Summary---Cognitive restructuring and prolonged exposure irk viw were compared in a cross- over drslgn with 21 agoraphobia.

Assessments were made at the beginning of treatment. at cross-over. at the end of treatment and at the follow-up one month later. Assessment urre carried out by an ~~~~e~en~e~t observer fphobic anxiety and avoidance scales and anxious mood) and by the ciirnt ~m~s~r~mc~t irt cica. phobic anxiq and avoidance scalrs. FSS. ASES. SDS and I-E scafel. Prolonged rxposure if8 C&D provrd to be a definitely superior form of treatment to cognitive restmcturing, as

measured by the behawral in cka measurement and rhc phobic anxiety and avoidance scalrs.

In the treatment of ~~~raph~bia by means of behavior therapy, the emphasis has in recent years been laid on the direct approach to avoidance behavior through exposure in I&XI procedures such as shaping, self-observation and ff~~di~~ or prolonged exposure in riro (Marks, 1975; EmmeCkamp, 1977).

A quite different procedure which is also aimed at altering phobic behavior is cognitive restructuring. According to cognitive theorists. reactions af anxiety can 5c aroused by the erroneous interpretation that is attached to a certain situation. Hence the modifica- tion of :he label that is attached to the situation can be elective in altering the emotional reaction and the avoidance behavior of phobics.

Several new cognitive behavior modification procedures have been developed recently. What these procedures have in common is shat anxious subjects are trained to abandon their anx~~~~“j~d~c~~g reflections and to emit more ~~~dl~ctive s~~f-st~t~me~~s~ Cograitive behavior modification procedures proved to be success~ur$ in the tr~~trne~t of small animal phsbias (D’ZurElfa, Wilson and Pi&on, 1973; ~~e~c~e~~~~rn, 1371; Wein, Nelson and Odom, 1973, test anxiety (Holroyd, 19%; M~ichcnbaum, 1977). and public speaking anxiety and under-assertiveness (Di Loreto, 197 I : Meichenbaum, Gilmore and Fedaravi- cius, 1971; Thorpe, 1975: Thorpe er ai., 1976; Trexler and Karst, 1972). All these investi- gations, however, were anstlogue studies with students as subjects: controlled ciinicai

trials are lacking at present.

In the present study, cognitive ~e~tFuct~~r~n~ was compared with proh~~ged exposure it1 ciao with agoraphobics as subjects. We chose the latrer method for our comparison because its effects are fairly well known ~~rnme~karnp and Wessels, 1975: Hafner and Marks, 1976; Hand, Lamontange and Marks, 1974). ,4s cognitive r~str~ct~r~~~ was car- ried our in the form of group treatment in most of the studies, and no difference was found between the effects of group treatment and ~~d~vid~a~ treatment with exposure in rim (Emmelkamp and ~rn~le~karn~-~enner~ 1975; Hafner and Marks, 1975). group treatment was used for both procedures.

A cross-uver design was used. After the pretest and intervie-v;, iwo groups were given cognitive restructuring treatment and two other groups were pi\en pr~~o~~~d exposure

RRT ihl--T 3. 3

in cico treatment. The effect was measured (the intermediate test). and then a second period of treatment followed. but now with each group being given the other treatment. Then the effect was again measured (the post-test), and after one month in which no treatment was given this measurement was repeated (the follow-up). Clients were assigned at random to the treatment groups. in the order of their application.

Treatment

The treatment in the case of both cognitive restructuring and prolonged cuposure in r&o consisted of five group sessions. each lasting two hours. As each subject received both types of treatment, this meant that the complete treatment consisted of ten sessions which took place within a period of two weeks. Each group was led by two therapists.

Cognitire restructwirlg

This treatment consisted of three different parts: (a) re-labeling. (b) the discussion of irrational beliefs. and (c) self-instructional training.

(a) Re-Wiling. The first phase was designed to provide the client with an explanatory scheme to enable him to understand the nature of his responses to phobic situations. With the aid of neutral examples and examples provided by the clients themseltcs. it was made clear that the situations depicted were not in themselves anxiety arousing. but that the anxiety was aroused as a result of maladaptive cognitive responses. At the end of the first session. a written rationale of the treatment was given to the clients to take with them. with instructions to study this before the next session. The clients were also given homework sheets (Goldfried and Goldfried, 19753 on which they wcrz to indicate, every time they experienced feelings of anxiety; (I) a description of the situation, (2) the initial anxiety level, (3) the irrational thoughts. (3) rational thoughts, and (5) the subsequent anxiety level. The object of this ‘homework’ was to make the client aware of the negative, anxiety engendering self-statements he emitted in phobic situations and to suggest to the client that he might experience anxiety reduction as a result of a re-labeling of the situation.

