Putting the spotlight on exposure therapy

It's long been known that exposing people to what they fear can sometimes help them overcome their anxieties. It's called exposure therapy. But there's an aspect of this approach for which the evidence remains inconsistent - that is, should the person being exposed to their fear, focus on it, or try to ignore it?

Imagine a spider phobic being exposed to spidey pics. The rationale for focusing on the pictures is that in relative safety, the person would gradually learn that their fear response is disproportionate, thus uncoupling spiders and "yikes!" in their mind. By contrast, the rationale for teaching the person to distract themselves from the pictures is more of a coping strategy, in that the person would gradually learn how to master being confronted with spiders without being overwhelmed by anxiety.

The evidence in favour of these approaches is mixed, but tends to suggest that distraction is better in terms of subjective feelings, whereas focusing is more effective in terms of physiological measures.

Now Gudrun Sartory and colleagues have tested both approaches with 63 people with a dentist phobia. The participants were shown four images of dental instruments and were either told to focus on them, or they were encouraged to learn how to distract themselves, helped by the researcher who played a puzzle game with them while the pictures were shown.

An assessment before the exposure treatment, and then a week after it, showed both exposure approaches were equally beneficial as judged by changes to the participants' heart rate when shown dentist-related pictures. However, in terms of dentist-related fearful thoughts and anxieties, the focusing approach to exposure was more effective, although all participants showed benefits.

So it seems this study supports a focusing approach to exposure therapy, but such a conclusion is undermined by the study's weaknesses: there was no control group, and no way of checking during exposure just how much the participants did or did not focus on the dental instrument pictures.
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Schmid-Leuz, B., Elsesser, K., Lohrmann, T., Johren, P. & Sartory, G. (2007). Attention focusing versus distraction during exposure in dental phobia. Behaviour Research and Therapy, 45, 2691-2703.

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