Joanna Kaye, MS - Department of Psychology, Drexel University
A large body of literature has determined that exposure-based cognitive-behavioral therapies are highly effective for a variety of anxiety disorders (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). Exposure therapies (ET) refer to a group of treatments that use exposure techniques to help individuals confront feared stimuli in a prolonged, repeated, and intense manner (Richard & Lauterbach, 2007). The various forms of exposure techniques include in vivo exposure (i.e., directly confronting feared stimuli in the real world), simulated exposure (i.e., confronting feared stimuli through role-play or “simulated” real-world scenarios), imaginal exposure (i.e., recounting anxiety-provoking thoughts or images verbally or in the form of written narratives), and interoceptive exposure (i.e., intentionally invoking feared body sensations).
Meta-analyses have determined that exposure-based cognitive-behavioral treatments (CBTs) lead to symptom improvement with large effect sizes in the treatment of panic disorder, specific phobia, social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD; Bandelow et al., 2015; Deacon & Abramowitz, 2004; Mayo-Wilson et al., 2014; Olatunji, Davis, Powers, & Smits, 2013; Olatunji et al., 2010). Additionally, exposure to feared stimuli is widely considered an empirically-supported principle of behavior change for anxiety disorders (Lohr, Lilienfeld, & Rosen, 2012). Exposure techniques are the cornerstone of CBT protocols for anxiety disorders, so much so that many debate if other treatment components add any incremental benefit above exposure alone (Barrera, Szafranski, Ratcliff, Garnaat, & Norton, 2016; Olatunji et al., 2010).
Given this evidence, why aren’t all mental health clinicians using exposure?
Despite the demonstrated efficacy of ET, many therapists do not use exposure therapy or use it only rarely (Becker, Zayfert, & Anderson, 2004; Freiheit, Vye, Swan, & Cady, 2004; Hipol & Deacon, 2013; Whiteside, Deacon, Benito, & Stewart, 2016). A key factor is lack of adequate dissemination of ET training. However, even when therapists indicate that they endorse a cognitive-behavioral orientation and have been trained in the use of exposure therapy methods, many report they do not utilize these methods or use them only infrequently. Given the established efficacy of exposure treatments for anxiety disorders, it is critical that we expand efforts to understand how to increase implementation of exposure techniques.
Another concerning factor related to the implementation of ET is the research that has found that even among therapists who report using exposure techniques, many do not deliver them in an optimal manner. Therapists in community settings appear to utilize client-directed exposure substantially more than therapist-directed exposure (Freiheit et al., 2004; Hipol & Deacon, 2013), which is concerning given indications that self-directed exposure is less effective (Abramowitz, 1996). Additionally, although findings suggest that effective exposure treatment requires its delivery in a prolonged, repeated, and intense manner, many therapists also endorse promoting arousal reduction techniques (e.g., deep breathing exercises) during exposure, despite theoretical and empirical contraindications for doing so (Blakey & Abramowitz, 2016; Schmidt et al., 2000). For example, Deacon and colleagues (2013) found that many therapists delivering interoceptive exposure for panic disorder utilized controlled breathing strategies during delivery, which have shown no benefit in treatment and stand in direct contrast to the prolonged and intense delivery suggested by validated treatment manuals.
Given the efficacy of exposure therapies for anxiety disorders, it is critical to examine the reasons behind underutilization and improper use of these methods. Many factors are likely to impede dissemination and effective implementation, including lack of adequate training, persistent beliefs that empirically-supported treatments conducted in research settings are irrelevant to clinical practice, therapists’ overemphasis on clinical intuition, and therapist concerns about exposure therapy (Deacon & Farrell, 2013).
What do we do about this?
Research must determine how to improve the implementation of exposure therapy through clinical training. Further investigation onto the barriers to dissemination and effective training will provide guidance about how to achieve these goals. Mental health clinicians clearly desire more training in exposure therapy. However, the question remains: which training method will prepare clinicians to deliver the most effective exposure therapy?
Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583-600.
Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology, 30(4), 183-192.
Barrera, T. L., Szafranski, D. D., Ratcliff, C. G., Garnaat, S. L., & Norton, P. J. (2016). An Experimental comparison of techniques: Cognitive defusion, cognitive restructuring, and in-vivo exposure for social anxiety. Behavioural and Cognitive Psychotherapy, 44(2), 249-254.
Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3), 277-292.
Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective. Clinical Psychology Review, 49, 1-15.
Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta‐analytic findings. Journal of Clinical Psychology, 60(4), 429-441.
Deacon, B. J., & Farrell, N. R. (2013). Therapist barriers to the dissemination of exposure therapy. In Handbook of treating variants and complications in anxiety disorders (pp. 363-373). New York: Springer.
Deacon, B. J., Farrell, N. R., Kemp, J. J., Dixon, L. J., Sy, J. T., Zhang, A. R., & McGrath, P. B. (2013). Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale. Journal of Anxiety Disorders, 27(8), 772-780.
Freiheit, S. R., Vye, C., Swan, R., & Cady, M. (2004). Cognitive-behavioral therapy for anxiety: Is dissemination working?. The Behavior Therapist, 27(2), 25-32.
Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence-based practices for anxiety disorders in Wyoming A survey of practicing psychotherapists. Behavior Modification, 37(2), 170-188.
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.
Lohr, J. M., Lilienfeld, S. O., & Rosen, G. M. (2012). Anxiety and its treatment: Promoting science-based practice. Journal of Anxiety Disorders, 26(7), 719-727.
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.
Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91-110.
Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics of North America, 33(3), 557-577.
Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33-41.
Richard, D. C. S. & Lauterbach, D. L. (2007). Handbook of exposure therapies. Boston: Academic Press.
Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424.
Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders, 40, 29-36.
Published September 2, 2017