Guided Mastery Treatment of Phobias

S. Lloyd Williams and Gwendolyn Zane

Lehigh University, Bethlehem, Pennsylvania and
Therapiezentrum der Gerhard Alber Stiffung, Stuttgart, Germany
Reprinted from:
Williams, S.L. & Zane, G. (1997). Guided mastery treatment of phobias. The Clinical Psychologist, 50, 13-15.


I. Description of Treatment

Guided mastery treatment (Williams, 1990) is a performance-based approach to phobia therapy derived from social cognitive theory (Bandura, 1986, 1988; Cervone & Williams, 1992) and its component self-efficacy theory (Bandura, 1988, in press; Williams, 1996). It is applicable to a broad range of specific and generalized phobias in both children and adults. In the self-efficacy analysis, phobic disability and distress result from people having lost their sense of self-efficacy, or confidence, that they can deal effectively with phobia-related activities or objects. Because people are most convinced that they can manage an activity by their own success at doing so, guided mastery treatment stresses overt performance mastery. The therapist's role is to promote performance successes by bringing to bear various techniques to enable clients to tackle scary tasks, and to execute them proficiently. Treatment is a collaboration between therapist and client in which the goal is to keep in motion a reciprocal interaction between increases in self-efficacy and greater performance successes, eventuating in mastery. This approach differs in important ways from phobia treatment conceived in terms of stimulus exposure and anxiety extinction (see Williams, 1990).

Guided mastery treatment includes three sets of techniques, designed in turn to raise the level, proficiency, and independence of people's performance. The therapist raises the level of self-efficacy and performance by intervening to help people do what they otherwise could not. One strategy for doing so is to perform therapeutic tasks with the client, such as riding with an agoraphobic person the first time she drives onto an expressway, or having a dog phobic man place his hand on the therapist's arm as the therapist pets the dog. Another is modeling, in which the therapist demonstrates or describes an action before asking the client to try it.

Other techniques include helping the person devise optimally challenging activities, not so hard that the person firmly believes he cannot do it, but not so easy that he would gain little self-efficacy by doing it. By identifying a sequence of progressively larger bridges to cross, or rounding up spiders of different sizes, the therapist can readily adjust task difficulty according to people's self-efficacy for particular tasks. People can usually do tasks for which their self-efficacy is 20 or higher on the 0-100 "confidence" scale used to assess self-efficacy. A self-efficacy strength rating in the range of 20 to 40 for each new treatment task is optimal, i.e., challenging but not overwhelming. Another technique consists of providing physical and mechanical support, for example, gloves to a spider phobic person for initially touching a spider, or holding the arm of a height phobic person when she first approaches a balcony railing. Additional techniques are described by Williams (1990).

Second, the therapist raises the proficiency and flexibility of people's performance by guiding them to do tasks without awkwardness, self-restrictions, or defensive coping rituals, and to carry them out in varied ways and under varied circumstances. Examples of defensive activities in a driving phobic person might be driving only in the slow lane, not passing cars, and gripping the steering wheel with "white knuckles"; a height phobic person might stand at a balcony railing in frozen immobility, staring at one place only; or a person with agoraphobia might carry water or tranquilizers while shopping to be used for dry mouth or mental breakdown. Such protective maneuvers undermine self-efficacy by reminding people of their limitations, and by leading them to attribute performance successes to the defensive rituals rather than to their own growing abilities. The mastery therapist guides the person to reduce and then eliminate defensive rituals, and to perform tasks in a flexible and varied manner and under varied circumstances. For example, the driving phobic person is guided to change lanes, pass cars, and loosen the grip on the wheel, the height phobic person to approach an elevated railing walking backwards and to gaze both near and far, and the agoraphobic to shop without the bottle of water.

Third, the therapist promotes functional independence by intervening only with as much assistance as needed to promote progress, by facing out the assistance quickly when progress is restored, by arranging for the client to have independent success experiences (for example, with "homework" assignments), and by training people to be their own therapists.

In self-efficacy theory, performance accomplishments strengthen self-efficacy and reduce anxiety regardless of whether clients initially become highly anxious or not when they try a new task. Therefore, the therapist encourages clients to do as much as they can at any point, despite anxiety. On the other hand, anxiety in itself has little therapeutic value, and the therapist's mastery assistance can enable people to do scary tasks with less anxiety than if they had to struggle unaided (Williams & Zane, 1989).


II. Summary of Studies Supporting Treatment Efficacy

Performance-based "exposure" treatments of phobia have long been known to be effective (Leitenberg, 1976; Marks, 1978; Barlow, 1988). Guided mastery and related treatments that emphasize the therapist actively helping clients while they tackle therapeutic tasks, have been evaluated for several decades. An early version known as "participant modeling," was evaluated in a long series of studies with clinically severe animal phobias (e.g., Bandura, Blanchard, & Ritter, 1969; Bandura, Jeffrey, & Wright, 1974). More recently, guided mastery (under that name or as "therapist-guided treatment" or "therapist assisted exposure") has been evaluated for agoraphobia (Williams, Dooseman, & Kleifield, 1984; Williams & Zane, 1989; Zane & Williams, 1993), specific phobia (Bandura, Taylor, Williams, Mefford, & Barchas, 1985; Öst, Salkovskis, & Hellstrom, 1991; Williams, Turner, & Peer, 1985), and social phobia (Mattick & Peters, 1989).

