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Exploring exposures: provider perspectives of CBT with underserved, diverse youth in-person and via telehealth

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Exploring exposures: provider perspectives of CBT with underserved, diverse youth in-person and via telehealth

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Content EXPLORING EXPOSURES:
PROVIDER PERSPECTIVES OF CBT WITH UNDERSERVED, DIVERSE YOUTH INPERSON AND VIA TELEHEALTH
by
Diana W. Woodward
A Thesis Presented to the
FACULTY OF THE USC DORNSIFE COLLEGE OF LETTERS, ARTS AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(DEPARTMENT OF PSYCHOLOGY)
December 2024
Copyright [2024] Diana W. Woodward

EXPLORING EXPOSURES
ii
Table of Contents
Abstract……………………………………………………………………………….…………..iii
Chapter One: Introduction…………..…….………………………………………………………1
Chapter Two: Method……………….…………………………………………………..……..….9
Chapter Three: Results………...…………………………………………………..…………..…15
Chapter Four: Discussion.……………………………………………………..…………………32
References……………………………………………………………………………………......41
Appendices……………………………………………………………………………………….53
Appendix A: COREQ guidelines………………………………………………...54
Appendix B: Semi-structured interview guide…………………………………..56
Appendix C: Codes………………………………………………………………58
Appendix D: Provider Demographic Survey…………………………………….61

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Abstract
Exposures, a core behavioral strategy in CBT designed to decrease anxiety through
systematic confrontation of the feared stimuli, may be a critical element in optimizing CBT
effectiveness. However, exposures are underutilized by mental health clinicians, particularly
when working with underserved, diverse youth with anxiety disorders in real-world settings.
Thus, gaining insight into mental health clinicians’ experiences in delivering exposures as part of
CBT is critical for effective implementation, both in-person and via telehealth. This study aimed
to explore providers’ experiences with exposure delivery to underserved, diverse youth with
anxiety disorders and their perceptions of delivering exposure to this population via telehealth.
Through semi-structured interviews with 37 real-world mental health providers, qualitative
thematic analysis revealed six themes: 1) Caregiver involvement in exposure delivery, 2) Impact
of clinician self-efficacy and anxiety on exposure delivery, 3) enhancing engagement and
acceptability through client-centered design, 4) logistical challenges in delivering exposures via
telehealth, 5) adapting exposures to telehealth: creativity, flexibility, and previous experience,
and 6) perceived benefits and improving attitudes towards telehealth. Future research should
identify specific, evidence-based strategies and adaptations to exposures to facilitate and
optimize their delivery in real-world settings. Additionally, opportunities exist for the
development and dissemination of best practice guidelines.

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Chapter One: Introduction
Mental health disorders are among the leading sources of illness and disability among
youth. Forty-five percent of the overall burden of disease in young people is accounted for by
mental illness (Gore et al., 2011), and more than 60% of individuals meet criteria for a
psychiatric disorder by the age of 21 (Copeland et al., 2011). Anxiety Disorders are highly
prevalent in children and adolescents, with approximately 1 in 10 children meeting formal
diagnostic criteria by age 12, and by age 18, an additional 11% will meet criteria for an anxiety
disorder (Copeland et al., 2014). In community samples, studies have shown that anxiety is one
of the most common youth mental health disorders (Cartwright-Hatton et al., 2006). This
prevalence is concerning because Anxiety Disorders in childhood and adolescence have been
established as risk factors for recurrent Anxiety Disorders in adulthood and also other
psychopathology, including depression (Copeland et al., 2014; Kendall et al., 2004), AttentionDeficit/Hyperactivity Disorder (ADHD) (Armstrong & Costello, 2003), Substance Use Disorders
(SUDs) (Kendall et al., 2004), Conduct Disorder (Kendall et al., 2010), and suicidal behavior
(Hill et al., 2011). Moreover, adults with anxiety disorders report overall lower quality of life,
physical health, finances, interpersonal relationships, and occupational functioning (Copeland et
al., 2014; Costello et al., 2005; Kendall et al., 2004; Kessler et al., 1994; V. Patel et al., 2007).
CBT for anxiety among youth
Cognitive behavioral therapy (CBT), a well-established and evidence-based
psychotherapeutic approach that combines behavioral strategies and cognitive strategies, is
widely recognized to be the most empirically supported treatment for anxiety disorders in youth
(LeCroy, 2008). In addition to anxiety disorders, CBT is effective in treating a range of other
mental health disorders in youth, including depression, obsessive-compulsive disorder,

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posttraumatic stress disorder (PTSD), and suicidal ideation and behavior (Brent et al., 1997;
Busby et al., 2020; Cary & McMillen, 2012; Kendall et al., 2008; Kendall & Choudhury, 2003;
Lack, 2012). Moreover, CBT has also demonstrated efficacy in improving anxiety outcomes in
diverse, underserved youth who face multiple barriers to accessing and engaging in mental health
treatment in multiple randomized control trials (Kendall et al., 2023). The efficacy of CBT for
anxiety disorders has led to its wide use in various settings, including tele-behavioral health
(Venturo-Conerly et al., 2021).
Despite the established efficacy of CBT in treating anxiety disorders among youth, a
significant portion of youth fail to respond to treatment. Approximately 60% of youth are
estimated to respond to CBT, however, this leaves 40% who do not respond at all (James et al.,
2015). Furthermore, remission rates are approximately 40% in randomized controlled trials
(Warwick et al., 2017) and even lower in community settings. For example, Southam-Gerow and
colleagues (2010) found that among youth with anxiety disorders receiving care in community
clinics, CBT did not outperform treatment as usual (Southam-Gerow et al., 2010). Moreover,
Wergeland and colleagues (2017) found that only approximately 25% of youth in public child
and adolescent mental health outpatient clinics receiving CBT fully recovered (Wergeland et al.,
2014).
Variability of effectiveness
Several factors may contribute to variability in CBT treatment outcomes among youth
with anxiety disorders; however, the extant literature has yet to demonstrate consistent and
reliable predictors of treatment response. Some evidence suggests patient-level factors may
moderate response to CBT (Pegg et al., 2022), including severity of symptoms (Kunas et al.,
2021; Wergeland et al., 2014), type of anxiety disorder (Evans et al., 2021), comorbidity

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(Walczak et al., 2018), treatment discontinuation (Kendall & Sugarman, 1997; Pina et al., 2003),
age (Ginsburg et al., 2011), and minority status (Ginsburg et al., 2011; Levy et al., 2022).
Furthermore, clinician-level characteristics, such as therapist ‘style’ (Creed & Kendall, 2005) and
therapists’ resistance (Whiteside et al., 2016), treatment fidelity (Wergeland et al., 2014), and
training experience, (Wergeland et al., 2014) may also be candidate factors in contributing to
variability in treatment outcomes. Still, more research is needed to understand why CBT is less
effective for some youth.
There also appear to be treatment disparities by race/ethnicity. In the Child/Adolescent
Anxiety Multimodal Study (CAMS), the largest multi-site trial of CBT for youth with anxiety
disorders, White youth were significantly more likely than Latinx and Black youth to achieve
remission, and Black youth were less engaged in treatment and attended fewer sessions (GordonHollingsworth et al., 2015). Differences in treatment response may reflect structural and
institutional racism where minoritized youth do not receive structurally and culturally responsive
treatment (Alegría et al., 2022; West et al., 2023); however, studies have not adequately
examined this. To answer these questions, there is a pressing need for research in community
settings rather than academic settings, as this is where diverse youth are most often seen.
Community-based research could provide valuable insights into the barriers faced by minoritized
youth and help tailor interventions to address their specific needs.
Implementation of exposure in CBT
The observed effectiveness gap in CBT for certain youth may stem from challenges
related to implementation, specifically in terms of incorporating exposure into the treatment.
Elucidating specific components of CBT treatment is, therefore, particularly important for
achieving anxiety disorder remission in youth. A recent body of research has revealed that

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exposures— a core behavioral strategy in CBT for anxiety designed to decrease anxiety through
systematic confrontation of the feared stimuli—may be a critical element in optimizing CBT
effectiveness (Bilek et al., 2022). For example, one meta-analysis of seventy-five studies
examining the frequency of CBT treatment components and their relation to anxiety symptom
improvement found that more in-session exposure was correlated to larger treatment
improvements (Whiteside et al., 2020). Similarly, Peris and colleagues (2017) found that in
addition to exposure dosage (I.e., Time devoted to exposure), the quality of exposures (I.e., Time
spent on more difficult exposures) was critical in achieving response and remission (Peris et al.,
2017). Notably, the samples in the studies by Peris and colleagues (2017) and Whiteside and
colleagues (2020) were both predominantly White (more than 75%), indicating a need for further
explorations of how exposures are being implemented in minoritized populations receiving CBT
for anxiety.
Despite the well-established importance of delivering exposures to youth with anxiety
disorders, there is an indication that its implementation has been limited, particularly in realworld settings. For example, in a study involving 2485 youth with anxiety disorders receiving
treatment in a public mental health system, only 15% were delivered exposures (C. HigaMcMillan et al., 2017). Even within the context of CBT specifically, the implementation of
exposures is lacking. In the previously mentioned meta-analysis of CBT treatment components,
Whiteside and colleagues (2020) observed that one-fourth of CBT treatment manuals included in
the study omitted exposures entirely, and clinicians delivered exposures in only 1 in 3 sessions
(Whiteside et al., 2020). Furthermore, the majority of mental health providers in practice,
including those who classify themselves as CBT therapists, do not incorporate exposure therapy
into their treatment approach for anxious youth (Becker-Haimes et al., 2017; Chu et al., 2015).

