Issues and Ethical Therapy Associated with Anxiety Disorders

© Springer-Verlag Berlin Heidelberg 2014
Grace Lee, Judy Illes and Frauke Ohl (eds.)Ethical Issues in Behavioral NeuroscienceCurrent Topics in Behavioral Neurosciences1910.1007/7854_2014_340

Ethical Issues and Ethical Therapy Associated with Anxiety Disorders

Kaylan L. Altis1, Lisa S. Elwood  and Bunmi O. Olatunji2

School of Psychological Sciences, University of Indianapolis, Indianapolis, IN 46227, USA

Department of Psychology, Vanderbilt University, Nashville, USA



Lisa S. Elwood


The prevalence of anxiety disorders is among the highest of all psychiatric diagnoses, with a lifetime morbidity rate of nearly 30 %. Given this prevalence, it is important to identify effective and ethical treatments. Empirically based treatments considered efficacious for anxiety disorders largely include cognitive behavioral treatments (CBT) , and among these, exposure therapy stands out as both useful and potentially concerning. Ethical concerns regarding exposure treatment for anxiety include fears of symptom exacerbation, high treatment dropout rates, client safety concerns, and the blurring of boundary lines between therapists and clients. Although concerns have been raised regarding exposure treatment generally, specific concerns have been raised related to the treatment of post-traumatic stress disorder (PTSD) given the vulnerable nature of the population. Despite these concerns, research largely supports both the efficacy and safety of exposure therapy. The present chapter provides a review of extant literature highlighting potential ethical concerns, research regarding the raised concerns, and suggestions for minimizing risk in treatment.


1 Introduction

The present chapter provides an overview of the current anxiety treatments that are identified as empirically supported, followed by an in-depth review of the ethical concerns that have been raised regarding treatment of anxiety , with a focus on exposure techniques. Criticisms of exposure therapy have frequently included concerns about symptom exacerbation, increased attrition rates, therapist training and beliefs, safety, and boundary issues. The current chapter reviews each of these concerns and the related literature and concludes that the benefits of exposure treatment for anxiety outweigh the risks. Finally, suggestions for minimizing risks while using exposure therapy and other clinical considerations are presented.

1.1 Overview of Anxiety

The Diagnostic and Statistical Manual Fifth Edition (DSM-5; American Psychiatric Association 2013) indicates that anxiety disorders are prevalent in individuals from childhood to adulthood, with most disorders beginning in adolescence or early adulthood, and occurring in both males and females. Furthermore, research has demonstrated that anxiety disorders are widespread, both nationally and internationally. In a study of prevalence rates, Baxter et al. (2013) used data from 87 studies in 44 countries to conduct a systematic review for the international prevalence rates of anxiety disorders. Results of this study revealed that current prevalence estimates range from 0.9 to 28.3 % and past-year prevalence ranges from 2.4 to 29.8 % across cultures (Baxter et al. 2013). A recent study conducted by Kessler et al. (2012) examined the prevalence of lifetime morbidity risk (LMR) and 12-month prevalence rates in the USA. Results revealed the following anxiety disorders listed from the highest LMR to the lowest, with the LMR listed first followed by the 12-month prevalence rate: specific phobia: 18.4/12.1 %; social phobia: 13.0/7.4 %; post-traumatic stress disorder: 10.1/3.7 %; generalized anxiety disorder (GAD): 9.0/2.0 %; separation anxiety disorder: 8.7/1.2 %; panic disorder: 6.8/2.4 %; bipolar disorder: 4.1/1.8 %; agoraphobia: 3.7/1.7 %; and obsessive-compulsive disorder: 2.7/1.2. Highlighting the prominence of anxiety disorders, data indicated that anxiety disorders have the highest overall prevalence rate among psychiatric disorders, with a 12-month rate of 18.1 % and a lifetime rate of 28.8 % (Kessler et al. 2012).

The presence of an anxiety disorder affects both individuals and society. At an individual level, anxiety disorders have been associated with substantial negative impact on quality of life (Mendlowicz and Stein 2000; Olatunji et al. 2010). A long-standing anxiety disorder can lead to both physical and emotional symptoms, and individuals can consequently suffer functional impairment at work and in other areas of life, lasting up to 1 year or longer, depending on the course of the disorder (Hoffman et al. 2008). Economic costs due to the impairment caused by a GAD, for example, include both personnel costs as evidenced by missed work or a lack of productivity at work and direct medical costs associated with seeking medical attention. Individuals with GAD, for example, seek medical attention significantly more times than individuals without GAD or a comorbid disorder (Hoffman et al. 2008). Overall, the estimated costs associated with anxiety disorders have been reported to be between 42 and 45 billion dollars (Kessler and Greenberg 2002). Thus, the effective treatment of anxiety disorders is necessary on both an individual and a societal level.

