Exposures for anxiety: A survey of practicing school psychologists

Abstract

Despite robust evidence supporting exposure‐based interventions for anxiety disorders in youth, these treatments are often underutilized, implemented with low fidelity, and delivered in an unnecessarily cautious manner. Few studies have examined important implementation variables (e.g., knowledge, training, perceptions) related to using exposures in schools. A national sample of school psychologists (N = 318) working in K‐12 public schools reported on their knowledge, training, perceptions, confidence, and use regarding exposures. Over 50% of respondents reported they do not use exposures. Only slightly more than half of the respondents received training in exposures through graduate coursework. Eighty percent endorsed negative beliefs about exposures, with nearly 50% expressing concern about acceptability of the intervention by parents. Barriers to delivering exposures within schools endorsed included inadequate time (79% of sample), training (61%), and access to training materials (51%). Implications for training, practice, and research in school psychology are discussed.

Full text

Received: 15 September 2023
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Revised: 6 February 2024
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Accepted: 10 April 2024
DOI: 10.1002/pits.23208
RESEARCH ARTICLE
Exposures for anxiety: A survey of practicing
school psychologists
Sheva Weiss
1
|Elisa S. Shernoff
1
|Adam Lekwa
1
|
Jeffrey Shahidullah
2
1
Graduate School of Applied and Professional
Psychology, Rutgers University, Piscataway,
New Jersey, USA
2
UT Health Austin Pediatric Psychiatry at Dell
Children's, Austin, Texas, USA
Correspondence
Sheva Weiss, Graduate School of Applied and
Professional Psychology, Rutgers University,
152 Frelinghuysen Rd., Piscataway, NJ
08854, USA.
Email: sc1716@gsapp.rutgers.edu
Abstract
Despite robust evidence supporting exposure‐based inter-
ventions for anxiety disorders in youth, these treatments are
often underutilized, implemented with low fidelity, and
delivered in an unnecessarily cautious manner. Few studies
have examined important implementation variables (e.g.,
knowledge, training, perceptions) related to using exposures
in schools. A national sample of school psychologists (N= 318)
working in K‐12 public schools reported on their knowledge,
training, perceptions, confidence, and use regarding expo-
sures. Over 50% of respondents reported they do not use
exposures. Only slightly more than half of the respondents
received training in exposures through graduate coursework.
Eighty percent endorsed negative beliefs about exposures,
with nearly 50% expressing concern about acceptability of
the intervention by parents. Barriers to delivering exposures
within schools endorsed included inadequate time (79% of
sample), training (61%), and access to training materials (51%).
Implications for training, practice, and research in school
psychology are discussed.
KEYWORDS
anxiety, behavior therapy, exposures, school mental health, school
psychology practice
Psychology in the Schools. 2024;61:3102–3120.3102
|
wileyonlinelibrary.com/journal/pits
This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which
permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no
modifications or adaptations are made.
© 2024 The Authors. Psychology in the Schools published by Wiley Periodicals LLC.

Practitioner Points
•This study documents school psychologists' training in
and experiences with using exposures, a critical inter-
vention component to address anxiety.
•The majority of school psychologists in the sample
reported at least some knowledge and training with
exposures, though the quality of training was identified
by many as suboptimal.
•The majority of school psychologists expressed limited
confidence in their ability to effectively deliver expo-
sures in school and more than half the sample endorsed
never using exposures in schools. This study informs
future directions for training of school psychologists.
1|EXPOSURES FOR ANXIETY: A SURVEY OF PRACTICING SCHOOL
PSYCHOLOGISTS
Anxiety disorders are commonly diagnosed among US school‐aged children, with recent estimates indicating that
32% of adolescents have an anxiety disorder (Merikangas et al., 2010). Depression and anxiety among US youth
were on the rise in the two decades preceding the Covid‐19 pandemic (Mojtabai et al., 2016). The Covid‐19
pandemic exacerbated rates of internalizing problems, and particularly generalized anxiety, social anxiety, panic, and
depression among youth (e.g., Hawes et al., 2022). When left untreated, anxiety disorders often lead to significant
impairment and distress and contribute to the development of chronic medical conditions (Scott et al., 2016),
substance use (Groenman et al., 2017), suicidality (Nepon et al., 2010), reduced educational attainment (Dalsgaard
et al., 2020), and economic burden (Insel, 2008; see Pollard et al., 2023 for a comprehensive review).
In the context of the concerning rise in anxiety and depression among US youth, many children and adolescents
face barriers to accessing mental health services in community mental health centers due to long waitlists, financial/
insurance limitations, transportation and scheduling barriers, and stigma (Radez et al., 2021). As such, schools are de
facto settings for delivering mental health services with 88% of treatments for school‐aged children delivered in
schools (Merikangas et al., 2011). Further, school‐based mental health services constitute the sole sources of
treatment for many children (Farmer et al., 2003). Fortunately, the school environment poses advantages for
delivery of exposures, given that anxiety frequently manifests within schools and impacts social functioning and
academic engagement and performance (Mychailyszyn et al., 2011). School‐based providers have the opportunity
to address students' challenges in contexts that matter, thus increasing the generalizability of treatment.
Among school‐based mental health providers, school psychologists are uniquely qualified to provide mental
health services given their knowledge of behavioral health interventions, instruction, child development, and the
intersection of education and mental health (e.g., Eklund et al., 2020; Shernoff et al., 2017). School psychologists are
often the primary mental health providers for youth (e.g., Simon et al., 2015). Furthermore, the provision of mental
and behavioral health services has been identified as a key practice area for school psychologists (National
Association of School Psychologists, 2020). Although school psychologists may be seen as uniquely qualified to
provide evidence‐based interventions (EBIs) to address anxiety, little is known regarding the extent to which school
psychologists have the knowledge and skills to implement a crucial component of anxiety treatment—exposure‐
based interventions (hereafter referred to as “exposures”).
