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Therapeutic Alliance and Treatment Expectations: Predicting Outcomes in Exposure Treatments for Specific Phobia

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Abstract

Background

Exposure-based treatments have demonstrated some of the largest effect sizes in the treatment of specific phobias (SP). There are different ways of delivering exposure such as Augmented Reality Exposure which has become an interesting alternative to In Vivo Exposure for treating SP. The present study aimed to investigate the therapeutic alliance and treatment expectations as possible predictors of treatment outcomes in these two exposure treatment conditions.

Methods

Participants were 63 adults who met diagnostic criteria for the diagnosis of a SP of cockroaches or spiders (animal subtype). Patients were randomized to receive a one-session treatment of either In Vivo Exposure (N = 31) or Augmented Reality Exposure (N = 32). The assessment protocol included diagnostic, as well as primary-, and secondary outcome measures. Materials included the Behavioral Avoidance Test for measuring symptoms and outcomes, the Expectations and Satisfaction Questionnaire, and the Working Alliance Inventory. We ran multilevel analyses for the study of predictors controlling for the treatment effect conditions.

Results

Results showed a significant effect of expectations on treatment outcomes (specifically avoidance and beliefs scores). The therapeutic alliance did not have a significant effect on treatment outcome. Patients reduced their symptoms of phobia.

Conclusion

These results empirically support treatment expectations as a relevant predictor of change in exposure treatments for SP.

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References

  • Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety (2nd ed.). Guilford Publications.

    Google Scholar 

  • Baños, R. M., Botella, C., Guillen, V., García-Palacios, A., Quero, S., Bretón-López, J., & Alcañiz, M. (2009). An adaptive display to treat stress-related disorders: EMMA’s World. British Journal Guidance Counselling, 37(3), 347–356. https://doi.org/10.1080/03069880902957064

    Article  Google Scholar 

  • Beck, A., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.

    Google Scholar 

  • Böhnlein, J., Altegoer, L., Muck, N. K., Roesmann, K., Redlich, R., Dannlowski, U., & Leehr, E. J. (2019). Factors influencing the success of exposure therapy for specific phobia: A systematic review. Neuroscience and Biobehavioral Reviews, 108, 796–820. https://doi.org/10.1016/j.neubiorev.2019.12.009

    Article  PubMed  Google Scholar 

  • Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy Theory Research Practice Training, 16(3), 252–260. https://doi.org/10.1037/h0085885

    Article  Google Scholar 

  • Borkovec, T. D., & Nau, S. D. (1972). Credibility of analogue therapy rationales. Journal of Behavioural Therapy Experimental Psychiatry, 3(4), 257–260. https://doi.org/10.1016/0005-7916(72)90045-6

    Article  Google Scholar 

  • Botella, C., Baños, R., Villa, H., Perpiñá, C., & García-Palacios, A. (2000). Virtual reality in the treatment of claustrophobic fear: A controlled, multiple-baseline design. Behavior Therapy, 31(3), 583–595. https://doi.org/10.1016/S0005-7894(00)80032-5

    Article  Google Scholar 

  • Botella, C., Fernández-Álvarez, J., Guillén, V., García-Palacios, A., & Baños, R. (2017). Recent progress in virtual reality exposure therapy for phobias: A systematic review. Current Psychiatry Reports, 19(7), 1–13. https://doi.org/10.1007/s11920-017-0788-4

    Article  Google Scholar 

  • Botella, C., García-Palacios, A., Villa, H., Baños, R. M., Quero, S., Alcañiz, M., & Riva, G. (2007). Virtual reality exposure in the treatment of panic disorder and agoraphobia: A controlled study. Clinical Psychology & Psychotherapy, 14(3), 164–175. https://doi.org/10.1002/cpp.524

    Article  Google Scholar 

  • Botella, C., Pérez-Ara, M. Á., Bretón-López, J., Quero, S., García-Palacios, A., & Baños, R. M. (2016). In vivo versus augmented reality exposure in the treatment of small animal phobia: A randomized controlled trial. PLoS ONE, 11(2), e0148237. https://doi.org/10.1371/journal.pone.0148237

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Bretón-López, J., Tortella-Feliu, M., del Amo, A. R., Baños, R., Llabrés, J., Gelabert, J. M., & Botella, C. (2015). Patients’ preferences regarding three computer-based exposure treatments for Fear of Flying. Behavioural Psychology, 23(2), 265–285.

