Psychotherapy Research, January 2006; 16(1): 41 /50
Do all treatments work for flight phobia? Computer-assisted exposure versus a brief multicomponent nonexposure treatment
´S XAVIER BORNAS, MIQUEL TORTELLA-FELIU, & JORDI LLABRE Department of Psychology, University of the Balearic Islands, Palma, Mallorca (Received 28 April 2004; revised 25 August 2004; accepted 15 November 2004)
Abstract Computer-assisted treatments have proven to be effective in the treatment of several anxiety disorders and depression, but the role of exposure remains unclear. This study compares the efficacy of a computer-assisted exposure treatment (CAE) with a brief multicomponent nonexposure treatment (MNE) for flight phobia. Outcome measure assessments were conducted at posttreatment and at 6-month follow-up. No differences were found between CAE and MNE in reducing fear of flying. In both conditions patients improved significantly and clinically meaningfully, and results were maintained at 6- month follow-up. These findings challenge the idea that exposure is essential in reducing phobic anxiety and support the idea that specific phobias may be well suited for brief cognitive /behavioral treatments.
Over the last years, research on psychological treatments has been widely devoted to streamlining existing effective cognitive /behavioral treatments to make them more efficient, cost-effective, and affordable, as pointed out by Hazlett-Stevens and Craske (2002). The most common way to enhance efficiency has been to reduce the number of treatment sessions of existing cognitive/behavioral interventions. The one-session exposure treatment for spe¨ st, cific phobias, including flight phobia (O Brandberg, & Alm, 1997), is a good example of ¨ st, 1997). this line of research (O Computer technology has allowed the development of computer-assisted (CA) treatments as another way to improve existing treatments. CA self-help programs have proven to be effective in the treatment of depression (Osgood-Hynes et al., 1998), obsessive/compulsive disorder (Greist et al., 2002), and phobia /panic disorders (Marks, Kenwright, McDonough, Whittaker, & MataixCols, 2004; Marks et al., 2003). Another kind of CA treatment provides systematic exposure to phobic images and sounds (CA exposure [CAE]) and has been used in the treatment of dental phobia (Coldwell, Getz, Milgrom, Prall, Spadafora, & Ramsay, 1998), spider phobia (Nelissen, Muris, & Merckelback, 1995), and fear of flying (Bornas, Tortella-Feliu, Llabre´s, & Fullana, 2001). The dramatic development of virtual reality (VR) technology
over the last few years and, perhaps, the initial failure in the Nelissen et al. (1995) case studies have slowed the development of CAE treatments. Regarding flight phobia, several studies have demonstrated the effectiveness of VR exposure treatments (Maltby, Kirsch, Mayers, & Allen, 2002; Mu¨hlberger, Herrmann, Wiedemann, Ellgring, & Pauli, 2001; Mu¨hlberger, Wiedemann, & Pauli, 2003; Rothbaum, Hodges, Smith, & Lee, 2000). It is important to note that exposure is a common component of these three strategies that have been used to make flight phobia treatments more effective, namely (a) reducing the number of sessions, (b) computerizing exposure, and (c) developing virtual environments. In this article we focus on the second strategy and try to elucidate the therapeutic role that exposure plays as the key component of a CA treatment for flight phobia. Bornas, Tortella-Feliu, et al. (2001) provided some empirical evidence about the effectiveness of the CA fear of flying treatment (CAFFT; see Bornas, Fullana, Tortella-Feliu, Llabre´s, & Garcı´a de la Banda, 2001, for a detailed description of the treatment program). In that study CAFFT (CAE group) was compared with a multicomponent treatment package, including CAE, aeronautical information, controlled breathing, and muscular relaxation (IRCAE group), and a control group taken from the waiting list. The results showed that
Correspondence: Xavier Bornas, Departament de Psicologia, Universitat de les Illes Balears. Edifici Guillem Cifre de Colonya. Carretera de Valldemossa km. 7.5, 07122 Palma, Mallorca. E-mail:
[email protected] ISSN 1050-3307 print/ISSN 1468-4381 online # 2006 Society for Psychotherapy Research DOI: 10.1080/10503300500091058
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both treatments were more effective than the control condition, and that the CAFFT treatment led to greater reductions in flight phobia self-reported measures than the multicomponent treatment package. CAFFT treatment in the IRCAE group was not enhanced by the additional sessions devoted to aeronautical information and arousal control techniques. Therefore, the authors assumed exposure to be the crucial contribution to the efficacy of the CAFFT. Further, this treatment was much shorter (fewer than five exposure sessions of 50 min) and less expensive than the multicomponent treatment, which in addition showed a higher dropout rate. However, the role of exposure in that study could not be clearly elucidated because CAFFT was one of the components of the multicomponent treatment package followed by the IRCAE group. In addition, the duration of the two treatments was quite different, the