Despite the demonstrated efficacy of PE and other exposure therapies for PTSD, clinicians have been slow to adopt the techniques into their practice. Becker, Zayfert, and Anderson (2004) surveyed a large sample of psychologists about whether they treated patients with PTSD and, if so, whether they were trained in the use of imaginal exposure and whether they used it with their patients. Although 63% of the sample reported having treated more than 11 patients with PTSD, only 27% of the sample were trained in the use of imaginal exposure for PTSD and even fewer (9%) reported regularly using imaginal exposure with their patients suffering from PTSD. Thus few therapists who see patients with PTSD are trained in the use of exposure therapy, and even fewer use it. What are the reasons for this low utilization rate?
Becker et al. (2004) found that the commonest reason for not using exposure therapy to treat PTSD was lack of training (60%). The next two commonest reasons were resistance to using manualized treatments (25%) and fears that patients would decompensate from the treatment (22%). As discussed above, although safety concerns have been raised, there is no empirical support for the conclusion that PE carries increased risk compared to other CBT treatments for PTSD or, more importantly, compared to the risk of withholding or delaying treatment. We have been aware of the limitations in adoption of PE resulting from the lack of training opportunities and clinicians' negative attitudes toward manualized treatments and have made several efforts to address these problems.
Over the last several years we have trained many professionals from various disciplines in workshops lasting from 2 hours to 5 days. Clinicians commonly report that they are attracted by the efficacy and efficiency of exposure therapy and are interested in using it with patients who have PTSD. However, they are also worried about being able to properly implement it without further assistance, and we strongly believe that few of these clinicians actually end up using PE in their practices. Although an extended workshop (e.g., 3-5 days) may be adequate for training clinicians who have a background in CBT and experience in utilizing exposure therapy with other disorders (e.g., phobias, panic disorder, obsessive-compulsive disorder), therapists trained in other models of psychotherapy (e.g., psychodynamic,
Rogerian) may find that applying PE requires them to think about and work with patients in an entirely new way. PE, like other CBT treatment programs, differs from traditional therapies in several important ways. For example, CBT programs focus on reducing specific symptoms, whereas other types of therapies may focus on processes such as the therapist-patient relationship or seek to understand the historical causes of the problems. These traditional therapies are often less structured, and the agenda is driven by what the patient wants to talk about from session to session. By contrast, the CBT therapist exerts a major influence in each therapy session because many CBT programs, including PE, follow detailed protocols that specify the content and the techniques to be utilized in each session. Thus non-CBT therapists need to learn not only the specifics of how to conduct imaginal and in vivo exposure, but also how to take an active role in setting the therapeutic agenda, keeping the focus of treatment on PTSD, instructing patients in doing home exercises, and so on.
Based on our own work and a review of the literature, two dissemination models have emerged. In the first model experts provide intensive training as well as continued supervision of the therapists who administer the treatment. In the second model experts provide the intensive initial training of the therapists, but ongoing supervision of the therapists and initial training new therapists are provided by local supervisors who consult with the experts but, over time, become experts themselves.
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