Behavioral Interventions 245
ation without support of a friend, family member, or spouse are unlikely to maintain
long-term gains in anxiety reduction (Antony & Swinson, 2000a).
Anxiety Management during Exposure
Given the importance of frequent and prolonged exposure to fear stimuli, one might
assume that any form of anxiety management has no place in exposure-based treat-
ment. Is it not better that the client remains in a heightened state of anxiety so that
the full effects of the disconfirming evidence can be processed and a natural reduction
in anxiety is achieved? In most instances it would be better to refrain from deliberate
anxiety management. However, there are times when some anxiety management may
be necessary in order to encourage prolonged and repeated exposure to high anxiety-
provoking situations. For example, clients who experience extreme levels of anxiety in
a wide range of situations or others who have exceptionally low tolerance for anxiety
could be taught some anxiety management strategies to reduce anxiety to the moderate
range, which is more optimal for successful exposure.
Steketee (1993) describes four types of anxiety management strategies that can be
used in exposure-based treatment to reduce subjective anxiety. The first is cognitive
restructuring in which individuals challenge their exaggerated threat appraisals by not-
ing evidence in the exposure situation that the danger is not as great as they expect
and that anxiety eventually declines naturally. Beck et al (1985, 2005) list a number of
“coping statements” that can be used by clients to encourage endurance in the anxious
situation. The aim of these cognitive strategies is to alter the appraisals and beliefs
responsible for the elevated anxiety in the situation. With Maria, cognitive interventions
focused on her erroneous beliefs about the source of her anxiety (e.g., “that other people
are looking at me”).
A second anxiety management approach is to provide the client relaxation training
such as progressive muscle relaxation, controlled breathing, or meditation. These cop-
ing responses could then be used during exposure to reduce anxiety. However, Steketee
(1993) warns that relaxation has been shown not to be particularly effective in moder-
ate to high anxiety. Also relaxation could easily be transformed into an avoidance or
safety- seeking response. For these reasons, relaxation training is rarely incorporated
into exposure-based treatment. Occasionally, however, it could be taught as a means
of bolstering perceived control for anxious individuals who initially refuse exposure
intervention because of low self- efficacy expectations. In other cases, like with Maria,
reliance on controlled breathing can prove detrimental because her breathing rate was
so exaggerated during peak anxiety that it actually bordered on hyperventilation and
probably drew attention from others.
A third approach is to use paradoxical intention in which a person is instructed to
exaggerate her anxious response in a fear situation. Asking people to exaggerate their
fear often highlights the absurdity and improbability of the fear, which has the intended
paradoxical effect of causing a reevaluation of the actual threat and vulnerability asso-
ciated with the situation (Steketee, 1993). For example, a person with panic disorder
and agoraphobic avoidance might be reluctant to take a walk five blocks from home.
Assuming proper medical clearance was obtained, the person could be instructed to jog
when he feels intensely panicky from an accelerated heart rate. The jogging, of course,
would elevate the heart rate even further but it would cause its reattribution to increased