Kaye, J. L. (2018) Targeting Therapists’ Experiential Avoidance During Exposure Delivery: An Experimental Investigation to Improve the Quality of Exposure-based Interventions (Doctoral Dissertation) Drexel University

Despite the large body of evidence that supports the efficacy of exposure therapy (ET) for anxiety disorders, many clinicians do not utilize exposure for these conditions, or they deliver exposure in an overly cautious, suboptimal manner. Research points to several therapist characteristics that might interfere with the decision to use exposure and with its optimal delivery: a persistent set of beliefs that ET is harmful and intolerable, experiential avoidance (EA) of anxiety and discomfort that arises during exposure, anxiety sensitivity, and intolerance of uncertainty. It is critically important to address these barriers to dissemination and implementation of ET. Though researchers have found promising results of didactic ET training that targets clinicians’ negative beliefs about exposure, no research has directly targeted therapists’ EA during didactic ET training. This study sought to determine whether incorporating techniques to improve therapists’ exposure-related willingness to experience anxiety into didactic training might improve the quality of their exposure delivery. Mental health clinicians and psychology graduate students attended a standard ET training workshop (ST; n = 53) that also targeted therapists’ concerns about ET or the same workshop with acceptance-based techniques (ST+ABT; n = 46) to improve therapists’ EA. Primary outcomes were assessed via the quality of participants’ exposure delivery as determined by a simulated exposure session. An additional dose of intervention was delivered at the conclusion at the exposure session via individualized feedback to participants about their exposure delivery. Secondary outcomes, including exposure delivery on a hypothetical case vignette, experiential avoidance, beliefs about exposure therapy, intolerance of uncertainty, and anxiety sensitivity were assessed after the xi workshop and at one-month follow-up. Reported frequency of exposure delivery after the workshop was also examined at the follow-up assessment. Results indicated that both groups delivered exposure therapy of equal quality according to objective ratings of therapists’ behaviors, but participants in the ST condition delivered better quality exposure according to a global subjective rating (p = .045). In contrast, there were no group differences in exposure delivery on the case vignette or actual use of exposure methods in the month after the workshop. Experiential avoidance scores did not improve from pre-workshop to post-workshop, though they improved by the follow-up assessment, and limited evidence suggests they improved to a greater degree in the ST+ABT group. Some evidence suggested that EA was associated with exposure delivery on the case vignette. In addition, negative beliefs about ET and intolerance of uncertainty were consistently associated with more cautious exposure delivery on the case vignette. No therapist factors were related to exposure delivery during the simulated session. Results suggest that the ST and ST+ABT protocols may have been more similar than distinct, and the ST+ABT protocol may have attempted to cover too much content in a half-day workshop; this may have resulted in greater consolidation of learning in the ST group. Results also suggest that therapists’ negative beliefs about ET and intolerance of uncertainty, and to some extent EA, may be critical barriers to effective exposure delivery. Future research should expand on efforts to identify which therapist factors most interfere with exposure delivery. Additionally, future research should examine the best methods for assessing therapists’ ET proficiency in real-world settings. Implications for the dissemination and implementation of ET are discussed.