Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings

Classified as probably not a substantial claim.

Exposure-based CBT has robust support from efficacy and effectiveness clinical trials.

“Despite the robust support for exposure-based CBT in efficacy and effectiveness clinical trials (Stewart & Chambless, 2009)”

• cites Stewart & Chambless, 2009 sourcePartly supported

  The Discussion reports that CBT for adult anxiety disorders was robustly effective in clinically representative settings, with effect sizes generally within the range of selected efficacy studies. The Method (Studies) defines CBT broadly to include cognitive treatments, behavioral treatments such as exposure, or both. The paper therefore supports the claim about CBT generally, but does not establish the same conclusion specifically for exposure-based CBT. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

The exposure component is considered a key active ingredient of CBT for anxiety disorders.

“with the exposure component considered to be a key active ingredient (Glenn et al., 2013)”

• cites Glenn et al., 2013 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

System-wide support for the training and delivery of evidence-based treatments plays a role in the uptake of treatments such as CBT.

“many models would suggest that system-wide support for the training and delivery of evidence-based treatments play a role in the uptake of evidence-based treatments such as CBT (Century, Cassata, Rudnick & Freeman, 2012; Damscroeder et al., 2009; Aarons, Hurlburt & Horwitz, 2011)”

• cites Century, Cassata, Rudnick & Freeman, 2012 sourceNot checked — no full text of the source
• cites Damscroeder et al., 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Aarons, Hurlburt & Horwitz, 2011 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Nascent work has begun to examine the effect of directly promoting psychotherapy to potential consumers.

“nascent work has begun to ascertain the effect of directly promoting psychotherapy to potential consumers (Gallo et al, 2015).”

• cites Gallo et al, 2015 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Recent work highlights direct-to-consumer marketing as a frequently overlooked and promising pathway for promoting EBPs, including exposure-based CBT, to adults treated in the community.

“Recent work (Gallo, Comer, Barlow, Clarke & Antony, 2015) also highlights the promise of a frequently overlooked pathway to promoting EBPs, including exposure-based CBT, to adults treated in the community – direct-to-consumer marketing.”

• cites Gallo, Comer, Barlow, Clarke & Antony, 2015 sourcePartly supported

  The Discussion (page unavailable) calls direct-to-consumer marketing a promising, previously underused way to promote psychological treatments, supported by preliminary increases in intention to seek treatment. But the campaigns promoted psychotherapy generally, not exposure-based CBT specifically. The Method and Limitations (pages unavailable) identify participants as undergraduate psychology students, not adults receiving treatment in the community. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

May combine two claims.

Many providers reported inadequate training to conduct exposure, feeling incompetent to deliver exposure, and discomfort with making patients anxious during treatment.

“many providers reported not receiving adequate training to conduct exposure, feeling incompetent to deliver exposure, and discomfort with making their patients anxious during treatment.”

May combine two claims.

No potential system- or organizational-level barrier was endorsed by most providers, and most providers strongly disagreed or disagreed with nearly all such statements.

“none of the potential barriers were endorsed by the majority of providers. In fact, most providers strongly disagreed or disagreed with nearly all of the statements”

May combine two claims.

Patients were generally satisfied with therapy but had mixed views about the acceptability and perceived efficacy of medication for their anxiety disorders.

“patients generally were satisfied with therapy but had mixed opinions regarding their acceptability and the perceived efficacy of medication for their anxiety disorders.”

May combine two claims.

About one-third of providers thought a structured treatment protocol was impractical in their setting, were uncomfortable making patients anxious, felt incompetent to deliver exposure, reported inadequate exposure training, and believed ongoing crises often interfered with starting CBT for anxiety.

“approximately one-third of the providers thought that a structured treatment protocol was not practical in their clinical setting, reported discomfort with making their patients anxious during treatment, felt incompetent to deliver exposure, reported receiving inadequate training in exposure, and believed that ongoing crises often got in the way of starting CBT for anxiety disorders.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Over half of provider participants were unlicensed.

“Over half of provider participants were unlicensed.”

May combine two claims.

