246 ASSESSMENT AND INTERVENTION STRATEGIES
physical activity. This would probably result in a reduction of subjective anxiety to a
more tolerable level.
A final anxiety management strategy involves calling the therapist, a family mem-
ber, or a friend for reassurance and support (Steketee, 1993). Given our previous discus-
sion on safety seeking, this form of intervention could quickly undermine the effective-
ness of exposure and so should be used sparingly. Any evidence that this form of support
seeking has become an entrenched coping style would require that it be immediately
faded from treatment. On the other hand, it may be that the provision of some support
may be needed for a brief interval, especially in the early phase of treatment, to encour-
age participation in the exposure sessions. Beck et al. (1985, 2005) recommended the
use of significant others to serve as auxiliary therapists in carrying out behavioral exer-
cises. White and Barlow (2002) concluded from their review of the empirical literature
that attending to the client’s social support system and utilizing significant others in
homework assignments might actually enhance the effectiveness of exposure treatment,
especially for individuals with agoraphobia. In the early stage of treatment, family mem-
bers accompanied Maria to long avoided social situations but their presence was quickly
faded as soon as possible. At the very least, then, the role of partners, family, and close
friends should be considered when setting between- session exposure assignments.
Clinician Guideline 7.2
Effective exposure interventions must activate fear schemas and provide disconfirming
threat information that will result in modification of the client’s fear structure. This is best
accomplished by providing frequent, moderately intense, and prolonged within- session and
between- session exposure that is implemented in a planned, systematic, and graduated man-
ner. Clients should be given a cognitive rationale for the exercises with a therapeutic orienta-
tion that emphasizes exposure as a direct, experiential evaluation of anxious appraisals and
beliefs. To enhance exposure assignments safety seeking, distraction, and escape/avoidance
should be eliminated. Clients should engage in daily exposure between sessions.Situational (In Vivo) Exposure
The most common form of exposure-based treatment involves repeated, systematic pre-
sentation of real-life experiences (Craske & Barlow, 2001). We see situational or in vivo
exposure used most often with specific phobias, panic disorder with agoraphobic avoid-
ance, OCD, and social phobia. In such cases the exposure hierarchy consists of a range
of real-life situations that elicit varying degrees of avoidance. Taylor (2006) notes that
exposure should not be used if the client has poor impulse control, uncontrolled sub-
stance use disorder, suicidal ideation or urges, or engages in stress- induced self- injurious
behavior. Furthermore, clients should have a physical examination by a physician to
determine if there are any medical contraindications for engaging in certain types of
exposure interventions.
As discussed previously, exposure is introduced as a powerful “learning through
experience” intervention that can reduce anxiety. However, the therapist will have to
take special consideration of clients who had a past negative experience with exposure.