Therapy involving exposure and exposure with response prevention (ERP) is a key component of cognitive behavioral therapy (CBT) for anxiety and obsessive-compulsive disorders (OCDs) that involves guiding clients in repeatedly facing their feared stimuli in the absence of safety behaviors, rituals, and/or avoidance. Many studies have demonstrated the effectiveness of exposure-based CBT for anxiety disorders and OCD among patients in Western countries,1,2 and exposure-based therapies are considered a first-line treatment for anxiety.3–5
Despite its well-documented effectiveness in the treatment of anxiety disorders, exposure therapy seems to be underutilized6–8 and commonly implemented in a suboptimal manner in the United States and other Western countries.9–11 A study on the implementation of exposure therapy in Germany found that over 80% of clients with OCD reported that their treatment included no exposure component.12 When exposure therapy is used, therapists frequently deliver it in a manner that appears to be cautious, differing significantly from the recommended prolonged and intense manner, and this may limit its effectiveness.11 Few data are available on the implementation of exposure therapy in Eastern countries.
Studies have shown that clinicians’ negative beliefs about the ethics, safety, and tolerability of exposure therapy are related to its underutilization and may play a critical role in its limited delivery.10,13 Deacon et al10 developed the 21-item Therapist Beliefs about Exposure Scale (TBES) in a sample of over 600 practicing therapists (master’s degree or higher, with a broad array of theoretical orientations) and found that the TBES provided an efficient, reliable, and valid assessment of a wide range of therapist beliefs about exposure therapy. Negative beliefs about exposure therapy were associated with therapists’ demographic characteristics, negative reactions to a series of case vignettes involving exposure therapy, and cautious delivery of exposure therapy in the treatment of a hypothetical client with OCD. Furthermore, training in exposure therapy was found to decrease therapists’ negative beliefs about exposure therapy.
Although CBT was introduced in China in the 1980s, fewer than 1000 psychiatrists and psychologists have received systematic and standardized CBT training consistent with established protocols.14 Moreover, although empirical data are lacking, some of the authors’ clinical experience suggests that exposure treatment was not widely accepted by a small but meaningful number of patients. Many Chinese therapists had concerns about performing exposure therapy because of such clinical experience.14 However, after an extensive search of academic search engines (eg, PubMed, PsycINFO), we were not able to identify any studies on the attitudes of Chinese therapists toward exposure therapy. Therefore, the goal of this study was to replicate and extend the findings of Deacon et al,10 by examining the psychometric properties of the Chinese version of the TBES and assessing Chinese therapists’ beliefs about exposure therapy. In addition, the modification of therapists’ beliefs about exposure therapy following a training course was measured. Finally, we sought to examine the relationship between Chinese therapists’ beliefs about exposure therapy and anxiety sensitivity; we predicted that negative beliefs would be associated with higher anxiety sensitivity, reflecting great “angst” about using exposure-based interventional components.
Athough a total of 203 therapists were recruited to complete the survey, only 174 therapists comprised the final sample (ie, 29 participants were excluded, 9 of whom failed to complete all TBES items and 20 of whom had no clinical experience). Of the final sample of 174 therapists, 90 participants completed the survey online (single time-point; www.jiandanxinli.com) and a total of 84 participants completed the survey on paper. Only the 84 participants who completed paper versions of the survey also completed the Anxiety Sensitivity Index-3 (ASI-3)15 and attended a training course on ERP, and only 69 of the 84 participants who completed paper versions of the TBES before training, also completed the TBES after training.
The mean age of participants was 35.6 years (SD=9.4 y), and the majority were women (n=145, 83.3%); 76 therapists (43.7%) reported having a bachelor’s degree (in China, therapists can practice clinically with a bachelor’s degree), 78 (44.8%) reporting having a master’s degree, and 12 (6.9%) reported having a PhD (degree was missing for 8 participants). Of the 174 participants, 83 were psychologists or psychotherapists (47.7%), 55 were neurologists or psychiatrists (31.6%), and 36 (20.7%) did not report their mental health profession. It should be noted that, in China, a physician may have a medical degree with a bachelor’s, master’s, or doctorate degree, as medical school starts immediately after high school. For the purposes of this study, neurologists and psychiatrists who reported having a medical bachelor’s degree were included in the bachelor’s degree category, those with a medical master’s degree were included in the master’s degree category, and those with a medical doctorate degree were included in the PhD category. The mean number of years working as a therapist was 7.6 years (SD=8.4 y), the mean proportion of working time spent providing clinical care was 54.5% (SD=26.7%), and the median caseload of clients with OCD was 5 and with an anxiety disorder was 20. Participants indicated the following theoretical orientations guiding their work: CBT/behavioral therapy (n=83, 47.7%), psychoanalysis and psychodynamic (n=67, 38.5%), humanistic/existential (n=10, 5.7%), and “other” (n=14, 8.0%).
