Cognitive Therapy of Anxiety Disorders

240 ASSESSMENT AND INTERVENTION STRATEGIES

days than on days when anxiety is especially elevated. If the exercises are planned in
advance, this will reduce the chance that clients will save homework for their “good
days.”

Within Session versus Between Sessions

Exposure exercises can be conducted with therapist assistance as part of the session
agenda or, more often than not, they are assigned as between- session homework. It
is recommended that the first few exposure exercises be completed with the therapist
present as part of the therapy session. This gives the cognitive therapist opportunity to
observe the client’s response to exposure and correct any problems that might arise.
Select a low to moderately difficult situation so a client’s initial experiences with expo-
sure are successful. The therapist first demonstrates how to carry out the exposure task
(i.e., modeling) and then coaches clients in the correct performance of the task, provid-
ing lots of praise and encouragement for confronting their fear and avoidance. In addi-
tion the cognitive therapist probes for any automatic anxious thoughts during the expo-
sure demonstration and uses cognitive restructuring strategies to generate alternative
interpretations. In this way a within- session exposure exercise can become an empirical
hypothesis- testing experiment of exaggerated threat appraisals and beliefs.
There are practical reasons for beginning exposure-based treatment with some
therapist- assisted within- session exposure. If the therapist moves too quickly into self-
directed exposure homework assignments, the client might become overwhelmed with
anxiety, resort to escape and avoidance responses, and then give up on the procedure.
There are many pressures on therapists to proceed quickly because often clients have
limited health insurance coverage. Nevertheless, this does not change the risks of intro-
ducing self- directed exposure too quickly. Although clients will differ on the amount
of therapist- assisted within- session exposure required in the early phase of treatment,
it would be the rare individual who could proceed directly into self- directed exposure
without requiring at least some practice with the therapist.

table 7.2. Differences between naturally occurring exposure and therapeutic exposure
Naturally occurring exposure Therapeutic exposure

Unpredicted and unsystematic Predicted, planned, and systematic

Brief duration → perceived defeat Prolonged duration → perceived victory

Infrequent and sporadic Frequent and repeated

Threat information exaggerated and safety
information ignored

Threat information evaluated and safety

information is processed

Intolerance of anxiety and heightened anxiety
control efforts

Increased tolerance of anxiety and reduced control

efforts

Reliance on escape and avoidance Elimination of escape and avoidance

Note. Based on Antony and Swinson (2000a).