Use Of Exposure Therapy Research Articles

Reviving life that has ceased on October the 7th: an attachment perspective on a virtual reality intervention

Unfortunately, in recent years, wars have forced many civilians to evacuate their homes and move to safe zones. The event of October the seventh that took place in many Kibbutzim near the Gaza strip, exposed families who were on a Jewish holiday, to the murder of family and community members. They had to leave their burned houses and move to hotels and apartment buildings in other parts of Israel. Many people, also from the Northen parts of the country, are still in new safe zones, and have huge difficulties in returning to their houses (and not only because of objective security reasons). In this “perspective” article we propose a Virtual Reality (VR) application, which is based on past and current research in the fields of attachment theory and traumatic grief. We propose that in addition to the use of exposure therapy, a VR simulation which will activate the attachment system, can reorganize the evacuees’ figure and place attachment representations. We suggest that such a simulation will revive the evacuees’ sense of safe-haven and secure base and enable them to return to their home place, or to adjust to a new place, thereby leading to optimal adjustment. We start with a presentation of the theory of attachment, place attachment, attachment and loss and the two-track model of bereavement. Then, we describe the design of our VR intervention that aims to address this challenge from the attachment theory perspective with the evacuees. Finally, we discuss the challenges that need to be dealt with to implement the VR interventions through resilience centers in Israel.

Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training.

The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies. Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions. Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001). The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide.

Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors.

Barriers to the use of exposure therapy by psychologists treating anxiety, obsessive-compuslive disorder, and posttraumatic stress disorder in an Australian sample.

Exposure therapy is a core component of the evidence-based treatment of anxiety, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). Despite this, many clinicians fail to use exposure therapy in clinical practice, with research highlighting a number of potential barriers. Those findings raise serious concerns regarding the effective dissemination and delivery of evidence-based treatments that in turn have a major impact on client care and cost-effectiveness of psychological interventions. The present study aims to examine barriers to the use of exposure therapy in the clinical practice of Australian psychologists treating anxiety, OCD and PTSD. One hundred registered psychologists, aged between 23 and 71 years and 84% female, participated in this study via online survey. Results suggest that the most common barriers to the use of exposure therapy include lack of confidence, negative beliefs about exposure therapy, insufficient underpinning theoretical knowledge, client-specific barriers, and logistical limitations. Future research may further examine those barriers and the components of additional training and supervision that can increase the uptake of exposure therapy, particularly in clinical areas where it is a gold standard of practice.

Using Technology to Promote Therapist Use of Exposure Therapy for Childhood Anxiety Disorders: A Randomized Pilot Study

Increasing the use of exposure by community therapists during the treatment of childhood anxiety disorders is critical to improving the quality of available treatment. The aim of the current study was to investigate whether a brief training in the delivery of an exposure-focused and technology-assisted treatment protocol increased community therapist openness to exposure therapy, use of exposure in treatment, and improvement in patient symptoms. Participants were 17 therapists recruited from a large health system to provide outpatient therapy to 32 youth ages 8–18 (M = 12.13, 78.1% girls) with treatment as usual or with the Anxiety Coach application (AC-app). Consistent with two of three hypotheses, therapists in the AC-app condition increased their openness to, and use of, exposure—however, these changes did not translate into improved therapeutic outcomes. Comparisons to benchmark studies suggest that the community therapists did not implement enough in vivo exposure of sufficient intensity or include parents enough to improve outcome. Results support the ability of exposure-focused treatment protocols to increase community therapists’ use of evidence-based treatment and suggest that future efforts should focus on improving the quality, in addition to quantity, of therapist-delivered exposure.

Utilisation and predictors of use of exposure therapy in the treatment of anxiety, OCD and PTSD in an Australian sample: a preliminary investigation

BackgroundCognitive-behavior therapy (CBT) is known to be an effective treatment for the anxiety and related disorders, with exposure therapy being a key component of this treatment package. However, research on the use of exposure therapy in clinical practice has presented mixed results, potentially due to differences in samples and training programs across countries. The present study aimed to extend upon existing research by examining the use and predictors of use of exposure therapy in a sample of psychologists working in clinical practice in Australia who treat clients with an anxiety disorder, obsessive compulsive disorder (OCD) or post-traumatic stress disorder (PTSD).MethodsOne hundred registered psychologists (Mage = 40.60; SD = 10.78; range 23 to 71 years; 84% female) participated in an online study investigating their clinical practices.ResultsResults suggested that while the general use of exposure therapy is high, the use of disorder specific techniques was considerably lower, particularly for anxiety disorders and PTSD but not OCD. Psychology registration status and level of training were positively associated with use of exposure therapy as was the experience in treating anxiety disorders.ConclusionsThese findings suggest that further or ongoing professional training may be required to optimize the use of disorder specific techniques.

