Why don’t therapists use exposure? And how psychological flexibility can help.

Exposure* is one of the most important and effective components in cognitive behavioural therapies for anxiety disorders, supported by decades of research. And yet it is under-used in clinical practice. Why?

Well, it isn’t just that many therapists use approaches that are not evidence-based. It seems that even those therapists who have been trained, end up not using exposure routinely. It is likely that exposure is the first empirically supported method that therapists stop doing soon after their training.

Some recent papers have explored this evidence-practice gap –

Meyer and colleagues (2013) assessed the beliefs therapists hold about exposure, in particular, when they decide to exclude exposure as part of treatment. They found that this was predicted by certain negative beliefs, combined with the therapist’s own fear of the sensations associated with anxiety (anxiety sensitivity). Therapist anxiety sensitivity has been found to predict less skilled delivery of exposure (such as terminating exposure sessions too early, or reassuring clients of safety) (Harned et al., 2014). The negative beliefs Meyer et al identified included concerns about harming clients, the ethics of exposure, and incorrect ideas about the effectiveness of exposure. Incorrect views involved believing that exposure is not helpful for clients who are diagnosed with a psychotic disorder, or for those deemed “emotionally fragile”; or those who are reluctant or ambivalent about engaging with an exposure program.

Deacon et al (2013) developed a scale to measure therapists’ beliefs about exposure. Alongside this measure, they asked therapists to respond to an exposure case vignette. The therapists that endorsed more negative beliefs about exposure also tended to respond to the case vignette in ways that would limit the benefit of exposure. This included using more strategies to reduce client distress during exposure sessions, or agreeing to client requests to use safety behaviours.

The same research team (Farrell, Deacon et al., 2013) designed an experiment to explore whether these negative beliefs  could influence the how cautiously aspiring therapists (university students) would approach the actual delivery of exposure. Participants received general information about conducting exposure, and then watched an information video about the beliefs that qualified therapists hold about using exposure. This video either presented negative beliefs about exposure, or described each of these negative beliefs and the research evidence to refute them (the positive condition). The participants were then asked to conduct an exposure session with a client (actually a confederate in the experiment, following a script of actions). The researchers found the participants in the negative belief condition conducted exposure in a more cautious fashion, compared to those who were presented exposure in a more positive light. This included trying to minimise the client’s anxiety, being less ambitious with creating an exposure hierarchy, and selecting a less-anxiety provoking task to do. Participants who held negative beliefs about exposure were also more anxious about conducting the session, both before and during exposure, and reported less interest in using exposure to treat anxious clients later in their careers!

So, it seems therapists’ beliefs about exposure, along with their anxiety sensitivity, may influence:
1) whether exposure is offered to certain clients,
2) how the therapist feels while doing exposure, and
3) the way that exposure is conducted (which can enhance or limit the treatment effect)

Considering this, are there ways that we can encourage therapists to remain committed to using exposure, and to deliver it in a way that optimises outcomes?

Checking out this literature got me wondering about whether contextual behavioural science may have something useful to add. In Acceptance and Commitment Therapy (ACT) the therapist’s behaviour is understood in terms of the same model of psychological flexibility as the client’s. This means that therapist beliefs that function as barriers to acting effectively can be worked with contextually – so that exposure may not be a matter of belief.

There have been a couple of studies which indicate that acceptance and commitment training is useful in increasing the openness and flexibility of learners to new material, and promoting the general effectiveness of therapists.

It seems to me that there may be mileage in promoting therapist psychological flexibility toward the use of exposure. As the exposure involves encouraging the client to engage in activities that put them in undefended contact with what they fear, this may benefit from flexible persistence on the part of the therapist, the kind that is promoted in ACT. Therapist rigidity about exposure (entanglement with unhelpful beliefs, unwillingness) may be addressed through using psychological flexibility skills, such as noticing, acceptance, defusion, and values clarification:
•    Doing exposure can involve the therapist witnessing client anxiety and being in contact with their own responses about this: there is the potential to get entangled with experiences, and act in ways  that limit the effect of exposure. As described above, this may include urges to avoid/ limit distress (by reassuring the client, suggesting “easier” steps on an exposure hierarchy).
•    Greater contact with the present moment may promote the therapist’s capacity to engage with offering and persisting with exposure. Present-moment noticing these thoughts and feelings about exposure, considering them in terms of workability, may help to build willingness toward these experiences as part of “doing exposure”.
•    Placing the exposure work within a larger frame of purpose (values clarification and committed action, rather than a primary aim of anxiety reduction), may strengthen client and therapist commitment to the process. Therapist motivation for exposure may be enhanced by deliberately connecting with the purpose of helping the client broaden their life – that exposure may allow the client to do more of the things that are important to them.

There are at least two ways that such psychological flexibility training could address the low take-up and persistence by therapists in using exposure:

1) For therapists in training, it may be pragmatic to introduce  skills in strengthening their own psychological flexibility prior to learning the theory and practice of exposure. Within this training could be acknowledgement of how doing exposure can put the therapist in contact with private experiences that invite  struggle and avoidance, and how being open to this and connecting with values may help the therapist to persist and remain effective.

2) For experienced therapists, it seems important to address the factors that influence the drift from using exposure. This could be tackled by workshops that present exposure skills alongside psychological flexibility training, with open exploration of what influences treatment decisions. This could also be reinforced through supervision and consultation.

These two ideas could also be the focus of research, extending the studies that I discussed above.

It’d be great to hear your views on how to help therapists to approach(!) and maintain using exposure in their clinical practice. Feel free to comment below!

*Exposure involves deliberate and repeated contact with cues that evoke a fear response while simultaneously engaging in behaviour that is incongruent with escape or avoidance – for a discussion, check out Moscovitch et al. 2009


  1. Great write up. This came up in our ACT chapter meeting at Boston, where a good number of folks come from the OCD unit at McLane Hospital. Some of the frustration of the full time OCD folks was that therapy does NOT end with the completion of exposure. Often, the therapeutic journey just begins. Cheers,

  2. wow, what timing. i’m busy preparing a workshop for Clin Psych students on doing Behavioural Experiments and exposure. Looks like i’ll need to allow extra time to discuss anxieties and do a hard sell. thanks

  3. Pingback: A Great Blog Post About Therapist Reluctance to Use Exposure – Portland Psychotherapy Training

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