Journal of Anxiety Disorders 27 (2013) 763–771 Contents lists available at ScienceDirect Journal of Anxiety Disorders Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation Nicholas R. Farrell * , Brett J. Deacon, Joshua J. Kemp, Laura J. Dixon, Jennifer T. Sy University of Wyoming, Department of Psychology, Dept. 3415, 1000 E. University Ave., Laramie, WY 82071, USA a r t i c l e i n f o Keywords: Exposure therapy Cognitive-behavioral therapy Anxiety disorders Dissemination a b s t r a c t Despite its effectiveness, exposure therapy is underutilized and frequently implemented in suboptimal fashion. Research has shown negative beliefs about exposure are related to its underutilization, and these beliefs are held by exposure therapists and may play a causal role in its suboptimal delivery. This study examined the effect of negative beliefs about exposure on treatment delivery. Participants (n = 53) received training in basic exposure implementation and were given additional information intended to elicit either positive or negative beliefs about the treatment’s safety, tolerability, and ethicality prior to conducting an exposure session with a confederate client. Results indicated that participants with experimentally induced negative beliefs about exposure delivered the treatment more cautiously (e.g. creation of a less ambitious exposure hierarchy, selection of a less anxiety-provoking exposure task, attempts to minimize client anxiety during exposure) compared to participants with positive beliefs who pursued more ambitious delivery of exposure (e.g. encouraging clients’ use of oppositional actions). The present findings suggest that therapist reservations about exposure cause suboptimal delivery and may adversely affect client outcomes. © 2013 Elsevier Ltd. All rights reserved. 1. Introduction Various forms of exposure therapy (ET) have consistently gen- erated empirical support in the treatment of anxiety disorders (Deacon & Abramowitz, 2004; Olatunji, Cisler, & Deacon, 2010), including posttraumatic-stress disorder (e.g. Foa, Rothbaum, Riggs, & Murdock, 1991; Taylor et al., 2003), obsessive-compulsive dis- order (e.g. Abramowitz, Franklin, Schwartz, & Furr, 2003; Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000), panic disorder (e.g. Barlow, Gorman, Shear, & Woods, 2000; Gould, Otto, & Pollack, 1995) and social and specific phobias (Öst, 1996; Rapee, Gaston, & Abbott, 2009). Findings supporting the efficacy of ETs in clinical trials extrapolate to “real world” practice (Stewart & Chambless, 2009). Clinical practice guidelines published by the American Psychiatric Association (2011) and the National Institute for Clinical Excellence (2011) recommend ET approaches as first-line anxiety treatments. Clearly, ETs are a well-established treatment for anxiety disorders, and the need to disseminate them is a high priority (Gunter & Whittal, 2010). However, despite the well-documented effectiveness of ET, its implementation is hindered by two dissemination problems: (a) it is an underutilized approach, and (b) when used, it is frequently * Corresponding author. Tel.: +1 414 530 1984; fax: +1 307 766 2926. E-mail address: nfarrell@uwyo.edu (N.R. Farrell). delivered in an unnecessarily cautious manner (e.g., refraining from use of highly anxiety-provoking exposure tasks, prematurely terminating exposure tasks, frequent use of anxiety reduction strategies; Deacon & Farrell, 2013). Becker, Zayfert, and Anderson (2004) found that a large majority (83%) of doctoral-level psychol- ogists treating PTSD reported not using ET. Similarly, van Minnen, Hendriks, and Olff (2010) reported that most trauma experts did not utilize ET in treatment of PTSD, and found that both client factors (e.g. comorbidity) and therapist factors (e.g. fear of client dropout) predicted decisions to not use exposure. This is despite published findings that ET for PTSD is more effective and as safe and tolerable as other non-exposure methods (Foa, Zoellner, Feeny, Hembree,& Alvarez-Conrad, 2002; Hembree et al., 2003). The underutilization of ET is not specific to PTSD. A study on the implementation of expo- sure in Germany found that although almost all therapists in the study requested coverage for ET from obsessive-compulsive clients’ health insurers, over 80% of the clients reported that no exposure component was used in their treatment (Böhm, Förstner, Kulz, & Voderholzer, 2008). In addition, Becker et al. (2004) noted that less than 15% of clinicians who received specialized training in ET to treat PTSD reported using the therapy when treating other anxiety disorders. When ET is used, research shows that therapists frequently deliver it in a manner that appears to be cautious. Freiheit, Vye, Swan, and Cady (2004) surveyed a large group of CBT-oriented psychologists and found that many reported delivering ET in combination with other techniques, including relaxation training, 0887-6185/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.janxdis.2013.03.007