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Among hundreds of clinical trials and several meta‐analytic reviews, exposures have been found to be an effective
component of anxiety treatments (Abramowitz et al., 2019; Chorpita et al., 2005; Deacon & Farrell, 2013). Chorpita et al.'s
(2005) landmark distillation and matching study, for example, found that exposures were included in 80% of evidence‐
based treatments for youth with anxiety. Manualized treatments, including Coping Cat (Kendall & Hedtke, 2006), Brief
Coping Cat (Beidas et al., 2013; Crawley et al., 2013), and Social Effectiveness Training for Children (Beidel et al., 2000)all
include exposures. In addition, transdiagnostic approaches, which consolidate conceptually similar treatment strategies that
appear across different treatments (e.g., Weisz & Bearman, 2020) and modular approaches to treating children and youth
(Chorpita & Weisz, 2009) also include exposures to treat anxiety, posttraumatic stress, and obsessive‐compulsive disorders.
The mechanism of change related to exposures is well documented (Chu et al., 2014; Kendall et al., 2005).
Exposures encourage individuals to repeatedly and systematically approach rather than avoid a feared stimulus
(Chu et al., 2014). Avoiding distressing situations influences the development and maintenance of anxiety disorders
(Chu et al., 2014) and manifests behaviorally (e.g., avoiding anxiety‐provoking situations) and cognitively (e.g.,
avoiding distressing thoughts, distraction). Avoidance can be adaptive in the presence of realistic threats but
becomes problematic when it persists in the absence of real danger. Avoidance can reduce anxiety in the moment,
but over time prevents individuals from the corrective experience of their anxiety naturally rising and falling
(Peterman et al., 2019). Avoidance also reinforces the original cognitive distortion that danger is present. Through
exposures, individuals can habituate to a feared stimuli (e.g., speaking in public) and experience corrective learning
(e.g., “My worst fears do not come true when I have to talk in class”).
1.1 |Use of exposures
The gap between research (i.e., randomized controlled trials demonstrating efficacy) and practice (i.e.,
implementation in real‐world settings) of EBIs is quite glaring, especially regarding treatment of anxiety via
exposures. Some studies have found that exposures are underutilized, implemented with low fidelity, and delivered
in an unnecessarily cautious manner (Deacon, Farrell, et al., 2013; Higa‐McMillan et al., 2016). This finding holds
even for clinicians trained in cognitive behavior therapy, who presumably would have been trained to implement
exposures during their graduate training (e.g., Chu et al., 2014).
Research has also examined variables that influence practitioners' use of exposures and potential barriers to
implementation. For example, Becker‐Haimes et al. (2017) found that clinicians' (N= 335) attitudes toward exposures
significantly predicted their use of exposures. Although we are unaware of studies that specifically examine school
psychologists' use of exposures in schools, research has examined school psychologists' use of EBIs broadly (e.g.,
Forman et al., 2009; Hicks et al., 2014; Shernoff et al., 2003). In a study by Hicks et al. (2014), 392 school
psychologists were asked to rate their knowledge, training in, and use of various EBIs. When averaging across the
EBIs, 89% reported using them rarely or never. Notably, school psychologists in this sample reported limited use of
protocols that incorporate exposures as a treatment element. Specifically, 77% reported they “rarely/never”utilize
Coping Cat and underutilize Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Jaycox et al., 2012).
The following sections will review factors that influence the use of EBIs in schools, including training,
knowledge, confidence, and perceptions. These factors related to implementation and motivation to change are
drawn from implementation science and social cognitive theories. Both these frameworks are optimistic in their
views of behavioral change, asserting that behaviors are not fixed and are closely linked to intentions and
motivation to change (see theory of planned behavior; Birken et al., 2020). Both frameworks underscore the
importance of training and knowledge as critical predictors of personal factors or attributes such as attitudes,
perceptions, and efficacy beliefs, which in turn influence behavioral practices (Bandura, 2001; Godin et al., 2008).
Given our interest in behavior as it relates to use of exposure, the goal of this study was to examine, among a
sample of practicing school psychologists, the type and quality of training, knowledge, confidence, perceptions, and
use of exposures.
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1.2 |Training and knowledge in exposures
Knowledge of therapeutic practices refers to awareness of a practice, familiarity with appropriate
implementation, and an understanding of the theoretical underpinnings of how a practice works (Rogers, 2010).
Although knowledge alone does not necessarily yield behavior change, it provides a foundation for
psychologists to then develop confidence and practice with the intervention, allowing for the possibility of
increased use (e.g., Baker et al., 2021; Schunk et al., 2014). Studies on transfer of training highlight that
knowledge is an important component of implementing new technologies with fidelity (Owens et al., 2017).
Forman et al. (2009) noted that school psychologists are more likely to use effective practices when they
perceive that they have adequate knowledge. However, school psychologists have been reported to have gaps
in their knowledge of EBIs. For example, Hicks et al. (2014) surveyed school psychologists regarding their
knowledge of EBIs and found that over half the sample endorsed being “not familiar”with manualized anxiety
treatments that include exposures.
Adequate training is conceptualized as a critical predictor of use of EBIs in school and clinical settings
(Hicks et al., 2014;Shernoffetal.,2003). Training is a primary means for increasing knowledge (Forman
et al., 2013) and is associated with improvements in attitudes, comfort, self‐efficacy, and delivery of EBIs (e.g.,
Hicks et al., 2014; Shernoff et al., 2017). A recent meta‐analysis found a large, positive effect of training on
mental health providers' knowledge of exposures (d
+
[sample weighted average effect size] = 1.18), attitudes
toward exposures (d
+
= 0.84), and self‐efficacy in delivering exposures (d
+
= 0.72; Trivasse et al., 2020). In
addition, meta‐analytic results indicated medium effects of training on providers intent to use exposures
(d
+
= 0.41) and actual use of exposures (d
+
= 0.35).
Despite training being associated with use of EBIs, studies of practitioners in community settings reveal
insufficient training in exposures. Becker et al. (2004), for example, in a sample of 207 licensed psychologists, found
that only 27% reported receiving training in in‐vivo exposures and only 29% in imaginal exposures. Notably, only
8% of the sample reported receiving training in imaginal exposures during graduate school and 59% of the sample
reported that limited training was the largest obstacle to delivering exposures. Uneven training in exposures could
contribute to limited use of this practice element in community settings.
