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

Clinical Considerations for Integrating Ethical Principles of Beneficence in the Development of Evidence-Based Interventions: The case of Pediatric Misophonia

Misophonia is a condition involving decreased tolerance and intense responses to specific sounds, often those that are human-generated and repetitive in nature. Misophonia frequently onsets during childhood and is associated with significant distress, impairment, and diminished quality of life. While misophonia research remains nascent and no definitive practice guidelines exist at present, extant studies offer several promising potential avenues in intervention development for adults with misophonia. However, such research is comparatively limited for youth. Before widespread adoption of promising treatments, it is important to consider the potential for harm or non-beneficence that may arise from the mis-informed application of such treatments. In this article, we identify several potential pitfalls within intervention development for pediatric misophonia and provide recommendations to circumvent them. To that end, we focus on the following three topic areas: (a) challenges arising when psychological mechanisms are not considered in intervention development, (b) importation of a cognitive-behavior therapy (CBT) framework for obsessive-compulsive spectrum disorders without nuanced tailoring to misophonia, and (c) neglecting to include individuals with lived experience in the process of intervention development research. Considering these key areas within misophonia intervention development will be critical for upholding beneficence and minimizing harm in treatment of misophonia across the lifespan.

Psychologists' Diagnostic Accuracy and Treatment Recommendations for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a debilitating condition prevalent in up to 2.3% of the population, yet obsessive-compulsive symptoms are commonly misidentified by mental health professionals, adversely impacting treatment recommendations. This study examined OCD misidentification rates across two different types of obsessions, the influence of misidentification on treatment recommendation, and attitudes associated with clinicians' decisions surrounding the diagnosis of OCD and treatment recommendations in a sample of 110 licensed psychologists. Results showed that over one-third (35.0%) of participants incorrectly diagnosed two vignettes, representing symptoms of sexual orientation OCD (SO-OCD) and symmetry. Of those who correctly diagnosed the vignettes, about half of participants (symmetry = 55.4%; SO-OCD = 47.1%) recommended exposure and response prevention (ERP) as the primary treatment choice. Participants who endorsed greater client empowerment were more likely to misdiagnose the SO-OCD vignette (t(108) = 2.97, p = 0.004). Less experience with evidence-based practice and negative attitudes toward evidence-based practice were associated with the choice of treatment other than ERP (t(71) = -2.98, p = 0.004 and t(72) = 3.40, p < 0.001, respectively). Elevated OCD misdiagnosis and its adverse impact on treatment recommendations, as well as knowledge of factors contributing to misdiagnosis and mistreatment, imply the need for greater education and training.

When Attempts to Help Backfire: Psychosocial Interventions that May Inadvertently Prolong Anxiety Among Youth

Anxiety disorders are among the most common and impairing mental health conditions in children and adolescents. Although exposure-focused cognitive behavioral therapy (CBT) is a well-established treatment for this population based on decades of psychological science, many available psychosocial interventions are not based on this strong empirical foundation. In some cases, interventions for youth with anxiety disorders have the potential to maintain anxiety in the long run. Grounded in a well-developed cognitive-behavioral theoretical frame, this commentary aimed to discuss popular and emerging psychosocial interventions for anxious youth that may inadvertently prolong anxiety. We argue that (1) although the availability of gold-standard CBT (with an adequate focus on exposure therapy) appears to be increasing, it continues to be difficult to access for many youth, (2) several available interventions prescribe avoidance-based strategies that do not enable a child to experience self-efficacy building and corrective learning experiences related to their fears or anxieties, thereby potentially maintaining anxiety in the long-run, and (3) several available interventions are not based in any clear, empirically-supported theoretical frame or evidence base, and thus have unclear benefits for anxiety. In a time when there is increasing alarm about anxiety disorders among youth, building systems that can support tried-and-true interventions based on strong science is of utmost importance. Future research, intervention deployment, and policy efforts should pay more attention to the harms that could arise from psychosocial interventions.