(b) Irrafional beliefs. Eight ‘irrational beliefs’ were culled from Ellis (1962). The irra- tional beliefs were chosen for their applicability to the agoraphobic’s situation, but non-agoraphobic examples were also discussed. Two such irrational ideas were discussed per session, beginning with the second session. Each time the clients were instructed to find examples of their own which had some connection with the irrational ideas under discussion. After the second session they also had to study ‘A rational counseling

primer‘ (Young, 1974), which explains Ellis’ theory in simple terms. The book was discussed at the following session.

(c) Self-instrilcrionnl training. The third phase of this form of therapy was designed to train the clients to emit more productive self-statements. Productive self-statements were practised at each session, beginning with the second, in the following order: (1) preparing, (2) confronting. (3) coping, and (3) reinforcing (Meichenbaum. 1975). At each session the clients cognitively rehearsed self-instructional ways of handfing anxiety by means of an imagination procedure. The therapist asked the client to imagine the situ- ations described by the therapist as vividly as possible. The client !vas instructed to ascertain how anxious he felt, to become conscious of his negative self-statements and then to replace them by productive self-statements. Situations which were cognitively rehearsed were for example walking in the street, traveling by bus or train, being in a crowded restaurant or supermarket.

Prolonged exposure in viva

During the first half hour of the first session, the clients exchanged information about the onset and development of their phobias and the therapists gave the treatment rationale. The role played by avoidance behavior in maintaining phobias was empha- sized and the clients were instructed to remain in the phobic situations until they had experienced anxiety reduction. Then the ciients and therapists together took a short

walk to the centre of town. the place where the clients would have to walk more and more on their own in future. After SO minutes of prolonged exposure irl rice. the clients’ experiences were assessed in a brief group discussion at the hospital. The

order of events in all the following sessions was (1) a group discussion (15 min) in which the day’s programme was discussed. (2) prolonged exposure in cico (90 min). and (3) a group discussion (15 min) in which the clients’ experiences were assessed. During the period of prolonged exposure in ciw the clients were exposed to situations which presented problems for them. at first in groups of 2. or 3, but as the treatment progressed more and more on their own. Difficult situations for the clients were for example walking in busy streets. shopping in department stores and supermarkets. and riding in buses. Not all the clients were exposed to the same type of situation, for example some clients had no difficulty in traveling on their own. whereas others required the presence of fellow clients.

The therapists were less and less frequently present during the esposure in tiw periods; they consciously faded from the groups. and during the final sessions were only present at the discussions precedin g and following the exposure periods.

Therapists

The therapists were six advanced clinical psychology students and one clinical psycho- logist. All the therapists had some experience in the treatment of agoraphobics. The therapists were supervised by the senior author.

Clients

Twenty-four clients took part in the investigation. One client (aged 68) dropped out during the cognitive restructuring treatment because she found the treatment in groups too noisy and strenuous. A total of 17 women and 6 men completed the treatment as far as the intermediate test. The data of 2 clients were not used because their score on the in riro measurement at the pretest was >45 min. The data of the remaining clients. 17 women and 4 men, were processed in the data analysis. The average age of the clients was 368yr. the range 23-60. The average duration of the complaint was 6.9 yr, the range 0.5-39 yr.

After the intermediate test. one client dropped out because of an illness. Thus 20 clients completed the project.

Assessments

Assessments were carried out at the pre-test, intermediate test, post-test and follow-up, by the client. In addition, an independent observer-a clinical psychologist-assessed the client at the beginning and at the end of the treatment.

Measrtrernenr in cico. The client had to walk along a certain route from the hospital towards the centre of town. He was instructed to stay outside until he began to feel uncomfortable or tense. then he had to come back straightaway. The duration of time spent outside by the client was measured by the therapist. (The maximum time was set at 100 min in connection with the calculations to be made.)

Phobic nnxiety arui acoidance scales. The client and the independent observer rated the client with regard to the following 5 situations on 9-point scales for phobic anxiety and phobic avoidance (Watson and Marks, 1971): (1) busy high street. (3) supermarket, (3) bus. (4) restaurant and (5) walking from hospital.

Amiorts nwad. The independent observer rated the client on a 9-point scale for anxious mood (Watson and Marks, 1971).