role of the therapist in the CAE group was not strictly controlled, and the final graduation flight with one therapist was not a good measure of the posttreatment avoidance level of the patients. These limitations should be overcome to clarify the role of exposure in the treatment of flight phobia. The major aim of this study was to elucidate the actual role of computerized exposure in the treatment of flight phobia compared with a nonexposure treatment program, overcoming some of the limitations of previous CAFFT research described previously. Using a randomized design, this study compared the efficacy of the CAFFT without any kind of additional exposure procedure (i.e., a graduation flight assisted by a therapist) and a brief multicomponent treatment with nonexposure (MNE). On the basis of the widespread and wellsupported belief that exposure is crucial to reduce phobic fears, our main hypothesis was that CAE would be more effective than MNE. However, some studies suggest that other cognitive /behavioral treatments might be effective as well in the treatment of anxiety disorders (Marks & Dar, 2000). Therefore, to assess the efficacy of the alternative, brief multicomponent treatment was another major goal of the study. Method Protocol Participants were recruited through advertisements in local newspapers. Fifty-one individuals asked for treatment (see Patient Flow section for a detailed description of the sample). The Anxiety Disorders Interview Schedule for DSM /IV (ADIS /IV; Brown, DiNardo, & Barlow, 1994) was used to individually assess all individuals who asked for
treatment. During the same session, various variables related to fear of flying and to therapy (e.g., motivation) were evaluated by means of several selfreport instruments (see Self-Report Instruments section). Individuals who were included in the study met the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM /IV; American Psychiatric Association, 1994) criteria for specific phobia (flying) as the main diagnosis, were older than 18, and signed an informed consent form. Exclusion criteria were as follows: current psychological treatment, psychotropic medication use, any other psychopathological disorder requiring immediate treatment, history of psychotic symptoms or current psychotic disorder, cardiovascular or respiratory illness, and current pregnancy. Evaluations before treatment, at the end of treatment, and at 6-month follow-up were carried out by three independent evaluators who were not involved in the randomization process and who were unaware of treatment conditions. Suitable candidates at pretreatment were randomly assigned to one of two experimental conditions: CAE or MNE. Randomization was stratified by gender and avoidance. Not having flown for two or more years was categorized as avoidance. One member of the research group who did not participate as a therapist in the study used random numbers generated by a computer to achieve randomization. All individuals who started treatment paid 90 Euros. Patient Flow Of 51 individuals screened, ten were unsuitable (six did not fulfil specific phobia criteria, three had panic disorder with agoraphobia, and one had major depression). Of the 41 eligible patients who were randomly assigned to groups, one did not start because of an unexpected personal conflict. All participants completed the treatment and data were successfully collected; however, eight of the participants did not respond to the 6-month follow-up evaluation. Therefore, complete data sets were available for 32 patients (13 CAE and 19 MNE). Pretreatment Features Clinical and sociodemographic information for the participants from both groups is shown in Table I. No statistically significant differences were found in any of the pretreatment variables. Thirteen participants had not flown during the last two years because of their fear of flying. The others had flown but with a high level of discomfort. The degree of avoidance for the entire sample was 5.77 (SD /2.62); each person rated him- or herself
Computer-assisted exposure treatment
43
Table I. Demographic and Clinical Characteristics of Computer-Assisted Exposure (CAE) and Multicomponent Nonexposure (MNE) Groups at Pretreatment.
Variable Age (years) M SD Sex (women) N % Age of onset of fear of flying M SD Avoidance Time since last flight (months) M SD Avoidance degree (0 /8) M SD Completely avoider (/2 years) (N ) Self-reported fear of flying scales FFQ FFS General discomfort (1 /9) Features related with treatment Motivation for treatment (before treatment explanation) (1 /9) Motivation for treatment (after group assignment/explanation) (1 /9) Treatment credibility (1 /9) Outcome expectancies (1 /9)
CAE (n / 19)
MNE (n /21)
38.00 10.69
34.77 10.38
14 73.68
17 80.95
24.11 9.40
25.67 6.45
41.37 51.28
42.71 47.46
6.42 2.17 8
5.19 3.17 5
M
SD
186.79 57.42 8.74
26.76 7.10 0.65
179.67 54.76 8.71
27.00 8.42 0.46
8.37 8.68 7.68 6.58
0.96 0.75 1.11 1.54
7.81 8.29 7.95 6.57
1.66 1.01 1.02 1.36
t /x2
p
t /0.97
.34
x2 /0.30
.58
t /0.61
.55
t /1.07
.29
t /1.44
.16
x2 /1.52
.22
M
SD
t
p
0.84 .41 1.07 .29 0.13 .90 1.28 1.42 0.80 0.02
.21 .16 .43 .99
Note. FFQ /Fear of Flying Questionnaire; FFS /Fear of Flying Scale.