Potential for Harm in the Treatment of Pediatric Obsessive-Compulsive Disorder: Pitfalls and Best Practices

Pediatric obsessive-compulsive disorder (OCD) can be debilitating and chronic unless treated early with efficacious intervention. The past several decades of intervention research have identified cognitive-behavioral therapy (CBT) with exposure and response/ritual prevention (ERP) as the first-line, evidence-based psychological intervention for pediatric OCD. Yet, many youths with OCD unfortunately remain inadequately treated. In well-meaning but misguided efforts to treat this complex disorder, clinicians holding misconceptions about ERP may fail to apply evidence-based treatments, misapply generic CBT techniques and ERP principles, or turn to non-evidence-based interventions. Potentially harmful treatments may worsen symptoms, while ineffective treatments can waste resources, impede patient access to efficacious treatment, and weaken public confidence in psychotherapy. The overarching goals of this review paper are to describe potentially harmful and ineffective practices in the treatment of pediatric OCD and to offer recommendations aligned with evidence-based practice. First, we dispel common misconceptions about ERP that may underlie its underuse among clinicians. We then describe potentially harmful and ineffective interventions for pediatric OCD, starting with misapplication of generic CBT techniques and ERP principles. We also identify non-evidence-based treatments for pediatric OCD that have limited conceptual or empirical foundations. Finally, we conclude with recommendations for clinicians who treat pediatric OCD, intervention researchers, training programs across mental health-related disciplines, and policymakers.

From Doubt to Direction: Untangling Pediatric Scrupulosity

Background: Up to 33% of individuals with obsessive-compulsive disorder (OCD) have scrupulosity symptoms, although less is known regarding the prevalence rates in youth, specifically. Scrupulosity translates to "fearing sin where there is none" and describes pathological guilt and distress related to religion and morality. Disentangling scrupulosity from true religious beliefs and actions may be difficult in youth for a number of reasons, including the nature of youth as a time of developing independent identities and values, expected ritualistic behavior (e.g., confession, ritualistic cleansing), scrupulosity being reinforced in some religious communities, and the discomfort or inexperience of clinicians with both these symptoms and various belief systems. The literature suggests limited knowledge of scrupulosity among mental health providers, including pediatric clinicians, and apprehension to discuss or target scrupulous beliefs and behaviors. Apprehension may be enhanced for providers working with youth populations, particularly given broader misconceptions about the efficacy and safety of gold-standard interventions. Objectives: This narrative review with practice guidelines examines the existing literature related to pediatric scrupulosity and its challenges and describes evidence-based treatments for scrupulosity in pediatric populations. Recommendations for clinical practice and research are discussed.

Perceptions and Use of Extended-Duration Exposure Therapy Amongst Psychologists

BACKGROUND

Extended-duration exposure therapy, in which treatment is delivered over a single prolonged session or cluster of long-duration sessions, is a highly efficacious and efficient treatment for anxiety disorders such as specific phobias. Despite this, little is known about the use of extended-duration exposure therapy in clinical practice.

METHODS

In the present study we investigated the perceptions and use of extended-duration exposure therapy amongst a sample of Australian psychologists via a survey, and the Therapist Beliefs about Exposure Scale. Additionally, we compared theoretical understanding of exposure therapy, and therapy delivery strategies (using a case study vignette), between psychologists who deliver exposure therapy via an extended-duration mode, versus the more traditional multi-session mode.

RESULTS

Extended-duration exposure therapy is widely underutilised, and this is associated with negative beliefs about exposure therapy in general, as well as several practical barriers. There were no differences in the reported theoretical mechanisms of exposure therapy between those who do and do not use extended-duration exposure therapy. However, psychologists who use extended-duration exposure therapy reported greater use of strategies with demonstrated efficacy (e.g., more intense delivery) and less use of therapy-interfering strategies (e.g., distress reduction techniques) relative to those who do not use extended-duration exposure therapy.

CONCLUSION

These findings identify potential mechanisms accounting for extended-duration exposure therapy's efficiency and point to strategies that may increase the uptake of extended-duration exposure therapy in clinical practice.

