Clinical Considerations in Designing Brief Exposure Interventions for Primary Care Behavioral Health Settings

Abstract

Introduction:

Prevalence rates of anxiety disorders and symptoms in primary care (PC) settings are very high. Behavioral health consultants in Primary Care Behavioral Health (PCBH) settings enable increased access to evidence-based anxiety treatment. Despite strong extant support for exposure-based therapy for anxiety disorders, the use of exposure to treat anxiety in PC settings is low. Although barriers to exposure therapy (ET) may be exacerbated in PC settings, many anxiety presentations in PC warrant an exposure-based approach to treatment. Thus, exploration of feasibility and efficacy of ET in PC represents a critical area for advancing evidence-based treatment of anxiety symptoms.

Methods:

The current article addresses this gap through the presentation of two case examples of ET conducted in PCBH. Theoretical and practical information regarding the implementation of exposure using a brief (≤30 minutes), time-limited (4–6 visit) approached are presented.

Results:

Results from the case examples demonstrate feasibility of conducting exposure in a brief format consistent with a PCBH approach. Additionally, patient outcomes presented suggest that ET conducted in PCBH reduces anxiety symptoms and may facilitate referral to specialty care settings.

Discussion:

Exposure may offer promise in improving the quality of anxiety treatment in PC. Future work documenting both effectiveness and implementation outcomes of exposure in PC in clinical work and research trials is needed.

Background: Primary Care Behavioral Health

Primary Care Behavioral Health (PCBH) offers an opportunity to increase access to evidence-based treatment for anxiety symptoms. Anxiety is highly prevalent in the primary care (PC) setting, with a past-year prevalence of 15–20% for anxiety disorders (Kroenke et al., 2007). Furthermore, subthreshold symptoms that do not reach full criteria of a diagnosable disorder are as, or more, common (Olfson et al., 1996; Rucci et al., 2003). Although anxiety is under-detected (Stein, 2003), under-treated, and treatment provided is most often pharmacological in PC (e.g., Stein et al., 2011; Weisberg et al., 2014), the proliferation of PCBH over the past two decades has facilitated access to behavioral treatment for anxiety. In the PCBH model (Reiter, Dobmeyer, & Hunter, 2018), behavioral health consultants (BHCs; e.g., clinical social workers, psychologists) embedded in the PC clinic deliver brief behavioral interventions to increase coping skills for managing anxiety symptoms. Notably, anxiety is the second most common reason for referral to BHCs after depression (Bridges et al., 2015; Funderburk et al., 2011).

Clinical guidance for PCBH practice commonly emphasizes brief focused visits and evidence-based interventions (Reiter et al., 2018). Such interventions may draw upon cognitive-behavioral therapy (CBT) due to its established evidence base and amenability to brief treatment (Hunter, Goodie, Oordt, & Dobmeyer, 2009; Rowan & Runyan, 2005). A recent review of behavioral anxiety interventions in PC found that a majority were CBT-based, such as relaxation training and cognitive restructuring (Shepardson, Buchholz, Weisberg, & Funderburk, 2018). However, exposure therapy (ET), arguably the most effective intervention for anxiety (Deacon & Abramowitz 2004; Foa & McLean, 2016; Pompoli et al., 2018; Olatunji, Cisler, & Deacon, 2010), has received little attention in the PC-based anxiety treatment literature. Indeed, a survey of PCBH providers regarding intervention techniques used in the most recent visit with a patient referred for anxiety found that only 21% delivered ET (Shepardson, Minnick, & Funderburk, in press). Furthermore, research in the context of evidenced based treatment for anxiety in primary care specifically highlights the importance of decreasing avoidance as such behavior may persist beyond symptom improvement and necessitate a behavioral approach (Roy-Byrne et al., 2009).

