Exposure Therapy in the NYT

[WisNeuro]

With Anxiety on the Rise, Some Children Try ‘Exposure Therapy’ (Published 2022)

A gold-standard treatment for phobias and anxieties encourages young people to follow an old and simple dictum: Face your fears.

www.nytimes.com

Good to see some positive press for actual science as opposed to pseudoscience for once!

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[cara susanna]

Oh wow, it's a NYT article and not by that San Diego VA patient who hates exposure! And it talks about how hard it is to access exposure therapy because so many therapists refuse to do it.

 

[WisNeuro]

Oh wow, it's a NYT article and not by that San Diego VA patient who hates exposure! And it talks about how hard it is to access exposure therapy because so many therapists refuse to do it.

This still baffles me. I was trained in a wide variety of therapy modalities and specific treatments, but BY FAR, exposure therapy lead to the biggest treatment gains, quickest treatment gains, and lowest rel;apse rates on checkups compared to anything else that I did. Who wouldn't want to see their patients vastly improved in 2-3 months with generally only minimal need for "tune-up" appointments?

But, then again, I imagine some therapists like the comfort of having a steady and consistent patient panel.

 

[futureapppsy2]

Oh wow, it's a NYT article and not by that San Diego VA patient who hates exposure! And it talks about how hard it is to access exposure therapy because so many therapists refuse to do it.

I 100% thought it was going to be that guy too and was pleased when it wasn't!

 

[futureapppsy2]

This still baffles me. I was trained in a wide variety of therapy modalities and specific treatments, but BY FAR, exposure therapy lead to the biggest treatment gains, quickest treatment gains, and lowest rel;apse rates on checkups compared to anything else that I did. Who wouldn't want to see their patients vastly improved in 2-3 months with generally only minimal need for "tune-up" appointments?

But, then again, I imagine some therapists like the comfort of having a steady and consistent patient panel.

I also think a lot of therapists are uncomfortable with the level of distress that exposure therapy initially causes, so there's an element of avoidance from the therapist side, too.

 

[WisNeuro]

I also think a lot of therapists are uncomfortable with the level of distress that exposure therapy initially causes, so there's an element of avoidance from the therapist side, too.

I get that, but I also feel that if you cannot deal with a high level of emotional distress, you aren't cut out to be a therapist. Unless you want to only treat subclinical and otherwise healthy populations. I'm biased though, I tell people on a weekly basis that they have an incurable neurological disease

 

[psycho1391]

I also think a lot of therapists are uncomfortable with the level of distress that exposure therapy initially causes, so there's an element of avoidance from the therapist side, too.

I was just about to say this. Therapists are too worried about pushing clients too far and having them prematurely terminate.

 

[cara susanna]

There's a lot of fragilization of trauma patients. I train people in CPT and have been seeing that tendency with people new to the approach (which isn't even exposure-based) so I can only imagine what it's like for new PE therapists. People would much rather give warm and fuzzies and comfort rather than do hard stuff that actually works. I have a theory that's why there's so much floofiness in the trauma treatment field.

Honestly, I do get it. I actually hate doing exposure sessions as a therapist. But I love the results so I do it anyway! Just like my patients tolerate and habituate to their distress, I tolerate and habituate to mine.

Edit: I just realized that I'm talking about trauma specifically, but I think we can make the same generalization to anxiety in general. People don't like to see their patients upset.

 

[iliketohelppeople]

Oh wow, it's a NYT article and not by that San Diego VA patient who hates exposure! And it talks about how hard it is to access exposure therapy because so many therapists refuse to do it.

Cara, do you have a link for this? Interested in reading it!

 

[Sanman]

This still baffles me. I was trained in a wide variety of therapy modalities and specific treatments, but BY FAR, exposure therapy lead to the biggest treatment gains, quickest treatment gains, and lowest rel;apse rates on checkups compared to anything else that I did. Who wouldn't want to see their patients vastly improved in 2-3 months with generally only minimal need for "tune-up" appointments?

But, then again, I imagine some therapists like the comfort of having a steady and consistent patient panel.

I really think it is the bolded plus folks can just be lazy because it can be bad for business. When I did cash only outpatient treatment, I did exposure therapy in a few cases. This often meant leaving the office to complete in vivo exposure. Not sure the headaches of pre-approving 90837s (if taking insurance) and the extra cost of leaving the office are financially worth it in all cases. Even the group highlighted in the story had to do a lot of leg work to get insurance to cover the treatment. I really wanted some good VR equipment for imaginal exposure back then.