Contemporary research in school psychology paints an encouraging picture regarding general training in EBIs.
Reddy et al. (2017), for example, surveyed 460 school psychology trainers regarding evidence‐based assessment
and intervention, and 75% of respondents indicated all students take at least one course in EBIs. In addition, 96% of
the sample indicated their program offered elective courses in EBIs. Respondents also reported very favorable
ratings regarding training in EBIs and administrative support for these courses. Additionally, Hicks et al. (2014)
found that 42% of respondents who graduated within the last 5 years indicated sufficient training in EBIs in
contrast to 22% of respondents who graduated more than 5 years ago. Although these findings are encouraging
regarding broad training in EBIs, less is known regarding practicing school psychologists' training specifically in
exposures, a gap in the literature this study was designed to address.
1.3 |Confidence and perceptions regarding exposures
Confidence includes comfort and a sense of self‐efficacy regarding one's ability to successfully engage in a
particular behavior or action (Bandura, 2001). The issue of comfort is particularly salient to the delivery of
exposures; the process of exposing clients to distress may evoke secondary discomfort in clinicians and may
therefore result in reluctance to deliver exposures (Castro & Marx, 2007). The discomfort associated with
implementing exposures has been found to impede its delivery, even among behaviorally oriented clinicians. For
example, Pittig et al. (2019) found that 37% of behaviorally trained clinicians (N= 684) reported their delivery of
exposures was hindered by the strain and distress associated with providing the intervention.
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A sense of self‐efficacy is influenced by prior performance which in turn can influence future beliefs
regarding performance (e.g., “I was able to implement that exposure intervention effectively with my student.
Next time I meet with that student, I am confident I can support the student to practice a skill higher on the fear
hierarchy”). Helping psychologists develop self‐efficacy in using exposures in schools is crucial given exposure
is a complex practice element that includes multiple component parts. However, if school psychologists avoid
using exposures given the discomfort involved, their opportunities for developing self‐efficacy in their
exposure skills will be limited.
Research suggests that self‐efficacy may mediate the relationship between training and use of an intervention.
One study with a sample of social workers (N= 174) found that participants' self‐efficacy after participation in an
evidenced‐based parent training program significantly predicted use of the program (Shapiro et al., 2012). In
another study, school psychologists' (N= 405) training in applied behavior analysis (ABA) predicted increased use of
ABA, and self‐efficacy mediated the relationship between training and use of ABA (Runyon et al., 2018). Although
existing studies highlight the influence of self‐efficacy on implementation of EBIs, self‐efficacy regarding use of
exposures has yet to be examined among school psychologists. Thus, another goal of this study was to address this
gap in the literature by surveying school psychologists regarding their confidence in delivering exposures for youth
in schools.
Prior research also points to the important role that perceptions play in the use of EBIs. Perceptions refer
to attitudes toward interventions and beliefs about obstacles to implementation, effectiveness, and ethicality
(Aarons et al., 2010;Redingetal.,2014). Perceptions of EBIs and exposures have been shown to predict rates
and fidelity of implementation of these interventions (Aarons, 2004;Aaronsetal.,2010;Beckeretal.,2004;
Reding et al., 2014). School psychologists' perceptions of exposures as being harmful, unethical, or not well
suited to the context of schools have implications for scaling up EBIs in schools. Prior research highlights that
exposures may suffer from a “public relations problem”(Richard & Gloster, 2007, p. 409); that is,
clinicians hold negative often unfounded beliefs about exposures (e.g., exposures are harmful, rigid,
insufficient to address complex cases, increase the risk of malpractice lawsuits, and are likely to result in high
rates of attrition; Cook et al., 2004;Feenyetal.,2003). Additionally, clinicians may feel that intentionally
provoking distress in clients is against the APA's Ethical Principles of Psychologists and Code of Conduct
(2002) of “do no harm”(Gola et al., 2016) in light of the inevitable distress that exposures evoke within
clients.
Although we are unaware of studies specifically examining school psychologists' perceptions regarding using
exposures, it is plausible that school psychologists may hold negative attitudes toward using this strategy in schools,
given exposures are complex and time intensive, and thus could be conceptualized as incompatible with the
complex nature of schools (Forman et al., 2013). In the current study, we were interested in examining school
psychologists' beliefs regarding perceived effectiveness, consequences, and ethicality of using exposures in addition
to their beliefs regarding barriers to implementing exposures in schools. This information can inform training and
whether traditional exposures require tailoring to fit within the context of schools.
1.4 |Research questions
This exploratory survey study examined practicing school psychologists' training, knowledge, perceptions,
confidence, and use of exposures for anxiety. We sought to answer the following research questions: (1) What
is the type and quality of training that school psychologists receive in exposures? (2) What is the extent of
school psychologists' knowledge of exposures? (3) What are school psychologists' perceptions and confidence
regarding using exposures for anxiety in schools? and (4) How frequently do school psychologists use
exposures?
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2|METHOD
2.1 |Participants
The sample included N= 318 practicing school psychologists in K‐12 public schools in the United States. Inclusion
criteria included being a practicing school psychologist in the United States. With regard to demographic
characteristics, the final sample included 85% female, 14% male and 1% other. Ninety‐one percent of respondents
had attended school psychology training programs and the remaining participants had attended counseling
psychology or combined clinical‐school psychology training programs. Forty‐four percent of the sample had earned
an EdS, 25.7% had earned an MA, 18.6% earned a PhD, 10.4% earned a PsyD and 1% earned an EdD. Thirty‐six
percent of respondents were licensed psychologists (see Table 1).
2.2 |Procedures
Institutional Review Board approval was obtained before conducting the study. Fifty state‐level school psychology
professional organizations and 197 school psychology program directors were emailed with a request they forward
the survey link to practicing school psychologists. The email contained instructions to complete the voluntary,
confidential survey and a link to access the online survey (using Qualtrics). Although we did not request
confirmation of email receipt, 21 state associations and 30 program directors indicated they had disseminated the
link via state association websites, social media pages, professional newsletters, and alumni listservs. The first
author also posted the survey on various social media platforms, including school psychology Facebook pages. To
increase the response rate and reduce nonresponse bias, respondents could opt into a raffle to win gift cards.