These studies show that after a brief guided mastery treatment program that can be as short as one or two sessions for specific phobias, most people show marked reduction in phobic disability and avoidance, in scary ideation, and in anticipatory and performance-related fear arousal. Several studies have found therapist-guided mastery to be significantly more effective than therapist encouragement to expose oneself to feared activities without therapist assistance (e.g. Bandura, et al., 1974; Öst et al., 1991; Williams et al., 1984, 1985; Williams & Zane, 1989). Generalized improvements in mood and in diverse areas of social and vocational functioning are routinely noted after performance-based treatment of phobia.


III. Clinical References

The following paper offers the greatest detail on specific guided mastery techniques:

Williams, S. L. (1990). Guided mastery treatment of agoraphobia: Beyond stimulus exposure. Progress in Behavior Modification, 26, 89-121.


The following references offer general guidance and much helpful information for conducting performance-based exposure treatment for agoraphobia and specific phobias. They vary in how much they emphasize active therapist assistance, and they include various additional techniques that lie outside the scope of guided mastery per se.

Antony, M. M., Craske, M. G., & Barlow, D. H. (1995). Mastery of your specific phobia. Albany, NY: Graywind.

(Now sold by the
Psychological Corporation
555 Academic Court
San Antonio, TX 78204
telephone 800-228-0752).

Brouillard, M., & Telch, M. J. (1988). The Stanford agoraphobia exposure protocol. In C. B. Taylor & B. Arnow (Eds.). The nature and treatment of anxiety disorders (pp. 342-368). New York: Free Press.

Steketee, G. & Chambless, D. L. (1988). Therapist manual for exposure treatment of agoraphobia. Unpublished

(Available from
D. Chambless
Psychology
UNC-CH
Chapel Hill, NC 27599-3270
include $4 to cover duplication and postage. Make checks payable to UNC-CH Department of Psychology.)


IV. Resources for Training

We are not aware of any training programs for guided mastery therapy per se. However, training in performance-based exposure therapies for phobias is available in several programs listed below.

Anxiety Disorders Center
Saint Louis Behavioral Medicine Institute
1129 Macklind Avenue
St Louis, MO 63110
Director, C. Alec Pollard
314-534-0200
fax 314-534-7996
email pollarda@sluvca.slu.edu

Laboratory for the Study of Anxiety Disorders
Department of Psychology
Mezes 330
University of Texas at Austin
TX 78712
Director, Michael J. Telch
512-471-3393.

UCLA Anxiety Disorders Behavioral Program
Department of Psychology
405 Hilgard Ave
Los Angeles, CA 90095-1563
310-206-9191
fax 310-206-5895
email craske@psych.sscnet.ucla.edu


V. References

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1988). Self-efficacy conception of anxiety. Anxiety Research, 1, 77-98.

Bandura, A. (in press). Self-efficacy: An exercise of control. New York: Freeman.

Bandura, A., Blanchard, E. B., & Ritter, B. (1969). Relative efficacy of desensitization and modeling approaches for inducing behavioral, affective, and attitudinal changes. Journal of Personality and Social Psychology, 13, 173-199.

Bandura, A. Jeffrey, R. W., & Wright, C.L. (1974). Efficacy of participant modeling as a function of response induction aids. Journal of Abnormal Psychology, 83, 56-64.

Bandura, A., Taylor, C.B., Williams, S.L., Mefford, I., & Bachas, J. (1985). Catecholamine secretion as a function of perceived coping self-efficacy. Journal of Consulting and Clinical Psychology, 53, 406-414.

Barlow, D. H. (1988). Anxiety and its disorders. New York: Guilford.

Cervone, D. & Williams, S. L. (1992). Social cognitive theory. In G.-V. Caprara & G. L. Van Heck (Eds). Modern personality psychology (pp. 200-252). New York: Harvester-Wheatsheaf.

Leitenberg, H. (1976). Behavioral approaches to treatment of neuroses. In H. Leitenberg (Ed.). Handbook of behavior modification and behavior therapy (pp. 124-167). Englewood Cliffs, NJ: Prentice-Hall.

Marks, I. (1978). Behavioral psychotherapy of adult neurosis. In S. L. Garfield & A. E. Bergin (Eds.). Handbook of psychotherapy and behavior change (pp. 493-547). New York, NY: Wiley.

Mattick, R.P., & Peters, L. (1988). Treatment of severe social phobia: Effects of guided exposure with and without cognitive restructuring. Journal of Consulting and Clinical Psychology, 56, 251-260.

Öst, L., Salkovskis, P. M., & Hellstrom, K. (1991). One-session therapist-directed exposure vs. self-exposure in the treatment of spider phobia. Behavior Therapy, 22, 407-422.

Williams, S. L. (1990). Guided mastery treatment of agoraphobia: Beyond stimulus exposure. Progress in Behavior Modification, 26, 89-121.

Williams, S. L. (1996). Therapeutic changes in phobic behavior are mediated by changes in perceived self-efficacy. In R. Rapee (Ed.). Current controversies in the anxiety disorders (pp. 344-368). New York: Guilford.

Williams, S. L., Dooseman, G., & Kleifield, E. (1984). Comparative effectiveness of guided mastery and exposure treatments for intractable phobias. Journal of Consulting and Clinical Psychology, 52, 505-518.

Williams, S. L., Turner, S. M., & Peer, D. F. (1985). Guided mastery and performance desensitization treatments for severe acrophobia. Journal of Consulting and Clinical Psychology, 53, 237-247.

Williams, S. L., & Zane, G. (1989). Guided mastery and stimulus exposure treatments for severe performance anxiety in agoraphobics. Behaviour Research and Therapy, 27, 237-245.

Zane, G., & Williams, S. L. (1993). Performance-related anxiety in agoraphobia: Treatment procedures and cognitive mechanisms of change. Behavior Therapy, 24, 625-643.


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