Hannah E. Frank, Lara S. Rifkin, Kate Sheehan, Emily M. Becker-Haimes,
Margaret E. Crane, Katherine E. Phillips, Sophie A. Palitz Buinewicz, Joshua Kemp,
Kristen Benito and Philip C. Kendall

Abstract:

Background: Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use – therapists’ negative beliefs about exposure – have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use.

Aims: This study aimed to assess: (1) therapists’ perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training.

Method: Therapists who underwent experiential training (n = 12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use.

Results: Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures.

Discussion: Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

Hannah E. Frank, Lauren Milgram, Jennifer B. Freeman,
and Kristen G. Benito

Abstract:

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.