Why do clinicians exclude anxious clients from exposure therapy?

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

doi:10.1016/j.brat.2014.01.004

Cited by 143 publications

(137 citation statements)

References 25 publications

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“…For example, we are less likely to implement evidence-based treatment for a specific disorder where there is comorbidity present (Gielen, Krumeich, Havermans, Smeets & Jansen, in press;McAleavey et al, 2014;Meyer, Farrell, Kemp, Blakey & Deacon, 2014), even though the available evidence does not support such drift (e.g., Karačić, Wales, Arcelus, Palmer, Cooper & Fairburn, 2011). Broadly speaking, we routinely attribute our decisions to deviate from protocol-driven evidence-based practice to the patient (e.g., lack of motivation, resistance, severity of symptoms) or to the circumstances (e.g., logistical problems), rather than to ourselves (e.g., McAleavey et al, 2014;Szkodny et al, 2014;Wolf In general, how likely we are to implement these evidence-based therapies is driven at least in part by the information that we have about them and the attitudes that we hold towards them (Cahill, Foa, Hembree, Marshall & Nacash, 2006;Harned, Dimeff, Woodcock & Contreras, 2013;Meyer et al, 2014). For example, in an experimental study (Farrell, Deacon, Kemp et al, 2013), clinicians who were taught more about negative consequence of exposure work were likely to reduce the demands of such therapy and to engage in inappropriate calming of the patient.…”

Section: Our Beliefs and Attitudesmentioning

confidence: 99%

“…Our own anxiety is particularly pertinent when understanding why we do or do not implement exposure-based methods. For example, Meyer et al (2014) have shown that more anxious clinicians are likely to reduce the demands of exposure-based methods for patients. In the eating disorders, Waller et al (2012) have shown that clinicians who report higher levels of anxiety are less likely to ask patients to undertake key CBT tasks (e.g., diary keeping, structured eating, behavioral experiments).…”

Section: Our Emotionsmentioning

confidence: 99%

“…In recent years, there has been more evidence to support the proposal that more anxious clinicians implement behavioral change less and are wary of implementing other central therapeutic techniques (e.g., Meyer et al, 2014;Turner et al, 2014;Waller et al, 2012). Such clinicians tend to focus on the role of the therapeutic alliance as an agent of change, and to prioritise its role over that of the therapeutic techniques that are supported by the evidence, even when doing so is associated with poorer outcomes (e.g., Brown et al, 2014).…”

Section: Our Safety Behaviorsmentioning

confidence: 99%

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Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Waller

Turner

2016

Behaviour Research and Therapy

199

147

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Article available under the terms of the CC-BY-NC-ND licence (https://creativecommons.org/licenses/by-nc-nd/4.0/) eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. TakedownIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. AbstractTherapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviors and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioral approach for therapists that addresses the cognitions, emotions and behaviors that drive and maintain our avoidance of evidence-based treatments.Keywords: therapist drift; psychotherapies; evidence-based practice; training; cognitivebehavioral therapy Therapist drift redux 3 Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track There are different reasons why evidence-based therapies might be delivered poorly, such as clinicians being inadequately trained in the therapy in question (e.g., Royal College of Psychiatrists, 2013) or working in a setting that does not permit the implementation of the necessary methods (e.g., not being permitted to provide the necessary number of sessions).Among those reasons is one that is centred in our own practice -therapist drift (Waller, 2009). Therapist drift can be conceptualised as our failure to deliver treatments that we have been trained to deliver, or failure to deliver them adequately, even where resources exist to allow us to do so. Such failure can be a consciously or an unconsciously-driven course of action. Regardless, it has the same consequence -the patient receives treatment that deviates significantly from the evidence-base, reducing their chances of improvement or recovery. This paper will review the substantial recent evidence fo...

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Section: Our Beliefs and Attitudesmentioning

confidence: 99%

Section: Our Emotionsmentioning

confidence: 99%

Section: Our Safety Behaviorsmentioning

confidence: 99%

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Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Waller

