Behavioral Interventions 247
Antony and Swinson (2000a) suggest that the therapist focus on highlighting the dif-
ferences between “bad” exposure and “good” exposure (see Table 7.2). In the end the
therapist must provide a convincing rationale for exposure that will encourage the cli-
ent’s full participation in the exposure procedures.
When implementing exposure, begin with therapist- assisted demonstrations in the
treatment session followed by well- planned, structured, and graduated between- session
self- directed exposure assignments that evoke moderate anxiety. Exposure should be
done daily with many of the sessions at least 30–60 minutes long and continued until
there is a 50% reduction in subjective anxiety. Each session begins with a 0–100 rat-
ing of initial anxiety level and recording any anticipatory anxious thoughts about the
exposure task. The individual then enters the fear situation and provides an anxiety
rating every 10–15 minutes. In addition clients should take note of any specific anxiety
symptoms experienced during the exposure session and their interpretation of the symp-
toms. As well, any apprehensive thoughts or images should be noted and clients should
be encouraged to use cognitive restructuring strategies to correct their thinking. A final
anxiety rating is completed at the end of the exposure session and observations noted
about the outcome of the exposure session. One of the core beliefs targeted in Maria’s
exposure assignments was “People are looking at me and will notice that I am anxious,
that I can’t breath, and conclude there is something wrong with me.”
The postexposure evaluation session is perhaps the most important part of the
intervention from a cognitive perspective (see previous chapter on consolidation and
summary stages of behavioral experiments). The cognitive therapist reviews in detail the
Exposure Practice Form and other materials that document the client’s thoughts, feel-
ings and behavior during the exposure exercise. In cognitive therapy, exposure is viewed
as a behavioral experiment or empirical hypothesis- testing exercise. Thus the client’s
observations of the exposure exercise can be recorded on the Empirical Hypothesis-
Testing Form (see Appendix 6.5) and this can be used to emphasize those features of
the exposure experience that disconfirmed core anxious appraisals and beliefs. It is
expected that repeated evaluation of multiple exposure experiences will ultimately pro-
vide the disconfirming evidence needed to modify the client’s anxious thoughts and
beliefs and lead to long-term reduction in anxiety. Examples of graded in vivo exposure
can be found in various behavioral treatment manuals (e.g., Antony & McCabe, 2004;
Kozak & Foa, 1997; Foa & Rothbaum, 1998; Steketee, 1993), as well as in Chapter 6
on empirical hypothesis testing.
Clinician Guideline 7.3
In vivo exposure is perhaps the most powerful behavioral intervention for fear reduction.
Whenever possible, employ this therapeutic tool in the treatment of anxiety disorders.Imaginal Exposure
The goal of any exposure intervention is to provoke anxiety or distress and allow it to
decrease spontaneously without recourse to avoidance, neutralization, or other forms
of safety seeking. There is considerable empirical evidence that this objective can be