as 4 or higher on a scale ranging from 0 to 8 in the ADIS /IV. Avoiders differed from nonavoiders in the pretreatment evaluation only in degree of avoidance, t (36.89) /4.25, p / .000, and degree of general discomfort around flying, t (26) /3.33, p /.003. Treatment Conditions Interventions included a maximum of six 50-min sessions (twice a week periodicity). To control for procedural fidelity, detailed session-by-session therapist manuals were used. Four therapists, two male and two female, with equivalent clinical experience conducted treatments at the Clinical Laboratory of the university. To control for nonspecific therapeutic variables, all four therapists conducted CAE and MNE treatments. At the conclusion of both treatments, patients were encouraged to take a flight on their own without any therapeutic help. The cost of the trip was the patient’s responsibility. The following recommendations were made: (a) Take a flight within 15 days of completing treatment, (b) the flight should be at least 30 min in length, (c) complete
the round trip on the same day, and (d) preferably fly alone, but if accompanied by a friend or relative, that person would be given brief instructions on appropriate companion behavior during the flight. To analyze the potential contribution of the actual flight to fear reduction, the same self-report measures on fear of flying used at pre- and posttreatment were also given at postflight for those participants who took a flight after treatment. CAE treatment was conducted using the CAFFT2 (see Apparatus section). Despite the preestablished length of CAE (Table II), participants’ treatment could be shorter if they completed the last exposure sequence before the sixth session, because all participants in this group followed their own fear hierarchy. MNE treatment included a reduced version of aeronautical information, breathing and relaxation training, and identifying and challenging negative thoughts. These procedures are typically used as part of multicomponent treatment packages for fear of flying (e.g., Doctor, McVarish, & Boone, 1990; Ekeberg, Seeberg, & Ellertsen, 1990; Van Gerwen, 2003). Also some of these are used during in vivo or
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Table II. Contents, Composition, and Duration of Each Exposure Sequence of the CAFFT2. Exposure sequences 1 2 3 5 4 6 Add’l exposure to special conditions
Sequence start
Sequence end
To travel agency to buy ticket Going to airport inside aircraft Watching safety demonstration inside aircraft In flight Announcing landing Aircraft accident At end of regular exposure to prior sequences, pts may choose additional exposure to each sequence by night or w/adverse weather conditions
Packing at home Waiting for take-off Taking off and ascending Inside plane while flying Inside airport terminal
No. pictures 10 16 16 14 17 10 Same as in regular seq.
Duration (min) 1.51 2.49 2.17 2.17 2.06 2.18 Same as in regular seq.
Note. CAFFT /computer-assisted fear of flying treatment.
VR treatments. The participants were not specifically told, however, that exposure is important for fear of flying reduction. For the MNE group the treatment lasted six sessions. See Figure 1 for the content of each of the six sessions of MNE and CAE.
credibility, or outcome expectancies, 9 /extreme motivation, credibility, or outcome expectancies ). Self-efficacy expectancies regarding participants’ self-confidence to take a flight on their own were also assessed at posttreatment and 6-month follow-up with a single item on a 9-point scale (1 /no self-efficacy, 9 /extreme self-efficacy ).
Apparatus CAE was conducted with CAFFT2 software (see Table II) installed on a PowerMac 6500 (64-megabyte RAM) with a 17-in. screen. Because the CAFFT has been fully described in previous reports (e.g., Bornas et al., 2002), we only mention features that have been added to the new version: an in-flight sequence, a flight-at-night/bad weather conditions sequence, and a detailed online help utility. Self-Report Instruments The 30-item Fear of Flying Questionnaire (FFQ; Bornas, Tortella-Feliu, Garcı´a de la Banda, Fullana, & Llabre´s, 1999) and a Catalan version of the Fear of Flying Scale (FFS; Haug, Brenne, Johnsen, Berntzen, Go¨testam, & Hughdal, 1987) were used to assess severity of fear of flying. Scores range from 30 to 270 for the FFQ and from 0 to 84 for the FFS. For the Catalan version of the FFS, Cronbach’s a and 15-day retest reliability were .95 (n /228) and .89 (n /106), respectively (Barcelo´ & Tortella-Feliu, 2002). General discomfort related to flying was assessed using a scale ranging from 1 (no fear) to 9 (extreme fear). Avoidance of flying was assessed with a scale ranging from 0 (no avoidance ) to 8 (extreme avoidance ) included in the ADIS /IV. Motivation for treatment (both before and after group assignment and explanation), treatment credibility, and outcome expectancies were assessed at pretreatment with four single items on a 9-point scale (1 /no motivation,
Statistical Analysis Psychometric treatment outcome measures were analyzed with mixed analyses of variance with group as the between-subject factor (CAE and MNE) and time as the within-subject factor (pretreatment, posttreatment, and follow-up). If necessary, Greenhouse-Geisser epsilon-corrected degrees of freedom were reported to correct for violation of the sphericity assumption. To test whether the outcome results were clinically meaningful, Jacobson and Truax’s (1991) indexes were used. FFQ scores were selected as the relevant outcome measure. To assess the reliability of the therapeutic change, we used the previously known test /retest reliability of the FFQ (rxx /.97), and the standard deviation of a nonphobic sample (S1 /30.97; M / 65.24; N / 454) to calculate the standard error of the measure. For a therapeutic change to be reliable (improved patients), the resulting value of dividing the difference between pre- and posttreatment by the standard error of the difference had to be greater than 1.96. In addition, the participant’s posttreatment score had to be decreased by at least two standard deviations from the pretreatment score to assess the clinical change as clinically significant (recovered). Chi-square tests were performed to evaluate the group differences regarding clinically significant improvement rates, the actual flight rates after treatment and at 6-month follow-up, and the follow-up dropout rates. In the follow-up dropout
Computer-assisted exposure treatment
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Results
S e
Attrition
s MNE
CAE
s #
1 20 min explanation of mechanisms contributing to the origins and maintenance of fear of flying as well as the rationale and structure of the treatments
10-page booklet (Fear of Flying)
26-page booklet (Fear of Flying and CAFFT)
Watch one sequence of CAFFT2 once in order to support explanation
Exposure (CAFFT2) to the first sequence
of anxiety*
of individual hierarchy until anxiety
2 Aeronautical Information. Watch a videotaped interview with a veteran
subsided
Self-Reported Treatment Outcome Measures
Exposure (CAFFT2) to remaining 5
Self-reported outcome measures assessed at pretreatment, posttreatment, and 6-month follow-up are given in Figure 2. Time main effects were significant for FFQ, F(2, 60) /53.40, p / .000, FFS, F(2, 60) /37.54, p / .000, and general discomfort rating, F(2, 60) /
sequences until habituation
pilot + 11-page booklet (more detailed explanation on the topic)
Although all participants in both experimental conditions (N /40) completed treatments and posttreatment data were available for all of them, complete data sets were available for only 32 participants because 6 in the CAE group (31.6% of 19) and 2 in MNE group (9.52% of 21) did not attend the 6-month follow-up session. Betweengroup differences were not significant, x2(1, N /40) /3.03 p / .297. The participants who did not attend the 6-month follow-up were not different in either the pretreatment or posttreatment variables compared with those who did attend.