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These findings underscore the significant gap between evidence-based practice and its
implementation in community settings, emphasizing the need for further investigations into the
barriers providers face in delivering exposures in routine clinical care for anxious youth.
Previous literature examining the experiences of real-world mental health providers has
revealed that a significant proportion of clinicians harbor negative beliefs about exposures.
Specifically, many therapists fear that exposures may induce harm by exacerbating symptoms
(Cook et al., 2004; Deacon, Lickel, et al., 2013; Olatunji et al., 2009), increasing the risk of
treatment dropout (Becker et al., 2004; van Minnen et al., 2010), and even inducing self-injury
(Becker et al., 2004). In an experimental study of 200 therapists reading vignettes of exposures,
the most frequently cited reasons for not endorsing exposure delivery were “dangerous/harmful
to client/others” and “not necessary for therapeutic success,” (Gagné et al., 2021). Similarly,
others have reported that clinicians are concerned that exposures are unethical (Deacon, Farrell,
et al., 2013) or unsafe (Meyer et al., 2014). In addition to fears about harming their clients,
clinicians may also worry about themselves— fears of vicarious traumatization (Zoellner et al.,
2011) and lawsuits for malpractice have been reported in the literature (Kovacs, 1996).
Understanding these perceptions is critical because negative beliefs about exposures are
correlated with the actual delivery (Becker et al., 2004; Becker-Haimes et al., 2017; van Minnen
et al., 2010). However, much of this work has focused on the treatment of PTSD and obsessivecompulsive disorder (OCD) rather than anxiety disorders (Becker et al., 2004; Benito et al.,
2021; Cook et al., 2004; Jelinek et al., 2024; Puccinelli et al., 2023; Scherr et al., 2015;
Schneider et al., 2020; Woodard et al., 2021), with even fewer studies investigating clinician
resistance to exposures within the context of CBT specifically. Given the likely impact of

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negative perceptions on exposure delivery in CBT with youth, further investigations into
provider attitudes working with this population are warranted.
Using exposures for CBT through telehealth
In addition to provider perceptions, numerous other potential barriers may hamper the
implementation of exposure therapy. Among the most recent challenges is the pivot to telehealth
prompted by the COVID-19 pandemic. To meet the increasing demands for mental health
services for youth during social distancing and lockdowns, mental health professionals quickly
transitioned to video platforms to deliver mental health treatment virtually. Although telehealth
has been utilized to deliver children’s mental health services for several years (Comer & Myers,
2016), the pandemic accelerated its adoption, with in-person mental health care decreasing by
approximately 50% in 2020 and Telehealth increasing by as much as 6500% (S. Y. Patel et al.,
2021; Reilly et al., 2020). Although CBT for children and adolescents can be effectively
delivered via telehealth (Venturo-Conerly et al., 2021), this shift likely brought new opportunities
and challenges. Indeed, there is some preliminary evidence that providers delivering CBT via
telehealth encountered difficulties with engagement and the therapeutic alliance, particularly
when working with youth (Sklar et al., 2021); however, how CBT-specific elements, such as
exposures, are effectively delivered via telehealth remains largely unexplored.
Aims of the present study
Understanding the perspectives of the mental health clinicians who deliver exposures via
telehealth is central to navigating and understanding the challenges of this modality, especially
considering that providers are frequently the “gatekeepers” of healthcare innovations, such as
telehealth (Brooks et al., 2013; Whitten & Mackert, 2005). As with exposures, clinician attitudes

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toward telehealth predict its use (Harst et al., 2019; McKee et al., 2021), particularly among
underserved communities (Gibson et al., 2011). Equipped with unique insights from direct
interactions with youth, these providers are ideally positioned to identify barriers and facilitators
in delivering exposures via telehealth. This may be especially pertinent among providers working
with underserved, diverse youth, as while telehealth may improve access to exposure-based
therapy, it also has the potential to exacerbate existing disparities (Mulia et al., 2023; Schriger et
al., 2022). Research that aims to harness real-world providers’ first-hand knowledge of
implementing exposures via telehealth with youth may provide valuable insights into optimizing
treatment design and delivery.
Given the centrality of exposures in the treatment of youth with anxiety disorders and the
shift to CBT delivery via telehealth, understanding mental health clinicians’ experiences
delivering exposures as part of CBT is critical for effective implementation in real-world
settings, both in-person and virtually. Thus, the overall aim of the present study is to qualitatively
analyze semi-structured interviews with clinicians participating in a large-scale Sequential
Multiple Assignment Randomized Trial (SMART) of CBT and fluoxetine for diverse pediatric
patients from underserved low- and middle-income households who have anxiety disorders.
More specifically, we aim to:
1. Explore providers’ overall experiences with exposure delivery to underserved,
diverse youth with anxiety disorders.
2. Investigate providers’ perceptions of delivering exposure to this population via
telehealth, including barriers and facilitators.

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By leveraging clinicians’ direct observations and insights, this research ultimately seeks to
inform clinical practice and enhance the effectiveness and implementation of anxiety treatment
for all youth.

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Chapter Two: Method
Methods are reported in accordance with the COREQ (Consolidated Criteria for Reporting
Qualitative Research (Tong et al., 2007) ) guidelines. The checklist is in Appendix A.
The SMART CBT and Fluoxetine Trial
Data for the present qualitative study were collected as part of a large-scale Sequential
Multiple Assignment Randomized Trial (SMART) of Cognitive Behavioral Therapy (CBT) and
fluoxetine. The main aim of the parent study is to identify treatment sequences that optimize
anxiety outcomes in ethnically diverse pediatric patients ages 8-17 from underserved low- and
middle-income households who have anxiety disorders. Youth participants in the SMART study
were recruited from 9 large clinical sites throughout the Los Angeles area that serve primarily
underserved ethnic minorities. Although the trial was initially intended to deliver CBT and
fluoxetine treatment in person, the trial was funded initially in February 2020 and had to pivot to
entirely Telehealth-delivered CBT because of the COVID-19 pandemic. As the pandemic
progressed and in-person activities became possible again, the trial transitioned to a hybrid
treatment model. Thus, this clinical effectiveness trial includes in-person and telehealth-delivered
CBT data.
Study design
Details of the design and methods of the SMART study have been previously published
(Peterson et al., 2021). SMART study clinicians were trained to deliver the Coping Cat
cognitive-behavioral therapy for pediatric anxiety (Kendall & Hedtke, 2006). Coping Cat (CC)
is a 16-session empirically-supported and manualized CBT treatment for youth 8-17 with
Anxiety Disorders that has been validated with multiple different populations and in languages

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including Spanish (Kendall et al., 2013). CBT clinicians in the SMART study were interviewed
to collect qualitative data about their experiences delivering CC after completing two courses of
CBT treatment or when they left the trial, whichever came first. A semi-structured qualitative
interview approach was chosen for the current study because it is ideally suited for exploring
experiences, perceptions, and influencing factors related to topics participants are personally
vested in (Braun & Clarke, 2006).
Setting and study participants
All study procedures were approved by the Children’s Hospital of Los Angeles
Institutional Review Board. We used a convenience sampling technique to recruit providers to
participate in semi-structured interviews via email. Participant providers were recruited from all
sites, with CBT clinicians participating in the SMART study. These included a hospital-based
community mental health program, two community mental health networks, a hospital-based
pediatric primary care clinic, a large HMO organization, and an extensive group private practice
network. The majority of these sites serve Medi-cal funded patients. Participant inclusion
criteria were mental health professionals trained to deliver CBT as part of the SMART parent
study who had completed at minimum two cases in the SMART study or were leaving the trial
(usually because they were leaving their organization).
Thirty-seven providers participated in semi-structured interviews. No providers refused to
participate in this qualitative sub-study during data analysis for the present study. Participants
include Clinical Psychologists (Ph.D., Psy.D), master’s level clinicians (LCSW, MSW, ACSW,
LMFT, AMFT and trainees in these disciplines), Psychiatrists (MD, DO, and psychiatry
trainees). There are no other inclusion/ exclusion criteria.

