Patients Accompanied by Therapists During Exposure Sessions Have Better Outcomes

AMSTERDAM – Cognitive-behavioral therapy for panic disorder and agoraphobia seems to work better when the therapist accompanies the patient during the in vivo exposure sessions.

Investigators from Technische Universität in Dresden, Germany, made this finding, and, additionally, found that therapists need not adhere strongly to a CBT manual to produce symptomatic changes.

The two studies were reported at the annual congress of the European College of Neuropsychopharmacology by Andrew T. Gloster, Ph.D., and Christina Hauke of the Institute of Clinical Psychology and Psychotherapy.

The first was a multicenter study of 369 patients with panic disorder and agoraphobia as well as a high rate of comorbid disorders (41%-73%). The study’s primary aim was to determine whether variations in treatment delivery affect outcomes of CBT.

The patients were randomized to two active variations of CBT. In one, the therapist was present during in vivo exposure exercises (n = 163); in the other, the therapist planned and discussed the exercises but did not accompany the patient (n = 138). A third group (control) was assigned to a wait list (n = 68).

“Leaving the room is crucial for the patient, and we explored whether there is a benefit for the therapist being with the patient for these exposures. Data suggest you can do the therapy both ways, but you absolutely must prepare the patient as to what will occur,” Dr. Gloster said. “We have this conversation many times with the patient. If the therapist is going with the patient, then the conversation can occur as it is needed.”

Attaining Better Response Rates

At the end of treatment, both active treatment groups were superior to the wait list group, but the therapist-present group obtained more favorable results on nearly every index. The largest differences were noted on agoraphobic avoidance and global functioning, he reported.

“We found there are additive effects when the therapist goes with the patient on all five exposure sessions,” Dr. Gloster said.

On global functioning, the mean baseline value was 5.4 for the therapist-present group, and 5.2 for both the therapist-not-present and the wait-list groups. From baseline to end of treatment (last observation carried forward), scores were reduced by nearly 2.5 points with the therapist present and 2.0 points without the therapist present (P less than .05). Patients continued to improve over time, and at the 6-month follow-up, these scores were further reduced (nonsignificantly) by another 1.0 and 0.75 points, respectively.

These numbers represented response rates post treatment of 49.7% for the therapist-present condition and 39.1% for therapist-not-present condition. At the 6-month follow-up, response rates rose to 68.7% and 60.9%, respectively.

The wait-list group showed little change post treatment, with scores reduced by a mean of less than 0.5, corresponding with a response rate of 7.4%, Dr. Gloster reported.

For agoraphobic avoidance, mean scores were approximately 3.0 at baseline for all groups and were reduced by approximately 1.2 points in the therapist-present arm and 0.75 in the therapist-not-present arm (P less than .05). Slight additional improvements were seen at 6 months. Wait-list patients showed little improvement.

Similarly, the percentage of patients panic free after treatment was 49.4% with the therapist present and 45.7% without, and at 6 months it was 66.3% and 60.9%, respectively. In the wait-list arm, just 25% became panic free. The number of panic attacks also was reduced, with statistical significance observed between the active treatment groups at 6 months. General anxiety similarly improved.

The rate of decrease in agoraphobic avoidance accelerated after the introduction of in vivo exposure, he added. Patients who exposed themselves to more anxiety-provoking situations had better outcomes.

“When the therapist accompanied the patient, at 6 months we saw a significantly greater reduction in panic attacks,” Dr. Gloster said. “Patients are having more spontaneous exposures, and this is the most important factor in the therapy.”

Strict Adherence Not Essential

The same investigators also reported a minimal inverse relationship between adherence to the CBT manual and outcome. “Overall, at a global level, adherence was not relevant to treatment outcome,” Ms. Hauke reported.

The finding could be biased, she acknowledged, by the fact that 80% of sessions were rated as “good adherence” or “highly adherent” so there was little room for improvement.

