (12%) had other treatments.
On almost all pretreatment clinical measures, patients who had had other treatments after week 26 had not differed from those who had not, but had been significantly worse than patients who had not at week 14 and 2 years. It is unlikely that they had further gains from other treatments after week 26 because week 14 and 2-year scores did not differ on repeated-measures ANOVA.
Perceived need for further treatment at 2 years
Of 67 patients who had been followed up 33 (49%) felt that they needed more
treatment for their phobia at 2 years (8/24 Ee; 14/23 e; 5/10
r-only; 6/10 rEe/r
e; 67% for agoraphobia, 43% for
social phobia and 38% for specific phobias) and their distribution did not
differ across the type of treatment. When asked if they would choose the same
type of treatment they had had before week 26, 32 (97%) replied, of whom 13
(41%) said yes (6/8 Ee, 5/14 e, 1/5 r-only,
1/5 r
Ee/r
e) and 19 (59%) said no (2/8
Ee, 9/14 e, 4/5 r-only, 4/5 r
Ee/r
e).
If this is a proxy for treatment preference, this was significantly greatest
for Ee, next for e and least for r (linear-by-linear
association:
2 (1)=4.36, P=0.043).
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DISCUSSION |
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Clinician-accompanied exposure had been given in a sufficient dose to show an effect. The six 90-min sessions during weeks 0-8 were even more than is usual in National Health Service clinics. For spider phobia, one 2-h session of clinician-accompanied exposure was compared with 2-h sessions guiding self-exposure over 2 weeks (Öst et al, 1991); clinician-accompanied exposure was superior up to 1 year but it is unclear how much this was due to its exposure bouts having been more prolonged and having included systematic modelling by a therapist. In present patients an effect of clinician-accompanied exposure sessions in Ee may have been overshadowed by the large amount of self-exposure homework.
About one-third of present e patients had recruited relatives or friends as co-therapists whose role during self-exposure might have resembled that of a clinician during Ee. Such a co-therapist in e was associated with slightly more phobia reduction in weeks 0-14 but not at 2 years, by which time some of these gains had been lost.
Contextual cues are important in learning and memory (e.g. Smith et al, 1978). Fear spreads more easily to a neutral context than does fear reduction (Bouton, 1988; Bouton & Swartzentruber, 1991). A clinician or co-therapist may serve as a dual-edged contextual (safety or reminder) cue during exposure, facilitating fear reduction during active treatment but raising the risk of relapse in new phobic situations (Rowe & Craske, 1998a) or when the context changes to having no clinician or co-therapist present (Rodriguez et al, 1999).
In Ee and e, compliance with self-exposure homework negotiated during week 0-8 sessions predicted better outcome at week 26 and 2 years. In obsessivecompulsive disorder, too, such compliance predicted more improvement up to six months (de Araujo et al, 1996). What determines compliance is largely unclear.
Compared with the 15% of patients without 2-year data, the 85% with such
data had been very similar at pretreatment. By week 8 the 85% had improved
more, and by week 26 more had had exposure in some form (Ee, e or
rEe/r
e) rather than r-only. If the 15% of patients
without 2-year data remained less improved at 2 years, then gains at 2 years
may be overstated for the entire sample. This does not affect our main
conclusions that Ee v. e did not differ significantly
in outcome, that doing self-exposure homework in weeks 0-8 predicted more
improvement at two years and that unimproved r patients improved after
subsequent exposure.
Need for further treatment
The improvement that continued beyond week 14 to two years is in accordance
with the stability of gains in other long-term follow-ups noted above.
Although exposure treatments reduce phobias, they seldom abolish them
completely (Lelliott et al,
1987; reviewed by Marks,
1987). At 2 years, nearly half of our patients felt that they
needed further treatment for their phobias; whether this should be more
exposure or another approach deserves study.
Patients who fear many phobic situations may need exposure to them all in order to maximise improvement. Both Ee and e had focused on three or four main phobic targets. Patients who had more phobic situations that they were not exposed to may have remained unimproved in such situations and so felt a need for further treatment. Bearing this out, the percentage of Ee or e patients who felt the need for further treatment was two-fold greater for agoraphobia than specific phobias (with social phobias, including both focal and diffuse phobias, in between).
It is unclear whether desire for further help is reduced by adding non-exposure treatments. Almost half of those with social phobia still sought further treatment during follow-up after exposure plus cognitive therapy (Mersch et al, 1991). Although patients receiving such combined therapy felt less need for further therapy, at 18-month follow-up exposure plus cognitive therapy had no better outcome than exposure alone (Scholing & Emmelkamp, 1996a,b). A liking of more therapist contact is common even when that does not enhance improvement.
Did relaxation have an effect?
Of the 27 original r patients, 10 had improved by week 14 and their
gains continued to 2 years. This non-random r-only subgroup, however,
was not comparable to the originally randomised Ee and r groups.
Of the ten r-only patients, four did a mean of 17 h of uninstructed
self-exposure during weeks 0-14, so it is unclear as to what to
attribute r-only's continuing gains at 2 years. The non-follow-up rate
for r-only was higher and their improvement was greater than that of
the total original r group. Our ten r patients who did not
benefit from self-relaxation but went on to improve with Ee or e
remained improved at 2 years.
Although r had been far less effective than Ee or e over weeks 0-14, at 2 years patients from all groups rated their treatments as having been similarly successful. However, the treatment that the original r patients rated as successful at 2 years had by then included self-exposure at some point in at least half of them. Satisfaction can be an unreliable guide to actual improvement.
Patients with post-traumatic stress disorder improved somewhat with therapist-accompanied plus self-relaxation, albeit less than with exposure or cognitive restructuring (Marks et al, 1998), in an RCT that did not test whether such improvement was a placebo or a relaxation effect.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication March 23, 2000. Revision received December 20, 2000. Accepted for publication December 22, 2000.
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