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Research Team
The authors include three female and one male doctoral-level clinical psychologists, one
female doctoral-level nurse, one male psychiatrist, one doctoral-level social worker, and two
female clinical psychology doctoral students. Semi-structured interviews were conducted by
three female research assistants (with, at minimum, an undergraduate degree) and one female
doctoral student, all of whom had previous contact with study participants via research activities.
Interviewers were trained in qualitative interview techniques by faculty with qualitative
expertise. Qualitative data was coded and analyzed by two female clinical psychology doctoral
students and one female doctoral-level clinical psychologist, all with prior qualitative research
experience. One had no previous contact with research participants, one coder participated in
qualitative data collection (conducting semi-structured interviews), and one coder was a prior
study provider in the SMART trial. Data analysis was supervised by a key senior study
investigator who is a female doctoral-level clinical psychologist and clinical scientist with
expertise in qualitative methods. Overall, our research team comprised individuals from diverse
racial and ethnic backgrounds, various genders, varied relationships with mental healthcare and
diverse experiences working with underserved youth. We sought this diversity to enhance our
interpretation and analysis of the data.
Procedures
Semi-structured interviews were conducted in English via Zoom or telephone between
May 2022 and September 2023. Only the interviewer and interviewee were present, and there
were no repeat interviews. Interviews consisted of 19 open-ended questions, focusing on
providers’ perceived strengths, challenges, acceptability, feasibility, and implementation
experiences of delivering CBT to the study population, including barriers and facilitators of

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Telehealth delivery. Interview questions started broadly, first covering the providers’ overall
impressions of the treatment and perceptions of the youth’s experience in therapy. Interviewers
then assessed barriers and facilitators to the youth’s access to therapy. For providers who
reported using Telehealth, the second half of the interview focused on their experiences with
Telehealth and their perceptions of the youth and family’s experiences with Telehealth.
Interviewers specifically inquired about the perceived efficacy of CBT via Telehealth versus inperson care and treatment components that were more difficult to deliver via Telehealth. For the
complete semi-structured interview guide, see Appendix B. The interview guide was developed
by the study team in collaboration with the two advisory groups of stakeholders, one consisting
of youth from the community with anxiety disorders and one of parents of children with anxiety
disorders from the community. The purpose of these advisory groups is to ensure stakeholder
engagement in developing the study questions, methods for data collection and analysis, and
interpretation of study results. Interviews take, on average, around 45 minutes. With participant
permission, interviews were video recorded and transcribed verbatim using Telehealth platformassisted transcription. Field notes were also taken during and after the interviews.
Data analysis
Data analysis followed Braun and Clarke’s 6-phase framework for thematic analysis: 1)
Data familiarization, 2) Coding the data, 3) Generating themes, 4) Reviewing themes, 5)
Defining themes, and 6) Writing up the results.
Data familiarization. First, the primary investigator (DW) read and listened to all the
transcripts to familiarize herself with the data and take notes on potential codes and topics to
explore further. She also took notes on her assumptions and reactions to the data. Inductive codes
were generated using transcript notes and combined with deductive codes from the semi-

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structured interview guide to form an initial codebook (See Appendix C). Codes were further
refined in consultation with the senior research team and the two previously mentioned
community advisory groups.
Coding the data. In the next phase of thematic analysis, transcripts were coded using
QSR International’s NVivo 12 qualitative data analysis software. A subset of transcripts (N=9)
was randomly selected, and the coding team (DW, RR, and EP) independently coded each
transcript. After each transcript was coded, DW, RR, EP, and AW met to achieve consensus by
discussing codes, addressing discrepancies, and refining the codebook. Once agreement was met,
the team coded the remaining transcripts (20% dual-coded).
Generating themes. After the transcripts were coded, all coded data was reviewed with
key senior research staff. Similar codes were grouped and compared to begin forming themes.
Reviewing themes. The research team further reviewed and refined the initial themes
through deliberation. This process began by gathering all data (text) related to a specific theme to
ensure all text fit within the given theme. Although text may have been coded in multiple and
sometimes overlapping ways, themes were reviewed to ensure they were coherent and distinct
(Braun & Clarke, 2006). Further, relationships between themes were also explored.
Defining themes. Once the relationships between themes were established, the research
team worked to define each theme.
Writing up the results. The primary author analyzed the finalized themes using specific
data extracts (i.e. exemplary quotes) and the extant literature. Participants were not given
transcripts for member checking, nor were they solicited for feedback on our findings. However,

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themes were presented to a diverse group of student researchers from multiple disciplines and
positionalities to elicit impressions of credibility and coherence.

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Chapter Three: Results
Demographic Characteristics*
Participants were 37 mental health clinicians who delivered CBT in the SMART study
throughout Los Angeles County. 64.9% of clinicians’ highest education level was a master’s
degree, 21.6% had a doctorate, and 13.5% had an MD. 18.9% spoke an additional language other
than English, and 75.7% provided therapy to children with public insurance (i.e., Medi-Cal).
*Other demographic characteristics were not collected at the time of data collection for the
present study but are being collected retroactively. Further demographic information will be
included in the final manuscript for publication. See Appendix D for the Provider Demographic
Survey.
Major findings
Six themes emerged from thematic analysis of the semi-structured interviews: 1) Caregiver
involvement in exposure delivery, 2) Impact of clinician self-efficacy and anxiety on exposure
delivery, 3) enhancing engagement and acceptability through client-centered design, 4) logistical
challenges in delivering exposures via telehealth, 5) adapting exposures to telehealth: creativity,
flexibility, and previous experience, and 6) perceived benefits and improving attitudes towards
telehealth. Subthemes within themes were also developed. Descriptions of these themes,
subthemes, and corresponding exemplary quotes follow. See Table 1 below.
Table 1. Themes, sub-themes, and exemplary quotes
Themes Sub-themes Exemplary Quote
Caregiver
involvement in
exposure
delivery
Initial hesitancy
from caregivers
towards
exposures
“I think parents are wired to protect their children. So
it's like, “oh, you're wanting me to do this thing
[exposure] that makes my child uncomfortable. How
does that work? Or what is the point of that? So I think
there's a skepticism” (#5)

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Importance of
caregiver
involvement
“I know with the teen version they have the couple
parent meetings, but it's not explicitly stated to keep
engaging parents. And I think that could be helpful as a
way to make sure that they're doing the [exposures]
because even teenagers need a lot of support and a lot
of reminders—especially teens with anxiety who may
just forget to do these things” (#36).
Caregiver
engagement as a
challenge
“Parents were more coming from the mindset of this is
my child’s treatment. And if they’re on telehealth, I can
kind of just go off and be doing my own thing or
maybe not even be home while my child is on their
phone doing their telehealth appointment” (#24)
External
stressors as
barriers to
caregiver
involvement
“The caregivers are very motivated to follow along
with the Coping Cat program. It’s just more like
circumstantial limitations if they have too much going
on…” (#27)
Clinician SelfEfficacy and
Anxiety: Impacts
on Exposure
Delivery
Exposures as
effective and
important
“The most helpful part is the exposures, having those
worksheets for them to record their exposures and
things like that. I think that’s where you see the most
symptom reduction” (#23).
Clinician selfefficacy and
anxiety about
exposures
“I’ve been told, like the theory around the power of
exposure. And so, I understood it from like a
psychoeducational theoretical piece. I just [didn’t
know] how to implement it and how to implement it in
a way that felt safe, but also kind of pushed clients a
little past their comfort level in order to increase their
distress tolerance.” (#14)
Clinicians
managing their
own anxiety
amidst external
stressors
“One of the barriers, I guess, that the client said is,
“well, my mom is undocumented, and she doesn’t want
to leave the house. We stay in the house.” And, you
know, it made sense. I validated that... But I felt at that
point like, oh my gosh, we’re stuck…I don’t want to
keep pushing her to do an exposure outside.” (#35)
The role of
clinician anxiety
in navigating
decision-making
challenges
“I wish I adopted [the exposures]... I think I wasn’t
comfortable exploring [exposures] with Mom… I just
wanted to be really sensitive…I wanted her to have
trust and to be able to have a positive experience. But I
think, in hindsight, it could have been good to talk
about.” (#35).
Enhancing
engagement and
acceptability
through clientClient readiness
to change
“ I think the challenge was more when we came to the
actual exposure, having the client participate…at the
beginning [the client] wasn’t really participating”
(#17).

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centered
exposure design
Tailoring
exposures to
meet client needs
“Nothing’s a panacea…there’s no one-size-fits-all of
any therapeutic model... And finding what works for
the population that we’re treating and having a really
big toolbox and the skills to utilize those different tools
is important” (#10).
Addressing
external
stressors in
exposure design
“External stressors are really difficult to overcome
when you don’t have a lot of safety net, a lot of support
and a community embedded around you. So I think for
individual families that are struggling to pay the rent
for next month or don’t get enough food for next week.
It’s a little challenging to say, hey, can you work less
hours each week to take your kid into a community for
exposure? And sometimes we need to find a secondary
caregiver or someone like that who can accompany the
child out there to do the exposure. I think they just need
to be a little bit more creative rather than just talk to the
parents, be like, Hey, can you do this right?” (#9)
Logistical
challenges in
delivering
exposures via
telehealth
Exposures
targeting social
anxiety are less
effective
“I thought that the phone calls to the businesses would
evoke a little bit higher [social] anxiety.. but she did it
and she said it was like at a four… I even had one of
my colleagues come [into the Zoom] and I turned off
my screen. She said she was also fine doing that , too…
So then I had another person come in and be a little bit
more rude. And she said it was fine because it was
telehealth.” (#27)
Clients could
avoid/evade the
exposure
“ I think she used turning off the camera and muting
herself as avoidance. Sometimes I would have to
prompt her to turn her camera back on during an
exposure so I could make sure that she was actually
engaging in the exposure” (#29).
Translation and
communication
difficulties with
non-English
speaking families
over telehealth
“I think maybe because mom speaks Spanish and so we
used the interpreter to explain those instructions. I
thought we were on the same page, but then when I
gave them a call the following week, they had already
done the exposure activity, so I was calling them after
the exposure… using a translator is not only a bit of a
logistical challenge, but then I think just interpersonally
sometimes, I think that can be a barrier as well.” (#30)
Adapting
exposures to
telehealth:
creativity,
flexibility and
previous
experience
Flexibility and
creativity in
telehealth
exposure design
“One example is there's this area in her neighborhood
that brings back some of those anxiety triggers. And we
thought of one way to overcome that barrier because
we couldn't go there together. It was to look at Google
Maps and look at images of those neighborhoods. And
so just finding creative ways to still have her
experience that exposure even if we had the limitation