Background: Exposure Therapy

Low utilization of ET in anxiety treatment is problematic and surprising due to its status as the gold-standard treatment for many anxiety disorders. Without exception, diagnostic and theoretical models of anxiety disorders place avoidance of a core fear at the center of symptom development and maintenance (American Psychiatric Association, 2013; Borkovec et al., 2004; Clark & Wells, 1995; Craske et al., 2014; Foa & Kozac, 1986). Exposure disrupts the cycle of reinforcement facilitated by avoidance that serves to acutely reduce anxiety but maintain maladaptive responding in the long run (see Foa & McLean, 2016). Accordingly, exposure is an integral component of many CBT protocols for treating anxiety disorders (e.g., Tolin, 2016) and is effective as a standalone treatment (e.g., Hoyer et al., 2009) even in transdiagnostic samples (i.e., treatment of broad anxiety symptoms rather than a particular diagnosis; e.g., Boswell et al., 2013). The limited research on use of ET in PCBH settings suggests it is infrequently used (Shepardson et al., in press), with one exception being new research investigating the efficacy of brief Prolonged Exposure for posttraumatic stress disorder (PTSD) adapted for PC (Rauch et al., 2017).

Prior research has identified numerous barriers contributing to infrequent delivery of ET in traditional specialty (non-PCBH) mental health settings (Becker-Haimes et al. 2017; Wolitzky-Taylor et al., 2015). Common challenges include competing treatment priorities, concerns about patients’ appropriateness for exposure, time constraints, and inadequate therapist training, competency, and supervision (Wolitzky-Taylor, et al., 2018). Negative therapist perceptions about exposure (e.g., exposure is harmful, intolerable, or unethical; Farrell, Deacon, Dixon, & Lickel, 2013) are related to suboptimal administration of ET (Abramowitz, 2010; Deacon et al., 2013). These challenges are likely exacerbated in PCBH practice due to the significantly shorter number and duration of visits. For example, BHCs may find it challenging to describe rationale for exposure and develop a fear hierarchy during a 30-minute visit. Practical considerations for conducting exposure exercises in a PC exam room may also present difficulties regarding the range of activities possible in a small space and limited access to settings to complete in vivo exposures. Moreover, BHCs may have ethical/safety concerns about conducting imaginal or in vivo exposures during brief visits that may not allow sufficient time for habituation to occur. However, research has demonstrated that within-visit habituation (i.e., reduction in anxiety after repeated exposures) is less important for ET outcomes than habituation that occurs between visits (Sripada & Rauch, 2015). Also, fear extinction (i.e., reduction in fear response) may result from inhibitory learning (i.e., new associations with anxiety provoking stimuli and contexts) rather than habituation, or pure reduction of anxiety (Craske et al., 2014).

Little to no work has been published regarding how to deliver effective ET for anxiety within the PCBH setting. It is possible to design feasible brief exposures that can be completed during brief visits or at home between visits. The purpose of this article is to review clinical considerations for delivering brief exposure interventions that are compatible with PCBH practice. Based on our knowledge of the ET literature and collective clinical experience in PCBH, we will discuss how to adapt the scope of traditional ET to fit the format and philosophy of PCBH and provide practical strategies and suggestions (see Table 1) for designing and conducting exposures. In addition, we present two case examples of transdiagnostic ET to illustrate how this approach can be successfully applied in PCBH.

Table 1.

Principles of exposure therapy: Tips and examples for implementation in Primary Care Behavioral Health

