Like lots of Brits, I have terrible teeth. The dentist always tells me off, yet I floss every day, brush my teeth twice per day, and use mouthwash. Last time I went, they recommended that I come in every 3-4 months rather than every 6 months like most people. Yet, when I asked whether there are any research articles showing that this would be beneficial, I was given a vague answer that essentially said “trust me, I know”. They weren’t able to provide me with actual articles, so I figured I’d research this myself. To my surprise, I found that Cochrane reviews (these are summaries of the literature) don’t support the dentist’s opinion, and several randomized controlled trials show that his recommendation would make little difference. I don’t know for sure, but I worry that I was actually given a recommended treatment option that was purely the dentist’s own opinion about what is best rather than what the available research shows makes sense.
This is relevant for psychological treatment because providers should be giving evidence-based treatment where possible, rather than doing what they “know” to work.
Forget “Trust Me, I Know” And Follow The Research
To treat anxiety disorders, cognitive behavioral therapy (CBT) is the most evidence-based treatment. CBT can involve various different techniques including cognitive restructuring, in vivo exposure, imaginal exposure, relaxation, mindfulness, blocking avoidance, meditation, acceptance, and motivational strategies. As such, CBT can look very different across providers. Although there are an array of strategies, exposure therapy is shown to be the key ingredient for successful treatment of anxiety disorders.
Exposure therapy is the foundation of anxiety treatment. It should be the front line treatment, and is recommended by various organizations across the world, including the NICE guidelines in the UK, and the APA in the US. It is as effective as medications in the short term, and superior over the long term. It can be relatively brief, and compared to almost every other treatment it is both faster and more effective. It is also a cost-effective treatment.
Yet Exposure Is Incredibly Under-Utilized
Yet despite all this, most therapists who provide CBT or other treatments don’t provide exposure treatment for anxiety, or they use it alongside potentially incompatible approaches. In fact, most “anxiety specialists” don’t provide the number one treatment at all, or at best apply it ineffectively. For example, one study found that for OCD, PTSD, Panic Disorder, and Social anxiety, only around 25-30% of therapists used exposures in sessions. Scarily, this is likely higher than in reality as research shows that when therapists say they are doing exposure therapy, their patients indicate that no exposure techniques occur. Therapists instead use non-evidence-based treatments such as psychodynamic treatment, thought field therapy, and art therapy at a comparable rate to exposure therapy. In addition, across the board, therapists use relaxation, mindfulness, and supportive treatments far more than exposure therapy. This all shows that exposure therapy is incredibly under-utilized.
Why Is This A Problem?
What this means is that most people seeking anxiety treatment are receiving either non-evidence-based treatment, or treatment of unknown efficacy. Imagine if this was the case for cancer treatment. You show up desperate for treatment and although the most effective and cost-effective treatment can be available at the drop of a hat, you don’t get it. Worse, you probably don’t even know that you’re not getting it. That would be a travesty.
Exposure is without a doubt the best treatment for anxiety disorders but it is underutilized for all the anxiety disorders. In fact, it is the LEAST used evidence-based treatment in the community. Take a moment to reread those last two sentences. They are mind-boggling.
This has been studied quite extensively for PTSD, a disorder with 3 clear evidence-based treatments (prolonged exposure, cognitive processing therapy, and trauma-focused cognitive-behavioral therapy (for kids)). Each of these involves a lot of exposure. Yet, in studies that look at how many therapists utilize these exposure strategies, the evidence shows that only around 10-30% of therapists do. This is even the case with therapists who are trained extensively in evidence-based techniques. This occurs for various anxiety-related disorders including panic disorder, social phobia, GAD, and OCD.
Let me sum this up: Exposure therapy is the best treatment, and the most under-used treatment for anxiety. In my opinion, getting the best treatment to as many people as possible is a public health necessity. So what’s the barrier?
What’s The Barrier?
Several barriers have been proposed. Therapists fear things like their rapport with the client being compromised, that clients can’t tolerate the therapy, that they’ll drop out of treatment, or they’ll get worse. For example, there are therapists out there that believe that exposure therapy for PTSD causes further PTSD. Is there any evidence for these concerns? No. They are myths.
The Myths Of Exposure Therapy
There have been several studies completed looking at these issues:
Exposure therapy ruins rapport:
Evidence shows that there is no difference in therapist client rapport between exposure therapy and other treatments. In fact, for several treatments, qualitative evidence shows that patients believe exposure therapy was the most helpful aspect.
Patients drop out of treatment more:
No they don’t. Again, there is no difference between exposure therapy and other therapies.
Patients can’t tolerate it:
Yes they can. More than 100 studies exist showing that patients benefit from exposure therapy for every anxiety disorder and across a range of severities.
Exposure therapy for PTSD causes PTSD:
Don’t even get me started with this one…First, there’s no research showing this. Second, it’s exactly the opposite! Using any treatment other than exposure therapy means a person is more likely to continue experiencing PTSD symptoms.
Unfortunately at this time, the myths prevail and this makes dissemination difficult. For example, therapists either do less intensive exposure therapy, including various safety behaviors like relaxation or cognitive reassurance (see my article on the problem with relaxation), or they don’t do it at all. This applies even for people very well trained in the strategies. This needs to change! I hope this article highlights the current issues involved so you are aware of the problems in anxiety treatment.
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