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of being miles and miles away from each other or
working together through the computer,” (#13).
Previous
telehealth
experience
“So I already had a lot of experience coming up with
exposures that work via telehealth. So I felt like I had
an advantage, like I just kind of drew from the arsenal
of exposure ideas that I’ve already done..” (#31)
Consultation
groups
““There were some struggles…trying to do the
exposures, trying to be creative, like, “okay, how am I
going to do an exposure through telehealth?”… [but] I
think the consultations did help, like giving some
examples of things that I could do through telehealth
(#11).
Perceived
benefits and
improving
attitudes towards
telehealth
Telehealth
benefits for
exposure
delivery
“For example, having a client who’s really scared of
their bathroom at home, doing in vivo exposures in
their bathroom at home is something that I wouldn’t
have been able to do if I didn’t have telehealth” (#14).
Shifting clinician
attitudes towards
telehealth
“I was someone who was kind of resistant to telehealth
before the pandemic….And then the pandemic
happened and I'm full telehealth and now…I do think
telehealth is effective… [clients are] less stressed out
and more open to doing [exposures] because they don't
have to leave work, get in the car, leave their home,
pay for parking, get to an office…” (#10).
Theme one: Caregiver involvement in exposure delivery.
Clinicians reported that caregiver engagement facilitated exposure delivery, particularly
when exposures were being delivered over telehealth. Clinicians also described a variety of
barriers that interfered with effective caregiver engagement in their child’s treatment.
Initial hesitancy from caregivers towards exposures: Caregivers often expressed
reluctance towards pushing their children to complete exposures, which clinicians interpreted as
an inherent desire to protect their children. Clinicians found that parents became more receptive
to exposure work after psychoeducation and once they saw the positive impact of exposures on
their child’s symptoms. As explained by one clinician, “I think parents kind of have to get used
to the idea that, oh, avoidance is actually not helpful… and that the role of the parent or even

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19
therapy isn’t to get rid of anxiety. I think that’s like a big aha moment for parents” (#5).
Likewise, another clinician noted, “I think mom was okay with [exposures] because she saw
“hey, it's working. We're doing exposures, and she's getting better at being out in public” (#21).
Importance of caregiver involvement: Clinicians emphasized caregivers' critical role in
effective exposure delivery. Some providers reported that engaging caregivers outside the
scheduled caregiver sessions helped ensure clients were completing their between-session
exposures. Moreover, many providers also noted the importance of parental engagement when
sessions took place over telehealth. In these sessions, clients often need adult support to complete
exposures in the community because the therapist is not physically present with the client. For
instance, one provider said—
We would practice in session, but I’d have to employ other family members, a parent, or
maybe even a sibling to do some of [the exposures]. And then, because of the pandemic,
I’m not with her. Whereas if we weren’t all telehealth… you don’t have to rely on just the
client and then a parent who are often really, really busy and they can’t fit in. (#10).
Caregiver engagement as a challenge: Despite its clear importance, clinicians described
involving families in exposures as challenging, particularly when sessions were conducted
virtually. Clinicians reported that caregivers often viewed treatment as their child’s responsibility
and that many caregivers were absent or disengaged, which hindered collaboration between the
clinicians and families. Several providers hypothesized this may have occurred because
caregivers may view their participation as less necessary over telehealth. Clinicians also noted
increased distractions during telehealth sessions with caregivers and expressed worry that the
decreased engagement may have compromised the effectiveness of the exposures –

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20
Mom was really busy. Even when we did do the parent sessions, she was constantly
doing other stuff or like, “Oh, hold on a minute.” She called me from work one of the
times. And so, I’m not even sure if Mom was able to internalize what we were really
doing with her child. (#7)
External stressors as barriers to caregiver involvement: Although many clinicians
underscored the challenges of engaging caregivers in exposure delivery, some also highlighted
difficulties in caregiver engagement due to external barriers rather than a lack of interest.
Clinicians described several obstacles that impeded eager caregivers from engaging in their
child’s treatment. Work commitments and schedules were among the most frequently endorsed
barriers to caregiver engagement. For example—
With the second kiddo who dropped out, that was a single mom who had a very
overwhelming schedule. She has two kids, working full time, going to school, doing a
nursing program. So, she just had a lot of her own demands that made it hard for her to
follow through on [exposures]. And the kiddo, just her anxiety being so high that she
couldn't handle trying to follow through on anything on her own. (#21)
Clinicians also reported that socioeconomic barriers negatively impacted caregiver
participation. As one clinician explained,
I think sometimes families that are experiencing a lot of socioeconomic, or sort of larger
societal pressures make it hard to engage with therapy in general. I think sometimes,
sitting down to talk about these various skills doesn't feel as relevant to them and then
they disengage. (#33)

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In general, clinicians reported that families in which caregivers experienced high levels
of external stress (e.g., single parents, parental incarceration, etc.) had the most difficulty
engaging with their child’s treatment. For instance—
We created an exposure hierarchy, and mom fell through on some of the activities we had
planned… she understood the model and what we were doing pretty well, [but] other
kind of factors [got in the way] …she's a single mom, so managing those two kids and
dad was incarcerated at the time. And that was just like bringing up a lot of emotions for
the family. (#34)
Theme two: Clinician Self-Efficacy and Anxiety: Impacts on Exposure Therapy Delivery
Clinicians reported a variety of emotional reactions to delivering exposures, despite
understanding their importance. Many reported that anxiety, frequently due to client distress and
safety concerns, interfered with effective exposure delivery. Clinicians reported that managing
their anxiety and tolerating their distress helped overcome these barriers to exposure delivery.
Exposures as effective and important: Overall, clinicians reported that they found CBT to
be acceptable and effective for treating diverse, underserved youth with anxiety disorders and
that exposures reduced symptoms more than any other treatment component. For example, one
provider reported that after their client worked through their exposure hierarchy they said, “I’d
be shaking and crying. now, I’m not as much stuck on the negative” (#14).
Clinician self-efficacy and anxiety about exposures: Clinicians frequently endorsed
anxiety about implementing exposures and any associated challenges. Despite understanding the
rationale behind exposures for the treatment of anxiety disorders, they often found it difficult to
witness their clients’ distress and lacked confidence in their ability to manage their own

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emotional reactions. Clinicians’ reflections highlighted the relevance of their own self-efficacy in
navigating exposure delivery and the importance of managing their own anxiety while ensuring
client safety. As one clinician described this experience—
I had to also tolerate seeing my kiddos go through symptoms sometimes right in front of
me. It’s also like a growing edge for me to be like, “okay, my role right now isn’t to
soothe my client or help them soothe. It’s almost like to tolerate it, to identify, oh my
gosh, I’m having actual symptoms talking about this. (#5)
Clinicians managing their own anxiety amidst external stressors: Providers reported that
external stressors and safety concerns present in their clients’ environments often complicated
their anxiety around exposure implementation. For example, one clinician described an exposure
in which they instructed their client to walk down their neighborhood street without an adult—
I think I was more anxious that session than he was because I was afraid that he might
confront something that was dangerous… he lived in… one of those neighborhoods in
south LA where there are more cars on the street than humanly possible. So just, you
know, it’s not a safe walking neighborhood. (#22)
While some clinicians pushed through their anxiety and facilitated exposures in stressful
environments, others did not. For instance, one provider reported, “I didn’t [follow through with
the exposure]. I just validated at that point, and I think it may have played a role in the client’s
anxiety” (#35).
The role of clinician anxiety in navigating decision-making challenges: Many providers
reported that their anxiety about and limited self-efficacy around exposure delivery impacted
their willingness to encourage clients to engage in exposures. Some clinicians speculated that

EXPLORING EXPOSURES
23
their anxiety may have interfered with treatment efficacy as they refrained from delivering
exposures entirely (see above quote). But other providers found that they were able to manage
their anxieties and deliver exposures effectively—
I think when I kept seeing it over and over— that they are okay at the end [of the
exposure] -- it’s kind of like a rubber band. It stretches my capacity of knowing, you’re
going to be okay, and I’ve witnessed other people being okay, and I’m also going to be
okay watching you go through this. (#5)
Theme three: Enhancing engagement and acceptability through client-centered exposure
design
Clinicians discussed the challenges of motivating clients to engage in exposures but
found that clients’ willingness to participate increased over time. They stressed the importance of
adapting exposures, especially by considering genuine stressors and threats to clients’ safety, to
improve client receptiveness.
Client readiness to change: Low motivation and lack of buy-in often interfered with the
clients’ willingness to complete exposures, particularly at the beginning of treatment. Clinicians
found that once clients began completing exposures, their willingness to engage improved—
I think as we worked on [the exposures] … there was a sense of competency…initially, it
was difficult to get her buy-in, but I would say once she started the exposure…, she
[started] feeling good about the fact that she did it. (#28)
Tailoring exposures to meet client needs: Clinicians underscored the importance of
tailoring exposures to meet clients’ individual environments and sociocultural contexts. For
example, one provider stressed that an individualized approach may be necessary for certain

EXPLORING EXPOSURES
24
clients— “Nothing’s a panacea…there’s no one-size-fits-all of any therapeutic model... And
finding what works for the population that we’re treating and having a really big toolbox and the
skills to utilize those different tools is important,” (#10).
Clinicians reported a range of adaptations they implemented during exposures to improve
client receptiveness and participation. Adaptations included involving additional adults other
than primary caregivers from the child’s environment, relying more heavily on psychoeducation
and validation, and dedicating extra time to building rapport and trust.
Designing exposures to address external stressors: Throughout these discussions of
exposure design, clinicians consistently emphasized the importance of recognizing the real
threats and stressors faced by clients. For instance, one clinician described adapting the
psychoeducation around exposures to help their client, who lived in a neighborhood with “a lot
of gang presence and gun violence” (#33), distinguish real threats from anxiety-induced
responses —
We’ve been teasing apart what is a real threat versus what is your anxiety alarms going
off when there is a threat… if you’re hearing a gun go off, that is a legitimate threat to
safety. And so, talking a little bit about like normal responses to threats…we don’t want
to take away vigilance that is protective in the environment that she’s living in… Like we
can’t go to the local store to do an exposure because that’s probably not a safe place to go
do that. I’m not going to make her go make a complaint or whatever, if that feels unsafe
in those spaces… (#33)