Principle	Conceptual explanation	Tips	Examples
Rationale for exposure	This discussion serves as the foundation of the therapeutic relationship by increasing the patient’s understanding of and buy-in for treatment	Normalize anxiety Express confidence in treatment approach Use examples from the patient’s experience to illustrate the benefits of overcoming fear	“Anxiety is a natural response that all people experience, and it’s most basic function is to help us avoid injury and keep us alive. You can think of it like an internal alarm system which uses unpleasant sensations like [insert patient examples of symptoms] that motivate us to escape danger. This is an extremely effective strategy when we are truly in danger, but this effectiveness is also what makes anxiety so troublesome when it becomes a problem. Often this is because anxiety is over-active and creates false alarms when we aren’t in danger. This may motivate us to do things to relieve anxiety in the short term, but in turn keep us from engaging in important and meaningful activities. We call these behaviors avoidance.”
Fear hierarchy	This is a tool that serves two main functions: (1) provides a guide or “road-map” for treatment, (2) enables the patient and provider to develop a specific and mutual understanding of the patient’s fears	Use SUDS to rank fears Complete anchor points in visit and finish for homework Try to connect items with the patient’s goals or values	Fear Hierarchy (social anxiety)
			Situation	SUDS
			1) Talking to boss	95
			2)
			3) Make small talk with stranger	50
			4)
			5) Talk on the phone with sister	25
			6)
Exposure	Core feature of treatment that provides opportunities to learn new responses to anxiety-provoking situations. Enables development of confidence managing anxiety through learning approach behavior.	Be creative and explore options for exercises that match the core fear Be willing to engage in the activities yourself with the patient Have patients predict their anxiety level and outcomes of exposure before, then examine these predictions after	Straw breathing Chair spinning Imaginal exposure Impromptu speech (see table 2 for more examples)
Safety behavior elimination	Eliminating safety behaviors is a strategy for maximizing the knowledge gained in exposure therapy. It allows for patients to develop a sense of mastery in experiencing and managing anxiety.	Remember safety behaviors are any strategies patients use to make anxiety provoking situations more tolerable Think of safety behaviors as subtle avoidance Use as a way to optimize previous exposure activities	Removing safety items from bag, purse, or pockets (e.g., anxiety medication, lucky/comfort object) Not using headphones at the gym Making eye contact during conversation Not asking for reassurance from friends, family, or colleagues

Note. SUDS = subjective units of distress score.

Adapting Exposure for Primary Care

Within specialty mental health settings, standard ET protocols consist of weekly hour-long visits across 12–20 visits (Tolin, 2016). Given the generalist (rather than specialist) philosophy of care in PCBH (see Reiter et al., 2018), it is essential to note that successful distillation of ET for PCBH will require more than merely attempting to administer an entire protocol within an abbreviated visit and treatment timeline. Important considerations include critical elements of existing ET protocols and the pragmatics of administration of such treatment within the PCBH framework. Factors influencing adaptation for implementation in PCBH include brevity during visits, limited treatment duration, reliance on between-visit homework, and the need for a transdiagnostic approach to treatment, as unspecified anxiety is the rule in PC, not the exception (Barrera et al., 2014). Fortunately, there is a rich literature on ET with a plethora of approaches for presentations ranging from circumscribed fear (i.e., specific phobias) to broader anxious distress (i.e., generalized anxiety disorder). Common themes among exposure-based protocols include rationale for exposure, development of an idiographic fear hierarchy, and repeated in- and outside of visit exposure exercises (e.g., Craske, Anthony, & Barlow, 2009; Hope, Heimberg, & Turk, 2010). As such, ET within PCBH settings can be highly individualized and flexible while capitalizing on strong evidence-based principles for relieving anxiety symptomatology. Specifically, in PCBH settings this may range from brief education regarding the role the avoidance behavior plays in maintaining anxiety symptoms (see Table 1) to a few brief visits incorporating exposure exercises into visits and homework assignments (see Table 2).

Table 2.

List of example exposure activities

Anxiety subtype	Exposure examples*
Social	In visit:
	Drop a handful of papers in primary care waiting room
	Make a phone call
	Homework:
	Skip while walking on the sidewalk
	Ask for directions to a building within sight
Generalized	In visit:
	Describe in detail everything causing worry that day
	Imagine a worst-case scenario (narrate and picture it happening)
	Homework:
	Send an email with typos to coworker or boss
	Write and read a detailed worry script about being fired from work
Panic	In visit:
	Jumping jacks (or mild exercise to increase heart rate)
	Spin around in a chair/on foot for 30 seconds (to induce dizziness)
	Homework:
	Induce gag reflex
	Wear extra clothes to induce sweating
Specific Phobia (Heights**)	In visit:
	Walk upstairs and look down from landing
	Look out a window on a high floor
	Homework:
	Walk over pedestrian bridge
	Visit mall with an atrium

Note.

