Cognitive Therapy of Anxiety Disorders

238 ASSESSMENT AND INTERVENTION STRATEGIES

strategies to counter the deleterious effects of heightened self- focused attention when in
social situations.

Clinician Guideline 7.1

Behavioral interventions are a critical therapeutic ingredient of cognitive therapy of anxi-

ety. These interventions are used to directly test the dysfunctional thoughts and beliefs

that maintain anxiety. Behavioral interventions are introduced early in treatment and used

throughout therapy in a highly structured and organized fashion as within- session demon-

strations and between- session homework assignments.

exposure interventions

Exposure involves systematic, repeated, and prolonged presentation of objects, situa-
tions, or stimuli (either internal or external) that are avoided because of their anxiety-
provoking properties. The effectiveness of in vivo exposure has been clearly demonstrated
for panic disorder, with situational exposure essential when agoraphobic avoidance
is present (van Balkom, Nauta, & Bakker, 1995; Gould, Otto, & Pollack, 1995). In
addition, exposure is an effective intervention strategy for OCD (see Foa, Franklin, &
Kozak, 1998; Foa & Kozak, 1996), social phobia (Heimberg & Juster, 1995), and PTSD
(Foa & Rothbaum, 1998; Riggs et al., 2006). Exposure, then, is one of the most power-
ful therapeutic tools available to the therapist for the reduction of fear and anxiety.
Exposure procedures are effective because they modify fear memory structures.
Foa and Kozak (1986) contend that exposure must present fear- relevant information
that fully activates the fear memory structure. Exposure information that is sufficiently
incompatible with meaning and response elements of the fear structure will lead to a
decrease in fear and anxiety, whereas information compatible with the fear structure
will have the opposite effect. Two important therapeutic implications can be drawn
from this analysis.

1. Effective exposure must activate fear schemas (i.e., memory structures). In other
   words, individuals must be moderately anxious during the exposure exercise in
   order to attain therapeutic threshold.


2. Effective exposure must present disconfirming information. The success of an
   exposure experience will depend on whether the individual is fully attentive to
   and processes incompatible information that disconfirms exaggerated threat and
   vulnerability elements of the fear schema.

In addition to a solid theoretical and empirical basis for exposure, these procedures
serve multiple functions within cognitive therapy for anxiety. Table 7.1 presents a sum-
mary of the reasons for using exposure in cognitive therapy of anxiety.
Three types of exposure interventions can be utilized in fear reduction: in vivo
or situational, imaginal, and internal exposure. Situational exposure involves contact
with physical objects or actual situations that are avoided in the external environment,