 

[bcliff]

Papers on barriers to adoption of exposure-based therapy in clinical practice, which is a big soapbox of mine.

The TLDR: "Overall, these results suggest that the primary barriers to the adoption of exposure therapy are therapist, not organizational or client, factors."

Predicting adoption of exposure therapy in a randomized controlled dissemination trial

The present study examined organizational, client, and therapist characteristics as predictors of use of and proficiency in exposure therapy (ET) afte…

www.sciencedirect.com

Why do clinicians exclude anxious clients from exposure therapy?

Despite research demonstrating the effectiveness of exposure therapy for pathological anxiety, this treatment is underutilized by clinicians. Anecdota…

www.sciencedirect.com

Correlates of therapist drift in psychological practice: A systematic review of therapist characteristics

Therapist drift refers to the tendency for psychologists to move away from the delivery of the evidence-based practices in which they are trained, eve…

www.sciencedirect.com

 

[WisNeuro]

Papers on barriers to adoption of exposure-based therapy in clinical practice, which is a big soapbox of mine.

The TLDR: "Overall, these results suggest that the primary barriers to the adoption of exposure therapy are therapist, not organizational or client, factors."

Predicting adoption of exposure therapy in a randomized controlled dissemination trial

The present study examined organizational, client, and therapist characteristics as predictors of use of and proficiency in exposure therapy (ET) afte…

www.sciencedirect.com

Why do clinicians exclude anxious clients from exposure therapy?

Despite research demonstrating the effectiveness of exposure therapy for pathological anxiety, this treatment is underutilized by clinicians. Anecdota…

www.sciencedirect.com

Correlates of therapist drift in psychological practice: A systematic review of therapist characteristics

Therapist drift refers to the tendency for psychologists to move away from the delivery of the evidence-based practices in which they are trained, eve…

www.sciencedirect.com

Definitely context dependent. For example, in the VA, Exposure therapy has been talked about in such a way, by other patients and VSOs, that the well is poisoned for a lot of people genuinely coming into therapy. Hard to talk someone into that, and if they begrudgingly start the therapy, some will never fully invest in it given that preconception. @cara susanna have you seen this?

Also, I wonder what those studies would look like now. The EMDR cult in many areas openly derides exposure therapy. I've heard from some patients that another provider, who does EMDR, told them about the "dangers" of exposure therapy when I recommend it for things now and then. Always a fun conversation with that provider having to threaten them with a board complaint if I hear about it again.

 

[Fan_of_Meehl]

I also think a lot of therapists are uncomfortable with the level of distress that exposure therapy initially causes, so there's an element of avoidance from the therapist side, too.

True. And I'd say that they and their clients need to meditate on the crucial distinction between FEELING UNSAFE and actually BEING UNSAFE as a rule of thumb metric for the presence/absence of a mental disorder involving anxiety as well as its clinical severity. The greater the gap in a particular situatuon between the client FEELING SAFE and actually BEING SAFE, the greater the distortions and more severe the disorder. To the extent that the difference between these is negligible...there IS NO DISORDER.

This is a good conceptual point to keep in mind when, for example, working with veterans who have PTSD diagnoses (and most of whom are service-connected for that condition). When they (particularly in groups) begin arguing that their fears are 'rational' and 'reality based' you can certainly explore and evaluate that position Socratically and with a spirit of guided discovery and collaborative empiricism...but it is also crucial to remind them that if their fears are actually and provably "rational" then they do not have a "disorder" like, say, PTSD.

 

[cara susanna]

Cara, do you have a link for this? Interested in reading it!

I think the latest is After PTSD, More Trauma

He used to randomly release articles every so often.

Definitely context dependent. For example, in the VA, Exposure therapy has been talked about in such a way, by other patients and VSOs, that the well is poisoned for a lot of people genuinely coming into therapy. Hard to talk someone into that, and if they begrudgingly start the therapy, some will never fully invest in it given that preconception. @cara susanna have you seen this?

Also, I wonder what those studies would look like now. The EMDR cult in many areas openly derides exposure therapy. I've heard from some patients that another provider, who does EMDR, told them about the "dangers" of exposure therapy when I recommend it for things now and then. Always a fun conversation with that provider having to threaten them with a board complaint if I hear about it again.

I would say there are a few who are like "NO WAY." For the most part, I would say they're open. Usually people just look a little horrified, so I always point out that initial reaction. Like, when I'm explaining exposure I will say something along the lines of, "I bet you're wondering, why the hell would I want to do that? Well, here's why!"

