Bibliography

Chapter 11 is a list of key references to research papers, chapters, and books that have informed the approach to exposure therapy that we described in the previous chapters. By listing these here, we (a) underscore that our approach is rooted in theory and guided by data from studies and clinical trials that have tested the principles, efficacy, and mechanisms of action of exposure therapy and (b) acknowledge that much of our thinking about exposure therapy and its delivery has been informed by the work of our mentors, peers, and students.

Fear of Emotions and Related Physical Sensations

Chapter 5 provides an overview of fear of emotions and related physical sensations and introduces exposure methods to address the fear of what lies within. This chapter is particularly focused on planning, delivering, and processing in vivo exposures to fear of fear (interoceptive exposure). The chapter describes how to modify the exposures to fit with different patient presentations and across multiple contexts, while fading the use of safety behaviors. Case examples are presented along with methods to avoid traps that can impede improvement. Research shows that relative comfort with the experience of anxiety-related symptoms predicts resilience in a wide range of situations.

General Approach

Chapter 3 outlines the general approach to exposure therapy including three phases: planning for exposure therapy, delivering exposure therapy, and processing exposure therapy. The first phase includes specific steps to take in planning for exposure therapy including the initial phone contact, administering a questionnaire battery, conducting the intake, and initiating self-monitoring. These steps guide the case formulation focused on maintaining factors (triggers/cues, appraisals, emotions, and actions/behaviors). Next the delivery of exposure therapy begins with socialization to the exposure therapy model and further planning by working together on an exposure planning worksheet. Exposure should then be delivered in a systematic, deliberate, repeated, and prolonged manner. Typical obstacles and traps to progress are discussed. Finally, the chapter describes postexposure processing, drawing attention to what was (and was not) learned and assigning homework.

Assessing Success

Chapter 4 describes the core yardsticks of improvement. The chapter describes how success is defined from both patient and therapist perspectives and how this is modified from early to later sessions. Patients naturally want to have less anxiety. Therapists, however, know the only way to achieve this goal is to go through (rather than around) the discomfort. Once fear is no longer the enemy, the anxiety eventually goes away. Assessment includes actions and measures before, during, and after exposure. Overall, exposure therapy is on track when the patient is approaching his or her feared cues, responding differently to fear/emotions/thoughts, and shifting his or her specific appraisals of threat to appraisals of safety. Finally, we also describe the importance of assessing patient engagement and command of the exposure therapy model.

Thinking Through Exposure

Chapter 2 introduces a model of fears in terms of a network of learned associations among interconnected nodes. When these memories are cued, they can elicit expectancies for potential threat outcomes. Exposure therapy is used to alter these danger expectancies through new learning through confronting feared cues. This is an active learning process in which patients learn unconditional safety in response to their fear cues across diverse contexts. Over time, patients learn the difference between danger and fear (true vs. false alarms). To achieve this, it is important to (a) identify negative outcome expectancies to safe but feared cues (false alarms), (b) actively test these expectancies with exposure, (c) conduct postexposure processing of what was (was not) learned, and (d) rehearse this learning between sessions.

Introduction

Chapter 1 introduces exposure therapy as an empirically supported, simple, and flexible strategy to reduce a broad spectrum of worries, anxieties, and fears. It describes both what exposure therapy is and what it is not, including many common myths about exposure therapy. The authors describe the art of “playing” with fear as an overall approach. In addition, personalized exposure therapy is introduced as driven by careful case formulation. Unlike a strict manualized approach, this book emphasizes the importance of flexibility using a transdiagnostic yet person-centered focus. Finally, the chapter describes how to use this book, including a review of the chapters and the book’s overarching goals.

Fear of Thoughts, Images, and Trauma Memories

Like Chapter 5 (fear of emotions and bodily sensations), Chapter 7 discusses the treatment of internal threats including thoughts, images, and trauma memories. Imaginal exposure is particularly effective for the treatment of these fears. It has advantages over in vivo exposure because it can be used when in vivo exposure may not be appropriate or feasible (e.g., for combat traumas, contracting a disease, dying alone, harming someone). It can be used alone or in combination with in vivo exposure. When used in combination, it is generally delivered first in therapy (sequentially) or along with in vivo exposure (concurrently). Imaginal exposure therapy steps include identifying the core threat (downward arrow technique) or trauma memory, developing an imaginal exposure script/planning sheet, delivery of imaginal exposure for approximately 30-minutes (recording patient voice, first person, present tense), processing of the imaginal exposure (what was learned/meaning), and assigning home practice (listen to the recording daily). Imaginal exposure can be used as a transdiagnostic approach to reduce fear. In particular, the chapter discusses slight modifications in the cases of generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder.

Psychoeducation about Anxiety, Fear, and the Role of Exposure

Chapter 10 is an accessible primer on the human alarm system and an introduction to exposure therapy. This general resource should be read by clinicians as an overall summary and may also be used as a patient handout as part of the psychoeducation phase of treatment. The handout discusses the alarm system as it related to worry, anxiety, and panic. Definitions are provided to differentiate between stress, worry, anxiety, and fear/panic. The handout also clarifies true versus false alarms and anxiety versus an anxiety disorder. Finally, a clear overview of exposure therapy is provided. The authors frequently suggest patients read this handout several times to overlearn the material such that it will be readily accessible even during times of high anxiety.

Assessment Strategies

Chapter 9 serves as a supplement to Chapter 4 and includes a list and brief description of available self-report measures that can help determine if the clinician and the patient are meeting the goals of exposure therapy. Consistent with the personalized approach to exposure therapy, the authors organize the list by feared cues, domains, and outcomes. Specifically, the chapter covers measures for fear of emotions and related physical sensations, fear of people, and fear of thoughts, images and trauma memories, designated by intervention targets and outcomes. Copies or links to URLs for the measures are provided on the companion website.

Combining Exposure Therapy with Medications

Chapter 8 covers the impact of combined medication and exposure treatments. Any time two treatments coincide, there is a risk that patients may wonder what gains are associated with which treatment. Fortunately, the research supports that patients who are taking medications still benefit from exposure therapy. However, if medication is discontinued after therapy, there is a risk of relapse due to misattribution and withdrawal symptoms. This is particularly true for benzodiazepine medications. Ideally, patients will agree to either eliminate use of benzodiazepines before exposure begins or at least switch from an as needed basis to scheduled dosing regimen. If, however, the patient completes exposure in the context of a medication he or she intends to discontinue, the authors recommend several strategies to protect against relapse. Interoceptive exposure can be helpful in preparing for a medication taper by learning safety even during uncomfortable withdrawal sensations. In addition, the authors recommend a slow taper combined with exposure before, during, and after medication discontinuation.