Creating courageous CBT therapists: how to work with therapist fears about using exposure therapy

Despite a wealth of evidence that it is one of the most effective ways to help people with anxiety disorders, exposure therapy remains underused by clinicians

As discussed in previous posts, clinicians’ attitudes and practices about exposure are influenced both by their knowledge about the approach and their openness to witnessing client discomfort (and experiencing distress themselves). Cautious clinicians, if they do offer exposure, may do it in a way that limits its effectiveness. 

So how do we support clinicians to use exposure more routinely, and effectively? 

It seems that what is needed is training and supervision that: 1) addresses knowledge gaps, and 2) increases clinician “courage” to offer exposure and deliver it in a way that maximises effectiveness. 

A recent paper published in Behaviour Research & Therapy investigates how to train clinicians in using exposure, by seeing what happens if you directly address their concerns by giving accurate information AND work with their feelings about engaging clients in the approach: 

Targeting clinician concerns about exposure therapy: A pilot study comparing standard vs. enhanced training

Nicholas R. Farrell, Joshua J. Kemp, Shannon M. Blakey, Johanna M. Meyer, & Brett J. Deacon

Abstract
Owing to concerns about the safety and tolerability of exposure therapy, many clinicians deliver the treatment in an overly cautious manner, which may limit its effectiveness. Although didactic training in exposure reduces clinician concerns about the treatment to a moderate extent, improved training strategies are needed to minimize these concerns and improve exposure delivery. The present study compared the effectiveness of a standard (i.e., didactic) exposure therapy training model to an “enhanced” training paradigm encompassing strategies derived from social-cognitive theory on attitude change. Clinicians (N = 49) were assigned to one of the two training approaches. Relative to standard training, clinicians who received enhanced training showed: (a) significantly greater reductions in concerns about exposure from pre- to post-training, and (b) superior self-reported delivery of the treatment. Reduction in concerns during training mediated the effects of training condition on clinicians’ self-reported exposure delivery. These findings underscore the importance of addressing clinician concerns about exposure therapy in training contexts.

The paper can be accessed here [PDF]. 

Training clinicians

The enhanced training procedure described in the paper involved providing accurate information about exposure, as well as addressing clinician concerns. The authors described that the enhanced training was informed by a social psychology perspective on how to influence people’s attitudes (the model described further here). In this study this was done by a balance of empirical information, correcting common mistaken beliefs about exposure, emotion-based appeals (client testimonials to the effectiveness and tolerability of exposure therapy), and an experiential/ self-practice exercise. 

The study compared two training packages: 

Standard training

 • an overview of exposure therapy, and a review of its efficacy, 

 • a description of cognitive-behavioural maintaining factors in anxiety disorders, 

 • applied practice in case formulation and treatment planning, 

 • descriptions of different variations of exposure (e.g., interoceptive, imaginal

 • training in developing exposure hierarchies, 

 • instruction in “coaching” clients during exposure exercises, 

 • a discussion of the importance of context in fear learning and extinction.

Enhanced training involved the elements of the standard training, along with presenting: 

 • direct, empirically-based information that challenged common clinician myths about exposure therapy

 • testimonials from clients who had experienced exposure therapy, attesting to it’s safety and tolerability

 • an interoceptive exposure exercise – where the training participants were encouraged to engage in hyperventilation as self-practice during training. This was done so that they may discover experientially the safety and tolerability of evoked sensations associated with anxiety. 

Outcomes

Compared to the standard training, the researchers found enhanced training resulted in a greater reduction in clinicians’ concerns about exposure therapy. Additionally, the enhanced training was associated with clinicians reporting the use of exposure in a higher quality way – endorsing various elements of practice closer to the ideal of how exposure should be offered. Finally, the mediation analyses (of the processes of change) suggest that the quality of clinician’s self-reported practices of exposure were influenced by reductions in their fears about it. 

There are a limitations with this study (discussed by the authors): the sample was made up of experienced clinicians, the outcome of the training in exposure was a single-item measure, and there was no more objective assessment of whether clinicians actually ended up doing exposure in a consistent way. The mediation analyses were conducted with concurrent data, rather than taking potential process measures at an earlier time to measuring outcomes (which may have demonstrated causality). 

Implications

This is a useful paper in exploring the ways that the training of practitioners can be strengthened, to increase the possibility that they will offer exposure to clients with anxiety. As a trainer of psychologists it made me consider how I can best teach them to use exposure: it seems that time spent providing the background and rationale for use of exposure, along with exploring clinicians beliefs about exposure, is important. Additionally, I like that an experiential and self-practice approach to learning about exposure seems useful (the interoceptive exposure component). 

I remain interested in whether enhanced training for exposure may also benefit from having components that address clinicians’ psychological inflexibility or anxiety sensitivity. This could be informed by using principles from Relational Frame Theory, such as motivative augmenting (e.g., relating the therapist offering exposure, being open to client distress, as being in a hierarchical network with the therapist’s values).  I also wonder about training that presents exposure with an alternate rationale, such as the “repertoire expanding” approach that is used in Acceptance & Commitment Therapy and other contextual CBTs (compared to a habituation, anxiety-reduction rationale for exposure). 

This pilot study suggests that giving a “how to” on exposure is not enough to train clinicians. If you want them to offer exposure to clients in a high quality way, then it is about taking time to address common concerns, share the experiences of clients who have participated in exposure, and use experiential exercises to help clinicians perspective-taking and discovery. 

 

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2 Comments

  1. Thanks Eric. Useful summary on that paper. Other areas of interest for me include the organisational context e.g. does reduced psychological safety in the practitioner caused by work stress mediate changes in their willingness to do exposure work consistently?

    Also, I’d like to see inclusion of Michelle Craske’s work that shows learning is more important than extinction in mediating outcome. Still not filtered through into curriculum as far as I know here in UK.

    • Thanks very much Jim. Yes, I think it would be useful to investigate the broader contextual factors such as the organisational environment, on whether clinicians are more likely to offer therapies like exposure.

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