 

[Sanman]

Papers on barriers to adoption of exposure-based therapy in clinical practice, which is a big soapbox of mine.

The TLDR: "Overall, these results suggest that the primary barriers to the adoption of exposure therapy are therapist, not organizational or client, factors."

Predicting adoption of exposure therapy in a randomized controlled dissemination trial

The present study examined organizational, client, and therapist characteristics as predictors of use of and proficiency in exposure therapy (ET) afte…

www.sciencedirect.com

Why do clinicians exclude anxious clients from exposure therapy?

Despite research demonstrating the effectiveness of exposure therapy for pathological anxiety, this treatment is underutilized by clinicians. Anecdota…

www.sciencedirect.com

Correlates of therapist drift in psychological practice: A systematic review of therapist characteristics

Therapist drift refers to the tendency for psychologists to move away from the delivery of the evidence-based practices in which they are trained, eve…

www.sciencedirect.com

Looking at Table 2 in the first linked article confirms my thoughts:
The most common barriers reported were: (1) no regular clinical supervision available ( M = 2.65), (2) unable to leave the clinic/office to do exposure in other settings ( M = 2.46), and (3) unable to conduct therapy sessions lasting longer than one hour ( M = 2.40).

One of the other issues mentioned though endorsed less, there is not financial incentive for the extra work. In private practice, this can be a much larger issue than an agency setting.

 

[cara susanna]

Looking at Table 2 in the first linked article confirms my thoughts:
The most common barriers reported were: (1) no regular clinical supervision available ( M = 2.65), (2) unable to leave the clinic/office to do exposure in other settings ( M = 2.46), and (3) unable to conduct therapy sessions lasting longer than one hour ( M = 2.40).

One of the other issues mentioned though endorsed less, there is not financial incentive for the extra work. In private practice, this can be a much larger issue than an agency setting.

PE is solving one of these barriers by adapting sessions for 60 min (and according to research so far, it's effective!)

The settings thing is an issue, but--as someone who also cannot leave the premises--I also think people have to get creative. Like this exposure therapist I watched a session recording of who literally made a giant closet out of cardboard for his patients with claustrophobia.

 

[Sanman]

PE is solving one of these barriers by adapting sessions for 60 min (and according to research so far, it's effective!)

The settings thing is an issue, but--as someone who also cannot leave the premises--I also think people have to get creative. Like this exposure therapist I watched a session recording of who literally made a giant closet out of cardboard for his patients with claustrophobia.

Adapting sessions for 60 min is a start and works better at places like the VA. However, we know that the grid at VAs does not adjust slots for more 90837s and a lot of folks even here have advocated keeping sessions to 45 min to have note writing time. On the the private insurance based end, 60 min still requires a pre-auth for many insurances which only reimburse for 45 min sessions without approval. We can all get creative, I have in the past. However, who paid for the time the therapist spent constructing the box? Could that time have been spent seeing another patient and earning a few bucks for a supportive or canned CBT worksheet session? End of the day, I don't think you see greater adoption until payors actually start reimbursing more for these services. As far as trauma therapy, I am hoping the data on written exposure therapy ends up looking as good as it sounds because it is adapted to a 45 min session and requires as few as 5 sessions. Much easier to train folks on as well.

 

[cara susanna]

Adapting sessions for 60 min is a start and works better at places like the VA. However, we know that the grid at VAs does not adjust slots for more 90837s and a lot of folks even here have advocated keeping sessions to 45 min to have note writing time. On the the private insurance based end, 60 min still requires a pre-auth for many insurances which only reimburse for 45 min sessions without approval. We can all get creative, I have in the past. However, who paid for the time the therapist spent constructing the box? Could that time have been spent seeing another patient and earning a few bucks for a supportive or canned CBT worksheet session? End of the day, I don't think you see greater adoption until payors actually start reimbursing more for these services. As far as trauma therapy, I am hoping the data on written exposure therapy ends up looking as good as it sounds because it is adapted to a 45 min session and requires as few as 5 sessions. Much easier to train folks on as well.

Oh, totally agree.

WET looks promising, but I'm very excited to see the outcomes on the studies comparing it to PE and CPT.

 

[AbnormalPsych]

Oh, totally agree.

WET looks promising, but I'm very excited to see the outcomes on the studies comparing it to PE and CPT.

This would be a game changer for my clinic and patients. It would probably at least triple the # of patient's who initiate this kind of tx and would be better than the pseudoscience they often get referred to. Planning to look for some CEs next year to get reimbursed to see where things are at and have time look into it more. If anyone knows any decent ones, please post.