^*Presented activities are meant to demonstrate the flexibility and variety of exposure exercises; activities chosen in therapy should be tailored to the patient’s core fear and agreed upon collaboratively by the patient and provider.

^**Specific phobia of heights is used as an illustrative template; exercises should target the patient’s core fear.

There are a variety of anxiety-related symptom presentations within PCBH where exposure would be beneficial; specifically, when patients report clear behavioral avoidance of a core fear. Examples of core fears that ET is well suited to address include but are not limited to: physical sensations of anxiety, such as increased heart rate, sweating, difficulty breathing; specific phobias, such as animals, heights, needles/injections; and fear of negative social evaluation, such as poor work or school performance, social rejection. Despite the benefits of exposure in such a case, significant barriers may emerge in the form of limited patient buy-in and low motivation to engage in exposure exercises. Here, a concise and relatable rationale, ideally incorporating the patient’s values to increase buy-in (i.e., explaining how exposure will facilitate engagement in valued activities the patient is currently missing out on due to avoidance), is a critical tool. Delivered effectively, brief rationale for exposure can instill hope for symptom improvement (e.g., Addis & Carpenter, 2000). Thus, it is important to normalize and validate the patient’s symptoms and the natural inclination to avoid anxiety-provoking stimuli, while providing psychoeducation regarding the relationship between anxiety and avoidance as well as how avoidance maintains anxiety.

Creating a fear hierarchy and conducting exposure activities are the remaining core components of ET. In contrast to traditional outpatient ET where a provider might spend an entire visit on creation of fear hierarchy, a PCBH visit may allow only five to ten minutes to complete this. Thus, developing a complete/comprehensive fear hierarchy can be assigned as an initial homework assignment. Specifically, the Subjective Units of Distress (SUDs) ratings (0–100) scale could be introduced in the visit in combination with having the patient generate examples of activities or situations that would be at a few specific points on the scale (e.g., anchor points at 0, 25, 50, 75, and 100). After generating a few examples spanning variety of distress levels, the patient could complete this exercise for homework.

With respect to specific exposure activities, the possibilities for exercises are at least as vast as the breadth of core fears with which patients present. Imaginal exposures where patients narrate a feared scenario in the first-person present tense (e.g., I am walking into the party) offer a straightforward and intuitive approach to exposure. Another helpful form of exposure is in vivo, or “real-life” exposures where patients engage in actual activities that provoke anxiety (e.g., going to a party). Although shown to be very effective (e.g., Cox et al., 1992) in vivo exposures may be more challenging. Within the basic framework that exposures are designed to activate anxiety (i.e., increase SUDs) and prevent escape and avoidance, BHCs can implement creative and idiographic activities specific to the patient’s needs (see Table 2 for examples). Furthermore, as research has demonstrated that between-visit habituation leads to more significant change than within-visit habituation (Sripada & Rauch, 2015), it is critical for BHCs to assign exposure exercises as homework. In doing so, it is important to help the patient anticipate practical and motivational barriers, including anxiety, and troubleshoot them ahead of time. It is imperative that patients understand that increased anxiety during the exposure is a desired outcome. Homework is also a great opportunity for patients to engage in exercises that would be impractical within PC setting. To illustrate the implementation of the principles discussed above, we share two case examples of brief ET delivered in PCBH by the first author, supervised by the second author.

Case examples

Patient 1 is a female in her 30s referred to PCBH after reporting to her PC provider that she had experienced two panic attacks in the past six months (approximately 5.5 and 3 months prior to referral). During the initial PCBH visit (visit 1), functional assessment revealed that among the broader symptoms of panic, the core and most fear-inducing features of the attack were feeling out of breath and having difficulty breathing. Detailed information regarding symptom presentation, assessments, and treatment tracking are reported in Table 3. Since experiencing the panic attacks, Patient 1 reported feeling increased general anxiety and arousal as well as sensitivity to her heart rate and breathing with accompanying fear of have more panic attacks.