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Similarly, other clinicians highlighted the necessity and challenges of finding innovative
solutions for exposures with clients who are exposed to genuine safety concerns or with limited
resources—
I do think Coping Cat is a really good tool for folks who are well-resourced, and I think
for folks that are a little less resourced, we just need to be a little more creative with
finding different [exposures] to help them… (#9)
Theme four: logistical challenges in delivering exposures via telehealth
While providers emphasized the difficulties in tailoring exposures to address external
stressors, all clinicians also discussed novel challenges in exposure implementation in the
telehealth context. Specifically, clinicians described the unique challenges of conducting
exposures via telehealth for clients struggling with social anxiety, clients engaging in avoidant
behaviors, and clients and families who did not speak English.
Exposures targeting social anxiety are less effective: Clinicians delivering exposures to
youth with social anxiety over telehealth concluded that in-person treatment would have been
more effective. For example, one clinician working with a client with social anxiety said, “I
wonder if the patient would have progressed more or if we were in-person. I feel like they might
have progressed a little bit better in person…” (#20). This was largely because “working one-onone with [clients with social anxiety] in-person could be a type of exposure in and of itself”
(#13), or, as another provider put it, “being able to be in-person could have challenged some
more of the social anxieties that they had…” (#20). Clinicians reported that some clients with
social anxiety also acknowledged the perceived ease of exposure activities conducted via
telehealth, further highlighting the limited impact of virtual exposures on social anxiety.

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26
Clients could avoid the exposure more easily: Relatedly, providers observed that clients
could more easily avoid exposure participation over telehealth compared to in-person therapy. As
one clinician described, “I think there’s an increased ability to avoid [on telehealth] more than in
person…sometimes I noticed a child would turn their camera a certain way because they don’t
want me to see their face” (#5) a clinician said.
This increased ability to avoid, combined with the fact that providers could not be
physically present during exposures, led many clinicians to wonder if their clients were actually
completing exposures. For example-- “I think he did his best with [the exposures], but a lot of it
was like, okay. Go ask your teacher or ask a silly question in class to get over this fear. I think I
think he did. I mean, I think what’s hard is you don’t really know if people are doing them or
not” (#10). Thus, some providers concluded that the challenge of ensuring that exposures were
completed was heightened in the telehealth context. “But I did wonder how our exposure is
actually being enforced at home. What’s the follow-through? So, I think in-person would have
helped me with that” (#31) a provider reported.
Translation and communication difficulties with non-English speaking families over
telehealth: Language barriers also posed significant challenges for clinicians implementing
exposures with non-English speaking caregivers, as clinicians often needed interpreters to
communicate instructions. Telehealth further exacerbated these challenges because coordinating
translation services for short check-in sessions with caregivers was not always possible –
As clinicians who work with kids, we just need to get on a five-minute phone call and
reach out to parents about planning or logistics or a little update…like with most client
sessions, parents will hop on at the beginning or at the end [of the session]. And if you
don’t have that ease of just being able to speak directly with them or you have to speak

EXPLORING EXPOSURES
27
through the child, sometimes that can be tough, especially if we’re trying to explain like
the structure of like exposures or like logistics. (#30)
Moreover, providers questioned whether the use of translators impeded building rapport with
families and exacerbated any interpersonal barriers in communication. “We had to get a
translator, so that was like part of the difficulty. But I mean, it’s not impossible. Like we can get
that, but it’s just harder. I feel like sometimes things don’t translate well, and I think it’s hard to
get a translator” (#35) one clinician explained.
Theme five: Adapting exposures to telehealth: the role of flexibility, previous experience,
and support
Clinicians took different approaches to adapting exposures for telehealth, but most
reported that flexibility and creativity were essential for delivery. While clinicians with previous
telehealth experience reported more comfort and success in adapting exposures, those with less
experience found support in consultation groups, enabling them to brainstorm and problem-solve
virtual modifications effectively.
Flexibility and creativity in telehealth exposure design: Though telehealth presented new
challenges, clinicians noted that they employed innovative strategies to adapt exposures to this
new modality. Clinicians reported that thinking creatively, working flexibly, and spending time
preparing for the exposure delivery all positively impacted their ability to deliver a useful and
effective exposure over telehealth. For example--
I definitely prepared ahead of time. [I tried] to get creative with how to do the exposures
[via telehealth], like calling a pizza place… I would change my background to a
classroom… role-playing, trying to involve the family as much as possible. I think there

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28
was one where they had to do a presentation, so I had a mom and the brother in the
session doing a presentation along with him. (#11)
Clinicians also reported using more role-plays, imaginal exposures during sessions, and
homework when doing exposure work virtually. One provider explained, “[We did] more
imaginal exposures and role plays. And I relied much more heavily on them getting those
experiences through homework assignments…” (#23) When another clinician encountered
resistance to role-playing over telehealth, they also demonstrated flexibility in pivoting to
alternative strategies to address the client's needs—
It was challenging over telehealth. I ran into some issues. One of my clients didn’t really
want to do exposures... I would try to suggest, let’s act out. And he would say, Oh, you’re
not so-and-so… So, it took some time to get creative… we did more imaginal
exposures… it was easier for him to kind of imagine it rather than us acting out. So yeah,
it took a little bit of adapting, I guess. (#35)
Another clinician observed that there was a “tendency for us to rely on verbal communication
rather than experiential, but because the [client] was so highly verbal, she could easily verbalize
her thoughts and feelings, I needed to be mindful… [that she was] acting on exposures
throughout most of the session rather than just verbalizing and reporting.” (#2)
Previous telehealth experience: Clinicians discussed the role of previous experience in
their ability to effectively adapt exposures to telehealth, with providers who had used telehealth
to deliver exposures reporting more comfort and success. Conversely, less experienced clinicians
described challenges devising innovative exposure strategies for telehealth. “I think having more

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29
experience [would have made things easier to do the exposures via telehealth], I think in kind of
allowing myself to think a little bit more out of the box” (#4), a provider reported.
Consultation groups: Clinicians with less telehealth experience reported that consultation
groups provided valuable support in helping them navigate challenges and generate creative
exposure adaptations. These consultation groups served as a platform for brainstorming and
problem-solving, aiding clinicians in overcoming barriers. One provider reported that the
consultation groups helped them generate ideas if they were “hitting a block” (#20). Clinicians
also underscored the role of consultation groups in enhancing the effectiveness of the exposures.
For instance, one clinician emphasized that “it’s also been really helpful having the consultation
groups with the study coordinators and being able to field questions on how to make an exposure
more effective” (#14).
Theme six: Benefits and improving attitudes toward utilizing telehealth for exposures
Clinicians reported a notable improvement in attitudes towards telehealth for exposure
delivery, with many highlighting the advantages of this modality over in-person exposures.
Clinicians also underscored the significance of this evolution, which recognizes that clinician
biases, rather than client attitudes, often hinder effective exposure implementation via telehealth.
Telehealth benefits for exposure delivery: Clinicians described two primary benefits
related to virtual exposure delivery: 1) increased insight into the client’s environment and 2)
conducting exposures in natural environments.
Providers discussed how telehealth allowed them to gain insight into their clients’ living
spaces and communities. Some clinicians remarked that this information contextualized clients’
anxieties and allowed providers to further integrate external stressors into treatment.

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30
Additionally, increased insight into the client’s environment gave clinicians valuable practical
information that informed the selection of exposures best suited to the specific client. One
clinician said—
What does their space at home look like? Do they have their own space, or are they
sharing a room with another person or multiple people? Or what are other stressors going
on for them? Or even like when I was doing exposures with my client who we had walk
outside. What does your neighborhood look like? Okay, you feel less safe in your
neighborhood. So, how do we balance doing this exposure with making sure that you stay
safe? (#36)
Another advantage of telehealth was clinicians’ ability to implement exposures in the
client’s environment, such as their backyard or bedroom. Providers discussed how this allowed
for more context-specific and individualized interventions. As one clinician described conducting
an exposure with a client who had a fear of the dark, “We’d try and take our session outside into
his backyard at night where it was darker and start turning off lights and we could do that with
his cell phone. We would not have been able to do that if we were here in the clinic,” (#22).
Ultimately, many providers believed that conducting these exposures in the real contexts
where their client experienced anxiety, as opposed to in-office, facilitated more effective and
rapid progress. One clinician stated, “I think that led to a lot of progress really fast because it was
specific to that content. We were practicing in the context where she experiences the fear. We
wouldn’t necessarily be able to do [that] if she was in the office.” (#29). Furthermore, telehealth
allowed clinicians to actively support their clients through the exposures, improving engagement
and accountability. For example, one provider explained the advantages of real-time coaching
versus homework—