1.2 Best Practices for Treating Anxiety

When striving to be an ethical clinician, individuals must avoid causing harm and seek to maximize the success achieved in therapy. To facilitate ethical practice through treatment choices, attempts have been made to provide recommendations for treatment approaches by identifying empirically supported treatments (ESTs) for specific disorders. In their efforts to compose a comprehensive list of current empirically validated therapies, Chambless et al. (1998) provide a list of treatments, termed “well-established treatments” and “probably efficacious treatments” used to treat numerous psychological disorders. The specific “well-established treatments” identified for anxiety primarily fall in the cognitive behavioral therapy (CBT) realm, although treatments may vary on their emphasis on either cognitive or behavioral components. CBT is listed as a well-established treatment for panic disorder (with and without agoraphobia) and GAD, while strict exposure therapy is listed as a well-established treatment for agoraphobia, specific phobia, and obsessive-compulsive disorder (OCD). The treatments for anxiety deemed as “probably efficacious” include applied relaxation for panic disorder and GAD; CBT for social phobia and OCD; exposure therapy for post-traumatic stress disorder (PTSD) and social phobia; eye movement desensitization and reprocessing (EMDR) therapy for PTSD; stress inoculation training for PTSD; and systematic desensitization for specific phobia and social exposure / social phobia (Chambless et al. 1998). As all of these treatments either are variants or include tenets of CBT , CBT is often deemed the gold standard for treatment of anxiety disorders (Rauch et al. 2012). Additionally, CBT has been identified as the most empirically supported treatment for child and adolescent anxiety (James et al. 2012; Sburlati et al. 2011).

CBT utilizes techniques to identify and modify maladaptive thoughts and behaviors (Beck 2011). A key CBT behavioral treatment for anxiety is exposure . Exposure approaches are based on classical conditioning theory. Exposure includes taking a feared, although not actually dangerous, stimulus and providing the individual with opportunities to experience the stimulus without associated negative consequences. The rationale is that repeated exposures without negative experiences other than the fear and anxiety will result in a reduction of fear. Exposure techniques may also include pairing feared stimuli with a positive experience, such as a relaxation exercise. The goal of Exposure is for the client to reach a point of habituation, which is achieved by first igniting the client’s fears. The anxiety and fear experienced during an exposure typically increases, reaches a plateau, and then decreases over time (Muller and Schultz 2012). Exposure exercises can take different forms, including either imaginal, in which one imagines the feared stimulus, or in vivo, when one confronts the stimulus directly. Exposure techniques can also vary in the progression of intensity. Systematic desensitization, for example, involves the creation of a hierarchy of feared stimuli and exposes the client gradually. Flooding, on the other hand, is an exposure that starts with the primary feared object. Exposure are a major behavioral technique utilized in CBT for anxiety and are often used to combat avoidance strategies (Beck 2011). Additional behavioral techniques that can be used include skills training and relaxation.

1.3 Current State of the use of Empirically Supported Treatments (EST)

Although CBT techniques have been identified as the predominant treatment for anxiety disorders, the current state of usage for these techniques does not reflect the research that supports their efficacy. A 10-year follow-up survey conducted by Woody et al. (2005) compares the current state of EST usage with the usage in 1993. The study examined the use of ESTs for anxiety and stress disorders in doctoral programs and internship programs. Eight CBT treatments for anxiety and stress disorders were included on both surveys. Of these eight treatments, seven were taught in a supervised way by the majority of doctoral programs in 1993, while only two were taught in a supervised way in the 2003 follow-up. Although only two treatments were taught in a supervised way, most programs provided at least brief instruction in courses for seven of the treatments. A similar pattern can be observed in the percentages of use by internship programs. In 1993, most internship sites provided formal supervision for four of the eight treatment methods, while in 2003, this number dropped slightly to three. Thus, supervised training for ESTs at both the doctoral and internship levels is lacking, despite the evidence supporting these treatments (Woody et al. 2005). Although the frequency of use of ESTs in general clinical practice is unknown, the suspected levels of implementation are low, and research indicates that for CBT specifically, approximately 30 % of patients in therapy receive this treatment (Goisman et al. 1999). Further, exposure therapy is underutilized in clinical practice, largely due to lack of training and effective dissemination (Cahill et al. 2006; van Minnen et al. 2010; McManus et al. 2008).