Providers used and seemed most experienced with general CBT skills such as relaxation or cognitive restructuring, but had little training and experience delivering exposure.

“providers used and seemed most experienced with general CBT skills such as relaxation or cognitive restructuring, but had little training and experience in delivering exposure”

May combine two claims.

Most providers believed their patients with anxiety disorders were appropriate candidates for CBT and could attend regular therapy sessions.

“The majority of providers also believed that their patients with anxiety disorders were appropriate candidates for CBT who could attend regular therapy sessions.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Patients reported that treating anxiety was considered an important part of their treatment plan.

“patients reported that treating anxiety was considered an important part of their treatment plan.”

May combine two claims.

All but two clinics reported that most of their patients were racial/ethnic minorities (59%-100%), and 85-100% of patients were defined as low-income.

“All but two of the clinics that provided information reported that the majority of their patients were racial/ethnic minorities (i.e., ranging from 59%–100%), with 85–100% of patients defined as low-income.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Most provider participants identified their primary clinical role as therapist or supervisor.

“identified their primary clinical role as therapist of supervisor”

May combine two claims.

Although many patients said the idea of facing their fears to overcome anxiety sounded terrifying, most endorsed items indicating acceptability of exposure.

“Although a large percentage of patients stated that the idea of facing their fears to overcome anxiety sounded terrifying, most participants endorsed items reflecting acceptability of exposure.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Forty-two patient participants completed surveys, with a mean age of 36.69 years (SD = 14.73).

“Forty-two patient participants (Mage = 36.69, SD = 14.73) completed surveys.”

Probably not a substantial claim: may not pass S3 (load-bearing).

General information was obtained from clinic administrators for 14 of the 18 agencies with participating providers.

“We obtained general information from clinic administrators about 14 of the 18 agencies with participating providers.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The size of DMH contracts across clinics ranged from $400,000 to $10 million.

“The size of DMH contracts across clinics ranged from $400,000 to $10 million.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Most provider participants had a master's-level clinical degree.

“The majority of providers had a masters-level clinical degree”

May combine two claims.

Only one-fourth of providers somewhat agreed that they conduct in-session exposure of any kind, and few completely agreed.

“Only one-fourth of providers reported somewhat agreeing with the statement that they do in-session exposure of any kind (i.e., in vivo, interoceptive, or imaginal), and few “completely” agreed with the statement.”

May combine two claims.

Participants identified few barriers to care, but the most highly endorsed barriers concerned their own symptoms interfering with receiving regular treatment.

“few barriers to care were identified by participants, but the most highly endorsed were those relating to their own symptoms getting in the way of receiving regular treatment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Most provider participants were early in their careers.

“were early in their careers”

Probably not a substantial claim: may not pass S3 (load-bearing).

Three of the clinics served youth primarily (ages 0-25) but also provided treatment to parents of the children they served.

“Three of these clinics served youth primarily (0–25 years old), but provided treatment to parents of the children they served.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The remaining clinics served either adults age 18 and older or patients across the lifespan.

“with the remaining clinics serving either adults age 18 and older, or patients at any age across the lifespan.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The number of adult patients treated annually at each clinic ranged from 20 to over 1200.

“The number of adult patients treated annually at each clinic ranged from 20 to over 1200.”

May combine two claims.

Most participants believed combined medication and therapy was better than either alone, though the vast majority thought therapy plus medication was better than medication alone, while fewer thought it was better than therapy alone.

“Most participants believed that a combination of medication and therapy was better than either treatment alone, though the vast majority of participants thought therapy + medication was better than medication alone, whereas fewer thought therapy + medication was better than therapy alone.”

May combine two claims.

Nearly three-quarters of participants said gradual confrontation of fears is or would be helpful, and over half said they would undergo an effective therapy requiring them to face their fears.

“nearly three-quarters of participants stated that a treatment that consists of gradually confronting fears is helpful (or would be helpful, if they were to receive it); and over half of the participants stated that, if offered an effective therapy that required them to face their fears, they would undergo the treatment.”

May combine two claims.