Should We Use Clinician Self-Report to Tailor Implementation Strategies? Predicting Use of Youth CBT with Clinician Self-Report Versus Direct Observation

Developing tailored implementation strategies to increase the use of evidence-based practice (EBP) requires accurate identification of predictors of their use. However, known difficulties with measuring EBP use complicates interpretation of the extant literature. In this proof-of-concept study, we examined whether the same predictors of use of cognitive behavioral therapy (CBT) are identified when CBT use is measured with clinician self-report compared to direct observation. We examined four candidate predictors of CBT use - clinician participation in an EBP training initiative, years of experience, caseload, and employment status - in a sample of 36 clinicians (64% female; 72% White and 28% Black) from 19 community mental health agencies treating youth in greater Philadelphia. CBT use was captured for 100 unique client sessions (M = 2.8 recorded sessions per clinician) through both clinician self-report and direct observation, using parallel measures. We used three-level (client, clinician, and agency) regression models with random intercepts to estimate the relationship between each predictor variable and CBT use in both measures and compared the magnitude and direction of each model across self-report and direct observation using z-tests. There was no alignment for any of the four candidate predictors between predictive relationships identified by self-report compared to those identified by direct observation. The findings in this study extend literature documenting limitations of using clinician self-report to capture clinician behavior and suggest that even the characteristics that predict higher self-reported CBT use do not align with (and often are discordant with) those that predict directly observed CBT use. This raises questions about the utility of relying on self-reported use to inform implementation strategy design.

Australian Clinicians' Capabilities, Opportunities, and Motivations in Implementing Exposure and Response Prevention for Youth with Obsessive-Compulsive Disorder: An Exploratory Study

Objectives: Informed by implementation science, this exploratory study examined the capabilities, opportunities, and motivations of Australian mental health clinicians (N = 38) associated with the implementation of exposure and response prevention (ERP) for youth (i.e., children and adolescents) with obsessive-compulsive disorder (OCD). It also explored how the capabilities and motivations of mental health clinicians untrained in ERP for youth (i.e., typical clinicians; n = 25) differed from clinicians experienced in the use of ERP for youth (i.e., experienced clinicians; n = 13). Methods: Questionnaires were administered to the entire sample alongside observational role-plays, which assessed observed adherence and competence delivering ERP against published best-practice standards among available participants. Results: In the whole sample, the reported time dedicated to implementing ERP was associated with a range of factors relating to capabilities, opportunities, and motivations to implement ERP. Experienced clinicians had greater knowledge, adherence, competence, and self-reported confidence using ERP and fewer negative beliefs about ERP relative to typical clinicians. They also intended to dedicate greater time to implementing within-session ERP for youth and reported greater within- and between-session time spent doing so compared to typical clinicians. The time intended to dedicate to implementing between-sessions ERP did not significantly differ between the clinician groups. Conclusions: In summary, compared to typical clinicians, experienced clinicians appeared to possess greater levels of capabilities and motivations to implement ERP for youth with OCD. Future research examining barriers and facilitators of ERP implementation in community settings and identifying effective strategies to improve it would benefit service provision and, ultimately, outcomes for youth.

Effectiveness of Video Teletherapy in Treating Obsessive-Compulsive Disorder in Children and Adolescents With Exposure and Response Prevention: Retrospective Longitudinal Observational Study

BACKGROUND

An effective primary treatment for obsessive-compulsive disorder (OCD) in children and adolescents as well as adults is exposure and response prevention (ERP), a form of intervention in the context of cognitive-behavioral therapy. Despite strong evidence supporting the efficacy and effectiveness of ERP from studies in research and real-world settings, its clinical use remains limited. This underuse is often attributed to access barriers such as the scarcity of properly trained therapists, geographical constraints, and costs. Some of these barriers may be addressed with virtual behavioral health, providing ERP for OCD through video teletherapy and supplemented by app-based therapeutic tools and messaging support between sessions. Studies of teletherapy ERP in adults with OCD have shown benefits in research and real-world settings in both small and large samples. However, studies of teletherapy ERP in children and adolescents thus far have been in small samples and limited to research rather than real-world settings.

OBJECTIVE

This study reports on the real-world effectiveness of teletherapy ERP for OCD in the largest sample (N=2173) of child and adolescent patients to date.