We recruited therapists from 2 cities in China, inviting them to complete a pencil-paper survey, which included demographic information, the TBES, and the ASI-3.15 After a half-day ERP training workshop that focused on the treatment of OCD conducted by a specialist in this field from the United States, participants completed the TBES again. The goal of the workshop was to provide attendees with information about the theoretical underpinnings of ERP, data concerning its efficacy in Western samples, and detailed information about implementation together with considerable role-playing. The mode of instruction was verbal (through a translator) together with viewing videos, translated slides, and written handouts. A postevaluation was completed at the conclusion of the workshop. We also recruited other Chinese therapists to complete an online version of the survey. The study was determined to be exempt by the University of South Florida Institutional Review Board, and completing the measures after reading an information sheet was considered to indicate consent.
The TBES10 is a 21-item questionnaire that assesses therapists’ negative beliefs about the ethics, tolerability, and safety of exposure therapy. Respondents use a 5-point scale ranging from 0 (strongly disagree) to 4 (strongly agree) to indicate their agreement with statements illustrating potential concerns about exposure. Total scores range from 0 to 84, with higher scores indicating more negative beliefs about exposure therapy. The TBES has demonstrated a clear single-factor structure, a normal distribution in a large and diverse sample of North American therapists, and excellent internal consistency (α=0.95) and 6-month test-retest reliability (r=0.89).
Permission was granted from the original authors to translate the TBES. The items were translated from English into Chinese by a professional translator with a background in psychotherapy, and then checked and revised by a senior psychiatrist fluent in both Chinese and English.
The ASI-315 is an 18-item measure that assesses individuals’ fear of their own anxiety reactions based on beliefs about their harmful consequences. The ASI-3 has three 6-item subscales that assess physical, social, and cognitive concerns. Respondents indicate their agreement with each item on a 5-point scale ranging from 0 (very little) to 4 (very much). Subscale scores range from 0 to 24 and total scores from 0 to 72, with higher scores indicating higher anxiety sensitivity. The scale has demonstrated good internal consistency (α=0.87) and criterion validity. The Chinese version of the ASI-3 has also shown great internal consistency (α=0.95), test-retest reliability (r=0.86), and criterion validity.16
A descriptive analysis was conducted to examine the demographic characteristics of the study participants and their TBES scores. The Kolmogorov-Smirnov test was used to examine whether the distribution of TBES scores was normal. Spearman correlation was used to examine the item-total and interitem correlations of the TBES. The internal consistency of the TBES was examined by computing the Cronbach α. A factor analysis using Varimax rotation was conducted to determine the factor structure of the 21-item TBES. Analysis of variance was used to assess the concurrent validity of the TBES. A 1-sample t test was used to assess the difference between the total TBES scores of the Chinese and American10 samples. Test-retest reliability of the TBES between pre-ERP and post-ERP workshop assessments was examined using Pearson correlation. A paired-samples t test was used to assess the difference between pre-ERP and post-ERP workshop TBES scores. Statistical analyses were conducted using SPSS 20.0. A 2-tailed value of P<0.05 was considered statistically significant.
Psychometric Properties of the TBES
The mean total TBES score was 42.79 (SD=7.81, range=19 to 63). The internal consistency of the TBES was acceptable (α=0.81). A Kolmogorov-Smirnov test indicated that the distribution of TBES scores was not significantly different from a normal distribution, z174=0.70, P=0.71. The 21-item TBES showed adequate item-total correlations (M=0.45, range=0.23 to 0.66), but low interitem correlations (M=0.20, range=0.11 to 0.30). Two items (2 and 12) yielded item-total correlations <0.30.
