Why do clinicians exclude anxious clients from exposure therapy?

Despite research demonstrating the effectiveness of exposure therapy for pathological anxiety, this treatment is underutilized by clinicians. Anecdotal evidence and clinical experience suggest that therapists who possess reservations about exposure therapy tend to exclude clients from this treatment based on client characteristics believed to predict worse response. When exceptions are made based on characteristics that do not reliably predict poor outcomes, clients face the opportunity cost associated with investment in less effective treatments. The present investigation assessed therapists' likelihood of excluding clients from exposure due to different client and therapist characteristics. Exposure therapists (N = 182) completed an online survey that included the Therapist Beliefs about Exposure Scale, Anxiety Sensitivity Index-3, and the Broken Leg Exception Scale (BLES), a novel measure assessing the likelihood of excluding clients from exposure based on 25 different client characteristics. The BLES demonstrated good psychometric properties. Client characteristics most likely to result in exclusion from exposure therapy were comorbid psychosis, emotional fragility, and reluctance to participate in exposure. Greater likelihood of excluding clients from exposure was associated with higher therapist anxiety sensitivity and endorsement of negative beliefs about exposure therapy. Clinical and training implications of these findings are discussed.