Exposure Therapy for Anxiety: Principles and Practice
By John S. Abramowitz, Brett J. Deacon, & Stephen P. H. Whiteside
I read this book because I thought I might like to recommend it to new therapists who are just learning exposure techniques. I actually found that it has a much broader range than that. As it turns out, this is a solid and comprehensive review of the behavioral principles of exposure therapy and a pretty fantastic guide to implementation of exposure with a wide variety of anxious patients.
The book is divided into three sections: Fundamentals, Implementation with specific types of problems, and Special Considerations.
The first section is dense. Chapters 1 & 2 give a quick and juicy overview of the history and evidence base for exposure therapy, followed by a review, in Chapter 3, of the theoretical assumptions underlying exposure. This is the section that many will be tempted to skip because we think we know those basic assumptions, but my advice is, DO NOT SKIP THIS SECTION! Abramowitz & colleagues present the theoretical concepts in an elegant and understandable way, and illustrate with many clinical examples to help the reader see the theory in action with all sorts of clients. Most importantly, as the authors point out, it is this theoretical framework that will take you from a cookbook follower (my words, not theirs) to a clinician who can approach an individual patient and create a plan of exposures that are tailored to the patient’s specific needs.
The rest of Section I covers treatment planning, including functional assessment, hierarchy development and treatment engagement. These are skill areas that even experienced therapists can improve. The authors continue to provide chapters dense with excellent advice, grounded in theory, and illustrated with clinical examples to help the reader connect the concepts to real patients. In fact, I can imagine experienced therapists will resonate with this section in a different way than beginners, because we have that backlog of patients who live in our memories. I found myself imagining different ways of approaching my past work as well as ways I might more efficiently and effectively help the therapists with whom I train and consult.
Section II takes each of the major categories of anxiety one by one and demonstrates how exposure can be applied in each case. Though many of the readers of this blog focus on PTSD, you will find the other categories of anxiety as useful to your practice as the PTSD section. First, PTSD is highly co-morbid with other disorders, and it is possible to address those anxiety issues concurrently, and more efficiently if you are aware of how exposure therapy can by applied to other types of anxiety. Second, even when another disorder is not present, trauma-related fears can sometimes take on a characteristics of other types of anxiety, for example, the fears of physical sensations common in Panic Disorder, or the ritualistic nature of avoidance and safety behaviors that are common in Obsessive Compulsive Disorder. Third, as providers in busy general clinics, even those who specialize in PTSD will often see these other types of patients. Exposure procedures are an important part of evidence-based practice targeting all types anxiety. As with the previous section, numerous clinical examples help this section come alive.
The final section covers Special Considerations in exposure therapy. In many books and articles this section is, quite honestly, a short, throw-away section that barely covers identification of special circumstances, but leaves the reader at a loss for how to practically approach the problem. This is often because the special circumstances in question are deserving of whole books to themselves. While the latter is true for this book – each of these topics could become a separate book; the former is definitely not true.
Abramowitz and colleagues treat each of the special considerations with enough time and space to help the reader adapt and respond more complex issues. That is not to say that readers will not want to learn more after reading the chapters, but the authors efficiently cover a range of important considerations in exposure therapy. The first five chapters of the section cover important clinical issues in treatment: Working with complex cases; treatment of children; involving significant others; combining treatment with medication; and maintaining improvement after treatment. There are detailed chapters, not quick summaries. I can imagine re-reading these chapters from time to time, and recommending them to colleagues as excellent stand-alone summaries of each topic.
The final chapter of this section is a Risk-Benefit Analysis exploring reasons for the low utilization rate of exposure therapy despite the robust evidence base supporting it in a wide variety of clinical problems. This is the chapter for my consultants and champions out there who need a deeper understanding of the barriers to implementing exposure therapy and some practical strategies for addressing those barriers. This chapter covers material we present in our consultant workshop, and that has been presented in other articles in the recent past, but the range of topics is much greater, and the practical solutions offered are among the best I have ever seen collected in one place.
I really have nothing critical to say about this book. I think everyone doing exposure treatment should own it and read it more than once. It is current (despite having been published in 2011), dense, clinically applicable, and thanks to the rich clinical detail provided, it’s also interesting to read. I definitely came away with some new ideas to incorporate in our consultant training, and I wish I had read this book sooner.
Kelly Chrestman, Ph.D., is a licensed clinical psychologist working as the lead for online consultation services at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.