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31
Instead of just giving them homework and saying this is what you have to do, and it
would be hard for me to assess what happened and if they actually did it. So, if I was
there [via telehealth], I could kind of see everything happen. (#8)
Shifting clinician attitudes towards telehealth: Comments from clinicians indicated that
many experienced a notable and positive shift in attitudes regarding the use of telehealth for
exposures. Importantly, clinicians reported that this shift frequently occurred after witnessing
telehealth’s utility first-hand.
During conversations about this transition from resistance to acceptance of telehealth,
some providers highlighted that clinician attitudes, not client factors, often hinder effective
implementation. For example, one clinician said—
I think there’s also, for clinicians, a kind of willingness to be goofy about the fact that
sometimes technology’s real dumb. I think the times I’ve seen telehealth be least
successful are when clinicians or the person who is providing a telehealth service gets
anxious about the technology not being everything they wished it was. And it’s like
sometimes it’s an opportunity for us to model effective adaptation. (#14)
Moreover, one provider challenged the notion that communication is hindered by telehealth.
Instead, they suggested, clinicians need to reconsider their perspective. They emphasized that
exposures conducted over telehealth are “in many ways more generalizable for people. It’s not
like you’re coming into therapy, and this is that compartmentalized place where you do
[exposure]… [telehealth] is how people are connecting right now, especially teens who lived
through Covid. This is a real mode of social connection. And I think it’s naive of the therapy
world to feel like there is something that is lost through online communications.” (#25)

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Chapter Four: Discussion
Overview of main findings
Several studies have emphasized the critical role of exposures in effectively treating
anxiety disorders in youth as part of CBT (Bilek et al., 2022; Peris et al., 2017; Whiteside et al.,
2020). Yet the implementation of exposures in community settings has been limited, which poses
a concern with respect to disparities given most underserved and diverse youth receive care in
these community settings (C. Higa-McMillan et al., 2017). Moreover, research on telehealth
delivery of exposures is lacking despite its potential to improve access to care for these youth.
Mental health clinicians play a central role in delivering exposures and have first-hand
experience providing care to these youth, yet their experiences providing exposures remain
understudied (Ramos et al., 2021). To address disparities in exposure implementation and anxiety
treatment outcomes, it is essential to incorporate the lived experiences of mental health
clinicians, particularly regarding the delivery of exposures to underserved, diverse youth both inperson and via telehealth.
This study aimed to investigate mental health clinicians’ perceptions of delivering
exposures as part of CBT to underserved, diverse youth in person and via telehealth. Through
qualitative thematic analysis, we found clinicians faced challenges navigating the complexities of
exposure delivery in real-world settings. Themes also revealed a range of engagement strategies
and adaptations clinicians utilized to address these challenges and improve exposure
effectiveness. The present study builds upon previous research on the implementation of
exposures in real-world mental health clinics by providing an in-depth investigation of
challenges and adaptations mental health clinicians experience in real-world settings. We found
key themes related to 1) caregiver involvement, 2) clinician anxiety and self-efficacy, 3)

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culturally competent exposure design, and 4) telehealth. These themes are further explored
below, with specific attention to informing clinical recommendations and the implementation of
exposures in settings that provide care to underserved and diverse youth.
Caregiver involvement in exposure delivery
In our study, clinicians underscored the critical role of caregiver involvement in effective
exposure delivery in youth with anxiety disorders. Interestingly, while the importance of
caregiver involvement in CBT for youth treatment outcomes has been widely advocated, there is
limited evidence to support this notion (Bodden et al., 2008; James et al., 2013; Pegg et al., 2022;
Spence et al., 2000). For example, one meta-analysis of 964 youth comparing CBT to parentinvolved CBT did not find a significant relationship between parent involvement and youth
anxiety symptoms post-treatment (Peris et al., 2021). Furthermore, caregiver involvement has
not been identified as a moderator for anxiety severity outcomes in adolescents receiving CBT
(Baker et al., 2021). However, recent work examining the role of caregiver involvement in
specific CBT treatment components suggests a more nuanced relationship; parent contribution to
exposures is associated with increased diagnostic recovery and greater reductions in clinical
severity at one-year follow-up (Fjermestad et al., 2022). This finding echoes our results and
indicates that certain aspects of CBT, such as exposure, may be particularly sensitive to caregiver
involvement. Moreover, it is also conceivable that caregiver involvement may be pivotal in
telehealth delivered-CBT, whereas the previously mentioned studies examined in-person CBT.
While our findings provide qualitative support for this theory— providers reported caregivers'
essential role in facilitating community exposures when they could not be physically present—
quantitative research examining the differential impact of caregiver involvement in telehealth
versus in-person CBT remains unknown. Additionally, future research elucidating the specific

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34
mechanisms through which caregiver involvement influences exposure outcomes may inform
more targeted interventions. The perceived barriers caregivers face in engaging in CBT, as
highlighted in our study, further emphasize the importance of understanding the role of caregiver
involvement in exposure delivery.
Clinician Anxiety and Self-Efficacy: Impacts on Exposure Decision-Making
In our study, clinicians reflected on how their personal anxiety influenced the delivery of
exposures to underserved, diverse youth. Although they expressed an understanding of the
therapeutic rationale behind exposures, clinicians nonetheless grappled with their emotional
reactions to seeing their clients in distress and worried about the appropriateness of exposures in
the context of environmental stress. Importantly, participants underscored that these reactions
likely posed significant challenges to their self-efficacy and ability to execute exposure-based
interventions effectively. This observed pattern aligns with a conceptual model proposed by
Becker-Haimes and colleagues (2022), which hypothesizes that clinicians’ emotional distress
during exposures may stem from worries about the potential for patients’ distress and fears of
inadvertently causing harm. This distress can lead to maladaptive anxious avoidance among
clinicians, ultimately hindering optimal exposure implementation (Becker-Haimes et al., 2022).
This conceptual model is supported by survey-based studies which have documented the
challenges clinicians face in managing their own emotional reactions during exposure (Mulkens
et al., 2018; Parker & Waller, 2019; Reid et al., 2017) and have indicated that clinicians who
experience anxiety during exposure delivery are more likely to discontinue or accommodate the
intervention (Meyer et al., 2014; Mulkens et al., 2018). However, our study adds to the literature
by uncovering the specific fears clinicians experience when working with underserved youth,
especially concerning the safety of some exposures in the community and the presence of real

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35
threats in clients’ environments. While prior work primarily focuses on clinician anxiety around
causing distress in general, our findings unearth unique apprehensions that have not been
previously explored. Furthermore, the anxiety clinicians discussed in the present study
underscore the complex socio-environmental factors influencing treatment adherence and deepen
our understanding of the interplay between clinicians’ anxiety, self-efficacy, and decisions
regarding exposure implementation. Further research to explore this pathway is needed.
Understanding clinicians' experiences in delivering exposures is crucial as it can
illuminate modifiable barriers to exposure implementation, enhancing the likelihood of
successful delivery. As discussed previously, our qualitative data suggests that providers’
emotional reactions may hinder exposure implementation, particularly when working with
underserved and diverse youth. Providers were sometimes concerned about the safety of the
client if the in-vivo exposures were to be performed in unsafe environments. While preemptively
avoiding exposures in therapy may reflect their own discomfort rather than the client’s, it is
always the case that exposures in clinical practice should be safe and be carried out with minimal
to no risk. Importantly, our study also suggests that clinician anxiety may be exacerbated when
working with underserved and diverse youth due to the myriad of stressors they face.
Importantly, these findings may redirect attention away from solely attributing exposure
implementation challenges to youth. Instead, it underscores the critical role of clinicians’
emotional responses, and the role of real, environmental concerns. This shift in focus may
promote a more nuanced understanding of the challenges faced during implementation and
illuminate the imperative of addressing clinician anxiety and fostering strategies for emotion
regulation within clinical training and practice. Notably, recent research examining the feasibility
of exposure-specific training for clinicians demonstrated that exposing clinicians to exposure

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36
improved clinician anxiety and self-efficacy regarding exposure implementation (Frank et al.,
2020). However, more work is needed to elucidate the interplay between client distress,
clinicians’ emotions, training interventions, and treatment outcomes, particularly in working with
underserved communities. Nonetheless, these initial findings offer promise that supporting
clinicians in managing their own anxiety around exposures may empower them to provide highquality care to underserved youth with anxiety disorders.
Culturally Competent Exposure Design
Mental health clinicians emphasized the importance of designing exposures that are
contextually sensitive to the lived experiences of their clients, thereby aiming to improve
treatment appropriateness and acceptability. Our findings build upon existing literature
advocating for cultural adaptation to EBTs to improve treatment outcomes and engagement
among diverse youth (Arora et al., 2021), with a growing emphasis on developing culturally
competent telehealth-delivered care (Willis et al., 2022). Culturally adapted EBTs have been
shown to improve treatment adherence, satisfaction, and effectiveness among diverse
populations (Arora et al., 2021; Chowdhary et al., 2014, 2014; Ramos et al., 2021; Soto et al.,
2018; van Loon et al., 2013). However, less is known about culturally tailoring specific treatment
components. Moving forward, there is a pressing need for further research investigating the
impact of culturally tailored exposure therapy on anxiety outcomes, as evidenced by clinicians’
observations of increased client engagement when exposures were tailored to the unique needs
and preferences of diverse youth.
Moreover, our study identified genuine stressors and safety concerns as crucial
considerations in exposure design, particularly in ethnically and socioeconomically diverse
communities. Clinicians grappled with striking a balance between challenging clients and

