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

Highlights

• Exposure therapy is underutilized in the treatment of anxiety disorders in community mental health settings.

• This study examined clinician and organizational predictors of clinician exposure use in community mental health.

• Both clinician and organizational characteristics related to clinician exposure use.

• Implementation strategies should be designed to address clinician and organizational characteristics.

Abstract

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.

Introduction

Anxiety disorders are the most common psychiatric conditions in youth (Merikangas et al., 2010). They are impairing (Rapee, Schniering, & Hudson, 2009), chronic (Ginsburg et al., 2014), and have a number of sequelae if left untreated (Neal & Edelmann, 2003). Cognitive-behavioral therapy (CBT) is a proven and efficacious treatment for anxiety demonstrating durable effects over time (Benjamin, Harrison, Settipani, Brodman, & Kendall, 2013; Ginsburg et al., 2014; Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Use of exposure, or confronting fear stimuli within the context of CBT, is the key ingredient of intervention leading to improved outcomes (Kendall et al., 2006, Peris et al., 2015). Despite scientific recognition that exposure is critical to the success of CBT for anxiety, recent estimates suggest that only 10–30 percent of clinicians endorse using exposure therapy in routine clinical care (Becker, Zayfert, & Anderson, 2004; Borntrager, Chorpita, Higa-McMillan, Daleiden, & Starace, 2013; Trask, Fawley-King, Garland, & Aarons, 2016; Whiteside, Deacon, Benito, & Stewart, 2016; Wolitzky-Taylor, Zimmermann, Arch, De Guzman, & Lagomasino, 2015). To date, most studies examining exposure use in the context of routine clinical care have largely focused on documenting the rates of exposure use with adult clients with anxiety or post-traumatic stress disorder (PTSD); the few studies with youth populations suggest comparably low rates of exposure use for anxious youth (Higa-McMillan, Kotte, Jackson, & Daleiden, 2016; Whiteside et al., 2016). However, little is known about clinician and organizational factors associated with clinician use of exposure in community mental health. Identifying characteristics associated with greater exposure use has important implications for designing effective implementation strategies to increase clinician exposure use. As such, this paper extends prior work by examining clinician and organizational predictors of exposure use for youth clients in community mental health settings.

The presence of a significant research to practice gap for psychotherapy is not new (Weisz, Donenberg, Han, & Weiss, 1995); however, uptake of exposure lags behind other evidence-based practice strategies for youth (Higa-McMillan, Francis et al., 2016, Higa-McMillan, Kotte et al., 2016). Said to suffer from a significant “public relations problem” (Richard & Gloster, 2006), exposure is one of the least used evidence-based interventions in routine clinical care (e.g., Borntrager et al., 2013, Trask et al., 2016) and is rated the most difficult CBT strategy to implement in community settings (Chu et al., 2015). In contrast, studies suggest that when clinicians report using CBT for anxiety following implementation efforts, clinicians often opt for treatment components such as progressive muscle relaxation or deep breathing over exposure (Becker, Becker, & Ginsburg, 2012; Chu et al., 2015, Edmunds et al., 2014). Relaxation is a common component in early cognitive behavioral protocols for anxiety (e.g., Kendall & Hedtke, 2006). However, as the science underlying the efficacy of exposures has expanded, experts have recognized that relaxation may be less than effective for anxiety and/or even contraindicated in the context of exposure therapy (Blakey & Abramowitz, 2016). Thus, it appears that the most evidence-based intervention, exposure, is the least used for treating anxiety disorders whereas the least evidence-based intervention, relaxation, is used most often. This shift underscores the importance of furthering the field’s understanding of barriers to the use of exposure.