2.3 |Instrumentation
Survey items were developed via an iterative process. First, a review of the literature determined variables
associated with implementation of exposures. Second, after the initial survey items were developed, two experts in
the field of anxiety and exposures provided feedback on the survey items and made suggestions for additional
items. Third, the survey was piloted with a sample of school psychology graduate students and revised based on
feedback. The survey took approximately 10 min to complete and consisted of the following sections.
2.3.1 |Training and knowledge in exposures
The knowledge domain was comprised of seven items and reliability—determined by the omega coefficient—was
deemed adequate (ω= .76). One item assessed general knowledge of exposures rated on a four‐point scale (0 = not
at all to 3 = very) and one item focused on familiarity with theories that guide exposures for anxiety rated on a four‐
point scale (0 = very unfamiliar to 3 = very familiar). Five items assessed familiarity with treatment protocols that
incorporate exposures for anxiety rated on a four‐point scale (0 = no knowledge to 3 = comprehensive understanding).
In addition to the knowledge domain, one forced choice response question asked respondents to indicate their
beliefs regarding the primary goal of exposures (i.e., eliminating anxiety, increasing confidence to manage anxiety,
reducing physiological hyperarousal, improving emotion regulation, or other goal).
The training domain included 12 items focused on the type, helpfulness, and quality of training in exposures. Seven
items assessed whether respondents had received various types of training (e.g., required course in graduate school,
clinical internship, postdoctoral fellowship) and whether they found the trainings helpful. These seven items were rated
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TABLE 1 Demographic data.
Domain
Current sample NASP membership
a
%n%
Gender
Female 85 238 84
Male 14 39 15
Nonbinary or not described 1 4 0.5
Years in practice
b
M= 10.3 (SD = 9 years) M= 12.2 (SD = 10 years)
0–5
c
40 112 30
6–10 20 55 16
11–15 15 41 14
16+ 25 69 28
Highest degree earned
Doctoral level 30 85 25
PhD 19 52 ‐
PsyD 10 29 ‐
EdD 1 4 ‐
Master's degree 26 72 20
Specialist degree 44 (Ed.S.) 123 55
Grade level served
d
Pre‐K/K 32 89 ‐
Elementary 74 206 ‐
Middle/junior high 40 113 ‐
High school 38 107 ‐
All levels 15 41 ‐
More than one level 49 138 ‐
Licensed psychologists 36 99 21
Theoretical orientation
Cognitive‐behavioral 63 176 ‐
Psychodynamic 2 5 ‐
Family/systems 3 9 ‐
Integrative 15 41 ‐
Other 5 15 ‐
No specific orientation 12 35 ‐
Note:N= 318. Values may not add up to the total group Ngiven not all respondents answered all items.
Abbreviation: NASP, National Association of School Psychologists.
a
McNamara et al. (2019); Walcott and Hyson (2018).
b
Data for current sample were based on years since graduation from graduate school.
c
1–5 years in NASP Membership study.
d
Respondents selected all applicable options.
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on a five‐point scale (0 = n/a; I did not receive training to 4 = very helpful). Five items assessed training quality, including
whether training addressed concerns regarding conducting exposures, theoretical underpinnings, how to deliver
exposures, information about the effectiveness of exposures, and training in specific treatment manuals. These items
were rated on a four‐point scale (0 = notatallto 3 = considerably). The reliability of the training domain scale was high
(ω= .92). In addition to this section about training in exposures, one item assessed adequacy of respondents' graduate
school training in EBIs, rated on a four‐point scale (0 = very inadequate to 3 = very adequate).
2.3.2 |Confidence and perceptions regarding delivering exposures
The confidence domain comprised two items and reliability was deemed high (ω= .88). One item focused on how
comfortable respondents would feel while delivering exposures and was rated on a four‐point scale (0 = very
uncomfortable to 3 = completely comfortable). A second item assessed respondents' confidence in their ability to
effectively deliver exposures and was rated on a four‐point scale (0 = not at all confident to 3 = very confident).
The perceptions domain comprised a checklist of 17 items, with 11 items reflecting themes identified in the
Evidence Based Practice Attitudes Scale (EBPAS; Aarons et al., 2010;Aarons,2004), which assesses perceptions about
using EBIs, and the Therapist Beliefs about Exposure Scale (TBES; Deacon, Lickel, et al., 2013), which assesses
perceptions about using exposures. Respondents selected an item if the perception/belief reflected served to inhibit
their use of exposures within schools. Three types of perceptions were assessed: attitudes about the effectiveness,
consequences, and ethicality of exposures, hereafter referred to as “perceptual obstacles”(11 items, e.g., exposure may
exacerbate symptoms of anxiety,exposure may result in violations of confidentiality); perceptions about concrete/contextual
barriers to using exposures (four items, e.g., insufficiency with regard to time, training, support from supervisors/
colleagues, and access to training materials); and perceptions related to the psychologist's distress evoked by conducting
exposure (two items). Reliability for the perceptions domain was deemed adequate (ω= .81).
2.3.3 |Use of exposures
Use of exposures was assessed with two items (ω= .81). One item focused on how often respondents used
exposures on a four‐point scale (0 = never to 3 = almost always). A second item asked respondents who used
exposures to indicate the extent to which they emphasized exposures relative to other treatment components,
rated on a four‐point scale (0 = n/a I skip the exposure modules to 3 = I emphasize exposure more than other treatment
elements). In addition, one item assessed future likelihood of using exposures for students with anxiety on a four‐
point scale (0 = not at all to 3 = considerably).
2.3.4 |Demographics
Demographic questions focused on respondents' theoretical orientation, highest degree earned, type of degree
program attended (e.g., school psychology, clinical psychology), grade levels served, licensure status, gender, and
the year they graduated from their training program.