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ensuring physical safety given external threats, such as neighborhood and gun violence. There is
a clear need for best-practice guidelines on cultural competencies within exposure therapy to
navigate these complexities effectively. Specifically, guidance on when cultural adaptations are
warranted is critical (Lau, 2006; Willis et al., 2022), as adverse effects of such adaptations on
EBTs on treatment outcomes have been documented in the literature (Huey et al., 2014).
Relevant to our findings, these adverse effects may arise from removing core mechanisms of
behavior change within EBTs (Huey et al., 2014), such as exposure therapy. Therefore, further
research is warranted to elucidate for whom and under what conditions culturally tailored
exposure design is needed. Once this knowledge has been ascertained, specialized training and
professional development will be essential to equip clinicians with the necessary skills to make
informed, evidence-based decisions about delivering exposures to underserved, diverse youth
with anxiety disorders. Additionally, involving community stakeholders in developing culturally
responsive exposures or adopting a systemic approach to individualizing exposure therapy
delivery may help clinicians foster inclusivity, equity, and empowerment in mental health care
(Galán et al., 2021).
Telehealth: Challenges, Benefits, Attitudes, and Adaptations
Our data suggest various challenges associated with delivering exposures via telehealth,
ranging from difficulties communicating with non-English speaking families to concerns about
clients’ increased ability to avoid participating in treatment. These challenges align with previous
literature that has identified barriers to implementing CBT via telehealth in community settings
(Barney et al., 2020; Schriger et al., 2022). For example, a survey of community mental health
clinicians delivering trauma-focused CBT for youth via telehealth highlighted individual client
characteristics, such as motivation, and logistical challenges, like access to a private space, as

EXPLORING EXPOSURES
38
barriers to therapy effectiveness (Schriger et al., 2022). Our study contributes uniquely to the
extant literature by focusing specifically on one component of CBT— exposures. This emphasis
is especially relevant considering exposures are often considered the "active ingredient" in CBT
(C. K. Higa-McMillan et al., 2016; Kendall et al., 2005), yet they pose significant
implementation challenges (Southam-Gerow et al., 2010). Moreover, questions have been raised
about whether specific treatment components are best delivered in person versus telehealth
(Schriger et al., 2022).
In addition to highlighting challenges, our findings underscore a notable improvement in
clinicians’ attitudes toward utilizing telehealth for exposure delivery with underserved youth.
This shift in attitudes echoes findings from prior quantitative work. Although providers initially
rated the acceptability of telehealth lower than patients’ before the COVID-19 pandemic
(Chakrabarti, 2015; Goldstein & Glueck, 2016), there is now evidence of improved acceptability
(Doran & Lawson, 2021; Sammons et al., 2020), even among providers who work with youth
(Schriger et al., 2022). Importantly, shifts in provider attitudes have also been documented in
real-world settings. Brooks and colleagues (2013) found that initial concerns among providers
working with underserved clients regarding telehealth use decreased following implementation,
with many providers reporting benefits for patients (Brooks et al., 2013), a sentiment echoed by
providers in our qualitative study with youth. One such benefit identified by providers in our
study, as well as others (Schriger et al., 2022), is an improvement in ecological validity due to
clinicians’ increased insight into clients’ environments, which may contribute to better treatment
outcomes in youth (Freitag et al., 2022). Further investigation into exposure delivery via
telehealth is warranted, as most research exploring provider-reported telehealth benefits has
discussed EBTs broadly (Freitag et al., 2022; Madigan et al., 2021; Schriger et al., 2022).

EXPLORING EXPOSURES
39
Examining exposures specifically can further enhance treatment engagement, particularly among
underserved youth.
In discussions regarding the challenges and benefits of telehealth, clinicians reported
several adaptations they utilized to navigate telehealth delivery effectively, underscoring the
pivotal role of clinician flexibility and creativity. Others have also reported telehealth-specific
adaptations for EBTs with youth, such as involving family members in treatment (Barney et al.,
2020), utilizing a chat function to address privacy concerns) (Barney et al., 2020), and adjusting
treatment length (Aisbitt et al., 2023). While Kendall and colleagues (2023) discussed anecdotal
examples and suggestions of CBT-specific adaptations (Kendall et al., 2023), there is little
empirical evidence to support these adaptations thus far, and also for specific treatment
components of CBT, such as exposures. Given our qualitative findings suggesting that clinicians
may be making these modifications in practice, further work is needed to examine the impacts of
these practices on improving engagement during virtual exposures. These findings will likely be
essential for helping clinicians harness the potential of telehealth to expand access to exposure
therapy and improve outcomes for underserved youth with anxiety disorders.
Limitations
The current study has several limitations. First, the study's results are limited to the
perspective of real-world mental health providers. Other points of view, such as those from the
youth, parents, and other staff working in the mental health clinics, were not analyzed here. .
Future studies ought to examine this topic from multiple perspectives to get a well-rounded view
of exposure to CBT in this population. Second, despite efforts to recruit a diverse group of
providers in terms of level of training, clinic type and patient population, the findings may
benefit from incorporating more perspectives from providers working in different conditions and

EXPLORING EXPOSURES
40
with other communities. Additionally, the generalizability of findings may be further limited
because this study was conducted partly during the COVID-19 pandemic. Third, in attempts to
decrease the participants’ burden, limited demographic data was collected. Future studies should
explore potential differences in experiences by race, ethnicity, and other characteristics. Fourth,
some interviewers knew interviewees, which may have caused increased social desirability
among participants. Finally, as in all qualitative studies, data collection, coding, and analysis
were susceptible to the research team members’ biases, preconceptions, and goals.
Conclusions
Despite these limitations, the present study has significant strengths. To our knowledge,
this study is the first to examine provider-reported barriers and facilitators to delivering
exposures as part of CBT to youth via Telehealth. Furthermore, prior research examining
providers’ experiences of CBT has been primarily conducted with mental health clinicians who
work with White, privately insured, upper-middle-class youth. Our study extends beyond this
scope by focusing on underserved and diverse youth and sheds light on the unique challenges
that arise when working with this population. By elucidating the difficulties therapists face in
delivering exposure to underserved youth and their strategies to address these barriers, this study
may help identify specific, evidence-based adaptations to exposure design and delivery to
facilitate and optimize implementation in-person and via Telehealth within real-world mental
health clinics. Finally, opportunities exist for developing and disseminating best practice
guidelines tailored to the needs of this population, which may pave the way for more equitable
and effective mental health care for all youth.

EXPLORING EXPOSURES
41
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Appendices
Appendix A: COREQ guidelines
Appendix B: Semi-structured interview guide
Appendix C: Codes
Appendix D: Provider Demographic Survey

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Appendix A. COREQ guidelines

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Appendix B. Semi-structured interview guide
Overall Experience:
1. Were most of your sessions in person or by telehealth?
a. Can you estimate a percent for each?
Experience with Therapy (pose only to therapists):
1. Was this the first time you had implemented the Coping Cat model?
a. If no, how many times previously have you used Coping Cat?
2. What did you like about implementing the Coping Cat model?
a. Which components of the model did you perceive as most helpful?
3. What did you find difficult or challenging about implementing the Coping Cat model?
a. What kinds of adaptations did you find you had to make to use the model with
your study patients?
4. Do you think Coping Cat was effective for treating your patient’s anxiety?
a. If yes, why?
b. If no, why not?
5. Did parents and children generally follow through with any recommendations made
during therapy?
a. Please share any thoughts about this.
6. Did you observe any barriers to accessing therapy?
a. If so, describe.
7. Will you continue to use Coping Cat in your clinical practice outside of the study?
a. Why or why not?
8. Did participating in this study change your perspective about what effective psychosocial
treatment for pediatric anxiety looks like?
a. If yes, how?
Experience with Telehealth
1. What is your past experience with telehealth (prior to this study)?
2. How has your experience with telehealth been?
a. Any issues?
b. Any benefits?
3. In your opinion, how was the child’s experience with telehealth?
4. In your opinion, how was the parent’s experience with telehealth?
5. Do you think telehealth therapy is as effective as in person?
a. If so, why?
b. If not, why not?
6. Which do you think is more effective, in person or telehealth?
a. Can you say more about that?
7. Are there things you were not able to do while using telehealth that you could have done
in person?
8. Is there anything that could make telehealth visits better?
a. Do you have some suggestions?
Final Thoughts
1. Would you participate in this study again?

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a. Why or why not?
2. Would you recommend the study?
a. To other patients?
b. To other clinicians?
3. What parts of the study should definitely be kept?
a. Do you have suggestions for improving the study?

