Disseminating exposure therapy

Sandra:

You have raised a whole bunch of good questions. We have struggled with some of them, and others are still on the back burner. We don't have any good empirical answers yet, but we are actively involved in researching how we can go about disseminating exposure therapy, how much initial training is required, how much continued supervision is needed, can agencies develop their own training and supervision practices that will insure adequate treatment fidelity, what proportion of patients comming through the doors would be appropriate for this kind of treatment, etc. etc. etc.

I would pose a similar question to you: Despite all the effort that goes into the dissemination of EMDR, are there any good data as to how well and how often people who have gone through Phase I and Phase II training administer EMDR?

Moreover, the same questions are appropriate for any specialized treatment for trauma, such as cognitive therapy and stress inoculation training (SIT). I actually find these last two treatment MORE difficult to implement than exposure therapy. With cognitive therapy, patients tend to run circles around me. By the end of an attempt to help them restructure their cognitions, I end up pretty much in agreement with their original beliefs.

My difficulty with SIT is a conceptual one, I believe in my heart of hearts that "managing anxiety" is just a fancy way of managing to avoid unpleasant thoughts and feelings. In that regard, the procedures are antithetical to my conceptual understanding of PTSD. Therefore, I know that SIT works, but I don't understand how it works (or how I think it works). As such, I don't have a roadmap for implementing it. I have to administer it strictly by the book, rather than really having a grasp of the method intellectually as well as procedurally. So I'm less effective (clinical opinion, not fact) in applying SIT to challenging cases that don't present exactly the way the manuals describe.

With exposure therapy, I have a deeper understanding of the the change priciples we think are involved and a much better understanding of the parameters of effective exposure. There are no studies of what are the boudnary conditions of SIT. As such, I feel much more competent to utilize exposure in a wider range of situations.

Finally, exposure is a useful tool for every anxiety condition. So when you learn to do it correctly, you are in a position to treat phobias, panic, PTSD, OCD, and social anxiety. At this point, there is no other treatment with evidence for efficacy across such a wide spectrum of DSM diagnoses. EMDR has its strongest data for PTSD, a little data for panic, and some contentious data on phobias. That is it.

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