Exposure to exposure: A protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation

Abstract

BackgroundExposure therapy is a highly effective but underutilized treatment for anxiety disorders. A primary contributor to its underutilization is therapist-level negative beliefs about its safety and tolerability for patients. Given functional similarities between anxious beliefs among patients and negative beliefs among therapists, the present protocol describes how exposure principles can be leveraged during training to target and reduce therapist negative beliefs.MethodsThe study will take place in two phases. First, is a case-series analysis to fine-tune training procedures that is already complete, and the second is an ongoing randomized trial that tests the novel exposure to exposure (E2E) training condition against a passive didactic approach. A precision implementation framework will be applied to evaluate the mechanism(s) by which training influences aspects of therapist delivery following training.Anticipated resultsIt is hypothesized that the E2E training condition will produce greater reductions in therapists’ negative beliefs about exposure during training relative to the didactic condition, and that greater reduction in negative beliefs will be associated with higher quality exposure delivery as measured by coding of videotaped delivery with actual patients.ConclusionImplementation challenges encountered to date are discussed along with recommendations for future training interventions. Considerations for expansion of the E2E training approach are also discussed within the context of parallel treatment and training processes that may be tested in future training trials.

Exposures for anxiety: A survey of practicing school psychologists

“…Farrell et al (2013) advise directly addressing negative beliefs about exposures within training through experiential activities; although trainers may be familiar with research indicating exposures are safe, ethical, and tolerable, they may continue to associate exposures with danger if they are not provided experiences wherein this expectation of harm is violated. Similarly, Kemp et al (2023) suggest an intriguing approach to training therapists to deliver exposures via exposure to exposure with the goal of experientially targeting misconceptions and discomfort about exposure. This training technique involves applying the principles of exposure to the training of therapists in exposures; that is, trainers provide opportunities for therapists to practice the same exposures they expect to conduct with clients and to learn that the exposures are tolerable and helpful.…”