بررسی رزرو درمانگر در مورد مواجهه درمانی برای اختلالات اضطرابی: باورهای درمانگر در مورد مقیاس مواجهه

Exposure therapy is underutilized in the treatment of pathological anxiety and is often delivered in a suboptimal manner. Negative beliefs about exposure appear common among therapists and may pose a barrier to its dissemination. To permit reliable and valid assessment of such beliefs, we constructed the 21-item Therapist Beliefs about Exposure Scale (TBES) and examined its reliability and validity in three samples of practicing clinicians. The TBES demonstrated a clear single-factor structure, excellent internal consistency (αs = .90–.96), and exceptionally high six-month test–retest reliability (r = .89). Negative beliefs about exposure therapy were associated with therapist demographic characteristics, negative reactions to a series of exposure therapy case vignettes, and the cautious delivery of exposure therapy in the treatment of a hypothetical client with obsessive-compulsive disorder. Lastly, TBES scores decreased markedly following a didactic workshop on exposure therapy. The present findings support the reliability and validity of the TBES.

A substantial body of research demonstrates the effectiveness of exposure-based cognitive behavioral therapy (CBT) for the anxiety disorders (Deacon and Abramowitz, 2004 and Olatunji et al., 2010). Exposure therapy (also known as exposure and response prevention) is the central procedure in numerous empirically supported treatment protocols for post-traumatic stress disorder (PTSD; e.g., Schnurr et al., 2007), obsessive compulsive disorder (OCD; e.g., Foa et al., 2005), social phobia (e.g., Davidson et al., 2004), panic disorder and agoraphobia (e.g., Gloster et al., 2011), and specific phobias (e.g., Ollendick et al., 2009). Exposure to feared stimuli is an empirically supported principle of change for pathological anxiety (Abramowitz et al., 2010 and Lohr et al., 2012), and the need to train clinicians in the competent delivery of exposure has been identified an important healthcare priority (McHugh & Barlow, 2010). Unfortunately, exposure therapy is underutilized by practitioners and difficult for clients to access. Most therapists, even those with specialized training in exposure therapy, rarely provide this treatment to their anxious clients (Becker et al., 2004 and van Minnen et al., 2010). When clinicians use exposure therapy its implementation often differs markedly from the typically prolonged and intense manner recommended in treatment manuals (Deacon et al., 2013, Freiheit et al., 2004 and Hipol and Deacon, 2013). Most clients with anxiety disorders do not receive efficacious treatment of any kind, and few receive competently delivered exposure therapy (Böhm et al., 2008 and Young et al., 2008). Negative beliefs about exposure therapy appear common among practitioners and likely pose an important barrier to the dissemination of this treatment (Feeny et al., 2003, Gunter and Whittal, 2010, Olatunji et al., 2009 and Zoellner et al., 2011). Therapists may fear that exposure will harm clients by producing cognitive decompensation (Becker et al., 2004), symptom exacerbation (Cook, Schnurr, & Foa, 2004), and physical harm (Rosqvist, 2005). To illustrate, Deacon et al. (2013) found that exposure therapists reported concerns that prolonged and intense interoceptive exposure would cause panic clients to decompensate, lose consciousness, experience a worsening of symptoms, and drop out of therapy. Therapists may also worry that exposure will harm themselves via vicarious traumatization (Zoellner et al., 2011) or malpractice litigation (Kovacs, 1996). Additionally, therapists may believe that the deliberate evocation of anxiety in exposure therapy is inherently unethical (Olatunji et al., 2009), unacceptably aversive to clients (Zoellner et al., 2011), and increases dropout rates (van Minnen et al., 2010). Finally, therapists may believe that exposure is insensitive to the unique needs of the client and requires concomitant treatment strategies (e.g., controlled breathing) to be safe, tolerable, and effective (Feeny et al., 2003). Despite a wealth of anecdotal reports that therapist reservations about exposure therapy impede its dissemination and optimal delivery, little empirical research has examined these issues. Several studies have demonstrated that therapist concerns about exposure are linked to its underutilization (e.g., Becker et al., 2004 and van Minnen et al., 2010). Two studies have examined the association between negative beliefs about exposure therapy and the manner in which it is delivered. Deacon et al. (2013) reported that therapists with greater concerns about the dangers of intense and prolonged interoceptive exposure for panic disorder were more likely to use controlled breathing strategies with their clients. Using an experimental design with an analog therapist sample, Farrell, Deacon, Kemp, Dixon, and Sy (in press), found that therapists with negative beliefs about exposure delivered this treatment in a more cautious manner to a confederate client with OCD. These preliminary research findings are consistent with the notion that therapist reservations about exposure may compromise its effective delivery. To illustrate, theorists have suggested that beliefs about the intolerability and dangerousness of exposure therapy may prompt clinicians to select less anxiety-evoking exposure tasks, permit clients to use safety behaviors, encourage the use of arousal-reduction strategies, and fail to expose clients to their most feared situations (e.g., Deacon and Farrell, 2013 and Rothbaum and Schwartz, 2002). Little empirical research exists to substantiate widespread speculation that negative beliefs about exposure are pervasive among clinicians and impede its competent delivery. A principal reason for this state of affairs is the absence of a reliable and valid measure of therapist reservations about exposure therapy. Historically, reports of therapist concerns about exposure therapy have been theoretical (e.g., Olatunji et al., 2009) or relied on study-specific items with unknown psychometric properties (e.g., Becker et al., 2004). The availability of a reliable and valid measure would inform future research by permitting the empirical examination of the frequency and consequences of negative practitioner beliefs about exposure therapy. Accordingly, the present series of studies were conducted to characterize the psychometric properties and construct validity of a novel measure: the Therapist Beliefs about Exposure Scale (TBES). With items based on therapist reservations about exposure identified from a comprehensive review of the existing literature (e.g., Becker et al., 2004, Deacon and Farrell, 2013, Feeny et al., 2003, Gunter and Whittal, 2010, Olatunji et al., 2009, van Minnen et al., 2010 and Zoellner et al., 2011), the TBES was developed to provide an efficient, reliable, and valid assessment of a wide range of therapist reservations about exposure therapy. Three studies were conducted to examine the following characteristics of the TBES: (a) psychometric properties (e.g., factor structure, internal consistency, test–retest reliability), (b) association with therapist demographic characteristics, reactions to clinical depictions of exposure, and exposure therapy delivery style, and (c) modifiability following didactic training in exposure therapy.