Mechanisms of Change in Exposure Therapy for Anxiety and Related Disorders: A Research Agenda

Kristen Benito^{1

2}, Andre Pittig³, Jonathan Abramowitz⁴, Joanna J Arch⁵, Denise Chavira⁶, Rianne de Kleine⁷, Alessandro S De Nadai⁸, Dirk Hermans⁹, Stefan G Hofmann¹⁰, Jürgen Hoyer¹¹, Jonathan D Huppert¹², Katharina Kircanski¹³, Peter M McEvoy^{14

15}, Heidi Meyer¹⁶, Marie-H Monfils¹⁷, Santiago Papini¹⁸, Winfried Rief¹⁰, David Rosenfield¹⁹, Eric A Storch²⁰, Michael J Telch²¹, Michael W Otto²², Jasper A J Smits²¹

Affiliations

¹ Brown University Warren Alpert Medical School, Psychiatry and Human Behavior, Providence, RI, US.
² Emma Pendleton Bradley Hospital, Pediatric Anxiety Research Center, East Providence, US.
³ Georg-August-Universität Göttingen, Georg-Elias-Mueller-Institute of Psychology, Gottingen, Niedersachsen, DE.
⁴ The University of North Carolina at Chapel Hill, Psychology, Chapel Hill, NC, US.
⁵ University of Colorado at Boulder, Department of Psychology and Neuroscience, Boulder, CO, US.
⁶ University of California Los Angeles, Psychology, Los Angeles, CA, US.
⁷ Leiden University, Institute of Psychology, Leiden, NL.
⁸ McLean Hospital, Harvard Medical School, Belmont, MA, US.
⁹ KU Leuven, Center for the Psychology of Learning and Experimental Psychopathology, Leuven, BE.
¹⁰ Philipps-Universität Marburg, Department of Psychology, Marburg, Hessen, DE.
¹¹ Technische Universität Dresden, Clinical Psychology and Psychotherapy, Dresden, DE.
¹² The Hebrew University of Jerusalem, Psychology, Jerusalem, IL.
¹³ NIMH, Emotion and Development Branch, Bethesda, MD, US.
¹⁴ Centre for Clinical Interventions, Centre for Clinical Interventions, AU.
¹⁵ Curtin University, School of Psychology, Perth, AU.
¹⁶ Boston University, Psychological and Brain Sciences, Boston, MA, US.
¹⁷ The University of Texas at Austin, Research and Operations, Austin, TX, US.
¹⁸ Kaiser Permanente, Division of Research, Oakland, CA, US.
¹⁹ Southern Methodist University, Psychology, Dallas, TX, US.
²⁰ Baylor College of Medicine, Psychiatry and Behavioral Sciences, Houston, TX, US.
²¹ University of Texas at Austin, Psychology, Austin, TX, US.
²² Boston University, Psychology, Boston, MA, US.

PMID: 40855858
PMCID: PMC12373099
DOI: 10.1177/21677026241240727

Mechanisms of Change in Exposure Therapy for Anxiety and Related Disorders: A Research Agenda

Kristen Benito et al. Clin Psychol Sci. 2025 Jul.

. 2025 Jul;13(4):687-719.

doi: 10.1177/21677026241240727. Epub 2024 May 25.

