What Factors Influence Therapists' Use of Exposure Therapy for Anxiety Disorders?

What you need to know

• Exposure therapy is highly effective for anxiety disorders but is underutilized in clinical practice
• Clinicians’ negative beliefs about exposure therapy are a key barrier to its use
• Targeted, practical training may improve implementation, especially for complex disorders like PTSD
• More research is needed on organizational and systemic factors affecting exposure therapy use

What is exposure therapy and why is it important?

Exposure therapy is a key component of cognitive-behavioral therapy (CBT) for anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). It involves gradually and systematically exposing patients to feared situations, objects, or memories in order to reduce anxiety over time.

Decades of research have shown that exposure therapy is highly effective for treating these conditions. It is recommended as a first-line treatment in clinical practice guidelines. However, studies have found that many therapists do not regularly use exposure therapy with their patients, even when it would be appropriate. This gap between research and practice means that many patients are not receiving the most effective available treatment.

Understanding why exposure therapy is underutilized and how to improve its implementation in real-world clinical settings is an important goal. This review aimed to synthesize the existing research on factors that influence therapists’ use of exposure therapy, in order to identify targets for improving implementation.

How was the study conducted?

The researchers conducted a systematic review, searching multiple databases to find all relevant studies on factors related to clinicians’ use of exposure therapy for anxiety disorders, OCD, and PTSD. They identified 52 studies meeting their criteria.

To organize and analyze the findings, they used an implementation science framework called the Theoretical Domains Framework (TDF). This framework outlines 14 domains that can influence healthcare providers’ behavior, such as knowledge, skills, beliefs about consequences, and environmental context. The researchers categorized each study’s findings into these domains.

They also looked at differences between anxiety disorders, OCD, and PTSD, as well as between treatments for youth versus adults. The goal was to identify both common factors and any unique considerations for specific disorders or age groups.

What factors influence exposure therapy use?

The review found that factors across multiple TDF domains influence clinicians’ use of exposure therapy. Some key findings include:

Beliefs about consequences

Clinicians’ beliefs and attitudes about exposure therapy emerged as one of the most important factors. Across multiple studies, therapists who held more negative beliefs about the consequences of exposure therapy - for example, believing it to be risky or harmful to patients - were less likely to use it. This was consistent across different anxiety disorders.

These negative beliefs seemed to be especially influential for treating youth. Some therapists had specific concerns about children’s ability to tolerate exposure therapy.

Knowledge and skills

Knowledge about exposure therapy, often gained through training, was associated with greater use - but with some nuances:

• For anxiety disorders in general, broad training in exposure therapy techniques was linked to increased use.
• For more complex presentations like PTSD, general exposure therapy training had inconsistent effects. Instead, specialized, practical training in specific techniques like prolonged exposure for PTSD was more consistently linked to implementation.

Practical clinical experience treating anxiety disorders or PTSD also appeared to increase use of exposure therapy.

Environmental context

Contextual factors in clinicians’ work environments also played a role:

• Working in specialty anxiety or PTSD clinics was associated with greater use of exposure therapy.
• Higher caseloads of patients with anxiety or PTSD predicted more use of exposure therapy.
• Some studies found that practical barriers, like lack of time or resources, reduced implementation.

Social influences

A few studies examined social and organizational factors:

• Leadership support for implementing evidence-based treatments like exposure therapy was linked to greater use.
• Weekly consultation calls with experts increased use of prolonged exposure for PTSD.
• Organizational culture supportive of implementation improved uptake.

Other factors

The review identified several other factors that may influence exposure therapy use, though evidence was more limited:

• Clinicians’ self-efficacy (confidence in their ability to deliver exposure therapy)
• Intentions to use exposure therapy
• Emotional factors like clinician anxiety

What are the implications for improving implementation?

Based on these findings, the authors suggest several strategies that could help increase the use of exposure therapy in clinical practice:

Target negative beliefs

Given the consistent importance of clinicians’ beliefs, efforts to address misconceptions and negative attitudes about exposure therapy should be a priority. This could involve education about the evidence for exposure therapy’s effectiveness and safety.

Provide specialized, practical training

While general knowledge is helpful, the findings suggest that detailed, hands-on training in specific exposure techniques for different disorders may be most effective - especially for complex conditions like PTSD. Training should go beyond lectures to include role-playing, case examples, and supervised practice.

Address contextual barriers

Healthcare systems and clinics should examine practical barriers that may hinder exposure therapy use, such as session length restrictions or lack of appropriate spaces to conduct exposure. Ensuring clinicians have the necessary time, resources, and support is crucial.

Leverage social influences

Creating a supportive organizational culture around evidence-based practices like exposure therapy appears beneficial. This could involve clear messaging from leadership, opportunities for consultation and supervision, and fostering a culture of continuous learning and improvement.

Consider multiple factors

The review highlights that exposure therapy implementation is influenced by factors at multiple levels - individual clinician, patient, organizational, and healthcare system. Comprehensive strategies addressing multiple domains are likely to be most effective.

Limitations and future directions

While this review provides valuable insights, the authors note several limitations in the current research:

• Most studies were conducted in Western, high-income countries, limiting generalizability.
• There was an imbalance in the disorders studied, with more research on PTSD than anxiety disorders or OCD.
• Adult populations were studied more than youth.
• Many studies relied on clinicians’ self-report of exposure therapy use, which may be biased.

The authors call for more research in several areas:

• Exploring implementation factors in diverse global contexts
• Examining exposure therapy use for anxiety disorders and OCD, especially in youth
• Using more objective measures of exposure therapy implementation
• Investigating understudied domains from the TDF, like clinician optimism or decision-making processes
• Conducting more studies using robust designs like randomized trials of implementation strategies

Conclusions

Exposure therapy is a powerful treatment for anxiety disorders, but its effectiveness in the real world depends on clinicians actually using it with their patients. This review synthesizes what we know about the complex factors influencing exposure therapy implementation.

Key takeaways include the importance of addressing clinicians’ negative beliefs, providing specialized and practical training, and considering contextual and organizational factors. The findings also highlight the need for tailored approaches for different disorders and age groups.

By using frameworks from implementation science, researchers can continue to build our understanding of how to bridge the gap between the strong evidence for exposure therapy and its use in everyday clinical practice. Ultimately, this work aims to ensure that more patients suffering from anxiety disorders have access to this effective treatment.