Behavioral Interventions 243
erature is clear that frequent, intense, and prolonged exposure is needed to bring about
significant and enduring fear reduction.
Attention versus Distraction
Foa and Kozak (1986) argued that use of distraction strategies that involve cognitive
avoidance such as pretending to be somewhere else, distorting a fear image, concen-
trating on nonfearful elements of a situation, and generating fear- irrelevant thoughts
or images will diminish encoding of fear- relevant information, impede fear activation,
and so lead to failure in emotional processing. Thus it is recommended that clients fully
attend to the fear elements of a situation during exposure and to minimize distraction
as much as possible (Craske & Barlow, 2001).
The empirical research on the effects of attention versus distraction in exposure-
based treatment has not been consistent (for reviews, see Antony & Swinson, 2000a;
Craske & Barlow, 2001). The best conclusion is that distraction may not have a particu-
larly negative effect in the short term but it does appear to undermine treatment effec-
tiveness in the long term. Based on Antony and Swinson (2000a), we make the following
recommendations for enhancing the effectiveness of exposure:
- Instruct clients to fully attend to the fear elements of the situation or image.
This is accomplished by having clients verbally describe elements of the situation, their
reaction to these features, and their interpretations of what they see or feel. Taylor
(2006) notes that the intensity of the exposure experience can be adjusted by altering
the amount of detail the client describes in the fear situation. - Minimize overt and covert sources of distraction as much as possible. Frequently
ask clients what they are thinking about at this moment. Remind clients to refocus on
the task at hand if attention becomes distracted. - Encourage clients not to fight their anxiety by trying to suppress their feelings.
Antony and Swinson (2000a) note that efforts to suppress anxious feelings or even
the attempt to reduce discomfort could paradoxically maintain or increase discomfort.
Thus “accepting the fear” is probably the most beneficial attitude to maintain during
exposure.
Controlled Escape versus Endurance
Standard exposure-based protocols assume that clients should continue (i.e., endure)
with an exposure exercise until there is a significant reduction in anxiety (e.g., Foa &
Kozak, 1985). An alternative view is that exposure should continue until individuals feel
their anxiety level is “too high” or intolerable, at which point they can escape from the
situation as long as there is an immediate return to the fear situation a few minutes later
(Craske & Barlow, 2001).
If one adheres to a behavioral view of anxiety reduction, then endurance is the pre-
ferred method in order to ensure within- session habituation of anxiety (Foa & Kozak,
1986). On the other hand, if anxiety reduction is explained in terms of increased self-
efficacy or the incorporation of safety signals, then controlled escape would be permis-
sible (Craske & Barlow, 2001). Once again the empirical research is not entirely consis-
tent on this issue (see review by Craske & Barlow, 2001). From a cognitive perspective,