    Google Scholar 

  • Buchholz, J. L., & Abramowitz, J. S. (2020). The therapeutic alliance in exposure therapy for anxiety-related disorders: A critical review. Journal of Anxiety Disorders, 70, e102194. https://doi.org/10.1016/j.janxdis.2020.102194

    Article  Google Scholar 

  • Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473–485. https://doi.org/10.1037/pst0000169

    Article  PubMed  Google Scholar 

  • Corbella, S., & Botella, L. (2003). La alianza terapéutica: historia, investigación y evaluación [versión electrónica]. Revista Anales De Psicología, 2(19), 205–221.

    Google Scholar 

  • Eaton, W. W., Bienvenue, O. J., & Miloyan, B. (2018). Specific phobias. Lancet Psychiatry, 5(8), 678–686. https://doi.org/10.1016/S2215-0366(18)30169-X

    Article  PubMed  PubMed Central  Google Scholar 

  • Emmelkamp, P. M., & Meyerbröker, K. (2021). Virtual reality therapy in mental health. Annual Review of Clinical Psychology, 17, 495–519. https://doi.org/10.1146/annurev-clinpsy-081219-115923

    Article  PubMed  Google Scholar 

  • Fernández-Álvarez, J., Di Lernia, D., & Riva, G. (2020). Virtual reality for anxiety disorders: rethinking a field in expansion. In Y. K. Kim (Ed.), Anxiety disorders. Advances in experimental medicine and biology. . Springer. https://doi.org/10.1007/978-981-32-9705-0_21

    Chapter  Google Scholar 

  • Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172

    Article  PubMed  Google Scholar 

  • Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: A controlled study. Behaviour Research and Therapy, 40(9), 983–993. https://doi.org/10.1016/s0005-7967(01)00068-7

    Article  CAS  PubMed  Google Scholar 

  • Gómez Penedo, J. M., Muiños, R., Hirsch, P., & y Roussos, A. (2019). La aplicación de modelos lineales jerárquicos para el estudio de la eficacia en psicoterapia. Revista Argentina De Ciencias Del Comportamiento, 11(1), 25–37. https://doi.org/10.32348/1852.4206.v11.n1.20412

    Article  Google Scholar 

  • Hagen, K., Solem, S., Opstad, H. B., Vogel, P. A., Ottesen Kennair, L. E., Kvale, G., & Hansen, B. (2016). Therapist variability in the task/goal dimension of the early working alliance predicts outcome in exposure and response prevention treatment for obsessive-compulsive disorder. Clinical Neuropsychiatry, 13(6), 94–99.

    Google Scholar 

  • Hazlett-Stevens, H., & Craske, M. G. (2009). Live (in vivo) exposure. In W. T. O’Donohue & J. E. Fisher (Eds.), General principles and empirically supported techniques of cognitive behavior therapy (pp. 407–414). Wiley.

    Google Scholar 

  • Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. Dialogues in Clinical Neuroscience, 17(3), 337–346. https://doi.org/10.31887/dcns.2015.17.3/akaczkurkin

    Article  PubMed  PubMed Central  Google Scholar 

  • Leehr, E. J., Roesmann, K., Böhnlein, J., Dannlowski, U., Gathmann, B., Herrmann, M. J., Junghöfer, M., Schwarzmeier, H., Seeger, F. R., Siminski, N., Straube, T., Lueken, U., & Hilbert, K. (2021). Clinical predictors of treatment response towards exposure therapy in virtuo in spider phobia: A machine learning and external cross-validation approach. Journal of Anxiety Disorders, 83, 102448. https://doi.org/10.1016/j.janxdis.2021.102448

    Article  PubMed  Google Scholar 

  • Levy, F., Leboucher, P., Rautureau, G., & Jouvent, R. (2016). E-virtual reality exposure therapy in acrophobia: A pilot study. Journal of Telemedicine and Telecare, 22(4), 215–220.

