تمرین مواجهه درمانی: ارتباط نظریه شناختی-رفتاری و نظریه انقراض نسل

Exposure therapy is the most effective psychological intervention for people with anxiety disorders. While many therapists learn how to implement exposure techniques through clinical training programs or instructional workshops, not all of these educational efforts include a focus on the theory underlying this treatment. The availability of treatment manuals providing step-by-step instructions for how to implement exposure makes it easier for clinicians to use these techniques with less training than they might otherwise receive. This raises questions regarding whether it is necessary to understand the theory behind the use of exposure. This article argues that knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome. Specific ways in which theory is relevant to using exposure techniques are discussed.

Across the mental health fields there is a great deal of inconsistency in how psychological treatments are taught to trainees (and to professionals). While most of this training necessarily focuses on technique—how to implement the various treatment procedures—considerably less attention is often paid to helping the trainee understand the theory that forms the basis for these treatment procedures. This lack of emphasis on theoretical models might be an unfortunate by-product of the field’s current (and important) emphasis on treatment manuals and outcome research. It also might be driven by the (similarly important) need to rapidly disseminate effective psychological treatments. Another reason theory might be less valued than technique is that psychological theories can be difficult to understand, requiring a large time commitment that some might feel is not essential to providing effective treatment. Yet this state of affairs begs the question of how effective one can be when delivering psychological treatments if there is no understanding of the science behind the treatments being delivered. In the present article I will argue that in the case of exposure therapy for pathological anxiety and fear (i.e., anxiety disorders), knowledge of contemporary cognitive-behavioral models of anxiety disorders and the principles of extinction (i.e., the type of learning that occurs with exposure) is extremely important in helping patients achieve optimal short- and long-term outcome. I will begin with a description of exposure techniques and reviews of contemporary cognitive-behavioral models of anxiety disorders and extinction theory on which the principles of exposure therapy are based. After a brief review of research supporting the efficacy of exposure, I will turn to some anecdotes and observations I have made of novice therapists who did not have sufficient knowledge of the relevant theory. I will then discuss several reasons supporting my contention that at least a working knowledge of the theoretical framework discussed in the first part of this article is vital in obtaining optimal short- and long-term success with exposure.

Treatment manuals, considered by many experts to be essential to outcome research studies (Foa & Meadows, 1997), are used to promote the standardization of therapy procedures across therapists and patients. Optimally, manuals should delineate the essential principles of treatment and provide clinicians with session-by-session procedural guidelines. Sometimes, however, the use of step-by-step manuals leads to taking for granted the theory behind the intervention. Exposure therapy is a set of therapeutic techniques that requires knowledge of the cognitive-behavioral model of anxiety disorders, and of how fear extinction works, in order to be implemented optimally. This article has addressed some of the important reasons this is so, and also highlighted what can happen when this theory is overlooked. It is hoped that in addition to providing training in the practical side of implementing exposure, workshop leaders and clinical training programs incorporate an overview (at the very least) of the theoretical underpinnings of this highly efficacious treatment procedure.