Just over one-third of providers somewhat agreed that they use cognitive restructuring, build fear hierarchies, and assign exposure homework, and few completely agreed with these statements.

“with just over one-third of providers reporting that they somewhat agree with statements that they use cognitive restructuring, build fear hierarchies, and assign exposure homework. Few providers “completely” agreed with these statements.”

May combine two claims.

In their current clinical positions, a similar pattern of training and supervision was observed, but somewhat more providers reported training and supervision in some CBT techniques.

“When asked about training and supervision while in their current clinical position (Table 2b), a similar pattern of findings was observed, but with somewhat more participants reporting training and supervision in some CBT techniques.”

May combine two claims.

Most providers believed exposure and cognitive restructuring were effective for anxiety and that exposure does not harm patients.

“Most providers thought exposure and cognitive restructuring were effective for anxiety and that exposure does not do harm to patients.”

May combine two claims.

Provider surveys showed that only a minority received ongoing training and supervision in most CBT skills, with especially low levels in exposure.

“Provider surveys revealed that only a minority of providers received ongoing training and supervision in most CBT skills, with particularly low levels of training or supervision in exposure.”

May combine two claims.

Patients reported somewhat less receipt of exposure therapy techniques than of cognitive restructuring and relaxation techniques, but about half reported receiving each exposure-based technique.

“patients reported somewhat less receipt of exposure therapy techniques compared to cognitive restructuring and relaxation techniques, but nonetheless, about half of patient participants reported receiving each exposure-based technique”

Probably not a substantial claim: may not pass S3 (load-bearing).

Two clinics served primarily older adults (55 years and older).

“Two other clinics served primarily older adults (55+ years old)”

May combine two claims.

Most providers reported that their supervision was adequate in quality and quantity and that their supervisors had the skills needed to supervise cognitive and behavioral techniques for anxiety disorders.

“Most providers reported that the quality and quantity of their supervision was adequate and that their supervisors had the skills necessary to provide supervision in cognitive and behavioral techniques for anxiety disorders.”

May combine two claims.

Despite generally positive attitudes toward exposure therapy, current providers simultaneously hold views incompatible with implementing exposure.

“despite generally positive attitudes toward exposure therapy, current providers simultaneously hold views that are incompatible with regard to implementing exposure.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In community-based settings serving children, client diversity and complexity are identified barriers to delivering evidence-based treatments.

“client diversity and complexity (Akin et al., 2014; Wharton & Bolland, 2014)”

• cites Akin et al., 2014 sourceNot checked — no full text of the source
• cites Wharton & Bolland, 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim. May combine two claims.

Exposure-based cognitive behavioral therapy is regarded as a first-line and highly effective treatment for anxiety disorders.

“CBT is considered the first-line treatment for anxiety disorders, particularly when it involves gradual confrontation with feared stimuli (i.e., exposure)”

• Also stated in: § Abstract · boosted

  “Cognitive behavioral therapy (CBT) that includes exposure to feared stimuli as a central component of anxiety disorder treatment is considered one of the most effective treatments that the mental health field has for any psychiatric disorder (Deacon & Abramowitz, 2004).”

• cites Deacon & Abramowitz, 2004 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

In community-based settings serving children, provider knowledge of, attitudes towards, and experience with evidence-based treatments are identified barriers to delivering them.

“provider knowledge of, attitudes towards, and experience with evidence based treatments (Aarons & Palinkas, 2007; Borntrager et al., 2009; Higa-McMillan, Nakamura, Morris, Jackson, & Slavin, 2015; Stephan et al., 2012 )”

• cites Aarons & Palinkas, 2007 sourceNot checked — no full text of the source
• cites Borntrager et al., 2009 sourceNot checked — no full text of the source
• cites Higa-McMillan, Nakamura, Morris, Jackson, & Slavin, 2015 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

In community-based settings serving children, organizational structure, climate, and culture are identified barriers to delivering evidence-based treatments.

“identified barriers include organizational structure, climate and culture (Glisson & Green, 2011)”

• cites Glisson & Green, 2011 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Imaginal exposure is the core component of a widely used and highly efficacious behavioral treatment for PTSD and a frequently used component for other anxiety disorders.