    Article  PubMed  Google Scholar 

  • Maiwald, L. M., Junga, Y. M., Lang, T., Montini, R., Witthöft, M., Heider, J., Schröder, A., & Weck, F. (2019). The role of therapist and patient in-session behavior for treatment outcome in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia. Journal of Clinical Psychology, 75(4), 614–626. https://doi.org/10.1002/jclp.22738

    Article  PubMed  Google Scholar 

  • Maltby, N., Kirsch, I., Mayers, M., & Allen, G. (2002). Virtual reality exposure therapy for the treatment of fear of flying: A controlled investigation. Journal of Consulting and Clinical Psychology, 70(5), 1112–1118. https://doi.org/10.1037/0022-006X.70.5.1112

    Article  PubMed  Google Scholar 

  • Maples-Keller, J. L., Yasinski, C., Manjin, N., & Rothbaum, B. O. (2017). Virtual reality-enhanced extinction of phobias and post-traumatic stress. Neurotherapeutics, 14(3), 554–563. https://doi.org/10.1007/s13311-017-0534-y

    Article  PubMed  PubMed Central  Google Scholar 

  • Meyerbroker, K., & Emmelkamp, P. M. (2008). Therapeutic processes in virtual reality exposure therapy: The role of cognitions and the therapeutic alliance. Journal of CyberTherapy and Rehabilitation, 1(3), 247–258.

    Google Scholar 

  • Öst, L. G., Salkovskis, P. M., & Hellström, K. (1991). One-session therapist-directed exposure vs. self-exposure in the treatment of spider phobia. Behavioural Therapy, 22(3), 407–422. https://doi.org/10.1016/S0005-7894(05)80374-0

    Article  Google Scholar 

  • Pan, D., Huey, S. J., & Hernandez, D. (2011). Culturally-adapted versus standard exposure treatment for phobic Asian Americans: Treatment efficacy, moderators, and predictors. Cultural Diversity & Ethnic Minority Psychology, 17(1), 11–22. https://doi.org/10.1037/a0022534

    Article  Google Scholar 

  • Price, M., Anderson, P., Henrich, C. C., & Rothbaum, B. O. (2008). Greater expectations: Using hierarchical linear modeling to examine expectancy for treatment outcome as a predictor of treatment response. Behavioural Therapy, 39(4), 398–405. https://doi.org/10.1016/j.beth.2007.12.002

    Article  Google Scholar 

  • Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods (2nd ed.). Sage Publications Inc.

    Google Scholar 

  • Rothbaum, B., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavioral Therapy, 37(1), 80–90. https://doi.org/10.1016/j.beth.2005.04.004

    Article  Google Scholar 

  • Shiban, Y., Diemer, J., Müller, J., Brütting-schick, J., Pauli, P., & Mühlberger, A. (2017). Diaphragmatic breathing during virtual reality exposure therapy for aviophobia: Functional coping strategy or avoidance behavior? A pilot study. BMC Psychiatry, 17, 1–10. https://doi.org/10.1186/s12888-016-1181-2

    Article  Google Scholar 

  • Totzeck, C., Teismann, T., Hofmann, S. G., von Brachel, U., Zhan, X. C., Pflug, V., & Margraf, J. (2019). Effective styles in panic disorder and specific phobia: Changes through cognitive behavior therapy and prediction of remission. Behaviour Therapy, 51(3), 375–385. https://doi.org/10.1016/j.beth.2019.06.006

    Article  Google Scholar 

  • Wechsler, T. F., Kümpers, F., & Mühlberger, A. (2019). Inferiority or even superiority of virtual reality exposure therapy in phobias?—A systematic review and quantitative meta-analysis on randomized controlled trials specifically comparing the efficacy of virtual reality exposure to gold standard in vivo exposure in agoraphobia, specific phobia, and social phobia. Frontiers in Psychology, 10, 01758. https://doi.org/10.3389/fpsyg.2019.01758

    Article  Google Scholar 

  • Weck, F., Richtberg, S., Jakob, M., Neng, J. M. B., & Höfling, V. (2015). Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis). Psychiatry Research, 228(1), 53–58. https://doi.org/10.1016/j.psychres.2015.03.042

    Article  PubMed  Google Scholar 

  • Wheaton, M., Huppert, J., Foa, E. B., & Simpson, H. B. (2016). How important is the therapeutic alliance in treating obsessive-compulsive disorder with exposure and response prevention? An Empirical Report, 13, 88–93.

