Category: Dissemination / Implementation
Keywords: Anxiety | Exposure | Dissemination
Presentation Type: Symposium
Background: Anxiety disorders are among the most common mental disorders in children and adolescents, with over 8% of youth in the United States reporting at least one anxiety disorder by the age of 18. Exposure therapy is the critical component of cognitive-behavioral therapy (CBT), the first-line psychotherapy for youth with anxiety disorders. Unfortunately, exposure-based techniques are rarely utilized by community providers who treat adult anxiety disorders.
For example, preliminary research suggests exposure-based techniques are used at rates comparable or lesser than several non-empirically supported techniques (e.g., art therapy, acupuncture, dream analysis). The goal of the present study was to identify how practitioners treat youth with anxiety disorders across the United States. Furthermore, a second goal was to investigate several potential therapist factors that may explain poor dissemination of exposure-based techniques.
Method: Recruited from public directories of psychologists, social workers, counselors, nurses, and psychiatrists, 302 community-based providers who treat anxious youth were surveyed. Each provider was asked to indicate how often they used each of 30 treatment techniques or therapies to treat youth with obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder (PD), and social anxiety disorder (SAD). A within-subjects analysis of variance (ANOVA) was used to compare how frequently practitioners reported using exposure techniques, non-exposure CBT techniques, and third-wave CBT techniques for OCD, PTSD, PD, and SAD. A within-subjects ANOVA was also used to compare the utilization rate of optimal (i.e., therapist assisted in vivo) versus less optimal (client self-directed in vivo) exposure techniques. Multiple proposed barriers to the dissemination of optimal exposure techniques were tested in a regression model. Independent variables in the regression model related to demographic factors (e.g., training history), therapist temperament, and negative beliefs about exposure techniques.
Results: Non-exposure CBT techniques were used significantly more than exposure techniques in the treatment of youth with anxiety disorders (e.g., SAD, F = 182.34, p < .001, partial η2 = .48). In contrast, there was not a significant difference between how frequently participants reported using third-wave CBT techniques and exposure techniques, with the exception of OCD where exposure techniques were used more often (F = 10.96, p = .001, partial η2 = .05). Exposure techniques were used significantly more than psychodynamic therapy in the treatment of youth with anxiety disorders (e.g., PTSD, F = 15.97, p < .001, partial η2 = .08). Therapist-assisted in vivo exposure was used significantly less often than client self-directed in vivo exposure in the treatment of youth with anxiety disorders (e.g., PD, F = 34.28, p < .001, partial η2 = .17). For PD, interoceptive exposure was the least utilized CBT technique (used only 11% of the time, on average). In general, providers with more training in exposure therapy and less negative beliefs about exposure were significantly more likely to use optimal exposure techniques to treat youth with anxiety disorders. Most providers have minimal training in exposure techniques, perceive a lack of training options, and believe there is benefit to acquiring more training.
Conclusions: Considering that a barrier to dissemination of CBT is the length and inflexibility of the manual, more dismantling studies are needed to identify the key CBT elements that community-based practitioners should emphasize or prioritize when implementing more flexible CBT that is better suited for a naturalistic clinical setting. Based on utilization rates, community practitioners seem to prioritize cognitive techniques (i.e., restructuring, mindfulness) when treating youth with anxiety. These results add to the growing evidence that most community practitioners view exposure-based techniques as a tool rather than the central active ingredient of anxiety disorder treatment. Practitioners have an ethical mandate to practice in a manner that is consistent with scientific and professional knowledge of the discipline and within their scope of expertise, thus more training opportunities in exposure-based techniques at the graduate and post-graduate level are needed. These trainings should emphasize building self-efficacy and challenging negative beliefs about exposure techniques.
McLean Hospital/Harvard Medical School
Sunday, November 19
8:30 AM – 10:00 AM
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