Identifying the organizational innovation-specific capacity needed for exposure therapy.

Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care. We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings. In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations. Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients' access to effective treatment for anxiety disorders.

Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles.

Despite strong evidence of effectiveness, exposure therapy is an underutilized treatment for anxiety disorders at a time when effective treatment for anxiety is greatly needed. The significant worldwide prevalence and negative impact of anxiety are documented and highlight the importance of increasing therapist and patient use of effective treatment. Obstacles to the use of exposure therapy are explored and steps to lessen these obstacles are proposed. In particular, virtual reality (VR) technology is discussed as a way to increase the availability of exposure therapy. Incorporating VR in therapy can increase the ease, acceptability, and effectiveness of treatment for anxiety. VR exposure therapy (VRET) permits individualized, gradual, controlled, immersive exposure that is easy for therapists to implement and often more acceptable to patients than in vivo or imaginal exposure. VR is presented as a scalable tool that can augment access to and effectiveness of exposure therapy thus improving treatment of anxiety disorders. VR also has the potential to help with assessment and with therapist training standardization. The authors advocate for providing continuing education in VRET to practicing clinicians and including training in exposure therapy and VRET in training programs. Ongoing development of VR applications for clinical use is encouraged, especially when developed in collaboration with software developers, clinical users, therapists who are experienced in VRET, and researchers.

Manipulating the theoretical framing of exposure therapy for eating disorders impacts clinicians' treatment preferences.

Exposure therapy is the most effective treatment for anxiety and related disorders and its efficacy in the eating disorders is rapidly gaining support. Despite the strong evidence behind exposure therapy, many anxiety disorder providers do not endorse the usage of exposure therapy. Limited research has explored the use of exposure therapy in eating disorder providers, as well as the impact of framing on likelihood to use exposure therapy. The current study (N = 125 eating disorder providers) manipulated the framing of exposure to feared foods (pizza). We framed the treatment as an exposure, behavioral experiment, or acceptance/mindfulness-based intervention. We also tested attitudes towards exposure therapy in eating disorder providers. Participants were more likely to endorse willingness to use a treatment framed as a behavioral experiment over exposure and acceptance-based framing. This effect did not vary by degree type, type of provider, years in practice, experience, or training. We also found that providers with more training, specifically in eating disorder exposure, were more likely to use exposure over acceptance-based framed intervention (and vice versa). Finally, we found that eating disorder providers had a somewhat positive view of exposure therapy. Framing of the intervention impacts likelihood that providers will endorse using specific interventions. Therefore, intervention development and dissemination efforts should consider the language around the description of evidence-based treatments. Furthermore, enhanced training and education specifically with eating disorder exposure therapy may enhance the likelihood of providers utilizing exposure therapy. Level I: experimental study.

An Online- and Mobile-Based Application to Facilitate Exposure for Childhood Anxiety Disorders

In the current paper, we describe an integrated online- and mobile-based application for the treatment of childhood anxiety disorders, Anxiety Coach. The technology is designed to increase the use of exposure therapy by therapists and patients. We begin by outlining the clinical content and design of the application, and then review the clinical administration and theoretical basis for the program. Next, using results from an implementation feasibility study, we illustrate how data collected during application use can inform therapists, supervisors, and researchers about process variables (i.e., use of exposure) and outcomes (i.e., symptom improvement). Implications of the potential for Anxiety Coach to increase access to evidence-based treatment and directions for further research are discussed.

Exposure therapy for youth with anxiety: Utilization rates and predictors of implementation in a sample of practicing clinicians from across the United States

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.

