Few studies have examined predictors of outcome for treatment of
specific and social phobias. However, the few studies that do exist fall into
two main categories. First, several investigators have attempted to match
treatment strategies to specific charac-teristics of patients. Secondly,
several studies have examined the relationship between individual differences
(e.g., duration and severity of illness, personality factors) and response to
Much more research is needed to identify predictors of outcome with CBT
and especially with pharmacological treatment. For example, little is known
about the effectiveness of treatments for specific and social phobias in
special populations (e.g., elderly persons, culturally diverse groups). There
has also been a lack of research on the impact of comorbidity on success of
treatment with specific phobias.
With respect to specific phobia, it is common for some return of fear to
occur in the presence of the phobic stimulus Relapse following treatment of a
specific phobia is believed to be rare. A number of variables have been
identified that predict return of fear including distraction during exposure, a
relatively quick reduction in fear during exposure, a relatively slow reduction
in fear during exposure, higher initial heart rate, spacing of expo-sure
sessions and the degree to which the exposure stimuli are varied, the tendency
to over associate fear-relevant stimuli with aversive.
Refractory Patients and Nonresponse to Initial Treatment
Several variables may lead to an initially poor treatment re-sponse. Anticipating potential difficulties will help increase treatment efficacy. Possible reasons for a worse outcome include poor compliance, poor motivation and poor understanding of the treatment procedures. In addition, interpersonal issues and other possible conflicts may interfere with the successful treatment of specific and social phobias.
Patients fail to comply with treatment procedures for a va-riety of
reasons. In the case of pharmacological treatments, pa-tients may avoid taking
medications because of side effects, lack of confidence in efficacy, or
preference for an alternative type of treatment. If patients are not compliant
with medications, the physician should attempt to identify the reasons for poor
compli-ance and to suggest methods of increasing compliance or chang-ing to
another type of treatment.
In the case of CBT, common reasons for poor compliance are anxiety about
conforming to treatment, lack of time and lack of motivation to conduct the
treatment properly. Because CBT re-quires patients to confront the situations
they fear most, patients often feel extreme anxiety about participating in the
treatment. Patients should be reassured that their anxiety is normal and that
they will never be forced to do anything that they are unwilling to try.
Furthermore, the difficulty of exposure tasks should be increased gradually to
maximize treatment compliance. If pa-tients do not have the time or motivation
to conduct treatment as suggested, therapists should be willing to find ways to
make the treatment more accessible to the patient. For example, involve-ment of
a friend or relative of the patient as a coach may allow the patient to conduct
more practices without the therapist’s as-sistance. The therapist could also
explore the possibility that the patient consider beginning treatment later,
when more time is available.
Poor motivation can lead to poor compliance with the treat-ment
procedures. If a patient’s symptoms are not especially se- vere, the distress
and impairment created by the disorder may not be enough to motivate the
patient to take medications regularly or to confront the phobic situation in a
systematic way. Furthermore, as a patient improves in treatment, she or he may
experience a de-crease in motivation. Patients should be encouraged to continue
with treatment assignments even after improvement. More com-plete improvements
may protect against a return of symptoms.
Finally, treatment procedures may be complicated for some patients. This
is especially the case for CBT. Patients may fail to complete homework
assignments (e.g., monitoring anxious cognitions) simply because the treatment
rationale and the specif-ics of how to conduct the treatment procedures were
not made clear. Therefore, therapists should continually assess the patient’s
understanding of the treatment procedures.