METHODS

Children and adolescents with OCD were treated with live, face-to-face video teletherapy sessions, with parent or caregiver involvement, using ERP. Assessments were conducted at baseline, after 7-11 weeks, and after 13-17 weeks. Additionally, longitudinal assessments of OCD symptoms were performed at weeks 18-30, 31-42, and 43-54. We analyzed longitudinal outcomes of OCD symptoms, depression, anxiety, and stress using linear mixed models.

RESULTS

Treatment resulted in a median 38.46% (IQR 12.50%-64.00%) decrease in OCD symptoms at 13-17 weeks, and 53.4% of youth met full response criteria at this point. Improvements were observed in all categories of starting symptom severity: mild (median 40.3%, IQR 8.5%-79.8%), moderate (median 38.4%, IQR 13.3%-63.6%), and severe (median 34.1%, IQR 6.6%-58.5%). In addition, there were significant reductions in the severity of depression, anxiety, and stress symptoms. The median amount of therapist involvement was 13 (IQR 10.0-16.0) appointments and 11.5 (IQR 9.0-15.0) hours. Further, symptom improvements were maintained or improved upon in the longitudinal assessment periods of weeks 18-30, 31-42, and 43-54.

CONCLUSIONS

These results show that remote ERP treatment, assisted by technology, can effectively improve both core OCD and related depression, anxiety, and stress symptoms in children and adolescents with OCD in a real-world setting. Notable outcomes were achieved in a relatively small amount of therapist time, demonstrating its efficiency. Demonstrating the usefulness of a delivery format that overcomes several traditional barriers to treatment, these findings have implications for widespread dissemination of accessible, evidence-based care for children and adolescents with OCD.

Childhood Anxiety Disorders

Anxiety disorders are common in children and adolescents, with many youths experiencing functional impairment in multiple domains because of these conditions. Biologic and cognitive-behavioral models provide a basis for the development and maintenance of these disorders. Cognitive behavioral therapy (CBT) with exposures and selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors are empirically supported treatments for childhood anxiety disorders. Exposures are a key component of CBT treatment and a case vignette demonstrates how to tailor exposures to the unique fears of the child.

A novel independence intervention to treat child anxiety: A nonconcurrent multiple baseline evaluation

Rates of child and adolescent anxiety have increased markedly over the past decade (Haidt & Twenge, 2023). Exposure-based cognitive-behavioral therapy is the gold standard in the treatment of anxious children (Hofmann et al. (2012)). However, many clinicians refrain from using exposure due to concerns about its safety, effectiveness, and ethics (Deacon et al., 2013; Whiteside et al., 2016). We propose a novel treatment approach for child anxiety composed of independence activities (IAs), which are child-directed, fun, unstructured, developmentally challenging tasks performed without parents' help. These tasks are purposely topographically unrelated to the stimuli that cause anxiety, in direct contrast to exposure therapy. Despite this dissimilarity, IAs target putative mechanisms involved in the development and maintenance of child anxiety (e.g., parental accommodation and overinvolvement, child avoidance, unhelpful thinking styles). Using a nonconcurrent multiple baseline design, this five-session treatment provided preliminary evidence of high treatment acceptability from children and parents. Medium to large improvements were reported in child anxiety and avoidance, parent and child (behavioral and cognitive) mechanisms involved in the maintenance of child anxiety, and untargeted secondary outcomes such as child happiness. Results may suggest a new treatment paradigm, which is desperately needed, given unabated increases in child and adolescent anxiety despite vast resources being directed toward the problem.

Obsessive-Compulsive Disorder in Children and Adolescents

Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions.

Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review

Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.

