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.For example, a person witha specific phobia may well have no associated psychopathology, and onthat basis be quite likely to respond rapidly to focused treatment.Conver-sely, the phobic element in a person with generalized and severe socialphobia may reflect a broader spectrum of anxieties with deeper roots, andthe social withdrawal inherent in this presentation acts to reduce the likelyresources and resourcefulness of the patient.Sceptical clinicians tend to point out that this admixture of diagnoses(which often includes mood disorder and is often complicated by poorlevels of functioning) makes research findings hard to apply, and perhapseven irrelevant to everyday practice.Certainly some force is given to thisargument when meta-analysis of outcome studies suggests a link betweenlarger effect sizes and the proportion of patients excluded from a trial [14].Equally, however, there is evidence that clinical judgement is not alwaysbased on accurate appraisal of what is or is not helpful.Schulte et al.[15]looked at treatment outcomes for specific phobias, contrasting standardizedin vivo exposure against an individualized treatment where therapists werefree to implement any therapeutic approach.The greatest benefit was foundwith in vivo exposure, and those who did well with an individualizedapproach had been given in vivo exposure.This result is salutary: specificphobia is a condition with a straightforward treatment approach of knownefficacy, and yet at least some clinicians elected to employ alternative andless effective techniques.This study raises questions about how therapistsmanage more complex conditions, where more sophisticated treatmentdecisions are needed (an issue discussed in Wilson s [16] thought-provoking paper).It also emphasizes the efficacy of a technique which ispragmatically (if not theoretically) simple to grasp.PSYCHOTHERAPEUTIC INTERVENTIONS FOR PHOBIAS: COMMENTARIES __ 213One very evident shift reflected in the 40 years of research covered byBarlow et al. s review is the development of cognitive therapy, focusingattention on the meaning and interpretation of events (both external andinternal to the patient).In relation to phobic disorders this makes muchclinical sense, but it is interesting to note that evidence for the benefit ofadding cognitive to behavioural techniques is not always consistent.Nonetheless, a striking aspect of this field is the development of cognitivemodels which propose mechanisms for the maintenance of disorders, andwhich imply a route of action for their treatment.Panic control therapies areone such example, but a more recent one would be Clark and Wells s [17]model of social phobia.Given that social phobics do not benefit fromnaturalistic exposure to social events, Clark and Wells hypothesize thattheir problems are maintained by engaging in a number of counter-productive cognitive and behavioural strategies.This model does notsupersede others, since it incorporates techniques known to be of value,such as exposure.Nor is it unique (e.g.[18]).However, it does demonstratehow therapeutic technique can grow out of astute clinical observation,experimental scrutiny (e.g.[19]) and successful clinical test [20], a powerfulcycle of activity which links experimental and clinical psychology, to thebenefit of patients and clinicians alike.Contrast of the status of treatments for anxiety disorders with those inother diagnostic areas suggests that this is a somewhat unusual area, partlyin terms of the clarity of outcomes achieved, and partly because of evidenceof technical innovation linked to explicit modelling of disorders.There arefewer examples of this approach elsewhere, and a current overview ofprogress in other diagnostic areas [21] suggests that the impact of manyinterventions (whether psychological or pharmacological) is less thanoptimal.That this should be so represents a challenge, and whether thissituation resolves is a matter for the future.The hope has to be that theprogress made in the management of anxiety disorders will at some pointbe reflected elsewhere in the field.REFERENCES1.Shear M.K., Pilkonis P.A., Cloitre M., Leon A.C.(1994) Cognitive behavioraltreatment compared with non-prescriptive treatment of panic disorder.Arch.Gen.Psychiatry, 51: 395 401.2.Teusch L., Bohme H., Gastpar M.(1997) The benefit of an insight-oriented andexperiential approach on panic and agoraphobia symptoms.Results of acontrolled comparison of client-centered therapy alone and in combination withbehavioral exposure.Psychother.Psychosom., 66: 293 301.214 __________________________________________________________________________________________ PHOBIAS3.Craske M.G., Maidenberg E., Bystritsky A.(1995) Brief cognitive-behavioralversus nondirective therapy for panic disorder.J.Behav.Ther.Exp.Psychiatry,26: 113 120.4.Shear M.K., Houk P., Greeno C., Masters S.(2001) Emotion focused psycho-therapy for patients with panic disorder.Am.J.Psychiatry, 158: 1993 1998.5.Muris P., Merckelbach H., van Haaften H., Mayer B.(1997) Eye movementdesensitisation and reprocessing versus exposure in vivo: a single sessioncrossover study of spider-phobic children.Br.J.Psychiatry, 171: 82 86.6.Feske U., Goldstein A.J.(1997) Eye-movement desensitization and reprocessingtreatment for panic disorder: a controlled outcome and partial dismantlingstudy.J.Consult.Clin.Psychol., 65: 1026 1035.7.Goldstein A.J., de Beurs E., Chambless D.L., Wilson K.A.(2000) EMDR forpanic disorder with agoraphobia: comparison with waiting list and credibleattention-placebo control conditions.J.Consult.Clin.Psychol., 68: 947 956.8.Lipsitz J.D., Markowitz J.C., Cherry S., Fyer A.J.(1999) Open trial ofinterpersonal psychotherapy for the treatment of social phobia.Am.J.Psychiatry, 156: 1814 1816.9.Wiborg I.M., Dahl A.A.(1996) Does brief dynamic psychotherapy reduce therelapse rate of panic disorder? Arch.Gen.Psychiatry, 53: 689 694.10.Milrod B., Busch F., Leon A.C., Aronson A., Roiphe J., Rudden M., Singer M.,Shapiro M., Goldman H., Richter D.et al.(2001) A pilot open trial of briefpsychodynamic psychotherapy for panic disorder.J.Psychother.Pract.Res., 10:239 245.11.Sharpe D.M., Power K.G.(1997) Treatment-outcome research in panic disorder:dilemmas in reconciling the demands of pharmacological and psychologicalmethodologies.J.Psychopharmacol., 11: 373 380.12.Goisman R.M., Warshaw M.G., Keller M.(1999) Psychosocial treatmentprescriptions for generalized anxiety disorder, panic disorder, and socialphobia, 1991 1996.Am.J.Psychiatry, 156: 1819 1821.13.Roth A.D., Parry G.(1997) The implications of psychotherapy research forclinical practice and service development: lessons and limitations.J.Ment.Health, 6: 367 380.14.Westen D., Morrison, K [ Pobierz całość w formacie PDF ]

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