Predictors of clinician use of exposure therapy in community mental health settings

Abstract

Exposure therapy is recognized as the key component of cognitive-behavioral treatment for anxiety. However, exposure is the least used evidence-based treatment in community mental health settings and is the most challenging technique for clinicians to adopt within the context of effectiveness and implementation trials. Little work has examined clinician and organizational characteristics that predict use of exposure, which is important for identifying implementation strategies that may increase its use. In a large sample of community health clinicians (N = 335) across 31 clinical practice sites, this study characterized clinician and organizational predictors of exposure use and relaxation for anxiety. Mixed effects regression analyses indicated that both clinician attitudes and an organization’s implementation climate may be important levers for interventions seeking to increase clinician exposure use. Greater clinician use of relaxation strategies was also associated with less exposure use. Results point to important implications for implementing cognitive-behavioral therapy for anxiety, including de-emphasizing relaxation and attending to organizational climate.

How community therapists describe adapting evidence‐based practices in sessions for youth: Augmenting to improve fit and reach

“…In both quantitative and qualitative reports of delivering multiple EBPs in a system‐driven implementation in children's mental health, community therapists reported making Augmenting adaptations to EBPs more frequently than making Reducing/Reordering adaptations (Barnett et al, 2018; Dyson, Chlebowski, & Brookman‐Frazee, 2019; Lau et al, 2017). These findings were encouraging, given concerns that therapists may remove core components of EBPs that they consider potentially distressing to clients, such as exposure for anxiety or evidence‐based strategies such as role‐plays (Becker‐Haimes, et al, 2017). Instead, in these studies, therapists were most often deploying fidelity‐consistent, Augmenting adaptations in attempts to boost client engagement, acceptability, and understanding of the practice.…”

Identifying the organizational innovation‐specific capacity needed for exposure therapy

“…Exposure therapy (“exposure”) is the key ingredient in cognitive‐behavioral therapy (CBT) leading to improved outcomes for anxiety and related disorders (Abramowitz, 2013; Higa‐McMillan, Francis, Rith‐Najarian, & Chorpita, 2016). Less than 30% of clinicians in routine clinical settings regularly use exposure with their anxious clients (e.g., Becker, Zayfert, & Anderson, 2004; Becker‐Haimes, Okamura et al, 2017; Cook, Biyanova, Elhai, Schnurr, & Coyne, 2010). Prior efforts to increase CBT use for anxiety have demonstrated success in increasing the use of strategies such as cognitive restructuring and relaxation (e.g., Becker, Becker, & Ginsburg, 2012; Hoyer et al, 2017) but little progress has been made in increasing clinician exposure use (Chu et al, 2015; Thomassin, Marchette, & Weisz, 2019).…”

“…Prior work has demonstrated that general organizational variables important for EBP implementation (e.g., proficient culture, implementation climate, and transformational leadership) are related to improved overall adherence to EBPs in community settings (e.g., Beidas et al, 2014; Cook et al, 2015; Farahnak, Ehrhart, Torres, & Aarons, 2019; Sayer et al, 2017; Williams, Glisson, Hemmelgarn, & Green, 2017). However, they are unrelated to clinician use of in vivo exposures (Becker‐Haimes, Okamura et al, 2017). Implementation scientists have argued that in addition to supportive leadership capacity for EBP, it is critical for organizations to develop innovation‐specific capacity for a given intervention (i.e., the human, technical, and fiscal conditions required for successful implementation of an intervention); this is thought to precede more traditionally studied organizational variables in mental health implementation such as implementation climate (Flaspohler et al, 2008; Scaccia et al, 2015; Wandersman et al, 2008).…”

COVID-19 and OCD: Potential impact of exposure and response prevention therapy

“…In light of the consistent finding that exposure-based treatment provides significant benefit for anxiety and OCD sufferers, the remedy for addressing contamination fear in the era of COVID may not be suspending the intervention, but instead more careful training of clinicians about the physical and litigation risks. Indeed, inflated litigation risk is a significant predictor of disuse of exposure treatment ( Becker-Haimes et al, 2017 ).…”