2.4 |Analyses
Data were analyzed using Qualtrics tools and JASP (JASP Team, 2020)anopen‐source software for conducting
statistical analyses (Version 0.12.2). There were 378 initial survey responses recorded in Qualtrics. A total of 60
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cases were excluded pairwise from the analyses. Six respondents did not meet inclusion criteria and 54
indicated consent but did not respond to any survey questions. All available participant data were included for
each item, which constituted a maximum of 318 respondents. Rates of missing data ranged between 12% and
23% across all survey items. Little's Missing Completely at Random Test (MCAR; Little,, 1988)yielded
nonsignificant results; therefore, pairwise omission was employed. Descriptive statistics summarized training,
knowledge, confidence, perceptions, and use of exposures for anxiety.
3|RESULTS
3.1 |Training in exposures
Seventy three percent of respondents (n= 214) had received some formal training in exposures, and 55.6% (n= 164)
received training in a required or elective course in graduate school. Training modalities endorsed most frequently
were independent reading (e.g., books, articles; 70.3%), required course in graduate school (53.6%) and workshops/
webinars (50.9%). Among those who had received training in exposures, more than 85% reported their training was
at least slightly helpful for each training modality identified on the survey (e.g., graduate coursework, externship,
internship, postdoctoral fellowships, conferences). See Table 2for results regarding type and helpfulness of training
in exposures.
Quality of training was assessed via questions about the extent training addressed key aspects of exposures
(i.e., concerns about exposures, theoretical underpinnings, how to deliver exposures, and information about
effectiveness). On average, respondents reported their training slightly to somewhat addressed key aspects of
exposures. Among respondents who had received formal training in exposures, 10.5% indicated they had not
learned about underlying theory at all, 12.8% had not learned about the effectiveness of exposures, 16.4% reported
their training did not address concerns about conducting exposures, and 20.1% reported their training did not
prepare them to practically deliver exposures. When asked about graduate training in EBIs more generally, 73% of
respondents reported their graduate training was generally adequate, and 27% reported EBI training was generally
inadequate.
3.2 |Knowledge of exposures
Forty‐two percent of the sample reported they were slightly knowledgeable regarding exposures, 44.3%
reported they were moderately knowledgeable, 6.9% percent reported they were not at all knowledgeable, and
6.9% reported they were very knowledgeable. Regarding familiarity with exposure theory, 82.7% of
respondents were somewhat unfamiliar to somewhat familiar,5.4%werevery unfamiliar, and 12% were very
familiar with the underlying theory. Knowledge of specific treatment protocols that incorporate exposures
variedacrossthefiveprotocolsincludedonthesurvey(M= 0.88, SD = 0.57). Overall, respondents endorsed
greater familiarity with Coping Cat, Brief Coping Cat, and CBITS, relative to Friends for Life (Barrett, 2005)and
Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH‐
ADTC; Chorpita & Weisz, 2009). Fifty percent of respondents indicated a basic understanding of Coping Cat,
33% had at least a basic understanding of Brief Coping Cat, and 47% had at least a basic understanding of
CBITS. In contrast, 71% of respondents had no knowledge of MATCH‐ADTC and 87.6% indicated no
knowledge of Friends for Life. Few respondents endorsed having a comprehensive understanding of the
manuals (i.e., Coping Cat–15.5%, Brief Coping Cat–6.7%, MATCH‐ADTC–5.1%, CBITS–12.6%, and Friends for
Life–0.3%).
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When asked to select the primary goal of exposures from a list of four goals, 42.8% of the sample endorsed the
primary goal was to increase students' confidence and ability to withstand anxiety, 34.6% endorsed the goal was to
reduce physiological hyperarousal, 17.5% endorsed the primary goal was to improve overall emotion regulation, and
2.8% endorsed the goal was to eliminate students' anxiety.
3.3 |Confidence and perceptions regarding exposures
Eighteen percent of the sample reported they were not at all confident to effectively deliver exposures, 37.8% of
respondents reported they were barely confident, 35.8% were somewhat confident, and 7.8% reported they were
very confident. When asked about comfort experienced delivering exposures, 11.4% of respondents reported
feeling very uncomfortable, 40.2% reported feeling somewhat uncomfortable, 37.3% reported feeling somewhat
comfortable, and 11.1% indicated feeling completely comfortable delivering exposures.
Respondents were presented a list of perceptual obstacles (i.e., perceptions related to the effectiveness,
consequences, and ethicality of exposures) and were asked to select a belief if it would inhibit their use of
exposures in schools. Eighty percent of the sample endorsed at least one negative belief about exposures,
60% endorsed at least two, 47% endorsed at least three, and 5% endorsed eight or more negative beliefs
regarding using exposures in schools. Table 3illustrates the percentage of school psychologists endorsing
perceptual obstacles to delivering exposures in schools. The obstacles endorsed most frequently included
concerns that exposures could upset parents (47.7%), may exacerbate symptoms of anxiety for students
(34%), may result in a lawsuit if the exposure did not proceed as planned (33.3%), and may retraumatize a
student (32.2%).
TABLE 2 Type and quality of training in exposures.
Training modality
% no training Helpfulness among respondents who had received training
Total %
training
received
I did not
receive
training
Not at
all % Slightly % Moderately % Very % M(SD)
Required course in
graduate school
46.4 6.3 48.1 31.0 14.6 2.54 (0.82) 53.6
Elective course in
graduate school
74.5 13.7 42.5 31.5 12.3 2.42 (0.87) 25.5
Practica or
externship
61.0 12.3 43.9 24.6 19.3 2.51 (0.94) 39.0
Clinical internship 71.5 14.5 28.9 28.9 27.7 2.70 (1.03) 28.5
Postdoctoral
fellowship
92.2 13.6 31.8 36.4 18.2 2.59 (0.94) 7.7
Professional
conferences
54.5 7.6 51.5 32.6 8.3 2.42 (0.75) 45.5
Workshops or
webinars
49.1 7.5 47.6 31.3 13.6 2.51 (0.82) 50.9
Independent reading 29.7 4.4 53.9 28.9 12.8 2.50 (0.77) 70.3
Note: Scores for training helpfulness, among respondents who received training, ranged from 1–4. A score of 0 represented
no training received. Mean helpfulness across all training modalities = 2.53.
