Why therapists don’t do what works: Case of exposure
There is no intervention that has had its effectiveness replicated more often than exposure for anxiety disorders. Despite this, surveys conducted in the US and Europe over the past 15 years have found that as few as 17% clinicians reported using exposure with their PTSD cases, 29% of clients with OCD reported their therapists using exposure, and therapists have reported using exposure with less than half of their anxiety disorder clients.
A recent study in Germany (Pittig, Kotter & Hoyer, 2019) tried to find out why clinicians don’t use exposure. They found 3 factors contributing to low usage: 1) practical barriers; 2) therapist negative beliefs about exposure; and 3) therapist self-reported competence. The main practical barriers were seen to be: a) the time involved with exposure was too unpredictable to schedule other clients afterward; b) needing to cancel other clients’ sessions; and c) the (perceived) high likelihood of unpredictable client absences that meant they therefore couldn’t bill a session. The main negative beliefs about exposure were: a) that arousal reduction strategies would be necessary for clients to tolerate evoked distress; b) that exposure would work poorly for complex cases; c) that exposure addresses superficial symptoms rather than the “root” of the problem; and d) the risk that clients will decompensate. Conversely, therapists were more likely to use exposure if they felt competent to do so. There was a strong correlation between therapists holding negative beliefs about exposure and feeling distressed when conducting exposure. Furthermore, the more training clinicians reported having done in exposure, the less they endorsed practical barriers and negative beliefs about it.
It’s worth noting that the investigated factors only accounted for 17% of the variance in exposure utilisation, perhaps reflecting the allegiance of the researchers who adopted a narrow perspective on why people might not be using exposure. For example, perhaps clinicians thought they had a more effective, more acceptable treatment strategy for anxious clients? Nevertheless, although our understanding of why exposure isn’t used more often is limited, there are still useful lessons to learn from this study.
Clinical implications:
Clinicians don’t use interventions if they don’t feel competent. On the surface, this seems reassuring. But what if clinicians’ sense of confidence isn’t particularly reliable? As other studies have shown (e.g., McManus et al., 2012; Miller & Mount, 2001; Nissen-Lie, Monsen, Ulleberg, & Rønnestad, 2013), therapist confidence isn’t always a good predictor of their competence. Should therapists avoid doing something that makes them feel ineffective if that thing might still be better for the client than something that makes them feel effective but doesn’t work?
If you’re put off of doing exposure because of practical barriers, this may suggest you have some out-of-date ideas about how to do exposure and why it is effective. Michelle Craske’s work (Craske et al., 2008; 2014) explains how the old-fashioned ‘exposure as habituation’ theory is not the mechanism by which exposure is effective and explains modern methods of execution. There is no reason why exposure should disrupt the rest of your client schedule. Tasks can be stopped and started at both the client’s and the therapist’s discretion, so time can be scheduled within session for debriefing and learning, and if necessary, arousal reduction prior to clients leaving your office.
This study highlights the important role of therapist’s therapy-interfering beliefs. Judith Beck, among others, has long called for therapists to check their own beliefs when encountering impasses with clients. There is no area more critical to examine than our beliefs about the efficacy of approaches that have been empirically supported, especially those with the weight of evidence that exposure has.
For the full paper: https://reader.elsevier.com/reader/sd/pii/S000578941830087X?token=215826CA38C82C48E43F0E0C77C7C39F6CAA2DC58E753F5FB397F250A546D24306B84C21BD2C8B458E7C16882B4541AD
References
Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46: 5-27.
Craske, M.G., Treanor, M., Conway, C.S., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58: 10-23.
McManus, F., Rakovshik, S., Kennerley, H., Fennell, M., & Westbrook, D. (2012). An investigation of the accuracy of therapists’ self-assessment of cognitive behaviour therapy skills. British Journal of Clinical Psychology, 51, 292-306.
Miller, W.R., & Mount, K.A. (2001). A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioural and Cognitive Psychotherapy, 29,457-471.
Nissen-Lie, H.A., Monsen, J.T., Ulleberg, P., & Rønnestad, M.H. (2013). Psychotherapists’ self-reports of their difficulties in practice as predictors of patient outcome. Psychotherapy Research, 23, 86-104
Pittig, A., Kotter, R., & Hoyer, J. (2019). The struggle of behavioral therapists with exposure: Self-reported practicability, negative beliefs, and therapist distress about exposure-based interventions. Behavior Therapy, 50, 353-366.