Authors

Affiliations

¹ Brown University Warren Alpert Medical School, Psychiatry and Human Behavior, Providence, RI, US.
² Emma Pendleton Bradley Hospital, Pediatric Anxiety Research Center, East Providence, US.
³ Georg-August-Universität Göttingen, Georg-Elias-Mueller-Institute of Psychology, Gottingen, Niedersachsen, DE.
⁴ The University of North Carolina at Chapel Hill, Psychology, Chapel Hill, NC, US.
⁵ University of Colorado at Boulder, Department of Psychology and Neuroscience, Boulder, CO, US.
⁶ University of California Los Angeles, Psychology, Los Angeles, CA, US.
⁷ Leiden University, Institute of Psychology, Leiden, NL.
⁸ McLean Hospital, Harvard Medical School, Belmont, MA, US.
⁹ KU Leuven, Center for the Psychology of Learning and Experimental Psychopathology, Leuven, BE.
¹⁰ Philipps-Universität Marburg, Department of Psychology, Marburg, Hessen, DE.
¹¹ Technische Universität Dresden, Clinical Psychology and Psychotherapy, Dresden, DE.
¹² The Hebrew University of Jerusalem, Psychology, Jerusalem, IL.
¹³ NIMH, Emotion and Development Branch, Bethesda, MD, US.
¹⁴ Centre for Clinical Interventions, Centre for Clinical Interventions, AU.
¹⁵ Curtin University, School of Psychology, Perth, AU.
¹⁶ Boston University, Psychological and Brain Sciences, Boston, MA, US.
¹⁷ The University of Texas at Austin, Research and Operations, Austin, TX, US.
¹⁸ Kaiser Permanente, Division of Research, Oakland, CA, US.
¹⁹ Southern Methodist University, Psychology, Dallas, TX, US.
²⁰ Baylor College of Medicine, Psychiatry and Behavioral Sciences, Houston, TX, US.
²¹ University of Texas at Austin, Psychology, Austin, TX, US.
²² Boston University, Psychology, Boston, MA, US.

PMID: 40855858
PMCID: PMC12373099
DOI: 10.1177/21677026241240727

Abstract

Anxiety and related disorders are a significant public health burden with rising prevalence in the wake of the COVID-19 pandemic. As demand for effective anxiety treatment increases, so too does the need for strategies to bolster treatment outcomes. Research on the mechanisms of exposure therapy, the frontline behavioral treatment, will be critically important for optimizing clinical outcomes. We outline an initial agenda for future research on the mechanisms of change of exposure therapy, developed in collaboration with a large international team of researchers through the Exposure Therapy Consortium (ETC). Key questions and recommendations for future research focus on five priority areas: conceptualization, measurement, study design/analysis, and individual/contextual differences. Rising to the challenge of addressing these questions will require coordinated action and availability of centralized tools that can be used across trials, settings, and research groups.

Keywords: anxiety; exposure therapy; measurement; mechanisms; treatment.

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Conflict of interest statement

Conflicts of Interest Dr. Hofmann receives financial support by the Alexander von Humboldt Foundation (as part of the Alexander von Humboldt Professur) and the Hessische Ministerium für Wissenschaft und Kunst (as part of the LOEWE Spitzenprofessur). He also receives compensation for his work as editor from SpringerNature and royalties and payments for his work from various publishers. Dr. Hoyer receives a research grant from Mindable Health GmbH for effort outside the submitted work. Dr. Otto receives compensation for his advisory role with Big Health and receives grant support from the National Institute on Drug Abuse (NIDA) and Big Health for effort outside the submitted work. Dr. Rief receives research grants from the German Research Foundation DFG (e.g., CRC 289; RTG 2271) and the Hessian Ministry of Science and Arts, and book royalties from Hogrefe publisher. He also received speaker’s honorarium from Boehringer Ingelheim. Dr. Smits receives funding from NIDA (R21DA049539, R01DA047933) and the National Cancer Institute (NCI; R01CA273221) and compensation from Big Health, Elsevier, American Psychological Association, and Oxford University Press outside the submitted work. Dr. Storch reports receiving research funding to his institution from the Ream Foundation, International OCD Foundation, and NIH. He is a consultant for Brainsway and Biohaven Pharmaceuticals. He owns stock less than $5000 in nView (for distribution of the Y-BOCS and CY-BOCS). He receives book royalties from Elsevier, Wiley, Oxford, American Psychological Association, Guildford, Springer, Routledge, and Jessica Kingsley.

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Mechanisms of Change in Exposure Therapy for Anxiety and Related Disorders: A Research Agenda

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Mechanisms of Change in Exposure Therapy for Anxiety and Related Disorders: A Research Agenda

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