Behavioral Interventions 249
it is likely that the number of imaginal exposure sessions is no more or less than for in
vivo exposure.
Third, cognitive avoidance is more difficult to control in imaginal than real-life
exposure sessions (Foa & Kozak, 1986). Individuals can distract themselves from the
fear image by replacing it with another thought or image, or they can imagine less
threatening versions of the fear scenario. This will weaken the effectiveness of exposure
by undermining the image’s capacity to activate fear schemas (see Foa & McNally,
1996).
To overcome this inherent limitation with symbolic representation, behavior ther-
apists have introduced certain modifications in order to enhance the effectiveness of
imaginal exposure. One procedure is to require the client to write down a full descrip-
tion of the fear imagery script (e.g., Kozak & Foa, 1997; Rygh & Sanderson, 2004).
(See discussion on imaginal reprocessing and expressive writing in Chapter 6.) For the
scripted narrative to be effective it must include details that have emotional significance
to the client as well as the client’s anxiety response (e.g., increased tension, heart palpita-
tions) to the fear scenario (Kozak & Foa, 1997). Developing an effective fear narrative
can be difficult, so this is usually done in the session with the therapist using guided
discovery to help the client come up with an effective imagery script. Once a script has
been developed, the first imaginal exposure sessions should be conducted in the therapy
session. The exposure exercise begins by having the client read the narrative aloud and
then closing her eyes to generate a full and complete image of the fear scenario. If the
image starts to fade, the client should open her eyes and reread sections of the narrative
to reestablish the image. This process continues for the duration of the exposure ses-
sion. After repeated presentations of the fear imagery, it may be necessary to modify the
narrative in order to maintain its evocative properties. The following is an example of
a narrative script for a 55-year-old man with GAD who was terrified of financial ruin
even though he had attained a high level of financial security.
“You wake up on a Thursday morning feeling particularly anxious. You’ve had very
little sleep because you’ve been tossing and turning all night long, worried about
your finances. You finally crawl out of bed feeling tired, exhausted. You have a low-
grade headache, your muscles ache, and you can hardly walk as you shuffle to the
kitchen. The house feels quite cool as you are the first up on this particular morn-
ing. It is dark and dreary outside with a light rain spattering on the window pane.
You sit at the kitchen table, your mind continuing to race about your investments
and whether you made the right decision while doing some online trading. You have
a sickening feeling that you left yourself financially vulnerable by overinvesting in
that tech stock. You notice that you are feeling tense, your chest aches, and your
heart is racing. You try to get control but the more you try the worse it gets. You are
now convinced that you’ve made a terrible mistake. How could you be so stupid as
to invest so much money in a high-risk stock? You can feel yourself becoming more
and more agitated, you get up and start pacing, wringing your hands as you walk.
All you can think about is that stupid investment when suddenly you notice that the
mail has come for that day. You try to distract yourself by going to the mailbox.
There is quite a bite of correspondence but your eye immediately drops to an enve-
lope from your bank. You notice that it is from your discount brokerage firm. You
know this is the monthly statement of your investments. With trembling hands, and