The study included 275 of the same patients as in the first study, treated by 62 therapists in the two exposure-based models described above. Investigators looked at the sample of completers (n = 230) who finished 12 twice-weekly sessions, and drop-outs (n = 45), who terminated before session 12. Therapist adherence ratings were generated by analysis of randomly selected videotapes of the sessions using the Therapist Adherence and Competency Rating Scales (TACRS) developed by Dr. Gloster and colleagues. Outcome measures were changes on scores on standard instruments.

Rates of adherence were similar for therapists of completers and drop-outs, approximately 5.5 on an 8-point scale, and higher level of adherence was associated minimally with worse outcomes, Ms. Hauke reported.

The therapists of the completers were significantly less likely to adhere to the protocol if they were assigned to the therapist-present exposure situation, compared with standard CBT (P = .025). Adherence was not, however, associated with outcomes for patients who dropped out. Therapists of patients who dropped out for exposure-related reasons (for example, anxious, not motivated) versus other reasons (for example, organizational problems, symptom improvement, or deterioration) had a strong trend toward lower levels of adherence (P = .05), which became significant after the researchers controlled for years of therapist experience (P = .036).

The findings might suggest “that levels of adherence should be matched with individual patient requirements before implementing a manualized therapy,” she said.

The main point, Ms. Hauke said, is that robust adherence to the CBT manual is not the only important factor in treatment outcome, and other modifiers should be examined.

The authors reported no potential conflicts of interest. The work was funded by the German Federal Ministry of Education and Research.

AMSTERDAM – Cognitive-behavioral therapy for panic disorder and agoraphobia seems to work better when the therapist accompanies the patient during the in vivo exposure sessions.

Investigators from Technische Universität in Dresden, Germany, made this finding, and, additionally, found that therapists need not adhere strongly to a CBT manual to produce symptomatic changes.

The two studies were reported at the annual congress of the European College of Neuropsychopharmacology by Andrew T. Gloster, Ph.D., and Christina Hauke of the Institute of Clinical Psychology and Psychotherapy.

The first was a multicenter study of 369 patients with panic disorder and agoraphobia as well as a high rate of comorbid disorders (41%-73%). The study’s primary aim was to determine whether variations in treatment delivery affect outcomes of CBT.

The patients were randomized to two active variations of CBT. In one, the therapist was present during in vivo exposure exercises (n = 163); in the other, the therapist planned and discussed the exercises but did not accompany the patient (n = 138). A third group (control) was assigned to a wait list (n = 68).

“Leaving the room is crucial for the patient, and we explored whether there is a benefit for the therapist being with the patient for these exposures. Data suggest you can do the therapy both ways, but you absolutely must prepare the patient as to what will occur,” Dr. Gloster said. “We have this conversation many times with the patient. If the therapist is going with the patient, then the conversation can occur as it is needed.”

Attaining Better Response Rates

At the end of treatment, both active treatment groups were superior to the wait list group, but the therapist-present group obtained more favorable results on nearly every index. The largest differences were noted on agoraphobic avoidance and global functioning, he reported.

“We found there are additive effects when the therapist goes with the patient on all five exposure sessions,” Dr. Gloster said.

On global functioning, the mean baseline value was 5.4 for the therapist-present group, and 5.2 for both the therapist-not-present and the wait-list groups. From baseline to end of treatment (last observation carried forward), scores were reduced by nearly 2.5 points with the therapist present and 2.0 points without the therapist present (P less than .05). Patients continued to improve over time, and at the 6-month follow-up, these scores were further reduced (nonsignificantly) by another 1.0 and 0.75 points, respectively.

These numbers represented response rates post treatment of 49.7% for the therapist-present condition and 39.1% for therapist-not-present condition. At the 6-month follow-up, response rates rose to 68.7% and 60.9%, respectively.

The wait-list group showed little change post treatment, with scores reduced by a mean of less than 0.5, corresponding with a response rate of 7.4%, Dr. Gloster reported.

For agoraphobic avoidance, mean scores were approximately 3.0 at baseline for all groups and were reduced by approximately 1.2 points in the therapist-present arm and 0.75 in the therapist-not-present arm (P less than .05). Slight additional improvements were seen at 6 months. Wait-list patients showed little improvement.

