Bryan Caplan  

Why Don't More Therapists Use Exposure Therapy?

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At least according to the Handbook of Exposure Therapies, exposure is the most effective treatment for anxiety, OCD, post-traumatic stress, and similar problems.  But most therapists don't use it.  If you're a health economist, it's only natural to wonder why.  The Handbook has a whole chapter that tries to explain why best practice fails the market test.  It begins by observing that:
First, the majority of therapists simply do not use evidence-based treatments such as exposure therapy, even when they are aware of their existence.  Second, implementing exposure therapy in an effective or optimal manner is often easier said than done.
The chapter goes on to blame under-use on - and debunk - three "common myths" among practitioners:
(1) participants in randomized trials are easy, straightforward treatment cases with a single diagnosis and no significant comorbidity; (2) the result of treatment outcome studies, based on these simple, rarified samples of patients, will not generalize to real-world outcomes; and (3) exposure can be harmful, and will make people worse, or cause them to dropout from treatment.
I suspect that most economists would focus on the demand side.  Maybe patients think that the exposure cure is worse than the anxiety disease.  But this explanation doesn't seem to work.  Therapy dropout rates are roughly 20%-25% for all the main treatments.  In 25 controlled trials of post-traumatic stress treatments, for example, "The average dropout rate was 20.6% for exposure-only treatments, 22.1% from cognitive therapy and anxiety management conditions, 26% from combinations of exposure and cognitive therapy or anxiety management, and 18.9% from EMDR."

The authors of the chapter focus instead on the supply side, blaming under-use on, "lack of training (or inadequate training), therapist dislike of manualized treatments, and therapist fears that exposure therapy will have harmful effects" - and citing "lack of training" as the primary problem.  But this isn't a very satisfying explanation.  They're trained in something; why not this?

I'm not sure what's going on either, but here's my best guess.  Therapists, like other doctors, have a lot of slack because patients trust them and - as long as they're insured - don't worry much about costs.  Under the circumstances, it's only natural for therapists to focus on techniques that they enjoy, and not worry too much about what actually works.  And if one thing comes through the Handbook, it's that exposure therapy is ugly to watch.  It's a lot more pleasant to spend an hour empathizing with a patient than pushing him to face his fears.  And if, as a side effect, your patients keep coming back because they still feel anxious, even better.


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COMMENTS (11 to date)
Prakhar Goel writes:

Handbook of Exposure Therapies...on exposure therapy.

Clearly no conflict of interest there.

Ted Craig writes:

Because their economic model is to keep patients in treatment indefinitely. Because if you put somebody on medication, you have them locked in for at least a year, theoretically. Because many patients don't really want to be cured.

Justin Martyr writes:

Research on the brain's neuroplasticity is challenging exposure therapy. Exposure therapy does work, but it can be traumatic. For example, in some extreme cases OCD patients have been advised to rub feces on their face and hair.

Neuroplastic techniques go to the root of the issue. The slogan is "neurons that fire together wire together". Even more simply "use it or lose it." What you need to do is let the unhealthy neural maps wither away as those neurons are repurposed for other things.

Interestingly enough, psychologists who study neuroplasticity are about the only group of people other than conservative Christians and feminists who think porn is bad. On the "neurons that fire together wire together" principle, people who view a lot of porn create larger and more novel neural maps that wire random parts of the brain to sexuality.

Ted Craig writes:

This short film sums things up nicely:

http://www.youtube.com/watch?v=vso9iPIpeu8

Doc Merlin writes:

If they actually cure patient, they lose their money cow.

Joel Schneider writes:

Having done exposure therapy with patients and having supervised beginning therapists trying to implement exposure therapy, I can say that it is often unpleasant for all involved. Both patient and therapist can delay treatment for months by talking about other things and trying to solve other problems. The other problems are always important and there is always a legitimate case to be made that it is the priority for today's session.


Although I don't buy all of the theoretical explanations for why it works, the variant of exposure therapy called EMDR seems to reduce somewhat the barriers to facing fears.

Rob Sperry writes:

This seems to fall under a wider category: Things that have lots of evidence that they work to solve important problems, but that are greatly underutilized.

Other instances:
Direct Instruction
Medical Checklists
H.O.P.E Probation program

Why don't these things spread faster?

So Brian as an educator how much Direct Instruction do you do?

Robin Hanson writes:

Your explanation makes sense to me.

Robert Speirs writes:

What would we say about a real doctor who refused to treat a patient with a real disease using a medicine or technique that cured the disease because he didn't enjoy, say, cutting off the patient's gangrenous leg?

q writes:

most? probably a lot of therapy is similar to "exposure therapy" (or incorporates similar elements) but goes by a different name. i guess you aren't counting any of that as exposure therapy.

so you are not breaking 'therapy' into the things that make up therapy, you are just relying on therapists' classifications of what they do.

i would think if you want to steer therapists you would analyse what they do and steer them. but you're not doing that. you're on the phone to the billing department and administrators and so on and so on, twisting arms.

Dave Halsey writes:

Exposure therapy works on any big ticket anxiety, fear, phobia, or PTSD. Tons of research supports exposure. Exposure doesn't have to be terribly uncomfortable at the outset. Gradual exposure or relaxation methods are used. People can use the Dive Reflex which will rapidly shut down flight/fight overwhelm. People do not have to get up and run
out of exposure therapy sessions like some may have 30 years ago. Exposure therapy whether it's Prolonged Exposure, the Emo Reviewer (A written exposure method), the Counting Method or so forth
really do the job on complex and very painful PTSD.

Here are descriptions of the Dive Reflex, a vagus nerve relaxation method, used to rapidly shutdown flight/fight overwhelm:
http://www.emoclear.com/thedivereflex.htm

Here is the written exposure method the Emo Reviewer: http://www.emoclear.com/emoreviewer.htm

Descriptions of Foa's Prolonged Exposure and Ochenberg's Counting Method can be found on the net.

Many war vets have been helped by exposure. They don't wake up with flashbacks and their lives
improve drammatically.

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