Short- and Long-Term Effectiveness of an Empirically Supported Treatment for Agoraphobia Kurt Hahlweg Christoph-Dornier Foundation Institut Braunschweig Wolfgang Fiegenbaum Christoph-Dornier Foundation Institut Marburg Monika Frank Christoph-Dornier Foundation Institut Marburg Brigitte Schroeder Christoph-Dornier Foundation Institut Braunschweig Ines von Witzleben Christoph-Dornier Foundation Institut Dresden ABSTRACT This study examined the effectiveness of individual high-density exposure (2—3 weeks, all day) for panic disorder with agoraphobia (PDAG). Participants were 416 unselected patients with a primary diagnosis of PDAG who were treated by 52 therapists in 3 outpatient clinics of the Christoph-Dornier Foundation of Clinical Psychology in Germany. Results 6 weeks after the end of therapy and at the 1-year follow-up showed highly significant reductions in anxiety symptoms, anxious cognition, agoraphobic avoidance, general symptomatology, and depressive symptoms. Results did not differ significantly between the 3 outpatient clinics and are comparable with the average effect sizes reported by meta-analytic studies of controlled efficacy research, using selected patients and specifically trained therapists. Effectiveness was not dependent on duration of disorder, number of treatment sessions, and therapist experience. The study suggests that high-density exposure can be transported from research settings to the mental health field. How well do the results of empirically supported treatments hold up in natural settings ( Chambless & Hollon, 1998 ; Kendall & Chambless, 1998 )? Recently, writers have begun to differentiate between psychotherapy efficacy and effectiveness ( Weisz, Donenberg, Han, & Weiss, 1995 ). Efficacy (or research therapy) refers to the effects of psychotherapy in randomized, controlled trials usually conducted in university settings, with the aim of trying to establish a high degree of internal validity. Effectiveness (or clinic therapy) refers to the effects of "natural" clinical psychotherapy conducted in the field (e.g., in private practice or in mental health centers) using quasiexperimental designs to try to establish a high degree of external validity or generalizability of results to various settings. Although the efficacy of psychotherapy is established, Weisz et al. (1995) reported for child and adolescent therapies modest or nonsignificant effectiveness, challenging the generalizability of the efficacy findings. The first clinically representative controlled study in the child psychotherapy area by Weiss, Catron, Harris, and Phung (1999) reported nonsignificant results and negative effect sizes for clinic therapy in contrast to a control group. Kendall and Southham-Gerow (1996) reviewed the various factors that may contribute to the gap between research and practice outcomes. Shadish et al. (1997) conducted a secondary analysis of past meta-analysis and found very few studies Journal of Consulting and Clinical Psychology © 2001 by the American Psychological Association June 2001 Vol. 69, No. 3, 375-382 For personal use only--not for distribution. Page 1 of 149/5/2001http://spider.apa.org/ftdocs/ccp/2001/june/ccp693375.htmlthat were at least somewhat clinically representative and only one that fulfilled the complete set of criteria for clinic therapy. Generalizability studies are therefore needed to explore the transportability of empirically supported treatments to the field of outpatient psychotherapy ( Wilson, 1996 ). Recently, some generalizability studies have been conducted. In a study using a benchmarking strategy, Wade, Treat, and Stuart (1998) examined the transportability of cognitive—behavioral therapy for panic disorder to a community mental health center (CMHC). The CMHC outcome data for 110 patients were compared with the results of two controlled efficacy studies ( Barlow, Craske, Cerny, & Klosko, 1989 ; Telch et al., 1993 ). Patients were self-referred or were referred by physicians and mental health professionals and treated by a manualized 15-session panic control intervention ( Barlow & Craske, 1994 ). Unlike the Barlow et al. and Telch et al. studies, no exclusions were made on age, presence of severe agoraphobia, severity of panic attacks, or use of psychotropic medications. Despite differences in settings, patients, and therapists, the CMHC outcomes were comparable with the controlled studies: 87% of patients were panic free at the end of treatment, and patients showed significant reductions in anticipatory anxiety, agoraphobic avoidance, anxiety, and depression. Panic control treatment seems, therefore, transportable to a CMHC. Two recent effectiveness studies were conducted in Germany. Wetzel, Bents, and Florin (1999) examined the long-term effects of high-density exposure (HDE) therapy with response prevention for obsessive—compulsive disorder (OCD). A sample of 85 unselected inpatients were treated by 28 therapist practitioners. Results showed comparable effects with controlled studies: Success rates were 68% at the 1-year follow-up, and effect sizes were greater than 1.0 for all measures. Tuschen-Caffier, Pook, and Frank (2001) evaluated the effectiveness of cognitive—behavioral therapy for bulimia nervosa. A sample of 73 unselected patients were treated by 16 therapists in an outpatient clinic of the Christoph-Dornier Foundation for Clinical Psychology (see below). At the 1-year follow-up, significant improvements were found in all outcome variables. The effect sizes were in the range of those found in controlled research. Another empirically supported treatment for panic disorder with agoraphobia (PDAG) exists: situational in vivo exposure ( Barlow, Esler, & Vitali, 1998 ; Trull, Nietzel, & Main, 1988 ). However, the transportability of this treatment to outpatient psychotherapy has not been tested as yet and is the focus of this article. Patients with panic disorder report experiencing recurrent unexpected panic attacks with physical symptoms (racing heart, dizziness, or sweating) leading to continued anxiety focused on experiencing future panic attacks (fear of fear). Those patients with agoraphobia avoid situations that trigger panic attacks and for which escape would be difficult in the event of a panic attack, such as crowded restaurants, department stores, buses, movie theaters, or trains. Lifetime prevalence rates for the disorder range from 3.5% to 5.3% ( Kessler et al., 1994 ). Panic
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