Kaiser-Meyer-Olkin (KMO) and Bartlett tests showed that the data were suitable for factor analysis (KMO=0.75, P<0.00). A principal component analysis was conducted to determine the factor structure of the 21-item TBES. The first 8 eigenvalues were 4.65, 2.12, 1.57, 1.39, 1.22, 1.06, 1.01, and 0.90. Examination of the screen plot indicated a better 5-factor solution that accounted for 52.14% of the TBES item variance. Table 1 presents the descriptive statistics for each TBES item as well as communalities and factor loadings for the 5-factor model. All items had salient (≥0.40) loadings on the 5 factors (range=0.45 to 0.76), which suggests that the 5-factor model accounted for a moderately large portion of the variance in most items. However, the factor structure was fairly scattered with no theoretically relevant groupings of items lending itself to developing factor scores.
Correlations Among the TBES, Demographic Variables, and Anxiety Sensitivity
Scores on the TBES were not significantly correlated with years working as a therapist (r=−0.03, P=0.68), age (r=−0.01, P=0.92), proportion of time spent working in clinic (r=−0.13, P=0.09), caseload of clients with anxiety disorders (r=−0.08, P=0.29), or caseload of clients with OCD (r=−0.135, P=0.086). TBES scores did not differ significantly between female therapists (M=42.6, SD=7.84) and male therapists (M=43.7, SD=7.71), t173=0.71, P=0.48. There were no significant differences in TBES scores associated with therapists’ education (F=0.43, P=0.73), profession (F=0.56, P=0.57), or theoretical orientation (F=1.9, P=0.13). TBES scores in our study were significantly higher than those found in the American sample as reported by Deacon et al10 (M=34.0, SD=17.5), t173=14.84, P<0.001, indicating more negative beliefs about exposure therapy in the Chinese sample.
Correlations between scores on the TBES and scores on the ASI-3 were not significant, both for ASI-3 total scores (r=0.01, P=0.92), and scores on the ASI-3 subscales for physical concerns (r=0.07, P=0.54), cognitive concerns (r=−0.01, P=0.91), and social concerns (r=−0.02, P=0.86).
Changes in TBES Scores Following the ERP Training Course
Among the 69 therapists who completed the survey after attending the training course, the correlation between TBES scores in the 2 assessments was 0.55 (P<0.001). Total TBES scores after the training course (M=30.2, SD=11.5) were significantly lower than in the original assessment (M=40.6, SD=7.5, t68=−8.90, P<0.001, d=1.07), and lower than the scores in the American sample10 (M=34.0, SD=17.5, t68=−2.75, P=0.008, d=0.26).
The reduction in TBES scores after training was received was not significantly correlated with years working as a therapist (r=−0.13, P=0.32), age (r=−0.03, P=0.84), proportion of working time spent in the clinic (r=−0.096, P=0.44), and caseload of clients with anxiety disorders (r=−0.25, P=0.05), but it was significantly correlated with the caseload of clients with OCD (r=0.40, P=0.002). There was no significant difference in reduction in TBES scores between female therapists (M=10.4, SD=9.6) and male therapists (M=9.9, SD=10.4), t67=−1.63, P=0.87, or on the basis of therapists’ education (F=2.4, P=0.08), profession (F=0.02, P=0.98), or theoretical orientation (F=0.82, P=0.487).
Correlations between the reduction in TBES scores and ASI-3 scores were not significant, both with ASI-3 total scores (r=.03, P=0.83) as well as scores on the ASI-3 subscales for physical concerns (r=0.09, P=0.46), cognitive concerns (r=−0.10, P=0.41), and social concerns (r=−0.09, P=0.47).
The purpose of this study was to examine the psychometric properties of the Chinese version of the TBES and evaluate Chinese therapists’ beliefs about ERP therapy. The scale demonstrated adequate internal consistency, moderate item-level psychometric properties, and a normal distribution in the sample of Chinese therapists. TBES scores were not related to therapists’ demographic characteristics or ASI-3 total and subscale scores. Nevertheless, Chinese therapists’ TBES scores were considerably higher than those in an American sample,10,11 indicating more negative beliefs about the implementation of exposure therapy. Moreover, TBES scores decreased significantly after participants attended an ERP training course although they still remained somewhat high, suggesting that more in-depth training may be needed. It is possible that a Chinese cultural framework related to support, nurturance, and healing17 is partially in conflict with ERP since this type of therapy does initially (and temporarily) increase anxiety in patients. Furthermore, the reduction in TBES scores was significantly correlated with therapists’ caseload of clients with OCD; we speculate that clinicians who treat OCD have more malleable beliefs about the safety, tolerability, and ethicality of exposure therapy. This finding indicates the need for increased training in providing exposure therapy to OCD clients to decrease providers’ negative beliefs about exposure therapy.