Prior implementation efforts to increase the use of CBT for anxiety have led to long-term clinician use of CBT strategies such as relaxation, but have done little to increase the rates of exposure (Chu et al., 2015, Edmunds et al., 2014). As this suggests that future implementation efforts may benefit from directly targeting clinician use of exposure, identifying factors specifically associated with greater likelihood of therapist use of exposure is important to developing effective implementation strategies aimed at increasing clinician exposure use. Implementation models posit factors impacting evidence-based practice (EBP) use at multiple levels (e.g., clinician, organizational levels; (Aarons, Sommerfeld, & Walrath-Greene, 2009; Damschroder et al., 2009). Consistent with this, prior work examining facilitators of EBP use more broadly have found both clinician factors, such as more positive attitudes toward EBP, and organizational variables, such as organizational culture and climate, to be associated with greater EBP use (Aarons, 2004, Beidas et al., 2015; Brookman-Frazee, Haine, Baker-Ericzen, Zoffness, & Garland, 2010). When barriers to exposure have been examined, data indicate that barriers to clinician use of exposure similarly arise across these multiple levels, and include negative clinician attitudes (Deacon et al., 2013), a lack of time to prepare for exposures (Farrell, Deacon, Dixon, & Lickel, 2013), little access to needed materials, and few trained supervisors (Ringle et al., 2015).

With respect to linking these cited barriers to clinician behavior, several studies have linked more negative clinician attitudes were associated with lower likelihood of exposure use for youth (Deacon et al., 2013, Whiteside et al., 2016). However, little work has examined whether these factors correlate with clinician use of exposure in community mental health settings. Additionally, no published studies have examined whether organizational context variables, such as organizational cultures and climates that value or emphasize evidence-based practice, are linked to clinician exposure use for youth. Some work drawn from a research trial aimed at disseminating exposure therapy suggests that clinician factors, rather than organizational factors, are primary barriers to exposure use for adults (Harned, Dimeff, Woodcock, & Contreras, 2013). However, the larger implementation literature suggests that organizational variables, such as organizational culture and climate, may be primary drivers of clinician EBP use (Beidas et al., 2015). Identifying organizational and clinician variables associated with clinician use of exposure will be key for designing targeted and comprehensive implementation strategies.

The primary aim of this study was to identify clinician and organizational level predictors of exposure use for anxiety disorders in youth community mental health settings. Clinician level predictors included attitudes toward and knowledge of evidence-based practice. We also included clinician years of experience, which predicts EBP use in other samples (e.g., Aarons, 2004; Becker, Smith, & Jensen-Doss, 2013). In addition, we examined whether clinicians who had participated in an evidence-based practice initiative that included some aspect of training in exposure (i.e., the Beck Community initiative (Creed, Wolk, Feinberg, Evans, & Beck, 2016), the Philadelphia Alliance for Child Trauma Services (Beidas et al., 2016), and Prolonged Exposure (Foa et al., 2005)) were more likely to use exposure for anxiety relative to those clinicians who did not participate. As lack of preparation time has been a cited barrier to exposure (e.g., Ringle et al., 2015), we also examined clinician caseload size. We anticipated that positive attitudes, greater knowledge, fewer years of experience, a lower caseload, and participation in an EBP initiative would be associated with greater use of exposure for anxiety. Based on work suggesting clinician preference for relaxation over exposure in anxiety treatment (Becker et al., 2012, Chu et al., 2015), we also examined the extent to which clinicians used relaxation for anxiety treatment as a predictor of exposure use, anticipating that relaxation would be used more frequently for youth anxiety than exposure and that clinicians who used relaxation more frequently would use exposure less often.

With respect to organizational predictors, we examined organization size (number of therapists) as well as commonly studied constructs of organizational climate (proficiency and rigidity; Williams & Glisson, 2013), organizational culture (functionality; (Williams & Glisson, 2014), and implementation climate (Weiner, Belden, Bergmire, & Johnston, 2011). We anticipated that more proficient organizational climates, more functional organizational cultures, and higher implementation climate would be associated with greater exposure use. We also anticipated that more resistant organizational cultures would be associated with less exposure use.