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In addition, respondents were surveyed about their perceptions regarding concrete/contextual barriers to
delivering exposures in schools. Seventy‐nine percent of respondents endorsed inadequate time as a barrier to
delivering exposures, 61% endorsed inadequate training in effective delivery of exposure, 51% reported inadequate
access to training materials, and 17.3% endorsed lack of supervisor/colleague support. Six percent of respondents
endorsed personal feelings of anxiety regarding delivering exposures and 3.3% endorsed exposures as causing
personal distress.
3.4 |Use of exposures
Fifty‐five percent of the sample endorsed never using exposures, 36% endorsed occasionally,6.3%endorsed
often, and 2.1% endorsed almost always using exposures. Fourteen percent of respondents who endorsed using
treatments that incorporated exposures indicated they skiptheexposuremodules, 48.4% indicated they
emphasize exposures less than other treatment elements, 31.8% indicated they emphasize exposures equally to
other treatment elements, and 5.6% indicated they emphasize exposures more than other treatment elements.
Finally, when asked about future likelihood of using exposures for students with anxiety (on a four‐point scale,
ranging from 0 = not at all to 3 = considerably),46%reportedtheywereslightly likely to use exposures (M=1.18,
SD = 0.89).
4|DISCUSSION
Previous studies demonstrate a gap in training in EBIs in both clinical and school psychology training programs (e.g.,
Becker et al., 2004; Forman et al., 2012). With regard to exposures, research has been conducted with samples of
providers in community mental health centers and has documented exposures are perceived negatively and
underused (e.g., Becker‐Haimes et al., 2017; Meyer et al., 2014; Richard & Gloster, 2007). The current study
addressed a gap in the literature by investigating practicing school psychologists' training, knowledge, confidence,
perceptions, and use of exposures for anxiety.
TABLE 3 Percentage of sample endorsing perceptual obstacles to delivering exposures.
Perceptual obstacles (n= 306) %
Exposure may be upsetting to parents 47.7
Exposure may exacerbate symptoms of anxiety for students 34
Exposure may result in a lawsuit if it does not proceed as planned 33.3
Exposure may be retraumatizing for students 32.2
Exposure is inappropriate for the school setting 28.4
Exposure may be intolerable for students/lead to student decomposition 26.1
Exposure may result in harmful consequences for students 23.5
Exposure based interventions are too inflexible for delivery in schools 17.7
Exposure may result in violations of students’confidentiality 16.7
It is unethical to intentionally evoke distress in students 8.5
Exposure may result in vicarious trauma (i.e., traumatic for the psychologist) 7.5
Note: On average, respondents endorsed two to three perceptual obstacles.
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4.1 |Key findings
4.1.1 |Findings from the current study paint a mixed picture regarding knowledge and
training in exposures and EBIs more generally
In the current study, respondents' knowledge of exposures and of specific treatment manuals that incorporate
exposures exceeded estimates in prior studies. Whereas McKevitt (2012) found that approximately 50% of school
psychologists were unfamiliar with various EBIs and Hicks et al. (2014) found that 53% of school psychologists were
unfamiliar with two manuals that incorporated exposures (i.e., Coping Cat and CBITS), 93% of respondents in the
current study indicated at least some knowledge of exposures. Their knowledge of specific protocols that
incorporate exposures varied across protocols, with 50% of the sample endorsing at least a basic understanding of
Coping Cat. Notably, however, 83% of the sample reported limited familiarity with the underlying theory of
exposures.
Findings from the current study suggest respondents were satisfied with the overall quality of EBI training, with
73% reporting their graduate training was generally adequate. This finding converges with more recent studies
painting a positive picture of training in EBIs in school psychology. Hicks et al. (2014) for example, found that recent
graduates endorsed participation in EBI training more frequently than non‐recent graduates and in Reddy et al.'s
(2017) survey of 460 school psychology trainers, 75% of graduate trainers reported their programs offer mandatory
EBI courses and 96% offer elective EBI courses.
In addition, 73% of respondents had received some formal training in exposures, with 56% indicating training
occurred within their graduate coursework. It is worth noting that 50% of the sample did not receive any graduate
training in exposures and 61% endorsed inadequate training as a barrier to delivering exposures in schools. These
findings are consistent with prior survey research with school psychologists regarding training in EBIs in schools.
For example, Hicks et al. (2014) found that 55% of their sample of nationally certified school psychologists indicated
that insufficient training was an obstacle to delivering EBIs in schools.
Although school psychology graduate training has been identified as a key avenue for improving
implementation of EBIs in schools, the proliferation of EBIs has made it nearly impossible for graduate coursework
to adequately cover all available protocols. In addition, school psychology intervention training tends to have a
more generalist focus wherein students are trained in a range of intervention and prevention models as opposed to
specializing, for example, in just anxiety treatments (Shernoff et al., 2017). However, innovations in EBIs, including
training in transdiagnostic, principle‐driven approaches, may hold promise for training school psychologists to
deliver exposures. Given transdiagnostic approaches apply more broadly and focus on identification if key
mechanisms of psychological distress across disorders (e.g., avoidance) and corresponding common practice
elements (e.g., exposure, cognitive restructuring; Chu et al., 2014), they are a promising avenue for overcoming
some of the challenges associated with current training practices (Shernoff et al., 2017; Weisz & Bearman, 2020).
4.1.2 |Findings from the current study highlight variable confidence in delivering
exposures and important obstacles to using exposures that is worth further study
Prior studies indicate that conducting exposures is often experienced as uncomfortable and aversive for clinicians
(e.g., Pittig et al., 2019), and in the current study, 56% of respondents reported very limited confidence in delivering
exposures. Given that studies document the importance of active learning opportunities and extensive feedback to
promote confidence, future research on exposures could explore pedagogical strategies that could be emphasized
in coursework and practicum experiences to maximize confidence to implement this complex practice element. This
is an important area for further research given that the use of specific practices is mediated through cognitions (e.g.,
Schunk et al., 2014) and self‐efficacy beliefs predict future performance and mastery experiences (Bandura, 2001).