Turner

2016

Behaviour Research and Therapy

199

147

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“…It is known that not only patient-related characteristics, such as comorbidity (Becker et al, 2004; van Minnen et al, 2010), but also therapist-related factors, are strongly related to the underuse of TFTs (Harned, Dimeff, Woodcock, & Contreras, 2013; Hundt, Harik, Barrera, Cully, & Stanley, 2016; Laska, Smith, Wislocki, Minami, & Wampold, 2013), such as therapists’ negative beliefs or expectations about the application of TFT (N. R. Farrell, Deacon, Kemp, Dixon, & Sy, 2013; Meyer, Farrell, Kemp, Blakey, & Deacon, 2014; van Minnen et al, 2010) or therapists’ own anxiety sensitivity (Meyer et al, 2014), indicating that some therapists may simply be afraid to conduct this type of therapy. In addition to these hesitations to start a TFT, during the TFTs some therapists drift from the protocol (Waller, 2009) or deliver their (exposure) treatment in a suboptimal way, for instance by using anxiety-diminishing techniques (Hipol & Deacon, 2013), avoiding encouraging patients to carry out exposure exercises that elevate high levels of anxiety, or avoiding the application of (therapist-assisted) exposure in vivo during the treatment sessions (N. R. Farrell et al, 2013; Hipol & Deacon, 2013).…”

Section: Introductionmentioning

confidence: 99%

Therapist rotation: a novel approach for implementation of trauma-focused treatment in post-traumatic stress disorder

Minnen

Hendriks

Kleine

et al. 2018

European Journal of Psychotraumatology

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Background: Trauma-focused treatments (TFTs) for patients with post-traumatic stress disorder (PTSD) are highly effective, yet underused by therapists.Objective: To describe a new way of implementing (adequate use of) TFTs, using a therapist rotation model in which one patient is treated by several therapists.Method: In this article, we will present two examples of working with therapist rotation teams in two treatment settings for TFT of PTSD patients. We explore the experiences with this model from both a therapist and a patient perspective.Results: Our findings were promising in that they suggested that this novel approach reduced the therapists’ fear of providing TFT to PTSD patients, increased perceived readiness for TFT, and decreased avoidance behaviour within TFT sessions, possibly leading to better implementation of TFT. In addition, the therapeutic relationship as rated by patients was good, even by patients with insecure attachment styles.Conclusions: We suggest that therapist rotation is a promising novel approach to improve implementation of TFT for PTSD.

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“…In the anxiety disorders, the reasons given for not using exposure are more related to clinicians' negative beliefs about exposure therapy (e.g., Deacon, Lickel, et al, 2013) than to evidence of possible outcomes . In both anxiety and eating disorders, clinician anxiety is also associated with poorer use of exposure-based methods (Meyer, Farrell, Kemp, Blakey & Deacon, 2014;Turner et al, 2014). Different proposals have been advanced regarding how clinicians might be encouraged to improve their uptake of exposure therapy, including role plays, the use of case material, and attitude inoculation (e.g., Farrell, Deacon, Dixon & Lickel, 2013).…”

Section: Impact Of Education On Clinicians' Attitudes To Exposure Thementioning

confidence: 99%

Impact of education on clinicians' attitudes to exposure therapy for eating disorders

Waller

Walsh

Wright

2016

Behaviour Research and Therapy

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Article available under the terms of the CC-BY-NC-ND licence (https://creativecommons.org/licenses/by-nc-nd/4.0/) eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. TakedownIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. Addressing clinicians' attitudes to exposure therapy AbstractIt is well established that clinicians use exposure therapy far less often than the evidence would suggest is justified. This shortfall has been explained as being at least partly a result of clinicians' beliefs and attitudes about exposure and their trait anxiety. Recent studies have shown that attitudes to exposure therapy for anxiety disorders can be improved through a simple educational approach. This study aimed to determine whether a similar educational approach can improve therapists' attitudes to exposure therapy for the eating disorders, and whether clinician's pre-intervention characteristics influenced the impact of the training. Thirty-four eating disorder clinicians (30 female, four male; mean age = 39.0 years; 85.3% Caucasian) attended a 90-minute didactic teaching session on the subject of the use of exposure in treatment of eating disorders. Their attitudes to exposure therapy were measured before and after the workshop, in a within-subject design. The outcome was a substantial improvement in attitudes, with a strong effect size (Cohen's d = 1.68) that was comparable to the outcome of a similar intervention among clinicians working with anxiety disorders. The improvement was not related to clinicians' anxiety levels, but was greater among those whose attitudes were more negative at the outset of the teaching. While this finding needs to be tested for long-term maintenance and its relationship to change in clinical practice, it adds to the evidence that a simple educational intervention is sufficient to result in substantial improvement in clinicians' attitudes to exposure therapy.

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Why do clinicians exclude anxious clients from exposure therapy?

Cited by 143 publications

References 25 publications

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Therapist rotation: a novel approach for implementation of trauma-focused treatment in post-traumatic stress disorder

Impact of education on clinicians' attitudes to exposure therapy for eating disorders

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