The therapist did not participate in the session (unless technical problems
Activation Control Techniques 3 (controlled breathing and progressive Patients prompted to find possible muscular relaxation). Practice answers to questions by means of the (Session 3 controlled breathing/Session 4 relaxation) + 15- program page booklet + encouraging home daily practice Patients were suggested to choose only 4
range 30-270
occurred)
one or two sequences for exposure in
205 195 185 175 165 155 145 135 125 115 105 95 85 75
65
(No home task)
post
Follow-up
Fear of Flying Scale (FFS)
60
and alternatives to assist patient in
55
range 0-84
challenging catastrophic cognitions)
CAE MNE pre
adverse conditions (night or bad weather).
5 Brief Cognitive Therapy (questions
Fear of Flying Questionnaire (FFQ)
50 45 40 35 30
6 Review + watch one sequence of
CAE MNE
25
CAFFT2 once in order to point out
pre
post
Follow-up
the utility of the strategies learned General discomfort
9
during treatment to control fear*
8
Planning an actual flight
range 1-9
7 6 5 4 3
Figure 1. Content of sessions for the multicomponent nonexposure (MNE) and computer-assisted exposure (CAE) treatments.
analysis, t tests were also conducted to compare clinical characteristics of participants who attended or did not attend the follow-up session.
2
CAE MNE
1 pre
post
Follow-up
Figure 2. Self-reported outcome measures for computer-assisted exposure (CAE) and multicomponent nonexposure (MNE) groups assessed at pretreatment, posttreatment, and 6-month follow-up.
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X. Bornas et al.
61.09, p / .000, revealing overall treatment effect. Post hoc analysis revealed a great reduction in selfreported fear of flying between pretreatment and posttreatment assessments: FFQ, F(1, 30) /90.65, p / .000; FFS, F(1, 30) /58.48, p / .000; general discomfort, F (1, 30) /111.71, p / .000. At 6-month follow-up, self-reported fear reduction remained stable as suggested by no statistical differences between this assessment point and posttreatment: FFQ, F(1, 30) /0.492, p / .489, ns ; FFS, F (1, 30) /1.92, p / .176, ns; general discomfort, F (1, 30) /0.130, p / .720, ns. Differences between pretreatment and 6-month follow-up also remained clearly significant. Treatment /Group interaction effects were not significant for FFQ scores, F (2, 60) /2.39, p / .100, FFS scores, F (2, 60) /1.69, p / .194, and general discomfort rating, F(2, 60) / 0.75, p / .477, indicating no different treatment effects. Group main effects were not significant for FFQ scores, F (1, 30) /0.713, p / .405, FFS scores, F (1, 30) /0.038, p / .847, and the general discomfort rating, F(1, 30) /1.12, p / .298. Effect sizes and percentages of improvement (symptomatic reduction) for both groups CAE and MNE at posttreatment and at 6-month follow-up are shown in Table III. Regarding clinically meaningful improvement at the 6-month follow-up, one patient in the CAE group did not change (7.7%), two improved (15.4%), and ten recovered (76.9%), with FFQ scores as the criteria. Four patients in the MNE group remained without change (21.1%), seven improved (36.8%), and eight recovered (42.1%). Although apparently a great number of recoveries occurred in the CAE group, contingency analysis did not reveal significant differences among treatment
conditions, x2(2, N /40) /3.81, p / .149. However, if a 2 /2 table is constructed by combining no-change and improved participants with a nonrecovered group, differences between both treatment conditions emerged: In the CAE there were three nonrecovered and 10 recovered participants, whereas in the MNE there were 11 nonrecovered and eight recovered participants, indicating that CAE had a significantly higher proportion (77% vs. 44%) of clinically recovered participants (Fisher’s exact test p / .046, one-tailed). Behavioral Outcome Measures Eleven participants in the CAE group (57.9%) and 16 (76.2%) in the MNE group booked and took a flight on their own within two weeks after the last treatment session, x2(1, N /40) /1.52, p / .280, ns. Only one participant in the CAE group flew with a relative who followed the instructions given by the therapist. Additionally, ten of 13 participants in the CAE group (76.92%) and 11 of 19 in the MNE group (57.9%) completed an actual flight within the 6-month follow-up period, x2(1, N /32) /1.24, p / .266, ns. Twenty-three of 27 noncomplete avoiders took a flight at the end of treatment, and six of 13 complete avoiders took a flight, x2(1, N /40) / 6.70, p / .01. At 6-month follow-up, six of 10 complete avoiders took an actual flight, as did 17 of 22 noncomplete avoiders, x2(1, N /32) /1.02, p / .31, ns. To analyze the potential contribution of the actual flight to fear reduction, a series of t tests were conducted comparing posttreatment and postflight means in the self-reported outcome variables. For the whole sample, no differences were found in FFQ,
Table III. Effect Sizesa and Percentages of Improvementb for Both Groups at Posttreatment and Follow-Up. Posttreatment
Follow-up
Variable
ES
% Improvement
ES
% Improvement
CAE FFQ FFS GD
3.59 2.58 /
42.34 31.74 47.19
3.77 3.62 /
43.78 44.32 44.11
MNE FFQ FFS GD
2.53 2.14 /
34.72 31.79 36.77
1.97 2.09 /
28.52 31.34 36.69
Note. CAE /computer-assisted exposure; MNE /multicomponent nonexposure; FFQ /Fear of Flying Questionnaire; FFS /Fear of Flying Scale; GD /general discomfort. a Effect sizes at posttreatment and at 6-month follow up for each experimental group were computed for FFQ and FFS scores according to the formulas (pretreatment M / posttreatment M )/pretreatment SD and (pretreatment M / 6-month follow-up mean)/pretreatment SD, respectively. b Symptomatic reduction for FFQ, FFS, and general discomfort scores at posttreatment was calculated according to the formulae (pretreatment M / posttreatment M )/pretreatment M ) /100. To establish follow-up percentage of improvement, the formula was (pretreatment M / follow-up M /pretreatment M ) /100.