Similarly, the percentage of patients panic free after treatment was 49.4% with the therapist present and 45.7% without, and at 6 months it was 66.3% and 60.9%, respectively. In the wait-list arm, just 25% became panic free. The number of panic attacks also was reduced, with statistical significance observed between the active treatment groups at 6 months. General anxiety similarly improved.

The rate of decrease in agoraphobic avoidance accelerated after the introduction of in vivo exposure, he added. Patients who exposed themselves to more anxiety-provoking situations had better outcomes.

“When the therapist accompanied the patient, at 6 months we saw a significantly greater reduction in panic attacks,” Dr. Gloster said. “Patients are having more spontaneous exposures, and this is the most important factor in the therapy.”

Strict Adherence Not Essential

The same investigators also reported a minimal inverse relationship between adherence to the CBT manual and outcome. “Overall, at a global level, adherence was not relevant to treatment outcome,” Ms. Hauke reported.

The finding could be biased, she acknowledged, by the fact that 80% of sessions were rated as “good adherence” or “highly adherent” so there was little room for improvement.

The study included 275 of the same patients as in the first study, treated by 62 therapists in the two exposure-based models described above. Investigators looked at the sample of completers (n = 230) who finished 12 twice-weekly sessions, and drop-outs (n = 45), who terminated before session 12. Therapist adherence ratings were generated by analysis of randomly selected videotapes of the sessions using the Therapist Adherence and Competency Rating Scales (TACRS) developed by Dr. Gloster and colleagues. Outcome measures were changes on scores on standard instruments.

Rates of adherence were similar for therapists of completers and drop-outs, approximately 5.5 on an 8-point scale, and higher level of adherence was associated minimally with worse outcomes, Ms. Hauke reported.

The therapists of the completers were significantly less likely to adhere to the protocol if they were assigned to the therapist-present exposure situation, compared with standard CBT (P = .025). Adherence was not, however, associated with outcomes for patients who dropped out. Therapists of patients who dropped out for exposure-related reasons (for example, anxious, not motivated) versus other reasons (for example, organizational problems, symptom improvement, or deterioration) had a strong trend toward lower levels of adherence (P = .05), which became significant after the researchers controlled for years of therapist experience (P = .036).

The findings might suggest “that levels of adherence should be matched with individual patient requirements before implementing a manualized therapy,” she said.

The main point, Ms. Hauke said, is that robust adherence to the CBT manual is not the only important factor in treatment outcome, and other modifiers should be examined.

The authors reported no potential conflicts of interest. The work was funded by the German Federal Ministry of Education and Research.

AMSTERDAM – Cognitive-behavioral therapy for panic disorder and agoraphobia seems to work better when the therapist accompanies the patient during the in vivo exposure sessions.

Investigators from Technische Universität in Dresden, Germany, made this finding, and, additionally, found that therapists need not adhere strongly to a CBT manual to produce symptomatic changes.

The two studies were reported at the annual congress of the European College of Neuropsychopharmacology by Andrew T. Gloster, Ph.D., and Christina Hauke of the Institute of Clinical Psychology and Psychotherapy.

The first was a multicenter study of 369 patients with panic disorder and agoraphobia as well as a high rate of comorbid disorders (41%-73%). The study’s primary aim was to determine whether variations in treatment delivery affect outcomes of CBT.

The patients were randomized to two active variations of CBT. In one, the therapist was present during in vivo exposure exercises (n = 163); in the other, the therapist planned and discussed the exercises but did not accompany the patient (n = 138). A third group (control) was assigned to a wait list (n = 68).

“Leaving the room is crucial for the patient, and we explored whether there is a benefit for the therapist being with the patient for these exposures. Data suggest you can do the therapy both ways, but you absolutely must prepare the patient as to what will occur,” Dr. Gloster said. “We have this conversation many times with the patient. If the therapist is going with the patient, then the conversation can occur as it is needed.”