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Although less than 6% of the sample endorsed personal distress or anxiety associated with delivering exposures
as obstacles to use (i.e., perceptions related to psychologists' distress), close to one‐third to one‐half of the sample
endorsed harmful consequences associated with exposures, including that exposures would be upsetting for
parents, could worsen anxiety symptoms, retraumatize students, were inappropriate for the school setting or even
result in lawsuits. Concerns endorsed in the current study converge with results from Deacon, Lickel, et al.'s (2013)
survey of 66 psychologists' perceptions of interoceptive exposure for panic disorder. Their study highlighted
concerns about negative perceptions (e.g., exposures were deemed as unethical, placed clients at unacceptably high
risk of harm, are stressful for clinicians to implement) and potential negative outcomes of exposures (e.g., premature
client dropout, exacerbation of anxiety symptoms). These findings held despite psychologists indicating these
outcomes rarely occurred (Deacon, Lickel, et al., 2013). Concern about caregiver acceptance of exposures as an
appropriate intervention (47% of the current sample) is an important obstacle to delivering exposures in schools;
future research should directly assess caregiver perceptions of exposures, especially because parental consent for
treatment is often required in schools.
The concerns regarding effectiveness, ethicality, and consequences of exposures reported in the current study
highlight the importance of identifying perceived obstacles and addressing some of the potential misconceptions
regarding exposures. Training and continuing education at national conferences may need to counter
misconceptions and ethical concerns about exposures that may inhibit their use in schools. For example,
continuing education may need to emphasize that the goal of inducing temporary distress through graded
exposures is to ultimately reduce long‐term harmful consequences or debilitating effects of anxiety. Training can
also emphasize that it would be unethical to expose clients to an objectively dangerous situation or one that is not
expected to be encountered by most people. Instead, the goal of the exposure is to help students confront the false
alarms that are causing avoidance and distress and preventing students from having corrective experiences.
Exposures have also been portrayed as an intervention that is provided in a cold, rigid manner—as something
that is done to, rather than with a client (e.g., Richard & Gloster, 2007). However, exposures must be provided in an
empathic manner, after clients have had a chance to learn about the rationale, discuss any hesitation, and jointly
agree on the boundaries/extent of the exposure. Graduate training and continuing professional development can
also highlight the mechanisms of change associated with exposures. This includes emphasizing the role of avoidance
in the development and maintenance of anxiety symptoms over time and the role that exposures play in unraveling
those fear structures (e.g., Foa & Kozak, 1986). This approach is consistent with a transdiagnostic paradigm that
emphasizes key maintaining features of disorders and associated critical treatment elements.
There are additional logistical obstacles related to delivering exposures that are worth further consideration.
Notably, school psychologists' perceptions regarding contextual obstacles to using exposures in schools in the
current study are consistent with prior studies documenting school psychologists' perceptions of obstacles to using
EBIs more generally. For example, in the current study, respondents endorsed inadequate time (79%), inadequate
training (61%), inadequate access to training materials (51%), and lack of support for exposures by colleagues and
supervisors (17%) as obstacles to use of exposures. Hicks et al.'s (2014) similarly found that lack of time (78%),
inadequate training in EBIs (55%), inadequate access to resources (67%), and inconsistency of EBIs with supervisor's
approach (19%) were identified as obstacles to implementing EBIs among school psychologists.
Inadequate time has been documented as one of the most significant obstacles to using EBIs in schools (Collier‐
Meeks et al., 2019; Shernoff et al., 2017). More research is needed to understand the time constraints associated
with delivering exposures from the perspective of school psychologists. For example, if time constraints are related
to opportunity costs (e.g., implementing exposures leads to less time to fulfill assessment responsibilities) then more
work is needed to understand how best to align this practice element with the core role and function of a school
psychologist. If time constraints are related to perceptions that conducting exposures is burdensome or a poor fit
for schools, then more work is needed to explore and address perceptions and consider ways of adapting the
intervention to suit the school setting.
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4.1.3 |Findings from the current study point to a gap between knowledge/training
versus use of exposures in schools by school psychologists
Interestingly, while reports of knowledge and training in exposures are encouraging (86% endorsed at least minimal
knowledge, nearly 75% had received some formal training—56% via graduate coursework), findings from the
current study also indicated that 55.6% of respondents had no prior use of exposures and that 21% emphasized
exposures less than other elements of treatment protocols. This finding is consistent with the research to practice
gap regarding use of exposures in community settings (e.g., Higa‐McMillan et al., 2016). For example, use of
exposures was found to be particularly low among child therapists (N= 332), with only 5% reporting they use
exposures, even though 80% of the sample endorsed using CBT techniques (Whiteside et al., 2016). Similarly, in a
study about use of EBIs for youth anxiety (Higa‐McMillan et al., 2016), only 15% of 616 surveyed therapists
reported using exposures, even though many therapists endorsed using EBIs. The discrepancy between knowledge
and training in exposures versus use of exposures found in this study has important implications for future training
and research.
4.2 |Implications for future training and research
A variety of factors can be hypothesized to contribute toward limited use of exposures even among school
psychologists with basic knowledge. First, implementation of EBIs in schools is an especially complex process for
school psychologists, given the scope of the school psychologist's role and the myriad contextual obstacles to
delivering EBIs within schools (e.g., limited time, high student caseloads, high demand for evaluation services;
pressures to conform to training standards set by multiple accreditation agencies, including NASP, APA, and state
licensures; see National Association of School Psychologists, 2020).