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Appendix C. Codes
Adaptations
• age adaptations
• comorbidity and crises adaptations
• COVID adaptations
• language and cultural adaptations
• language, culture, SES adaptations
• telehealth adaptations
• timing and structure adaptations
Caregiver acceptability
• Attitudes towards mental health or therapy
• Resistance to exposures
Caregiver engagement
• as a barrier
• as a facilitator
• involvement in exposures
• via telehealth
Caregiver perceived benefits for child
Challenges of Coping Cat; what clinicians did not like
• Age
• co-morbidity and crises
• external stressors (e.g. family dynamics)
• goodness of fit
• patient and family buy in and engagement
• Time
Child acceptability, readiness for tx, engagement
• patient comfort with exposures
Child benefits
• Decline in symptoms
• Exposures particularly helpful
• Specific aspects of CC clients liked
Clinician acceptability

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• clinician comfort with exposures
• effectiveness
• evidence based
• flexibility
• Psychoeducation
• Shift in perspective
• Structure; manualized
Clinician self-efficacy
• confidence in delivering CC
• confidence with telehealth
Comparison in-person vs telehealth
Consultation and training
Did clinician think CC was effective for treating anxiety
• no not effective
• yes and no effective
• yes effective
Medication
Plans for continued use of CC
• No plans to continue
• Yes plans to continue
Suggestions to improve telehealth
Suspected culture, diversity, SES
Telehealth advantages
• Ability to conduct exposures they couldn't have done in-person
• accessibility
• convenience and flexibility
• increased attendance
• increased insight into the home
Telehealth appropriateness
• Age
• child previous experience with video conferencing
• comorbidity and crises

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• distractions
• privacy and confidentiality
Telehealth challenges
• Avoidance (e.g. turning camera off)
• Cancellations and lateness
• Caregiver engagement
• Exposure challenges via telehealth
• Play and toys
• Practical or tech issues
• Reading body language and non-verbal cues
• Therapeutic alliance

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Appendix D. Provider Demographic Survey
General Questions:
1. Age: __________ years
2. What is your current gender identity?
a. Male
b. Female
c. Genderqueer/ Gender non-conforming
d. Different identity (please state): _______________________
3. My race and/or ethnicity is best described as (check all that apply):
a. Hispanic/Latino/Spanish Origin
b. Asian
c. Black or African American
d. American Indian or Alaska Native
e. Native Hawaiian or Other Pacific Islander
f. White
g. Other (please specify): _________
h. Decline to state
4. Do you speak any languages other than English? (Yes/No)
a. If yes:
i. Please specify __________
5. What is your current professional role?
a. Trainee
i. MD
ii. DO
iii. NP
iv. PhD
v. LCSW

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vi. LMFT
vii. MSW
viii. EdD
ix. Other (specify)________________________
b. Attending / Clinician
i. MD
ii. DO
iii. NP
iv. PhD
v. LCSW
vi. LMFT
vii. MSW
viii. EdD
ix. Other (specify)________________________
6. About how many years of full-time professional/clinical experience have you had since
your training ended? ________ years
7. How many years have you worked at your current clinic? ________years
8. About how many active cases do you typically carry at one time? ________ cases
9. At your current clinic, about how many hours of supervision do you receive each week?
________ hours
10. What is your primary therapeutic orientation? (CBT provider only)
a. Psychoanalytic/ Psychodynamic/ Insight Oriented/ Play therapy
b. Person-Centered / Humanistic
c. Behavioral/ Cognitive/ Cognitive Behavioral Therapy (CBT)
d. Integrative/ Holistic
e. Third wave (e.g., Acceptance and commitment therapy (ACT), Mindfulness
Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT))
f. Family/ Family Systems

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g. Other (specify) __________________________________
11. In what percentage of your work with children and adolescents have you used the
following theoretical orientations in conceptualizing cases and thinking about
therapeutic goals? (CBT provider only)
a. About _______ % Psychoanalytic/ Psychodynamic/ Insight Oriented/ Play
therapy
b. About _______ % Person-Centered / Humanistic
c. About _______ % Behavioral/ Cognitive/ Cognitive Behavioral Therapy (CBT)
d. About _______ % Integrative/ Holistic
e. About _______ % Third wave (e.g., Acceptance and commitment therapy (ACT),
Mindfulness Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy
(DBT))
f. About _______ % Family/ Family Systems
g. About _______ % Other (please specify)
__________________________________
12. In what percentage of your work with children and adolescents have you used the
therapeutic methods and techniques advocated by the following orientations? (CBT
provider only)
a. About _______ % Psychoanalytic/ Psychodynamic/ Insight Oriented/ Play
therapy
b. About _______ % Person-Centered / Humanistic
c. About _______ % Behavioral/ Cognitive/ Cognitive Behavioral Therapy (CBT)
d. About _______ % Integrative/ Holistic
e. About _______ % Third wave (e.g., Acceptance and commitment therapy (ACT),
Mindfulness Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy
(DBT))
f. About _______ % Family/ Family Systems
g. About _______ % Other (specify) __________________________________
13. Do you consider yourself...
a. Primarily a child-adolescent provider?
b. Primarily an adult provider?

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c. Other _____ (please specify)
14. About what percentage of your clinical experience has focused on work with children and
adolescents? ______%
15. About what percentage of your experience has focused on work with underserved, ethnic
minority clients? ______%
16. How often, if ever, do you experience a feeling of professional burnout?
a. 0 (never), 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (constantly)
Prior Experience Questions:
17. Where in your formal education did you receive education and training on the
psychopharmacological treatment of anxiety in children and adolescents? (mark all that
apply) (Med provider only)
a. medical school
b. graduate school
c. nursing school
d. nurse practitioner program
e. residency
f. fellowship
g. Other (specify)________________________
h. None
18. Prior to joining the SMART study, about how many total hours have you spent in
workshops or other training programs focused on child therapy techniques (not including
supervision)? (CBT provider only)
a. None
b. 1-10 hours
c. 11-20 hours
d. 21- 30 hours
e. 31- 40 hours
f. 41- 50 hours

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g. Over 50 hours
18. Prior to joining the SMART study, about how many total hours have you spent in
workshops or other trainings (outside of school, residency, or fellowship) focused
on medication treatment of anxiety in children or adolescents? (Med provider
only)
a. None
b. 1-10 hours
c. 11-20 hours
d. 21- 30 hours
e. 31- 40 hours
f. 41- 50 hours
g. Over 50 hours
19. In total, how would you characterize the extent of your educational training in
medication treatment of anxiety in children or adolescents? (Med provider only)
a. Cursory (limited or no practical application, included as part of other curriculum)
b. Moderate (some dedicated curriculum, some practical application)
c. Robust (common subject of focus, extensive application in practice)
d. Other _____
e. Not applicable, I did not receive this specific training as part of my formal
education
20. Prior to joining the SMART study did you have experience delivering exposures?
(Yes/No) (CBT provider only)
21. Prior to joining the SMART study did you have experience with CBT? (Yes/No) (CBT
provider only)
a. If yes:
i. About how many unique clients have you treated using CBT? (Yes/No)
ii. About how many hours have you spent delivering CBT? (Yes/No)

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iii. As part of CBT, with about how many clients have you done an exposure?
(Yes/No)
21. Prior to joining the SMART study did you have experience with pharmacological
treatment of anxiety in children and adolescents? (Yes/No) (Med provider only)
a. If yes:
i. About how many unique children and adolescents have you treated using
medication for anxiety? ____
22. Prior to joining the SMART study did you have experience with Coping Cat? (Yes/No)
(CBT provider only)
a. If yes:
i. About how many unique clients have you treated using Coping Cat?
(Yes/No)
ii. About how many hours have you spent delivering Coping Cat? (Yes/No)
iii. As part of Coping Cat, with about how many clients have you done an
exposure? (Yes/No)
23. Prior to joining the SMART study did you have experience with TF-CBT? (Yes/No)
(CBT provider only)
a. If yes:
i. About how many unique clients have you treated using TF-CBT?
(Yes/No)
ii. About how many hours have you spent delivering TF-CBT? (Yes/No)
iii. As part of TF-CBT, with about how many clients have you done an
exposure? (Yes/No)
24. Prior to the COVID-19 pandemic had you utilized Telehealth for your psychotherapy
sessions? (Yes/No) (CBT provider only)
a. If yes:
i. About how many cases? _____ cases
ii. For about how many years? ______ years

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24. Prior to the COVID-19 pandemic had you utilized Telehealth for your
psychopharmacology sessions? (Yes/No) (Med provider only)
a. If yes:
i. About how many cases? _____ cases
ii. For about how many years? ______ years

Abstract (if available)

Abstract Exposures, a core behavioral strategy in CBT designed to decrease anxiety through systematic confrontation of the feared stimuli, may be a critical element in optimizing CBT effectiveness. However, exposures are underutilized by mental health clinicians, particularly when working with underserved, diverse youth with anxiety disorders in real-world settings. Thus, gaining insight into mental health clinicians’ experiences in delivering exposures as part of CBT is critical for effective implementation, both in-person and via telehealth. This study aimed to explore providers’ experiences with exposure delivery to underserved, diverse youth with anxiety disorders and their perceptions of delivering exposure to this population via telehealth. Through semi-structured interviews with 37 real-world mental health providers, qualitative thematic analysis revealed six themes: 1) Caregiver involvement in exposure delivery, 2) Impact of clinician self-efficacy and anxiety on exposure delivery, 3) enhancing engagement and acceptability through client-centered design, 4) logistical challenges in delivering exposures via telehealth, 5) adapting exposures to telehealth: creativity, flexibility, and previous experience, and 6) perceived benefits and improving attitudes towards telehealth. Future research should identify specific, evidence-based strategies and adaptations to exposures to facilitate and optimize their delivery in real-world settings. Additionally, opportunities exist for the development and dissemination of best practice guidelines.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Woodward, Diana (author)

Core Title Exploring exposures: provider perspectives of CBT with underserved, diverse youth in-person and via telehealth

School College of Letters, Arts and Sciences

Degree Master of Science

Degree Program Psychology

Degree Conferral Date 2024-12

Publication Date 11/27/2024

Defense Date 04/24/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag anxiety,CBT,exposures,telehealth,Youth

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor West, Amy (committee chair), John, Richard (committee member), Margolin, Gayla (committee member), Oh, Hans (committee member)

Creator Email diana.w.woodward@gmail.com,dwwoodwa@usc.edu

Unique identifier UC11399E4HD

Identifier etd-WoodwardDi-13659.pdf (filename)

Legacy Identifier etd-WoodwardDi-13659

Document Type Thesis

Format theses (aat)

Rights Woodward, Diana

Internet Media Type application/pdf

Type texts

Source 20241202-usctheses-batch-1225 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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