“the core component of a widely-used, highly efficacious behavioral treatment for post-traumatic stress disorder (Foa, Hembree & Rothbaum, 2010) and a frequently-used component of treatment for other anxiety disorders (e.g., generalized anxiety disorder).”

• cites Foa, Hembree & Rothbaum, 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

People with more positive beliefs about exposure-based therapy have been shown to deliver it more optimally and to be less likely to inappropriately exclude anxious patients from exposure-based treatment.

“those with more positive beliefs about exposure-based therapy have been shown to more optimally delivery it (Farrell, Deacon, Kemp, Dixon & Sy, 2013; Deacon, Lickel, Farrell,, Kemp, & Hipol, 2013) and to be less likely to inappropriately exclude anxious patients from exposure-based treatment (Mayer, Farrell, Kemp, Blakey & Deacon, 2014).”

• cites Farrell, Deacon, Kemp, Dixon & Sy, 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Deacon, Lickel, Farrell,, Kemp, & Hipol, 2013 sourceNot checked — no full text of the source
• cites Mayer, Farrell, Kemp, Blakey & Deacon, 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

These findings challenge the conventional view that patients and providers resist exposure and add to literature showing that patients and providers find exposure highly acceptable once they learn about it.

“These findings challenge the conventional wisdom that patients and providers are resistant to exposure, and add to the growing body of literature demonstrating that patients and providers find exposure highly acceptable once they learn about it (Arch et al,., 2015).”

• cites Arch et al,., 2015 sourceNot checked — no full text of the source

May combine two claims.

Training in exposure-based CBT for anxiety disorders appears to have been excluded from the funded training curriculum, even though the surveyed clinics' organizational cultures appeared to prioritize treating anxiety disorders.

“training in exposure-based CBT for anxiety disorders appears to have been excluded from the funded training curriculum, despite the fact that the organizational cultures of clinics surveyed here appeared to prioritize and acknowledge the importance of treating anxiety disorder.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The patient survey had excellent internal consistency, with Cronbach's alpha ranging from .81 to .90 across its substantive sections.

“Internal consistency within each section of the patient survey was excellent, with Cronbach’s α ranging from .81 to .90 across the substantive sections of the survey (i.e., not including demographic information section).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

One hundred six providers across 18 participating agencies entered the survey, and 95 completed one or more sections.

“106 providers across the 18 participating agencies entered the survey, and 95 providers completed one or more sections of the surveys.”

Probably not a substantial claim: may not pass S2 (checkable).

Reducing the burden of anxiety disorders ultimately depends on government or other funds supporting ongoing training and supervision of clinical staff to deliver CBT treatments.

“lessening the burden of anxiety disorders ultimately depends on government (or other) funds to support the ongoing training and supervision of clinical staff to deliver CBT treatments.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The provider survey had good to excellent internal consistency, with Cronbach's alpha ranging from .77 to .91 across its substantive sections.

“Internal consistency within each section of the provider survey was good to excellent, with Cronbach’s α ranging from .77 to .91 across the substantive sections of the survey.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Interoceptive exposure is the core component of a widely used and highly efficacious CBT treatment for panic disorder.

“the core component of a widely-used and highly efficacious CBT treatment for panic disorder (Barlow & Craske, 2007)”

• cites Barlow & Craske, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study received approval from the UCLA Institutional Review Board and the Los Angeles County Department of Mental Health Research Committee.

“The study was approved by the UCLA Institutional Review Board and by the Los Angeles County Department of Mental Health Research Committee.”

May combine two claims.

Discomfort about inducing anxiety during exposure is likely due to low self-efficacy and skill in delivering exposure, which usually develops through training and supervised experience.

“Discomfort about inducing anxiety during exposure is likely to be the effect of low self-efficacy (and skill) in delivering exposure, which typically comes with training and supervised experience.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Providers who self-selected to participate may differ in some ways from those who did not participate.