Computer-assisted exposure treatment t (28) /1.59, p / .123, ns, and general discomfort ratings, t (28) /0.52, p / .610, ns, but there were differences in FFS scores, t (28) /3.07, p / .005. Analyzing both treatment conditions separately, the only contribution of the actual flight to the decrease of fear took place in the CAE group, and it was observed only in the FFS scores, t (9) /2.82, p / .017. Discussion Significant and Clinically Meaningful Reduced Fear of Flying The results indicate that both treatments reduced fear of flying significantly and with equivalent weight, and that the improvement was maintained for at least six months. The effect sizes, at both end of treatment and 6-month follow-up, were well above .80 and are similar to the results of in vivo and VR treatments. Therefore, our initial hypothesis that CAE treatment would be superior to a brief nonexposure treatment was not confirmed. However, it should be noted that using only two clinical improvement categories (recovered vs. nonrecovered), CAE treatment is associated with a greater number of recovered participants. Attrition and Efficiency of Computer-Assisted and Other Brief Cognitive /Behavioral Treatments
Although participants normally do not fail to complete simulated or VR exposure treatment (e.g., Bornas, Tortella-Feliu, et al., 2001; Mu¨hlberger et al., 2001, 2003), significant dropout rates are not rare in longer multicomponent treatments (e.g., Bornas, Tortella-Feliu, et al., 2001). Although a strong treatment adherence in the CAE group could be expected, the high adherence in the MNE group, and perhaps part of the success of this group, could be attributed to the brief duration of the treatment and the simplicity of the procedures. The efficacy and effectiveness of brief treatments have been well ¨ st documented (i.e., one session in vivo exposure [O et al., 1997] or VR [Maltby et al., 2002; Mu¨hlberger et al., 2001, 2003; Rothbaum et al., 2000]). Our study adds to the literature on the utility of brief exposure techniques in the treatment of flight phobia. Additionally, they also contribute to the growing body of knowledge indicating that brief nonexposure treatments may be useful in the treatment of some specific phobias (e.g., Hellstro¨m, ¨ st, 1996; O ¨ st, Fellenius, & Sterner, Fellenius, & O 1991). Because no between-group differences were found regarding the cost /benefit relationship of the treat-
47
ments used in this study, it appears that CAE is preferable to MNE. Not only does the CAE therapist spend less time with patients, but training of the CAE therapist is less time consuming (Bornas et al., 2002). In addition, we look forward to the possibility of a true self-application of the CAFFT2 because the detailed online help might be sufficient to replace the assistance of a therapist. Finally, the mean duration of the CAE treatment was 4.11 sessions (SD / 1.24); that is, participants in this group finished treatment before the maximum preestablished sixsession treatment length (i.e., the MNE treatment length). Therefore the CAE treatment could save time and resources compared with regular face-toface treatments. Do All Interventions Work in Flight Phobia Treatment? The unexpected success of the MNE treatment, like the one obtained in the attention-placebo group in Maltby et al. (2002), leads us to question the role of exposure in the treatment of fear of flying. Marks and Dar (2000) provide a brief review of evidence of reliable fear reduction without systematic exposure in several anxiety disorders. The core idea is that exposure alone as well as certain other approaches varying from fairly simple procedures to more complex treatment packages (e.g., cognitive therapy) is sufficient to reduce fear in anxiety disorders. Different procedures would alter different elements of the fear response network (psychophysiological, behavioral, or cognitive), and the effect would reach the other elements because of their interconnections within the network. However, our results do not agree completely with that theory because we did not apply, in the MNE group, any one procedure in its entirety that could have the power to affect any of the network components (e.g., cognitive therapy in the MNE treatment lasted only 1 hr). Therefore, it is difficult to attribute fear reduction to any one of those shortened procedures. At a very speculative level, from the dynamic systems perspective (Kelso, 1995; Lewis, 2000; Pikovsky, Rosenblum, & Kurths, 2001), the results of this study may be that both CAE and brief MNE treatments, in a large number of participants, achieved a critical point and induced the emergence of a nonphobic pattern of response in front of the stimuli that were previously feared. This perspective incorporates the idea that therapeutic change (e.g., a patient’s fear reduction) cannot be exclusively attributed to any one specific psychological intervention alone. On the contrary, the therapeutic change will depend on the interaction between that