Table 3.

Treatment information from case examples

Case example	Treatment information
Patient 1	Referral source and reason:	Primary care provider, due to patient’s report of panic symptoms
	Presenting symptoms:	Panic attacks (2 within last 6 months) Fear of shortness of breath
	Symptom tracking:	Initial assessment:
		Severity Measure for Panic Disorder: 33/40
		Visit 2:
		SUDS: pre = 0, peak = 10, post = 3
		Visit 3:
		SUDS: pre = 2, peak = 10, post = 5
		Visit 4:
		SUDS: pre = 0, peak = 10, post = 3
		GAD-7 = 4
		Visit 5:
		SUDS: pre = 0, peak = 3, post = 0
		GAD-7 = 2
Patient 2	Referral source and reason:	Primary care provider, due to patient terminating an MRI early, preventing a needed assessment (MRI)
	Presenting symptoms:	Long-standing claustrophobia, recently exacerbated by using new CPAP mask and was preventing a needed medical examination (i.e., MRI)
	Symptom tracking:	Initial assessment
		No SUDS measured
		Visit 2:
		SUDS: pre = 0, peak = 0, post = 0
		GAD-7 = 14
		Visit 3*:
		SUDS: pre = 0, peak = 10, post = 0
		GAD-7 = 7
		Visit 4:
		SUDS: pre = 2, peak = 10, post = 6
		GAD-7 = 7
		Visit 5:
		SUDS: pre = 2, peak = 10, post = 5
		GAD-7 = 7
		Visit 6:
		SUDS: pre = 1, peak = 6, post = 2
		GAD-7 = 7

Note. CPAP = continuous positive airway pressure; GAD-7 = Generalized Anxiety Disorder-7; MRI = magnetic resonance imaging; SUDS = subjective units of distress.

^*A more anxiety provoking exercise was utilized from visit 3 forward, as the earlier exercise did not elicit anxious responding critical for fear extinction.

Patient 1’s symptoms included a core fear of shortness-of-breath and avoidance behaviors that enabled the maintenance of symptoms; thus, ET was identified as a good fit for treatment. She was able to identify specific goals for her treatment: reducing anxiety related to panic symptoms, reducing fear in crowds, and eliminating safety behaviors. The recent onset of symptoms, which were mild to moderate in nature; specific, well-defined treatment goals; and the coordination of care between the BHC and PC provider (regarding the initiation of fluoxetine) made Patient 1 a good fit for ET in the PCBH setting.

During visit 2, the BHC presented brief psychoeducation, including the rationale for interoceptive exposure, and introduced a straw breathing exercise (see: Table 3 for more information). The BHC then guided Patient 1 through two repetitions of the straw breathing exercise (e.g., hold nose and breath through a straw for 1 minute) designed to induce a sensation of shortness of breath. She was then asked to complete this exercise at least once daily for homework between visits. The following visits (3–5) each included a review of straw breathing homework and more in-visit straw breathing exposures. Exposures were calibrated to her mastery by increasing the intensity of discomfort (i.e., moving the straw further back in the mouth to induce a gagging reflex). The BHC engaged in exposures alongside Patient 1 at times, as the BHC’s confidence in the intervention and willingness to engage in exposure exercises along with the patient are critical elements of the provider-patient alliance when conducting exposures. These strategies also enabled the BHC to model approach behavior in the face of discomfort.

In addition to in-visit exposures, safety behavior elimination was integrated into treatment beginning in visit 3. Although this process can be fairly time consuming in a specialty treatment setting, brief adaptations of psychoeducation and implementation strategies can be accomplished within PCBH treatment (see: table 1). Homework was assigned and reviewed at all remaining visits to track progress of safety behavior elimination. During each visit the BHC discussed Patient 1’s treatment goals and collaboratively evaluated whether those goals had been met; if not and Patient 1 was agreeable, a follow-up session was scheduled. By visit 5, Patient 1 had met her goals related to reduction of anxiety related to panic symptoms (i.e., shortness of breath) and eliminated her safety behaviors; therefore, the brief course of ET was concluded.