Moreover. the chent filled in the following questionnaires: Fear Surrey Schedule (FSS) (Wolpe and Lang, 1964; range 76-380); ~~~fe~~u~-~,~~e~~~a~ Controi Scale (I-E) (Rotter. 1966; range 12-71); Setfrrafing Depression Scale (SDS) (Zung, 1965; range 23-92): and A&/r Self-Expression Scale (ASES) (Gay, Hollandsworth and Galassi, 1975; range

O-192). Variations adapted for use in the Netherlands were used.

36 PALL .M. G EW.~ELK.LWP, AUTOISETTE C. Xl. KLIPERS and JOHAS B. EGGER.LAT

RESULTS

The data were tested with two-tailed r-tests for dependent or independent samples. The means of the variables did not differ significantly at the pretest.

Prolonged exposure and cognitice restructuring combined-total treatment effect

The combined results of all four groups showed an improvement on almost all the variables at the post-test (see Table 1). No significant sequence effect was noticeable at the post-test.

EfSects of the individual treatments

The effects of the individual treatments are shown in Table 2. Prolonged exposure irr cico. whether it was the first or the second type of treatment received, resulted in significant improvements on most of the variables. Cognitive restruc- turing, with the group for which it was the first type of treatment received, resulted in a significant improvement only on a few phobic anxiety and avoidance scales. With the group for which it was the second type of treatment received, it resulted in a signifi- cant improvement only on the I-E scale and the SDS.

Comparison of prolonged exposure and cognitive restructuring

The pretest/intermediate test change scores are shown in Figs 1 and 2. Prolonged exposure proved to result in significantly more improvement than cognitive restructuring (both as the first type of treatment received) on the in uiuo measurement (t (19) = 4.24. p < 0.001). on the phobic anxiety scales busy high street (t (19) = -2.15. p < 0.05), restaurant (t (19) = -2.38. p < 0.05), walking from hospital (t (19) = -2.79, p < 0.02) and bus (t (19) = -3.71, p < O.Ol), and on the phobic avoidance scales restaur- ant (t (19) = -3.14, p < 0.01). walking from hospital (t (19) = -3.40, p < 0.01) and

Table I. Overall treatment effect

Variables Pretesr Post-test

M SD M SD df t

1~ ciao measurement (min) Phobic am\-irty

Busy highstreet

Restaurant

Walking

Supermarket

Bus

Phobic aroidmcr

Busy highstreet

Restaurant

Walking

Supermarket

Bus

Amiota mood FSS ASES I-E scale SDS

13.5

C 6.0

0 6.9

C 5.2 0 5.7 c 6.2 0 6.5

c 5.5 0 6.5 C 5.6

0 6.0

c 6.8 0 6.1

C 6.6 0 6.8 c 6.9 0 7.0

c 6.3 0 6.8

C 6.4 0 6. I

4.3 177.0

104.1 40.1 56.0

* p < 0.01 c = client t p < 0.001 o = independent observer.

8.5 46.9 21.6

2.1 2.7 2.0

2.2 2.9 I.8 2.5 2.4 1.6 2.4 2.4 2.0 2.1 2.3 I.6 1.8 2.5 l.S 1.9 2.6 2.0 I .9 3.2 2.1 1.9 2.1 1.9 7.1 2.5 2.3

2.4 2.8 2.6 2.9 2.5 3.2 2.4 3.0 2.3 2.8 3.3 3.6 2.3 2.4 2.3 2.6 I .9 2.9 2.0 2.9 2.4 2.2 3.1 3.5 2.3 3.1 2.7 3.3 3.2 3.6 2.4 3.1 1.7

46.7 135.6 40.3 14.4 105.1 12.3

5.7 38.2 9.3 9.0 47.9 9.1

I9

19 19 I9 I9 I9 I9 I9 I9 I9 I9

19 19 I9 19 19 19 I9 I9 19 I9 I9 19 I9 I9 I9

-FL01t

5.77t 7.00t 4.9gt 5.95t 7.14t 9.45t 6.03t 5.57t 6.lOt 4.54t

6.5St 4.90t 5.57t 4.33t 7.781 6.93t 7.66t 4.54t 5.25t 3.12’ 2.08 5.44t

-0.37 I.13 3.48”

Cogmtive modilicatron versus prolonged exposure UI CICO 37

Table 2. EtTect of the tndiridual treatments

Variables

First treatment Second treatment prolonged cognitive prolonged cognitive e*posure restructuring exposure restructuring

df r d/ c d/ f dj I

In viva measurement (min) Phobic an.xiet_v

Busy highstreet Restaurant Walking Supermarket Bus

Phobic acoidance

Busy highstreet Restaurant Walking Supermarket

Bus FSS ASES I-E scale SDS

- 7.23

3.02t 4.60: 4.26: 4.62: 4.11: 4.72:

-0.75 0.77 2.g4t

IO -

IO IO IO IO IO

IO 10 IO IO IO IO IO IO IO

-2.14 9 -3.79: 9 - 1.64

I .66 9 4.43: 9 - 0.46 0.75 9 3.4s: 9 I .os 2.X* 9 2.93t 9 I .oo 1.66 9 3.16t 9 I .os 0.18 9 4.09: 9 I.41

2.sot 9 4.12: 9 I .29 1.79 9 3.12: 9 1.29 I .90 9 -1.37: 9 0.92 2.92t 9 7.11 9 0.79 0.00 9 4.11: 9 0.52 I .97 9 3.05t 9 I.17 0.00 9 - 0.99 9 -0.60 0.00 9 0.33 9 ‘.-IO’ 0.00 9 LOS 9 2.32*

* p < 0.05. t p < 0.02. : p < 0.01. \\p < 0.001

bus (t (19) = -3.82. p < 0.01). There was not one variable on which cognitive restructur- ing proved to result in more improvement than prolonged exposure irk cico.

The combined data for identical first and second treatments show that the effects of prolonged exposure were clearly superior to those of cognitive restructuring (see Table 3).

Fig. I. Mean change scores (pretest-intermediate test) on the measurement i)r ciro

Busy highstreet

Walking Supermarket

r-l Exposure in viva

Phobic Anxiety (0 - 8) I

Ccgnitive restructuring

7-

BUSY highstreet

Restaurant Walking Supermarket Bus

r-l Exposure in viva

Phobic Avoidance (0 - 8)

Cognitive restructuring

Fig. 1. Mean change scores (pretest-intermediate test) on phobic anxiety and avoidance scales.

Foliow-up

Between the post-test and the follow-up, no treatment was given, The results of the Follow-up are almost the same as those of the post-test. A comparison of the scores of the pretest and those of the follow-up shows that the complete treatment led to

Table 3 Change scores identical first and second treatment combined

Variables Prolonged Exposure Cognitive Restructuring

M SD M SD dl I

In viva measurement (mlnl -25.1 15.8 Pllohic ansietJ

Busy hlghstreet 3.9 2.1 Rrsuurant 2.3 2.1 Walking 3.1 2.5 Supermarket 2. I 2.1 Bus i.0 2.2

Phobic atoidutw

Busy highstrert 3.0 2.7 Restaurant 2s ‘2 Walking 3.8 2.3 Supermarket 2.1 2.4 BUS 3.2 2-l

FSS 78.3 24.0 ASES - I.1 7.5 I-E scatc 0.1 -l. 1 SDS 4.2 5.3

0.5 2.3 39 3.54i 0.1 1.6 39 3.Zi

0.9 1.7 39 3.33t 0.8 1.9 39 2.07*

0.J 1.6 39 1.38:

I .o I.8 39 ‘.YM 0.9 1.9 39 3.03+ 0.7 1.7 39 4-U: 1.1 I .9 39 2.01 0. I I.5 39 4.sfl;

I-1.3 29.0 39 I.66 -0.8 1 I.5 39 -0.19

1.6 6.4 39 -0.70 3 6 IO..! 3Y 0.75

* p < 0.05. :p < 001. : p < 0.001

Cogn~u~r modtficatlon ~WAIS prolonged cuposure in CICO 39

a significant improvement on the in ciao measurement (p < 0.001). on all the phobic

anxiety and avoidance scales (p < 0.001). on the FSS (p < 0.001) and on the SDS (p c 0.02). Only the ASES and the I-E scale showed no significant improvement. as was the case with the post-test. No significant sequence effect was found.

DISCUSSION

Prolonged exposure in riro proved to be a definitely superior form of treatment to cognitive restructuring, as measured by the behavioral in ciao measurement and the phobic anxiety and avoidance scales. In fact,‘cognitive restructuring only led to a slight improvement. The favourable effect of prolonged exposure in cico corroborates the result of earlier studies (Emmelkamp and Wessels. 1975; Hafner and Marks. 1976; Hand, Lamontagne and Marks, 1974). Group exposure in cim is probably the most effective and the most efficient behavioral treatment for agoraphobia known at present.

Neither of the two methods of treatment resulted in a significant change in assertive- ness. It is interesting to no&e that protonged exposure in tico as the first type of treatment received. as well as cognitive restructuring as the second type of treatment received, led to a reduction of feelings of depression as measured by the SDS. Only cognitive restructuring as the second type of treatment received led to a significant improvement on the I-E scale.