Implementation and Preliminary Outcomes of an Exposure-Based Summer Camp for Pediatric OCD and Anxiety

Despite the high prevalence of anxiety disorders in children and adolescents and the existence of effective evidence-based treatments for them, access to psychological care remains a major public health concern. Summer camps may provide an effective treatment avenue for youth who might not otherwise have access to care. This study describes the design and implementation of Fear Facers, a semistructured, 5-day, daytime exposure-therapy-based summer camp designed for youth with a primary diagnosis of obsessive-compulsive disorder (OCD), social anxiety, separation anxiety, or a specific phobia. Preliminary data regarding feasibility and patient outcomes is also reported. Among 52 children and adolescents aged 7 to 16 who attended one of six camp sessions between 2018 and 2021, significant reductions in anxiety (d = 0.54) and OCD symptoms (d = 0.57) were observed from pre-camp to immediately post-camp. A subset of campers who were followed for an additional 3 months post-camp (n = 22) showed maintenance of treatment gains. Retention rates for the intervention were high. Our investigation provides further support for the use of a camp-based design for cognitive-behavioral approaches, and may provide a unique setting to maximize elements of inhibitory learning in exposures. We also discuss a number of elements regarding feasibility that need consideration for those hoping to develop similar interventions.

Closing the Gap for Children with OCD: A Staged-Care Model of Cognitive Behavioural Therapy with Exposure and Response Prevention

Childhood obsessive-compulsive disorder (OCD) is among the most prevalent and disabling mental health conditions affecting children and adolescents. Although the distress and burden associated with childhood OCD are well documented and empirically supported treatments are available, there remains an unacceptable "treatment gap" and "quality gap" in the provision of services for youth suffering from OCD. The treatment gap represents the large number of children who never receive mental health services for OCD, while the quality gap refers to the children and young people who do access services, but do not receive evidence-based, cognitive behavioural therapy with exposure and response prevention (CBT-ERP). We propose a novel staged-care model of CBT-ERP that aims to improve the treatment access to high-quality CBT-ERP, as well as enhance the treatment outcomes for youth. In staged care, patients receive hierarchically arranged service packages that vary according to the intensity, duration, and mix of treatment options, with provision of care from prevention, early intervention, through to first and second-line treatments. Based on a comprehensive review of the literature on treatment outcomes and predictors of treatments response, we propose a preliminary staging algorithm to determine the level of clinical care, informed by three key determinants: severity of illness, comorbidity, and prior treatment history. The proposed clinical staging model for paediatric OCD prioritises high-quality care for children at all stages and levels of illness, utilising empirically supported CBT-ERP, across multiple modalities, combined with evidence-informed, clinical decision-making heuristics. While informed by evidence, the proposed staging model requires empirical validation before it is ready for prime time.

Things that make you go Hmm: Myths and misconceptions within cognitive-behavioral treatment of obsessive-compulsive disorder

The past four decades have yielded a robust body of evidence supporting the efficacy and effectiveness of cognitive-behavioral therapy (CBT) as a gold-standard treatment for obsessive-compulsive disorder (OCD) across the lifespan. Exposure and response prevention (E/RP) has been identified as a key component of this approach. Despite robust research support for CBT with E/RP, several myths and misconceptions continue to proliferate in both research and practice settings. Such myths and misconceptions are concerning, as they lack empirical basis, may hinder widespread dissemination and implementation of CBT for OCD, and run contrary to the practice of evidence-based psychological medicine. Focusing on the importance of promoting evidence-based practice and generative clinical science, the present review article synthesizes relevant research within the field of treatments for OCD to address the following myths / misconceptions: (a) uncertainty exists concerning the evidence base supporting CBT for OCD, (b) E/RP attrition and dropout rates are unacceptably high due to excessive risk and perceived patient intolerability, and (c) alternative treatments for OCD need to be expeditiously developed due to major limitations of E/RP. Recommendations for future research and clinical dissemination and implementation to further advance a generative clinical science of OCD treatment are discussed.

