Objective: Many therapists are reluctant to conduct exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD). Negative beliefs about the safety and tolerability of ERP are common, especially for harm-related OCD symptoms. The study examined the nature and frequency of ERP-related serious negative consequences (SNC) and therapist attitudes and experiences providing ERP for harm-related OCD. Methods: An anonymous survey was completed by 277 therapists with experience treating OCD using ERP. Questions assessed clinical experiences of harm-related exposures, the nature of SNC, and concerns and clinical considerations regarding ERP.Results: Therapist's willingness to treat harm-related OCD was high. SNCs were reported for 6 clients (per-client risk: adults 0.05%, youth 0.01%) and 13 therapists (per therapist risk 4.73%, therapist per-year risk 0.004%). Qualitative analysis identified themes relating to the conduct of treatment, specific exposure types, professional issues, and negative perceptions of ERP.Conclusion: SNC associated with ERP for OCD are rare and primarily represent unintended secondary consequences of OCD or misunderstandings regarding the process and rationale behind ERP. Improving access to ERP will require good communication with clients, families, and other professionals regarding the rationale and safety of ERP. K E Y W O R D S assessment/diagnosis, child/adolescent, cognitive behavioral therapy, dissemination/ implementation, obsessive-compulsive disorder
Treatments targeting social connectedness have the potential to address a significant public health concern. Functional analytic psychotherapy (FAP) is based on a behavioral interpretation of how the therapeutic relationship can serve as a significant agent of change. Examine the efficacy of FAP compared to watchful waiting (WW) in a randomized controlled trial. Twenty-two participants with difficulties in interpersonal relating, according to the Fear of Intimacy Scale (FIS), and who met Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR) criteria for an anxiety disorder or avoidant personality disorder, were randomized to 6 (45–60 min) sessions of FAP (n = 11) or 6 (15 min) sessions of WW (n = 11). FAP outcomes were superior on the primary dependent variables: FIS, Psychiatric Diagnostic Screening Questionnaire (PDSQ) total symptom score, and DSM–IV–TR diagnostic status (as determined by blinded assessors). Adherence coding of sessions showed group differences on the FAP subscale (application of the FAP rules), but not on the supportive listening subscale. Measures of therapeutic alliance also favored FAP. The Working Alliance Inventory—Short Form (WAI) served as a statistical mediator of the relationship between treatment and FIS change and the FAP subscale mediated change on the PDSQ. FAP was more beneficial than WW and, while not definitive, some evidence was found to support the hypothesis that the effects were mediated by events occurring in the therapy relationship. These results are consistent with the FAP model of change. Replication and extension with larger and more diverse samples and more stringent control conditions seems warranted.
The proposed mechanism of action in Functional Analytic Psychotherapy (FAP) is therapist-contingent responses to client in-session behavior that parallels out-of-session problematic behavior. In theory, these responses shape adaptive behaviors that generalize into the client's daily life (Tsai et al., 2009). Therefore, the therapist's response repertoire must be ripe with interpersonally effective responses to model and shape client behavior. Thus, trainings in FAP were designed not only to equip therapists with a skillset in implementing the fundamentals of shaping but also to serve several other functions, including facilitating the development of an effective interpersonal repertoire to promote shaping. Kanter, Tsai, Holman, and Koerner (2013) demonstrated that 8-week FAP trainings may increase knowledge of FAP principles as measured through self-report and analogue tasks; however, no research examines reported changes in therapists' interpersonal behavior in or out of session. We believe that an 8-week FAP training will increase therapist use of effective interpersonal behavior (tCRB2) and decrease therapist maladaptive behavior (tCRB1). Four newly graduated and graduatelevel therapists attended an 8-week FAP training. Using an AB single-subject design, we examined the frequency of targeted interpersonal behavior. Results indicated that FAP trainings may have an impact on therapists' daily life behaviors as demonstrated through changes in weekly frequency counts. Although the design includes significant limitations (see Discussion), these data provide some support for the utility of 1 theorized function of FAP trainings.
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