If one assumes that the majority of clinicians are striving to practice ethically , which would include providing effective and standard of care treatments, it is helpful to consider what factors have resulted in the discrepancy between EST recommendations and the treatments being utilized in care settings. As a result, much debate has emerged related to barriers to dissemination and implementation of ESTs into general clinical practice. Arguments provided as explanations for the lack of implementation include lack of time and resources for training, a shortage of trained supervisors, inappropriateness for certain populations, and philosophical opposition (Woody et al. 2005). A particular area of ethical concern involves the use of exposure therapy for anxiety , especially PTSD. Supporters of the technique suggest that a lack of training leads to misconceptions of the treatment and its effectiveness, and these misconceptions evolve into ethical concerns. The ethical concerns surrounding the use of exposures in clinical practice focus on the possibility of causing harm by exacerbating symptoms, pushing boundaries within the therapeutic relationship, and experiencing hesitation from clients to relive their negative experiences (Olatunji et al. 2009; Wolitzky-Taylor et al. 2012).

2 Review of the Ethical Concerns for Exposure Therapy

exposure therapy is utilized among several anxiety disorders, including specific phobias, OCD, panic disorder, PTSD, social anxiety , and GAD (Gillihan et al. 2012; Olatunji et al. 2009). As noted previously, exposure therapy was deemed a “well-established treatment” or “probably efficacious treatment” for use with numerous anxiety disorders (Chambless et al. 1998). Despite this support, authors have noted that clinicians remain hesitant to utilize this method for various reasons (Foa et al. 2002; Neuner 2012; Olatunji et al. 2009). Some of the most noted ethical concerns surrounding the use of exposure include symptom exacerbation, attrition rates, therapist training and negative beliefs, safety and risk, and boundary issues (Cahill et al. 2006; Foa et al. 2002; Frye and Spates 2012; Olatunji et al. 2009; van Minnen et al. 2010; Wolitzky-Taylor et al. 2012). The following is a review of these concerns and strategies for how to minimize risk during exposure .

2.1 Symptom Exacerbation

The possibility of causing harm to clients through symptom exacerbation is arguably the primary reason for clinician avoidance of exposure treatment (Olatunji et al. 2009). As exposures involve the confrontation of feared stimuli, whether imaginal or in vivo, the critique follows that exposure evokes stress in clients and thereby can cause harm. Further, the argument states that this harm is not worth the outcome and is insensitive to the client’s experience (Wolitzky-Taylor et al. 2012). There is some evidence to support the noted concerns for symptom exacerbation within exposure treatment; however, review of the literature suggests that these concerns are minimal and do not interfere with overall treatment. One study compared the use of imaginal exposure with that of cognitive therapy for participants of trauma therapy and found a statistically significant difference between the groups from pre- to post-treatment, with more patients in the prolonged exposure group showing symptom exacerbation (Tarrier et al. 1999). This significant finding was, however, not maintained at the 6-month post-treatment assessment (Tarrier et al. 1999). Foa et al. (2002) conducted a study to determine whether participants experienced an exacerbation in PTSD, anxiety , or depression symptoms due to imaginal exposure. Participants met DSM-IV criteria for chronic PTSD and were divided into two treatment conditions, prolonged exposure and prolonged exposure plus cognitive restructuring. When measuring symptom exacerbation during the implementation of imaginal exposure , the researchers found minimal levels of symptom exacerbation among participants: 10.5 % experienced an increase in PTSD, 21.1 % in anxiety , and 9.2 % in depressive symptoms, overall accounting for 20 participants out of 76 that experienced symptom exacerbation. Further, the researchers found that this temporary symptom exacerbation did not interfere with treatment and that attrition rates and symptom exacerbation were not correlated. Additional reviews on the use of exposure therapy further state that any symptom exacerbation with this treatment is no worse than the exacerbation found with other treatments (van Minnen et al. 2010; Cahill et al. 2006; Neuner 2012

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