Enhanced Cognitive-Behavioral Treatment for Anxiety Disorders in Children of Clinically Anxious Parents: Two Case Studies

Children with anxiety disorders are significantly less likely to recover following cognitive-behavioral therapy (CBT) if they have a parent with clinical anxiety. Despite this, prior research which has adapted CBT treatments to cater for this vulnerable clinical cohort of children is limited. In response to the identified need to optimize treatment outcomes for this particular group of children with anxiety disorders, an enhanced CBT intervention was recently developed, specifically to target anxiety maintenance factors in clinically anxious child–parent dyads. This dual case study presents the implementation of the enhanced intervention with two children with complex clinical presentations. Prior to treatment, both children met criteria for multiple anxiety disorders, as did their mothers. The presented case studies describe session-by-session treatment accounts, with a particular focus on the children’s experiences of individual and joint-observational exposure treatment components. Outcome data is provided for both children and their mothers, based on assessment measures collected at pre- and post-treatment, and during the intervention. At post-treatment, both children demonstrated symptom reduction and improved functioning across all diagnoses, including remission on a secondary diagnosis, although both still met criteria for their primary diagnoses. Additionally, self-reported outcomes on intervention acceptability measures were favorable. Results implied that the enhanced intervention provided a viable alternative treatment approach for children and their parents with co-occurring anxiety disorders. Recommendations are provided for clinicians delivering CBT to clinically anxious child–parent dyads.

The effects of an exposure therapy training program for pre-professionals in an intensive exposure-based summer camp

Although exposure therapy (ET) is an effective treatment for anxiety disorders and obsessive-compulsive disorder, many clinicians report not utilizing it. The present study targeted common utilization barriers by evaluating an intensive ET training experience in a relatively inexperienced sample of pre-professionals. Thirty-two individuals at the undergraduate or college graduate level without formal clinical experience participated as camp counsellors in a 5day exposure-based therapeutic summer camp for youth with anxiety disorders and/or obsessive-compulsive disorder. Participants were trained in ET through a progressive cascading model and answered questionnaires before and after camp. Repeated measure MANOVA revealed significantly increased feelings of self-efficacy conducting exposures, and significantly decreased feelings of disgust sensitivity and contamination-related disgust from pre-camp to post-camp. A subset of individuals providing data 1 month after the camp maintained a significant gain in ET self-efficacy. Regression analyses revealed that contamination-related disgust, but not disgust sensitivity, significantly predicted post-camp ET self-efficacy. These findings suggest that individuals early into their post-secondary education can learn ET, and the progressive cascading model holds promise in its utility across experience levels and warrants further investigation. Disgust may also play a role in feelings of competency conducting ET. Implications on dissemination and implementation efforts are also discussed.

Key learning aims

(1)

Expanding the reach of evidence-based mental health interventions to private practice: Qualitative assessment using a policy ecology framework

Background

Evidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research.

Methods

Qualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy.

Results

Responses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice.

Conclusions

Using the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.

The impact of implementation climate on community mental health clinicians’ attitudes toward exposure: An evaluation of the effects of training and consultation

Background:

Most evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) and anxiety disorders include exposure; however, in community settings, the implementation of exposure lags behind other EBT components. Clinician-level determinants have been consistently implicated as barriers to exposure implementation, but few organizational determinants have been studied. The current study examines an organization-level determinant, implementation climate, and clinician-level determinants, clinician demographic and background factors, as predictors of attitudes toward exposure and changes in attitudes following training.

Method:

Clinicians (n = 197) completed a 3-day training with 6 months of twice-monthly consultation. Clinicians were trained in cognitive behavioral therapy (CBT) for anxiety, depression, behavior problems, and trauma-focused CBT (TF-CBT). Demographic and background information, implementation climate, and attitudes toward exposure were assessed in a pre-training survey; attitudes were reassessed at post-consultation. Implementation climate was measured at the aggregated/group-level and clinician-level.

Results:

Attitudes toward exposure significantly improved from pre-training to post-consultation (t(193) = 9.9, p < .001; d = 0.71). Clinician-level implementation climate scores did not predict more positive attitudes at pre-training (p > .05) but did predict more positive attitudes at post-consultation (ß = −2.46; p < .05) and greater changes in those attitudes (ß = 2.28; p < .05). Group-level implementation climate scores did not predict attitudes at pre-training, post-consultation, or changes in attitudes (all ps > .05). Higher frequency of self-reported CBT use was associated with more positive attitudes at pre-training (ß = −0.81; p < .05), but no other clinician demographic or background determinants were associated with attitudes at post-consultation (all p > .05) or with changes in attitudes (all p > .05).

