1 - (IOP 41) A Systematic Review of Barriers and Facilitators to Implementing Exposure Therapy

Background: Anxiety disorders are prevalent, costly, and increasingly common. Exposure therapy, in which clients gradually face feared situations, is a key active ingredient in the treatment of anxiety disorders. Despite its strong empirical support, exposure therapy is underutilized in routine clinical care, with only 5-40% of clinicians regularly using it. The primary goal of this systematic review was to examine barriers and facilitators influencing the use of exposure therapy.

Methods: We conducted a literature search in PubMed, PsycINFO, and Web of Science between 2021 and 2024. Inclusion criteria included English-language, peer-reviewed, and a focus on anxiety, obsessive-compulsive disorder, or trauma. Studies must have focused on exposure therapy and linked determinants to exposure-related implementation outcome. Studies primarily focused on virtual reality or published before 2001 were not included. Initial search yielded 18,540 articles; 183 articles remained after title/abstract review, and the final sample included 61 articles.

Results: Results were organized by the domains of the Consolidated Framework for Implementation Research. At the individual clinician level, lack of training, negative attitudes, and therapist anxiety hinder exposure therapy implementation. Professional characteristics such as non-CBT orientation, lower post-graduate education, and greater years of experience have been associated with reduced exposure use. Individual client-level barriers included high severity, comorbid conditions, cognitive impairments, or lower motivation. External stressors, including financial limitations, transportation difficulties, and childcare constraints, further restrict client access to exposure therapy. Inner settings factors include a shortage of trained providers, high staff turnover, large caseloads, and limited supervisory support hinder implementation. Policies restricting session length, prohibiting clinicians from conducting exposures outside the therapy room, and inadequate administrative support further limit exposure use. Few studies examined outer setting determinants. Those that did noted payment and reimbursement restrictions, shortages of trained providers, and public mistrust of institutions that provide mental health treatment. Finally, at the implementation process level, therapist training tended to be a facilitator except when it was very brief or did not explicitly focus on skill development.

Discussion: Addressing the barriers identified in this systematic review will require a multifaceted approach, including enhanced training programs, ongoing supervision, institutional policy changes, and structural supports to facilitate exposure therapy delivery in real-world settings. By identifying and addressing these barriers, clinicians and organizations can improve access to this evidence-based intervention and ultimately enhance treatment outcomes for people with anxiety and related disorders. This review highlights key areas for future research and practical strategies to optimize the dissemination and implementation of exposure therapy in diverse clinical contexts.