Behavioral Interventions 239
whereas internal self- focused procedures involve exposure to feared physical sensations
(Antony & Swinson, 2000a). Imaginal exposure involves presentation of symbolic fear
stimuli. Later we will discuss the implementation of each of these exposure procedures,
but first we consider a number of issues that must be addressed when undertaking an
exposure-based intervention.
General Guidelines for Exposure Procedures
Probably no other psychotherapeutic intervention has been misjudged more often
than exposure-based treatment. The intervention appears deceptively simple and yet
most therapists can attest to the difficulty of its implementation. Ensuring that clients
receive sufficient “dosage” to be therapeutically effective is a challenge in its own right.
Many individuals give up after one or two exposure attempts so their experiences only
heighten rather than reduce anxiety. The following issues must be taken into account
when planning an exposure intervention. (For an expanded discussion of guidelines for
implementing exposure procedures, see Antony & Swinson [2000a]; Craske & Barlow
[2001]; Foa & Rothbaum [1998]; Kozak & Foa [1997]; Steketee [1993]; and Taylor
[2000, 2006].)
Rationale and Planning
The cognitive therapist explains exposure procedures as effective interventions that
provide direct experience with information that disconfirms anxious appraisals and
beliefs. It is emphasized that learning from experience has a much more powerful effect
on changing emotion-based thinking than logical persuasion. However, some clients
might express skepticism about the therapeutic benefits of exposure-based treatment by
pointing out that they already encounter fear situations and yet remain anxious. This
potential objection can be addressed by discussing the differences between naturally
occurring exposure and therapeutic exposure. Table 7.2 lists some of the differences
between natural and therapeutic exposure noted by Antony and Swinson (2000a).
It is important that between- session exposure exercises (i.e., homework assign-
ments) be highly structured and well planned. Antony and Swinson (2000a) note that
individuals with panic disorder may be inclined to carry out exposure on less anxious
table 7.1. purpose of exposure in Cognitive therapy of anxiety
Reasons for including exposure procedures in cognitive therapy
••To provide assessment information on the anxiety response in avoided situations
••To provide corrective information that disconfirms perceived threat and vulnerability
••To test catastrophic beliefs through behavioral experimentation
••To confirm alternative, more adaptive appraisals and beliefs
••To reinforce adaptive coping strategies and challenge the utility of maladaptive responses
••To weaken reliance on safety-seeking cues and behavior
••To provide new learning experiences about fear and anxiety
••To reduce or eliminate escape and avoidance behavior