Patient 2 was a male in his 60s referred to PCBH from his PC provider secondary to anxiety preventing him from obtaining a magnetic resonance imaging (MRI) scan. During the initial PCBH functional assessment, Patient 2 reported that he has experienced anxiety in enclosed places for as long as he could remember, but his symptoms had recently become impairing due to the need to have an MRI for shoulder pain and to begin using a continuous positive airway pressure (CPAP) mask for obstructive sleep apnea. The patient reported having a brain bleed some years prior, which led to fear and avoidance behavior (e.g., avoiding being alone, avoiding tight spaces) in situations in which escape would be difficult. Thus, ET in PCBH was a good fit for his symptomatology and treatment goals (i.e., to be able to tolerate MRI procedure). Details regarding symptom presentation, assessment, and treatment tracking can be found in Table 3.

During visit 2, Patient 2 was asked to ride the clinic elevator with and without the BHC. During these exposures the patient reported that his SUD score remained at a 0. As a result, in visit 3, the in-visit exposure was adjusted in order to provoke a higher level of anxiety (i.e., SUD). Specifically, patient 2 was asked to lie on the floor of the office with his head and torso underneath a chair to simulate an enclosed space consistent with his goal of receiving an MRI. Once again, the patient reported very low SUDs, so the BHC consulted with his supervisor to brainstorm additional creative exposure ideas. At subsequent visits (visit 4–6) the BHC used a collapsible child’s play tunnel paired with a speaker playing recorded MRI noises to conduct in-visit exposures, which were much more successful in eliciting anxious arousal. These adjustments to the treatment plan demonstrate the flexibility to tailor exposure exercises to the specific needs of the patient in order to disrupt the reinforcing cycle of avoidance in response to anxiety.

After implementing the tunnel exposure in visit, the BHC worked with Patient 2 to identify ways to practice this type of exposure at home. Patient 2 reported making a tunnel out of cardboard that he used to complete his exposure homework. By the end of visit 6, he had completed exposures in visit and at home for over 15 minutes (the reported length of his needed MRI scan). However, in visit and for homework he reported that he would end the exposures when his anxiety became unbearable. Thus, exposures were ending in avoidance behavior that was likely contributing to the continued maintenance of symptoms However, for patient 2, at this point in treatment his overall anxiety symptoms had reduced some (see Table 3), and he had scheduled the MRI (i.e., primary goal). Given the long-standing nature and persistence of symptoms as well as his interest in continuing treatment, Patient 2 agreed to a referral to specialty care for CBT for claustrophobia.

Discussion of Case Examples

Both Patients 1 and 2 had presentations that indicated good fit for ET and treatment in PCBH. Specifically, both patients were referred by medical providers, had specified core fears and avoidance behaviors, and had goals that fit with an abbreviated treatment timeline. These cases illustrate the feasibility of implementing exposure in an idiographic and tailored way to meet the patient’s needs. Moreover, the variability in outcomes demonstrates the multiple ways in which PCBH treatment can be successful. For Patient 1, symptom reduction and completing a course of brief treatment were ideal indicators of successful treatment. For Patient 2, treatment was adequate in helping patient reach his immediate goal of scheduling an MRI, and a successful referral to specialty care was made to address persistent symptoms. In contrast to specialty care in which high-intensity treatment targets complete remission of a diagnosis, PCBH entails lower-intensity treatment focused on improving patient functioning (Strosahl, 1996). Both cases are examples of the feasibility, acceptability, and utility of brief exposure treatment in PCBH. It is important to note that although referral to specialty care is an option when patient non-adherence to homework is impeding treatment, the exposure framework also enables the BHC to adjust the homework to make it more manageable for the patient by moving down the exposure hierarchy.