Why did cognitive restructuring produce such poor results in the present investigation, while other experimenters claim to have achieved such impressive results with this same

method of treatment or variants of it’? Unlike the present study, all the other studies on this subject were analogue studies: the effects of treatments in analogue studies might be more strongly influenced than in clinical trials by factors such as demand characteristics (Borkovec, 1973) and expectancy of therapeutic gain (Emmelkamp, 1975). Besides, it seems probable that the level of intelligence of our (mostly lower-class or middle-class) clients will on the average have been lower than that of the subjects in the analogue studies, who were students in almost all cases. Cognitive restructuring might well be more effective with intelligent students used to thinking rationally than with a clinical population. The degree of physiological arousal in anxiety engendering situations too might differ considerably for agoraphobics and for subjects in analogue studies: the latter probably react with a much slighter degree of arousal than the former

(Lader, 1967). It is quite possible that cognitive restructuring constitutes an effective form of treatment for low physiological reactors (such as the subjects of analogue studies), while such treatment will be effective for high physiological reactors (such as agoraphobics) only after the autonomic component has been reduced. It would be worth- while to examine the part played by physiological arousal in further studies.

In the present study, the process of cognitive restructuring included both insight into unproductive thinking and cognitive rehearsal of productive self-statements. The cogni- tive procedure may have suffered from the condensation of these techniques into a relatively brief period of time (10 treatment hours). However, this would not seem to be a serious limitation, since other studies which combined both insight and rehearsal in one form of treatment did show positive results, even in cases where the treatment hours were fewer. The question nevertheless arises whether the combined form of cogni- tive treatment as used in the present study is the best possible form. It seems advisable to devote more attention to insight into unproductive thinking in future investigations, as Thorpe et al. (1976) in a recent analogue study found that insight was more important than instructional rehearsal. Until the effects of such procedural variations have been clarified by further research with clients with clinical phobias, no definitive conclusions concerning the relative efficacy of insight versus instructional rehearsal can be drawn.

With cognitive restructu~ng, a transfer gap often proved to exist between practising during the treatment sessions and applying the new forms of behavior in real-life situ- ations. Although most of the clients after some practice were able to think productively when imagining phobic situations. they found it much more difficult to make use of productive self-statements in real-life situations (for example on the way home). The

40 P~LC Lt. G. EIISIELKLMP. A%TOINETTE C. M. KCIPERS and JOHA> B. EGCER.~.\I

effect of cognitive restructuring might be increased if this procedure was combined with

real-life exposure in phobic situations. In the clinical use of Rational Emori\e Therapy, for example. use is often made of in ciao homework assignments (Ellis, 1962). To what

extent a combination of cognitive restructuring and exposure in riro produces greater effect than exposure in riro by itself is. however, a question which requires investigation.

Giving a form of treatment a name is not the same as elucidating the therapeutic process involved. Whether the treatment ‘cognitive restructuring’ does actually produce a modification of cognitive processes is a debatable point. On the other hand, the effects of prolonged esposure in cico could at least partly be explained in terms of cognitive restructuring. Durin g treatment with prolonged exposure in vile clients notice.

for example. that their anxiety diminishes after a time and that the events which they fear. such as fainting or having a heart attack, do not take place. This may lead them to transform their unproductive self-statements into more productive ones: ‘There you are, nothing will go wrong with me’. A number of clients reported spontaneously that their ‘thoughts’ had undergone a much greater change during prolonged exposure irl vice than during cognitive restructuring. It is possible that a more effective cognitive modification takes place through prolonged exposure in ciao than through a procedure which is focused directly on such a change.

One limitation of the cross-over design used in this study is that a follow-up per method is impossible. For this reason possible long-term effects of cognitive restructuring

could not be ascertained. In summary: prolonged exposure iu ciao proved to be a clearly superior method

of treatment to cognitive restructuring. The results of the present investigation should make therapists take a critical attitude towards the use of cognitive restructuring in the case of clinical phobias. Further studies with ‘real’ clients should be carried out before definitive conclusions can be drawn concerning the effects of cognitive restructur- ing.

.-1c~,ro~c/udyo,rc,rrs_Thc authors arc grateful to Frans Aibersnagel. serving as independent observer and to Jolanda Klein. G\ban Kwce. W’im Rexwinkel and Anke Walstra for their assistance m thr treatment of

the clients. Requests for reprints can be addressed to Paul M. G. Emmelkamp. Academic Hospital. Department of

Clinical Psychology, Oostersingel 59. Groningen. The Netherlands.

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