Attaining Better Response Rates

At the end of treatment, both active treatment groups were superior to the wait list group, but the therapist-present group obtained more favorable results on nearly every index. The largest differences were noted on agoraphobic avoidance and global functioning, he reported.

“We found there are additive effects when the therapist goes with the patient on all five exposure sessions,” Dr. Gloster said.

On global functioning, the mean baseline value was 5.4 for the therapist-present group, and 5.2 for both the therapist-not-present and the wait-list groups. From baseline to end of treatment (last observation carried forward), scores were reduced by nearly 2.5 points with the therapist present and 2.0 points without the therapist present (P less than .05). Patients continued to improve over time, and at the 6-month follow-up, these scores were further reduced (nonsignificantly) by another 1.0 and 0.75 points, respectively.

These numbers represented response rates post treatment of 49.7% for the therapist-present condition and 39.1% for therapist-not-present condition. At the 6-month follow-up, response rates rose to 68.7% and 60.9%, respectively.

The wait-list group showed little change post treatment, with scores reduced by a mean of less than 0.5, corresponding with a response rate of 7.4%, Dr. Gloster reported.

For agoraphobic avoidance, mean scores were approximately 3.0 at baseline for all groups and were reduced by approximately 1.2 points in the therapist-present arm and 0.75 in the therapist-not-present arm (P less than .05). Slight additional improvements were seen at 6 months. Wait-list patients showed little improvement.

Similarly, the percentage of patients panic free after treatment was 49.4% with the therapist present and 45.7% without, and at 6 months it was 66.3% and 60.9%, respectively. In the wait-list arm, just 25% became panic free. The number of panic attacks also was reduced, with statistical significance observed between the active treatment groups at 6 months. General anxiety similarly improved.

The rate of decrease in agoraphobic avoidance accelerated after the introduction of in vivo exposure, he added. Patients who exposed themselves to more anxiety-provoking situations had better outcomes.

“When the therapist accompanied the patient, at 6 months we saw a significantly greater reduction in panic attacks,” Dr. Gloster said. “Patients are having more spontaneous exposures, and this is the most important factor in the therapy.”

Strict Adherence Not Essential

The same investigators also reported a minimal inverse relationship between adherence to the CBT manual and outcome. “Overall, at a global level, adherence was not relevant to treatment outcome,” Ms. Hauke reported.

The finding could be biased, she acknowledged, by the fact that 80% of sessions were rated as “good adherence” or “highly adherent” so there was little room for improvement.

The study included 275 of the same patients as in the first study, treated by 62 therapists in the two exposure-based models described above. Investigators looked at the sample of completers (n = 230) who finished 12 twice-weekly sessions, and drop-outs (n = 45), who terminated before session 12. Therapist adherence ratings were generated by analysis of randomly selected videotapes of the sessions using the Therapist Adherence and Competency Rating Scales (TACRS) developed by Dr. Gloster and colleagues. Outcome measures were changes on scores on standard instruments.

Rates of adherence were similar for therapists of completers and drop-outs, approximately 5.5 on an 8-point scale, and higher level of adherence was associated minimally with worse outcomes, Ms. Hauke reported.

The therapists of the completers were significantly less likely to adhere to the protocol if they were assigned to the therapist-present exposure situation, compared with standard CBT (P = .025). Adherence was not, however, associated with outcomes for patients who dropped out. Therapists of patients who dropped out for exposure-related reasons (for example, anxious, not motivated) versus other reasons (for example, organizational problems, symptom improvement, or deterioration) had a strong trend toward lower levels of adherence (P = .05), which became significant after the researchers controlled for years of therapist experience (P = .036).

The findings might suggest “that levels of adherence should be matched with individual patient requirements before implementing a manualized therapy,” she said.

The main point, Ms. Hauke said, is that robust adherence to the CBT manual is not the only important factor in treatment outcome, and other modifiers should be examined.

The authors reported no potential conflicts of interest. The work was funded by the German Federal Ministry of Education and Research.