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intervention and the system and its dynamics (e.g., Makeig et al., 2002). Then the critical question may no longer be ‘‘Which techniques work?’’ but rather ‘‘Which interactions between techniques and subjects lead to the emergence of more adaptive patterns of behavior or more effective patterns of self-organization?’’ We cannot say that all treatments work for flight phobia, but we may be able to say that a treatment that is able to modify an essential parameter to a specific critical point might lead to significant change in the entire system or patient. Therefore, in our opinion the dynamic systems approach may complement the explanation given by Marks and Dar (2000). Limitations Four potential methodological limitations of this study need to be addressed: (a) the absence of a control group without treatment, (b) the absence of a behavioral avoidance test in the initial participant assessment, (c) the reduced size of the sample, and (d) the possible effects of the sequencing of the MNE components. In a previous study (Bornas, Tortella-Feliu, et al., 2001), CAE treatment, when evaluated and compared with a waiting list control group, obtained much better results than the waiting list control group. In addition, some researchers ¨ st, 1997) have indicated that the absence of a (e.g., O control group without treatment in studies determining the efficacy of treatments for specific phobias is not an important methodological problem because of the clear superiority of these treatments and the almost insignificant proportion of participants who spontaneously recover with time. The absence of a behavioral avoidance test in the initial assessment is an important limitation when we examine the results related to the number of participants who flew at the end of treatments, because being a complete avoider was not an inclusion criterion. However, self-reported avoidance degree for the entire sample was quite high (M /6 on a 0 /8 scale). The mean avoidance time was more than 30 months. In addition, our participants’ self-reported fear of flying in the FFS scale was equivalent to that of participants in the study by ¨ st et al. (1997). In that study, avoiding flying for at O least two years was an inclusion criterion. Therefore, we believe the absence of a behavioral avoidance test is not a serious limitation when we look at selfreported measures. The small number of participants in each group is a serious detriment because the discriminating power of the tests we used is limited; therefore, the generalizability of our results is weak. In the future a multicenter study could overcome this limitation.
Finally, there was no randomization of the presentation sequence of the components of the MNE treatment package. Although the sequence in MNE treatment is the same in regular multicomponent treatment packages, further research should address this issue to ascertain whether presentation sequencing actually affects treatment effectiveness. Acknowledgements This study was funded by Spanish Ministry of Science and Technology Grant PS98-0167. We thank Dr. G. Garcı´a de la Banda and F. Barcelo´ for conducting treatments, Dr. M. A. Martı´nezAbascal, M. Balle, and M. Font for their help conducting independent assessments, and Dr. I. Marks and Dr. D. Mataix-Cols for their helpful comments. All authors share intellectual property rights in the CAE software (CAFFT2). References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC. Barcelo´, F., & Tortella-Feliu, M. (2002). Psychometric properties of the Catalan version of the Fear of Flying Scale . Unpublished manuscript. Bornas, X., Fullana, M. A., Tortella-Feliu, M., Llabre´s, J., & Garcı´a de la Banda, G. (2001). Computer-assisted therapy in the treatment of flight phobia: A case report. Cognitive and Behavioural Practice , 8 , 234 /240. Bornas, X., Tortella-Feliu, M., Garcı´a de la Banda, G., Fullana, M. A., & Llabre´s, J. (1999). Validacio´n factorial del cuestionario de miedo a volar (QPV) [The factor validity of the Fear of Flying Questionnaire]. Ana´lisis y Modificacio´n de Conducta , 25 , 885 /907. Bornas, X., Tortella-Feliu, M., Llabre´s, J., Barcelo´, F., Pauli, P., & Mu¨lhberger, A. (2002). Clinical usefulness of a simulated exposure treatment for fear of flying. International Journal of Clinical and Health Psychology, 2 , 247 /262. Bornas, X., Tortella-Feliu, M., Llabre´s, J., & Fullana, M. A. (2001). Computer-assisted exposure treatment for flight phobia: A controlled study. Psychotherapy Research , 11 , 259 /273. Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM /IV (ADIS-IV), Adult Version . Albany, NY: Graywind Publications. Coldwell, S. E., Getz, T., Milgrom, P., Prall, C. W., Spadafora, A., & Ramsay, D. S. (1998). CARL: A LabVIEW 3 computer program for conducting exposure therapy for the treatment of dental injection fear. Behaviour Research and Therapy, 36 , 429 / 442. Doctor, R. M., McVarish, C., & Boone, R. P. (1990). Long-term behavioral treatment effects for the fear of flying. Phobia Practice and Research Journal , 3 , 33 /42. Ekeberg, O., Seeberg, I., & Ellertsen, B. (1990). A cognitive/ behavioral treatment program for flight phobia with 6 months and 2 years follow-up. Norsk Psykiatrisk Tidsskris , 44 , 365 /374. Greist, J. H., Marks, I. M., Baer, L., Kobak, K. A., Wenzel, K. W., Hirsch, M. J., et al. (2002). Behaviour therapy for obsessive compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. Journal of Clinical Psychiatry, 63 , 138 /145. Haug, T., Brenne, L., Johnsen, B. H., Berntzen, K. G., Go¨testam, K. G., & Hughdal, K. (1987). A three-system analysis of fear of
Computer-assisted exposure treatment flying: A comparison of a consonant vs. a nonconsonant treatment method. Behaviour Research and Therapy, 25 , 187 / 194. Hazlett-Stevens, H., & Craske, M. G. (2002). Brief cognitivebehavioral therapy: Definition and scientific foundations. In F. W. Bond & W. Dryden (Eds), Handbook of brief cognitive behaviour therapy (pp. 1 /20). Chichester: Wiley. ¨ st, L.-G. (1996). One vs. five Hellstro¨m, K., Fellenius, J., & .O sessions of applied tension in the treatment of blood phobia. Behaviour Research and Therapy, 34 , 101 /112. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59 , 12 /19. Kelso, J. A. S. (1995). Dynamic patterns: The self-organization of brain and behavior . Cambridge, MA: MIT Press. Lewis, M. D. (2000). Emotional self-organization at three time scales. In M. D. Lewis & I. Granic (Eds), Emotion, development, and self-organization. Dynamic systems approaches to emotional development (pp. 37 /69). Cambridge, UK: Cambridge University Press. Makeig, S., Westerfield, M., Jung, T. P., Enghoff, S., Townsend, J., Courchesne, E., & Sejnowski, T. J. (2002). Dynamic brain sources of visual evoked responses. Science , 295 , 690 /694. Maltby, N., Kirsch, I., Mayers, M., & Allen, G. J. (2002). Virtual reality exposure therapy for the treatment of fear of flying: A controlled investigation. Journal of Consulting and Clinical Psychology, 70 , 1112 /1118. Marks, I. M., & Dar, R. (2000). Fear reduction by psychotherapies. Recent findings, future directions. British Journal of Psychiatry, 176 , 507 /511. Marks, I. M., Kenwright, M., McDonough, M., Whittaker, M., & Mataix-Cols, D. (2004). Saving clinicians’ time by delegating routine aspects of therapy to a computer: A randomised controlled trial in phobia/panic disorder. Psychological Medicine , 34 , 1 /10. Marks, I., Mataix-Cols, D., Kenwright, M., Cameron, R., Hirsch, S., & Gega, L. (2003). Pragmatic evaluation of computer-aided self help for anxiety and depression. British Journal of Psychiatry, 183 , 57 /65. Mu¨hlberger, A., Herrmann, M., Wiedemann, G., Ellgring, H., & Pauli, P. (2001). Treatment of fear of flying with exposure therapy in virtual reality. Behaviour Research and Therapy, 39 , 1033 /1050. Mu¨hlberger, A., Wiedemann, G., & Pauli, P. (2003). Efficacy of a one-session virtual reality exposure treatment for fear of flying. Psychotherapy Research , 13 , 323 /336. Nelissen, I., Muris, P., & Merckelbach, H. (1995). Computerized exposure and in vivo exposure treatments of spider fear in children: Two case reports. Journal of Behaviour Therapy and Experimental Psychiatry, 26 , 153 /156. Osgood-Hynes, D. J., Greist, M. D., Marks, I. M., Baer, L., Heneman, S. W., Wenzel, K. W., et al. (1998). Self-administered psychotherapy for depression using a telephone-accessed computer system plus booklets: An open U.S.-U.K. study. Journal of Clinical Psychiatry, 59 , 358 /365. ¨ st, L.-G. (1997). Rapid treatment of specific phobias. In G. C. .O L. Davey (Ed.), Phobias. A handbook of theory, research and treatment (pp. 227 /246). Chichester, UK: Wiley. ¨ st, L.-G., Brandberg, M., & Alm, T. (1997). One versus five .O sessions of exposure in the treatment of flying phobia. Behavior Research and Therapy, 35 , 987 /996. ¨ st, L.-G., Fellenius, J., & Sterner, U. (1991). Applied tension, .O exposure in-vivo, and tension-only in the treatment of blood phobia. Behaviour Research and Therapy, 29 , 561 /574.
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Pikovsky, A., Rosenblum, M., & Kurths, J. (2001). Synchronization. A universal concept in nonlinear sciences . Cambridge, UK: Cambridge University Press. Rothbaum, B. O., Hodges, L., Smith, S., & Lee, J. H. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68 , 1020 /1026. van Gerwen, L. (2003). Multi-component standardised cognitivebehavioural group treatment programme for fear of flying. In R. Bor & L. van Gerwen (Eds), Psychological perspectives on fear of flying (pp. 143 /167). Hant, UK: Ashgate.