Conclusions:

Clinician perceptions of implementation climate predicted greater improvement of attitudes toward exposure following EBT training and consultation. Findings suggest that organizational determinants outside of training impact changes in clinicians’ attitudes. Training in four EBTs, only two of which include exposure as a component, resulted in positive changes in clinicians’ attitudes toward exposure, which suggests non-specialty trainings can be effective at changing attitudes, which may enable scale-up.

Exposure is highly effective for treating trauma symptoms and anxiety-based disorders, but it is not commonly used in community mental health settings. Clinicians who endorsed higher expectations, support, and rewards for using exposure in their agency had more positive attitudes toward exposure after training and consultation. Additionally, clinicians who endorsed that exposure is expected, supported, and rewarded in their agency showed a greater improvement in attitudes throughout the training process. Organizational culture can affect clinicians’ attitude changes in the training process, and therefore should become a focus of training efforts.

Pediatrician-friendly perspectives on cognitive behavioral therapy for anxious youth: Current status and clinical implications for the next normal

Pediatric anxiety disorders are common and often debilitating conditions. Cognitive is a psychosocial intervention that represents a potentially powerful antidote to these disorders. This article reviews data from treatment outcome studies, meta-analyses, and systematic reviews as well as from moderation/mediational investigations. The literature supports the efficacy, effectiveness, and durability of positive treatment outcomes for pediatric anxiety disorders. Recommendations for clinical applications are suggested.

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

BACKGROUND

Cognitive-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).

METHODS

One hundred registered psychologists (M_age = 40.60; SD = 10.78; range 23 to 71 years; 84% female) participated in an online study investigating their clinical practices.

RESULTS

Results 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.

CONCLUSIONS

These findings suggest that further or ongoing professional training may be required to optimize the use of disorder specific techniques.

A Meta-analysis to Guide the Enhancement of CBT for Childhood Anxiety: Exposure Over Anxiety Management

Cognitive behavior therapy (CBT) is the most empirically supported therapy for childhood anxiety disorders (CADs) but has not reliably outperformed other credible interventions. The current study used meta-analysis to examine the frequency with which the most common treatment components are included in outcome studies and the relation of these components to symptom improvement. Seventy-five studies were identified that included youth with an anxiety disorder treated with CBT or a comparison condition. The protocols for the 111 CBT conditions generally consisted of 12, 1-h sessions delivered to the child with minimal parent inclusion. A greater amount of in-session exposure was related to significantly larger effect sizes between CBT and waitlist control across reporters (- 0.12 to - 0.15; P's < .05) and from pre- to post-treatment for child report (- .06; P < .01). Compared to treatments that omitted relaxation, treatments that included relaxation strategies were associated with significantly smaller pre- to post-treatment effect sizes across reporters (0.38 to 0.80; P's < .05). The current study suggests that CBT protocols for CADs that emphasize in-session exposure and do not include relaxation have the potential to improve the efficacy and effectiveness of therapy. Dismantling studies directly testing these hypotheses are needed.

Virtual Reality One-Session Treatment of Child-Specific Phobia of Dogs: A Controlled, Multiple Baseline Case Series

Specific phobia (SP) typically onsets in childhood and frequently predicts other mental health disorders later in life. Fortunately, childhood SP can be effectively treated with cognitive behavior therapy (CBT), including the exposure-based one-session treatment (OST) approach. Despite empirical support for CBT and OST, clinicians, for various reasons, frequently fail to implement exposure-based therapy in routine clinical practice, including perceived difficulties in implementing exposure. Virtual reality (VR) exposure therapy may overcome some of these challenges and provides an alternative modality of therapy. This preliminary study examined the efficacy of VR OST for 8 children with a SP of dogs (aged 8-12 years) (M = age 10.25; SD = 2.11) using a multiple-baseline controlled case series. Following a stable baseline period of either 2, 3, or 4 weeks, it was expected that specific phobia severity would significantly decline after VR OST and remain improved over the 3-week maintenance phase. Assessments were conducted posttreatment and at 1-month follow up (study end-point). It was found that phobia symptoms remained relatively stable across the baselines, with significant reductions from pretreatment to posttreatment and to follow-up on clinician severity ratings (pre- to post- g = 1.12; pre- to follow-up g = 2.40), target symptom ratings (g = 1.14; 1.29), and behavioral avoidance (g = -1.27; -1.96). The treatment was also associated with clinically significant outcomes, whereby at one-month follow up, 75% of children were considered "recovered" and 88% completed the BAT (interacted with their feared stimuli). This study provides support for the effectiveness of VR OST.