Deacon et al10 found that lower TBES scores were associated with younger age, male sex, PhD-level education, and scores on the ASI-3 physical concerns subscale. However, in our study, negative attitudes toward exposure could perhaps be attributable to more limited training concerning this treatment modality.18 Chinese therapists had more negative beliefs about exposure than did American therapists, which highlights the importance of disseminatng information about exposure therapy.14 Indeed, many studies in Western cultures have identified clinicians’ negative beliefs as a critical barrier to the propagation of exposure therapy.19–22 For example, a recent study found that a more positive attitude toward exposure therapy and less use of relaxation strategies were associated with greater use of exposure among American clinicians.23 Conversely, one study experimentally induced negative or positive beliefs about exposure therapy among American therapists who had received training in basic exposure implementation; in this study, the therapists with negative beliefs delivered the treatment more cautiously.10 Suboptimal implementation of exposure therapy has important clinical implications. Illustrating this, a randomized controlled trial indicated that low-intensity interoceptive exposure (ie, exposure to anxiety-provoking internal stimuli such as rapid heart rate) was less effective in reducing the fear of anxiety-related body sensations compared with a more intensive exposure-based intervention.9 Therefore, if clinicians who have significant concerns about exposure therapy deliver it with excessive caution, the overall effectiveness of the treatment is likely to be undermined.11 Consequently, strategies need to be developed to address therapists’ concerns about exposure therapy and thus increase its use so that more clients can receive standardized valid treatment.
Fortunately, our study found that negative beliefs about exposure therapy were significantly reduced after the ERP training course, a finding that was consistent with those of previous studies.9,11,20,21,24 However, the reduction in negative beliefs observed in our study was less than reductions reported in other studies.9 It is possible that Chinese therapists’ beliefs about exposure, because of their greater magnitude, may take more effort to change relative to the beliefs of therapists in the United States; this may pose a significant barrier to the dissemination of ERP treatment in China. We also found that a greater reduction in negative beliefs was related to having a higher caseload of clients with OCD. Therapists with clinical treatment experience with OCD may have a better understanding of exposure and be more responsive to training than those with more limited experience with OCD/anxiety.
Our study had several limitations. First, the sample size was not large enough to determine the best fitting structure for the TBES. Second, we only examined the internal reliability of the scale; test-retest reliability was not investigated. Third, even though this study found that therapists’ concerns about exposure therapy could be modified through training, factors such as the content and quality of the training and therapists’ intentions to utilize ERP clinically in the future that could have influenced the therapists’ concerns were not examined. Fourth, the heterogeneity of the clinicians who participated in our study challenges the generalizability of our findings to specific groups. It is possible that group differences may exist as a function of certain variables that we were not powered to examine (eg, clinicians’ theoretical orientation). Finally, only therapists who were interested in learning more about exposure therapy were included. Those who were not interested and did not attend may have more resistance to exposure therapy.
In summary, the study supports the reliability of the Chinese version of the TBES. Chinese therapists had more negative beliefs about exposure than American therapists; however, therapists’ negative beliefs decreased significantly after attending an ERP training course. Qualitative research on therapists’ views of ERP would be helpful, particularly to understand why the initial ratings on the TBES in the Chinese sample were higher than in an American sample and why the decline in scores on the TBES was lower after training than expected. Our study suggests that there are barriers to the dissemination of exposure therapy in China, especially therapists’ concerns about utilizing the treatment, yet our findings also highlight the need for increased education and training concerning ERP in China. Future studies need to explore effective strategies to improve the dissemination and delivery of exposure therapy in order to make this potent intervention more accessible to individuals with anxiety.
The authors acknowledge Xi Chen for her assistance.
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