Zusammenfassung Sind alle Behandlungen gleichermaßen effizient bei Flugangst? Die Gegenu¨berstellung einer computerunterstu¨tzten Exposition und einer kurzen Multikomponentenbehandlung ohne Exposition Computerunterstu¨tzte Behandlungen haben sich als erfolgreich erwiesen bei einigen Angststo¨rungen und bei Depression, aber die Rolle von Exposition bleibt unklar. Diese Studie vergleicht den Effekt von einer computerunterstu¨tzten Expositionsbehandlung mit einer kurzen Behandlung ohne Exposition mit mehreren Komponenten bei Flugphobie. Kontrollbeurteilungen des Erfolgs wurden nach der Behandlung und bei einer Katamnese nach sechs Monaten durchgefu¨hrt. Es wurden keine Unterschiede zwischen den beiden Behandlungen hinsichtlich der Flugangst gefunden. Unter beiden Bedingungen verbesserten sich die Patienten signifikant und in klinisch bedeutungsvoller Weise, und die Ergebnisse waren auch nach sechs Monate noch stabil. Diese Ergebnisse stellen die Notwendigkeit von Exposition ¨ ngsten in Frage und unterstu¨tzten die bei phobischen A These, dass zur Reduktion bestimmter Phobien auch kognitiv-verhaltensma¨ßige Behandlungen geeignet sind.
Re´sume´ Les traitements de la phobie de l’avion marchent-ils tous ? Exposition assiste´e par ordinateur versus traitement de non-exposition bref et en composantes multiples. Des traitements assiste´s par ordinateur ont prouve´ leur efficacite´ dans le traitement de plusieurs troubles d’anxie´te´ et de la de´pression, mais le roˆle de l’exposition reste peu clair. Cette e´tude compare l’efficacite´ d’un traitement d’exposition assiste´ par ordinateur (CAE) avec un traitement de non-exposition bref et en composantes multiples (MNE) pour la phobie de l’avion. L’e´valuation des re´sultats a eu lieu a` la fin du traitement et 6 mois apre`s. Aucune diffe´rence n’a e´te´ trouve´e entre CAE et MNE pour re´duire la phobie de l’avion. Les deux conditions voyaient les patients s’ame´liorer de fac¸on significative et cliniquement constructive, et ces re´sultats persistaient 6 mois apre`s. Ces re´sultats de´fient l’ide´e que l’exposition est essentielle dans la re´duction de l’anxie´te´ phobique, et ils soutiennent l’ide´e que des phobies spe´cifiques pourraient bien se preˆter a` des traitements cognitivo-comportementaux brefs.
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Resumen ¿Se ocupan todos los tratamientos de la fobia a volar? exposicio´n asistida por computadora versus un tratamiento breve sin exposicio´n de multicomponentes Los tratamientos asistidos por computadora han resultado efectivos en el tratamiento de varios deso´rdenes de ansiedad y depresio´n, pero el rol de la exposicio´n permanece incierto. Este estudio compara la eficacia de un tratamiento de exposicio´n asistido por computadora (CAE) con un breve tratamiento de no exposicio´n con multicomponentes (MNE) para la fobia a volar. Se llevaron a cabo evaluaciones de resultados al final del tratamiento y a los seis meses de seguimiento. No se encontraron diferencias entre CAE y MNE en la reduccio´n del miedo a volar. En ambos casos los pacientes mejoraron significativa y clı´nicamente, y los resultados se mantuvieron a los seis meses. Estos hallazgos hacen dudar de que la exposicio´n sea esencial para reducir la ansiedad fo´bica y apoyan la idea de que los tratamientos breves cognitivocomportamentales pueden ser aptos para las fobias especı´ficas.
Resumo Sera´ que todos os tratamentos resultam para a fobia de voar? Exposic¸a˜o assistida por computador vs. um tratamento breve multimodal sem exposic¸a˜o Os tratamentos assistidos por computador mostraram ser eficientes no tratamento de va´rias perturbac¸o˜es ansiosas e depressivas, pore´m permanece pouco claro o papel da exposic¸a˜o. Este estudo compara a efica´cia de um tratamento assistido por computador (TAC) com um tratamento multimodal sem exposic¸a˜o (TME) breve para a fobia de voar. Foram realizadas avaliac¸o˜es com medidas de monitorizac¸a˜o de resultados no perı´odo po´s-tratamento e aos 6 meses do perı´odo de seguimento. Na˜o foram encontradas diferenc¸as entre o TAC e o TME na reduc¸a˜o
do medo de voar. Em ambas as condic¸o˜es os pacientes melhoraram significativamente e clinicamente e os resultados mantiveram-se nos 6 meses de seguimento. Estes resultados desafiam a ideia de que a exposic¸a˜o e´ essencial na reduc¸a˜o da ansiedade fo´bica e suportam a ideia de que as fobias especı´ficas podem ser bem resolvidas com tratamentos cognitivo-comportamentais breves.
Sommario Tutti i trattamenti funzionano per la fobia del volo? esposizione computer assistita contro un breve trattamento con piu´ componenti senza esposizione I trattamenti computer assistiti sono risultati essere efficaci nel trattamento di numerosi disturbi d’ansia e della depressione, ma il ruolo dell’esposizione rimane poco chiaro. Questo studio paragona l’efficacia di un trattamento di esposizione computer assistito (cae) ad un trattamento breve con piu` componenti senza esposizione (MNE) per la fobia del volo. Le valutazioni di misura del risultato sono state condotte al post trattamento ed a 6 mesi di follow-up. Nessuna differenza e` stata trovata fra il cae e MNE nella riduzione del timore del volo. In entrambi i pazienti miglioravano significativamente e clinicamente e i risultati sono stati mantenuti ad un follow-up 6 mesi. Questi risultati vanno contro l’idea che l’esposizione sia essenziale nella riduzione dell’ansia fobica e sostengono l’idea che specifiche fobie potrebbero essere adatte per i brevi trattamenti cognitivo comportamentali.