Feasibility and Acceptability of a Toolkit to Facilitate Clinician Use of Exposure Therapy for Youth

ABSTRACTExposure therapy is a key element of cognitive-behavioral therapy for youth with anxiety. However, few clinicians outside of specialty anxiety clinics routinely use exposures with anxious youth. This study reports on the acceptability and feasibility of a clinician support toolkit for exposures with anxious youth in community settings. The toolkit was developed through an extensive literature review of exposure science and cited barriers to exposure therapy, with input from multiple experts in pediatric anxiety (n = 10). Acceptability and feasibility data were gathered via survey from 70 community clinicians attending a training on exposure therapy for youth. Qualitative data were collected from a subset of participants who used the toolkit with youth on their caseload for approximately 1 month. Survey data suggested that the toolkit was viewed highly favorably. Qualitative interviews indicated that the toolkit was viewed as a feasible therapeutic tool that positively impacted clinician motivation to use exposure. Primary challenges related to exposure use more generally and included client and service-setting barriers. Results suggested initial toolkit acceptability and feasibility. Future work to refine the toolkit and test its efficacy as an implementation strategy to increase clinician use of exposure therapy is warranted. Next steps include development of additional content in partnership with key stakeholders and testing the toolkit’s impact on increasing clinician use of exposure therapy.

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

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.

Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders.

This study investigated the prevalence of common barriers to the use of exposure therapy (ET) in the treatment of youth with anxiety disorders, specifically examining both logistical limitations and negative beliefs about ET. Results from 230 practicing clinicians who treat youth with anxiety disorders found that the top three barriers were session length (56%), lack of training (48%), and concern about parent reaction (47%). Endorsement of barriers to ET was associated with less ET utilization and less optimal implementation of ET. Results suggest that several barriers, especially logistical limitations, must be addressed in order to improve the dissemination of ET.

Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

The use of exposure therapy for child anxiety disorders in a medical center.

The use of exposure therapy for child anxiety disorders in a medical center.

Exposure therapy for OCD from an acceptance and commitment therapy (ACT) framework

This article addresses the use of exposure therapy for OCD as informed by an acceptance and commitment therapy (ACT) framework. The model on which ACT is based is covered, including its philosophy, basic research, targeted process of change, individual treatment components, and general manual. Specific suggestions for how to prepare, select, set up, and conclude exposure exercises from an ACT perspective are included and illustrated using the case of Monica as an example. Empirical support for this approach is briefly covered.

The role of therapist experiential avoidance in predicting therapist preference for exposure treatment for OCD

Despite the overwhelming evidence that the behavioral components of cognitive-behavior therapies (CBTs) are critical for patient improvement, particularly in the case of anxiety disorders, there remains a wide gap between science and practice in their consistent use. In particular, exposure therapy for anxiety is under-used, even among self-proclaimed cognitive-behavior therapists. Some have speculated that this under-use is related to therapist discomfort with and avoidance of the temporary increase in distress that patients often experience during exposure therapy, and the secondary distress that this may cause in therapists themselves. Recent studies have begun to examine therapist characteristics that are associated with the use of evidence-based psychotherapies, but this research has focused on evidence-based practice as a whole rather than on specific interventions such as exposure, and have not addressed therapist psychological variables. We examined the role of therapists׳ experiential avoidance in the hypothetical use of exposure-based interventions to treat fictional patients for whom exposure therapy is clearly indicated. A total of 172 therapists watched simulated therapy intake sessions and were asked to designate the percentage of time they would allot toward various therapeutic modalities, including exposure. Results suggested that participants exhibiting higher experiential avoidance tended to allot less time to exposure therapy for the fictional patient. Additional therapist personality factors, such as intuitive personality style and attitudes toward evidence-based treatments, were associated with self-reported use of exposure therapy as well.

Case Report: 16-Year-Old Male with Autistic Disorder with Preoccupation with Female Feet

This paper highlights clinical challenges faced when diagnosing and then treating an individual presenting to a child and adolescent psychiatry clinic because of unwelcome comments he made to female peers about their feet. Novel use of exposure therapy helped him effectively decrease his comments from 1 to 2 times per month to once every 6 months. Conceptualizing this case as the individual's failed attempts toward relationships with females instead of sexual harassment led to diminution of problematic behavior. Implications for diagnosis and treatment of individuals with Autistic Disorder displaying problematic behaviors are presented.

Prolonged Exposure With a World War II Veteran: 60 Years of Guilt and Feelings of Inadequacy

There is extensive empirical support for the use of exposure therapy in treating posttraumatic stress disorder (PTSD); however, there is little documented research on the use of these treatments with older adults. Questions exist regarding the appropriateness of exposure therapy with this population, given that the treatment is intense and often involves autonomic nervous system arousal. The current case study details a course of prolonged exposure (PE) therapy in an 88-year-old, World War II veteran, diagnosed with PTSD. The patient was found to respond remarkably well to the treatment and his posttraumatic stress symptoms decreased to subclinical levels in seven sessions. Concerns regarding the appropriateness of using PE to treat older adults are addressed.