“It is possible that those providers who self-selected to participate may differ in some ways from those who did not participate.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

It is unclear whether these findings generalize to other counties in California or to other states.

“it is unclear whether these findings will generalize to other counties within California or to other states.”

May combine two claims.

Provider and administrator data came from both urban and rural service areas, but the patient sample came from clinics in urban areas of Los Angeles County.

“although we obtained provider/administrator data from both urban and rural service areas, the patient sample was comprised of clinics from urban areas in Los Angeles County.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Patient reports could be biased because clinic staff gave them the surveys, although the study tried to minimize this by having staff leave the room during completion and collecting surveys only after patients sealed them in envelopes.

“there could be potential biases in patient reports since staff at their clinic gave them the surveys, though we attempted to minimize this bias by ensuring that clinic staff left the room while participants completed the surveys and only collected them after they were placed in sealed envelopes by the patients.”

May combine two claims.

Positive attitudes, beliefs, and preferences across stakeholder groups for treating anxiety disorders with CBT, along with few patient- and organizational-level barriers, indicate willingness for exposure-based CBT to be used more widely in adult community mental health settings.

“Positive attitudes, beliefs, and preferences across stakeholder groups for treating anxiety disorders using CBT, coupled with few patient- and organizational-level barriers, point toward a willingness for exposure-based CBT to be utilized more widely in adult community mental health settings.”

May combine two claims.

Because provider participants were recruited from many clinics and agencies, the sample size was insufficient to nest within clinics or investigate differences among organizations.

“Given the large number of clinics and agencies from which the provider participants were recruited, our sample size was insufficient to nest within clinics or to investigate differences among organizations.”

May combine two claims.

The study did not know how many providers across all participating agencies received the survey email and therefore did not know the provider participation rate.

“we do not know how many providers across all of the participating agencies received the email about the surveys, and thus do not know what the participation rate was for providers.”

May combine two claims.

Most agencies contacted for participation did not respond to the invitation, and the study could not provide funds directly to participating agencies as incentives.

“The majority of agencies we contacted for participation did not respond to the invitation and the study could not provide funds directly to participating agencies to help incentivize their participation.”

Probably not a substantial claim: may not pass S2 (checkable).

That statement represents the precise opposite goal or process of exposure therapy.

“This statement represents the precise opposite goal or process of exposure therapy.”

May combine two claims.

The patient sample came from only four of the many clinics whose providers participated, so provider and patient responses could not be compared within organizations.

“our patient sample was obtained only from four out of the many clinics whose providers participated; therefore, we were unable to compare provider and patient responses within organizations”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Exposure-based CBT can be successfully implemented in community settings that treat anxious children and U.S. military veterans with PTSD.

“Researchers have shown that exposure-based CBT can be successfully implemented in community settings that treat anxious children (Weisz et al., 2012) and U.S. military veterans with PTSD (McLean & Foa, 2013)”

• cites Weisz et al., 2012 sourceNot checked — no full text of the source
• cites McLean & Foa, 2013 sourceNot checked — no full text of the source

May combine two claims.

These patients represent those seemingly willing and able to attend at least some sessions and interested in participating in a survey to improve care, so they may not represent the larger population seeking treatment at publicly funded community mental health centers.

“these patients represent those who are seemingly willing and able to attend at least some sessions, are interested in participating in a survey to improve care, and therefore may not be representative of the larger population of those seeking treatment at publicly funded community mental health centers.”

May combine two claims.

The number of agencies in which at least one provider responded was large, which increases generalizability.

“the number of agencies in which at least one provider responded is large, increasing generalizability.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Reinforcing behavioral avoidance would be hypothesized to lead to worse functional outcomes for anxiety disorder patients, reinforcing the avoidance that is a core causal and maintenance factor for anxiety disorders.

“Generally, reinforcing behavioral avoidance would be hypothesized to lead to worse functional outcomes for anxiety disorder patients – reinforcing the very avoidance that signifies a core causal and maintenance factor for anxiety disorders (Barlow, 2002; Craske, 1999).”

• cites Barlow, 2002Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Craske, 1999Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.