Second, the literature highlights widespread reluctance to using exposures related to provider concerns about
effectiveness, ethicality, and consequences of exposures (e.g., Feeny et al., 2003;Golaetal.,2016). Many respondents in
this sample lacked confidence in their ability to effectively deliver exposures and endorsed reservations about
conducting exposures due to concerns about the ethicality, effectiveness, and appropriateness of conducting exposures
in schools. Although the current study did not examine the relationship between knowledge, training, confidence,
perceptions, and use of exposures and thus we cannot make conclusions regarding causal relationships, research drawn
from social cognitive theory and implementation science highlights the influence of perceptions and confidence on
behaviorsaswellasthepotentialfortrainingtoinfluence these perceptions (e.g., Reding et al., 2014;Runyon
et al., 2018;Schunketal.,2014;Shapiroetal.,2012). Future research can shed light on the degree to which the various
factors explored in this study (i.e., knowledge, training, confidence, perceptions) predict use of exposures, so that trainers
can address the gaps from a scientifically informed lens.
Although a foundation of graduate training is important for improving delivery of services to youth in schools (e.g.,
Hicks et al., 2014; Karekla et al., 2004;Shernoffetal.,2017), mere coverage of exposures is insufficient. Given that
quantity of graduate training is insufficient in predicting knowledge and skills (see Karekla et al., 2004), future studies
should examine ways to improve the quality of training by identifying which aspects of training (e.g., practice with
supervision and factors explored in this study, such as addressing theoretical underpinnings, therapist concerns, practical
delivery) are critical in promoting graduate students' understanding and delivery of exposures in schools. Farrell et al.
(2013) advise directly addressing negative beliefs about exposures within training through experiential activities;
although trainers may be familiar with research indicating exposures are safe, ethical, and tolerable, they may continue
to associate exposures with danger if they are not provided experiences wherein this expectation of harm is violated.
Similarly, Kemp et al. (2023) suggest an intriguing approach to training therapists to deliver exposures via exposure to
exposure with the goal of experientially targeting misconceptions and discomfort about exposure. This training technique
involves applying the principles of exposure to the training of therapists in exposures; that is, trainers provide
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opportunities for therapists to practice the same exposures they expect to conduct with clients and to learn that the
exposures are tolerable and helpful. Preliminary findings indicate that this form of experiential practice reduces
therapists' negative beliefs and anxiety about exposures, but more research is needed to examine the impact of the
training on subsequent delivery of exposures. Identifying and targeting core training aspects is especially important for
trainers in school psychology training programs, given these programs may have limited time to provide training in EBIs
(see Shernoff et al., 2003) in light of the multifaceted role of school psychologists, as noted above.
It also may also be necessary to reframe exposure as a common element that can be subtly and effectively
integrated into other treatment modalities. For example, a psychodynamic approach that gently encourages a client
to experience rather than avoid or defend against an unwanted or rejected emotion is in essence a form of
emotional exposure designed to improve the client's capacity for emotional experiencing, reduce maladaptive use
of defense mechanisms, and improve quality of life. Perhaps a rebranding of exposures as outlined by Becker‐
Haimes et al. (2023) is needed such that there is an emphasis on exposures being delivered in a sensitive and
nuanced manner that has application in schools. For instance, school psychologists can help students recognize how
they may be engaging in productive exposures in their own lives (e.g., when they are vulnerable with a close friend
enabling them to receive support and validation, when they ask a question in class despite social anxiety).
In addition to addressing negative perceptions of exposures, it is important to consider the compatibility of
exposures within schools, given 30% of the current sample endorsed concerns about the appropriateness of using
exposures in schools and given their endorsement of contextual obstacles to using exposures in schools. Taken
together, a two‐pronged approach is likely necessary to improve delivery of exposures within the complex school
setting. First, efforts should be made to improve training in exposures, so that the coursework directly teaches how
to deliver exposure, explains underlying rationale, and addresses concerns about delivery (a top‐down approach, as
outlined above). In addition, graduate trainers may need to help trainees make modifications to exposures and to
consider the contextual obstacles to delivering these interventions.
In a similar vein, it may be worth exploring ways that teachers and parents can assist with the delivery of
exposures in order to reduce the burden on school psychologists and to aid in identifying and providing
interventions before problems escalate. From the perspective of implementation science, future studies should
examine ways to embed the philosophy of exposures into the school environment.
4.3 |Limitations
There are several limitations worth noting. The representativeness of the sample may be limited, given recruitment
through school psychology training program alumni and state association member listservs. Also, there may have been
self‐selection bias, wherein school psychologists passionate about addressing youth mental health needs or those with
more experience using exposures may have been disproportionately drawn to respond. Additionally, given that
respondents were recruited in three ways (i.e., via state associations, alumni listservs, and Facebook groups), it is possible
that the three groups may have differed from one another in term of their training, knowledge, perceptions Future
studies can incorporate more direct assessment methods (e.g., observations, direct assessment of knowledge) to
improve the external validity of findings. Third, given the survey was developed for this study, its psychometric
properties, although adequate in this sample, have not previously been examined and are not fully established.
5|CONCLUSIONS
This study explored school psychologists' training, practices, and perceptions related to exposures. Survey results
indicate that the majority of school psychologists had at least minimal knowledge of exposures and had received
some formal training in exposures but that many perceived their training to be inadequate and lacked confidence in
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their ability to effectively deliver exposures. The study also demonstrated that exposures are largely underutilized
by school psychologists. Respondents endorsed negative perceptions about the intervention related to
effectiveness and ethicality, as well as concerns about contextual barriers within schools including limited time
and resources. Future research should explore variables that may predict increased use of exposures and should
consider strategies to improve training and confidence for graduate students and practicing school psychologists.
Lastly, researchers and school psychologists may need to consider ways to adapt exposures for the school setting,
given the contextual barriers endorsed.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data
are not publicly available due to privacy or ethical restrictions.
ETHICS STATEMENT
All procedures performed in studies involving human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
ORCID
Elisa S. Shernoff http://orcid.org/0000-0002-7649-118X
Jeffrey Shahidullah http://orcid.org/0000-0003-2123-0609
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How to cite this article: Weiss, S., Shernoff, E. S., Lekwa, A., & Shahidullah, J. (2024). Exposures for anxiety:
A survey of practicing school psychologists. Psychology in the Schools,61, 3102–3120.
https://doi.org/10.1002/pits.23208
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