Experiences of online exposure-based treatment with parental support for teenagers with excessive worry

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Key learning aims

(1)

Community Therapist Response to Technology-Assisted Training in Exposure Therapy for Childhood Anxiety Disorders

Despite the efficacy of exposure for childhood anxiety disorders (CADs), dissemination has been unsuccessful. The current study examined community-therapist response to a brief (90-minutes) training in technology-assisted exposure therapy for CADs. The results indicated that therapists found the training in the therapy approach and technology acceptable, despite endorsing mainly non-exposure-based practice prior to the training. Training also increased positive beliefs about exposure, t (23) = 4.32, p < .000, that persisted 6 months later, t (23) = 4.56, p < .000. In addition, the number of therapists reporting an intention to implement exposure increased substantially from baseline (41.7%) to post-training (83.3%), with many therapists (70.8%) reporting use of exposure within the 6 months following training. However, automatically recorded data indicated little use of the technology. Results suggest that a dissemination message focusing on exposure is acceptable and has the potential to increase the use of this central treatment component.

Treatment barriers, preferences and histories of individuals with symptoms of body dysmorphic disorder

BACKGROUND

Individuals with mental health concerns face many barriers when accessing psychological treatment. Even when patients overcome these barriers, they often do not receive an evidence-based treatment. Although the current literature highlights these issues clearly across psychological disorders, the research is limited in relation to body dysmorphic disorder (BDD).

AIM

The aim of this study was to examine psychological treatment barriers, treatment delivery preferences and treatment histories of individuals with symptoms of BDD.

METHOD

A total of 122 participants with clinically significant BDD symptoms (94% female; mean age = 34.19 years, SD = 10.86) completed the cross-sectional study.

RESULTS

The most frequently reported barriers to accessing psychological treatment for individuals with BDD symptoms were the cost of treatment (41%) and the belief that the symptoms did not warrant treatment (36%). Although 69% of treatment-seeking participants reported previously receiving cognitive behavioural therapy (CBT) for BDD, only 13% of participants appeared to receive best-practice CBT. The preferred modality of future psychological treatment delivery was face-to-face treatment with a therapist once a week (63%), rather than accelerated or remote treatment approaches.

CONCLUSIONS

The study suggests that there are significant barriers to accessing CBT for BDD. Reducing these barriers, as well as increasing consumer mental health literacy, is required to improve treatment access and treatment outcomes for individuals with BDD.

Serious negative consequences associated with exposure and response prevention for obsessive-compulsive disorder: A survey of therapist attitudes and experiences

OBJECTIVE

Many therapists are reluctant to conduct exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD). Negative beliefs about the safety and tolerability of ERP are common, especially for harm-related OCD symptoms. The study examined the nature and frequency of ERP-related serious negative consequences (SNC) and therapist attitudes and experiences providing ERP for harm-related OCD.

METHODS

An anonymous survey was completed by 277 therapists with experience treating OCD using ERP. Questions assessed clinical experiences of harm-related exposures, the nature of SNC, and concerns and clinical considerations regarding ERP.

RESULTS

Therapist's willingness to treat harm-related OCD was high. SNCs were reported for 6 clients (per-client risk: adults 0.05%, youth 0.01%) and 13 therapists (per therapist risk 4.73%, therapist per-year risk 0.004%). Qualitative analysis identified themes relating to the conduct of treatment, specific exposure types, professional issues, and negative perceptions of ERP.

CONCLUSION

SNC associated with ERP for OCD are rare and primarily represent unintended secondary consequences of OCD or misunderstandings regarding the process and rationale behind ERP. Improving access to ERP will require good communication with clients, families, and other professionals regarding the rationale and safety of ERP.