Notably, Hunter and colleagues (2017) recommend reporting of fidelity indicators in the PCBH literature. These cases incorporated the following elements consistent of the PCBH approach (see Hunter et al., 2017): evidence-based/informed intervention, 30-minute appointments, same-day appointments (warm-handoffs from PC provider), and mutually developed care plans. Furthermore, with respect to the GATHER approach of PCBH (see Reiter et al., 2018) the following principles were applied: Generalist: the BHC was working in an adult primary care setting seeing patients of any age over 18 years for a variety of health concerns related to biopsychosocial factors (e.g., depression, anxiety, substance use); Accessibility: same-day (warm-handoff) appointments were available with the BHC and supervisor of the current cases; Team-based: in both cases the BHC coordinated with the PCP and broader treatment team regarding course of treatment and symptom monitoring; High Productivity: patients were seen in a primary care clinic where BHCs were available for 10 or more 30 min visits each day; Educator: the BHC coordinated with the PCP in both cases regarding the use and rationale for exposure based intervention for anxiety treatment; Routine: the BHC attended all PC staff meetings and reviewed charts of PCP patients each day to take note of potential biopsychosocial influences on health (e.g., depression, substance use, anxiety, mental health history) and alerted PCPs in the morning of potential patient concerns to help facilitate efficient same-day appointments.

Conclusions and Future Directions

Through flexibility and creativity, BHCs can effectively implement brief, goal-focused ET to treat anxiety symptoms. The two case examples demonstrate the feasibility of implementing ET in a PCBH setting. Combined with tips and suggestions provided in Tables 1 and 2, this work provides a practical tool for supporting BHCs interested in integrating exposure into their own practice. Widespread implementation of exposure in the PCBH setting would be an important advancement in the treatment of anxiety broadly due to the strong evidence base supporting exposure as a gold-standard treatment, and the current limitations to effective anxiety treatment in PC. The goal of exposure in primary care is flexible and can be adapted to the patient’s needs, such that outcomes may include symptom remission and/or achievement of treatment goals, facilitating specialty care referral, and symptom mitigation during referral and waiting period. Furthermore, this treatment technique can be provided by any BHC providing mental health services for anxiety in primary care. ET is most well suited for anxiety presentations with a clear pattern of avoidance of specific anxiety provoking situations, objects, or contexts.

Additionally, we have reviewed two real cases as illustrative examples of implementation of brief exposure-based treatment in PCBH while collecting data regarding symptoms and treatment outcomes. However, this work is still limited in generalizability. For example, the current approach is focused on adults and recommendations would need to be adapted to be developmentally appropriate for youth. It is important to note that often patients may only attend one visit for a variety of reasons (e.g., low levels of symptoms/distress; lost to follow-up). This reality presents an opportunity for the flexibility of the PC setting. Although applying a treatment protocol is untenable in such a scenario, the patient may benefit from simply learning the rationale (e.g., Addis & Carpenter, 2000) regarding how avoidance maintains anxiety and how exposure helps. Research has demonstrated single session exposure protocols to be effective in reducing anxiety symptoms (Ollendick & Davis, 2013); however, these protocols generally entail long visits (2.5–3 hours), and research is needed to explore the efficacy of single brief sessions in the PC setting. Furthermore, it is unlikely that ET represents the best treatment for all anxiety presentations.

In an effort to continue advancing this important area of PCBH practice, we encourage BHCs to collect outcome data on their patients to whom they deliver ET and researchers to conduct clinical trials of brief transdiagnostic ET in PCBH. It would be particularly beneficial to examine exposure in subclinical anxiety as a potential strategy to prevent escalation to clinically significant anxiety symptoms, as it is very common in PC (e.g., Rucci et al., 2003) and research supports a dimensional rather than categorical conceptualization of anxiety (e.g., Bernstein et al., 2010; Broman-Fulks et al., 2010). A critical next step would be to conduct an efficacy trial within a transdiagnostic sample that may include subthreshold and mild symptoms such that outcomes may inform prevention efforts in addition to interventions. Additionally, it would be beneficial for future research to examine quality of life and functionality measures as treatment outcome indicators in addition to symptom measures. Increasing the use of exposure in PCBH would improve the quality of anxiety treatment available to PC patients.