    Google Scholar 

  • Wiederhold, B. & Bouchard, S. (2014). Claustrophobia: efficacy and treatment protocols. In Advances in virtual reality and anxiety disorders. series in anxiety and related disorders. Springer. https://doi.org/10.1007/978-1-4899-8023-6_7

  • Wrzesien, M., Botella, C., Breton-Lopez, J., del Rio Gonzalez, E., Burkhardt, J. M., Alcañiz, M., & Angeles Perez-Ara, M. (2015). Treating small animal phobias using a projective-augmented reality system: A single-case study. Computers in Human Behavior, 49, 343–353. https://doi.org/10.1016/j.chb.2015.01.065

    Article  Google Scholar 

  • Wrzesien, M., Burkhardt, J. M., Botella, C., & Alcañiz, R. L. M. (2012). Evaluation of the quality of collaboration between the client and the therapist in phobia treatments. Interacting with Computers, 24(6), 461–471. https://doi.org/10.1016/j.intcom.2012.09.001

    Article  Google Scholar 

  • Wu, M. S., Caporino, N. E., Peris, T. S., Pérez, J., Thamrin, H., Albano, A. M., Kendall, P. C., Walkup, J. T., Birmaher, B., Compton, S. N., & Piacentini, J. (2020). The Impact of Treatment Expectations on Exposure Process and Treatment Outcome in Childhood Anxiety Disorders. Research on Child and Adolescent Psychopathology, 48, 79–89. https://doi.org/10.1007/s10802-019-00574-x

    Article  CAS  Google Scholar 

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Funding

This study was funded by the Ministry of Economy and Competitiveness (Spain), (Plan Nacional I + D + I. PSI2010-17563), and the Institute of Health Carlos III (ISCiii). CIBERobn is an initiative of ISCIII. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. Department of Psychology, University of Buenos Aires & CONICET, Lavalle 2353, 1052, Buenos Aires, Argentina

    Malenka Areas, Andrés Roussos & Juan Martín Gómez Penedo

  2. Clinical Psychology and Psychotherapy Department, University of Bern, Bern, Switzerland

    Anna Margarete Babl

  3. Adelphi University, New York, NY, USA

    Anna Margarete Babl

  4. Asociación Aiglé Valencia, Valencia, Spain

    Javier Fernández-Álvarez

  5. Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, Castello de la Plana, Spain

    Javier Fernández-Álvarez, Cristina Botella, Azucena García-Palacios, Soledad Quero & Juana María Breton

  6. Departamento de Personalidad, Evaluación y Tratamientos Psicológicos, Universidad de Valencia, Valencia, Spain

    Rosa Baños

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  1. Malenka Areas
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Correspondence to Malenka Areas.

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Conflict of interest

Malenka Areas, Anna Margarete Babl, Javier Fernández-Álvarez, Andrés Roussos, Cristina Botella, Azucena García-Palacios, Rosa Baños, Soledad Quero, Juana María Breton and Juan Martín Gómez Penedo declare that they have no conflict of interest.

Ethical Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethical Committee of the Jaume I University (Comisión Deontológica de la Universitat Jaume I) in January 2011. The study was based on a Randomised Control Trial (RCT) [Main outcome paper (Botella et al., 2016)]. It was registered in the National Institute of Health Registration System (http://www.clinicaltrials.gov) with Clinical Trials Registration Number: NCT01361074.

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No animal studies were carried out by the authors for this article.

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Informed consent was obtained from all individual participants included in the study.

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Areas, M., Babl, A.M., Fernández-Álvarez, J. et al. Therapeutic Alliance and Treatment Expectations: Predicting Outcomes in Exposure Treatments for Specific Phobia. Cogn Ther Res 47, 222–231 (2023). https://doi.org/10.1007/s10608-022-10343-8

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